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!

People Are Waiting Longer To Get Pregnant But If We Imagine That There Is A Bolt Of Your Eggs By The Time You're Born, You Have 1-2 Million In Your Reproductive Years, 300,000 This Means If You And Your Partner Wait till 35! Your Chances Are Getting Pregnant Are Going To Be Approximately... I Feel Like I Better Get Amazed 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 Bertility Doctor

People To Optimize Their Lifestyle To Improve Fertility Rates Of Infertility Are Increasing 1 Out Of Every 8 Women Would Have Infertility And Now It's 1 Out Of Every 5 And There's Multiple Factors That Are Intributing Including Irregular Or Lack Of Having A Period There's More Autoimmune Disease, Robicity, Chronic Stress People Are Waiting But At 40! Your Chance Of Mascarage Is 50% Instead Of Me, You're Left Behind And I Know That Because I Had 4 Pregnancy Losses And I'm Going To Car Now

Lots of People Will Be Struggling With A Variety Of The Things You've Talked About What Would You Tell Them? You Can't Control Everything But You Should Be Abel To Control The Factors You Can So What Would My Daily Habits Look Like? I Love That Question So What About Got Misconceptions Around How To Increase Our Odds Of Being Pregnancy? Yes There's So Many Miss 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 Impact Their Reproductive System?

So Straight Forward It's Not A Pill That You Take For A Major Change Of Behaviour It Is Simply... Congratulations, Dariovese Ogan, 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 It 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 Gest Get

Thank You And Enjoy This Episode So What Is The Difficult To Change The TREJECTORY 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 Make Some Decisions For People?

And When We Talk About Getting Started Earlier And Thinking About This Earlier, When We Hear The Top Of A Fertility I Think Most Of Us Think It's Something That People Over The Age Of 35 You To Start Worrying About Or You Know Once We Get Up Until Close To Our Forties 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 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 All Timers, 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 Macrosocial Holtrol Back Drop To This Because The Conversation Around Fertility And Infertility To Me And This Might Just Be A Perspective By Us Seems To Have Suddenly Increased Over The Last Couple 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 Inceive Children. Because There's Like Social Factors At Play. Exactly. What Is That Social Back Drop? So It's Very Interesting When You Try To Put The Whole Picture Together. One Because We Are More Where A 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 Frazing Didn't Exist. You Couldn't Do IVF Unless You Travel 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 Where 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.

So Social Yes, Rates Of Infertility Are Increasing. We Used To Say One Out Of Every Eight Women Would Have Infertility. And Now In The US, It's One Out Of Every Five, Who's Just Trying To Conceive For The First Time. We'll Have Infertility. So That's A Huge Increase. It Stays Even When You Confound Studies For Age. So The Number One Thing Everybody Says As Well, People Are Waiting Longer To Get Pregnant.

Which Is Absolutely True. I Think Only Five Percent Of People Started Their Family Overage 30 Back In The 70s. And Now It's 25 To 30 Percent. So We See A Huge Increase. And The Number People Who Are Waiting To Start Their Family. I Did You Are. Especially As Women Are Being Empower To Chase Other Dreams. Go To Professional School. They're Delaying Entry Into Child Baring. 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 And 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 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 Enter Course. There Really Are Other Factors That Play That Are Very Socially Acceptable That Are Influencing The Ability To Get Pregnant. I was reading through some research earlier about fertility in 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 Expect To Drop To 1.59 Births Per Woman By 2100.

Which Means That Where There's Clearly A Trajectory. I Mean If This Is True, Then There's A Trajectory To Having Less Kids. Yeah. And The US It's 1.3 Is The Average Right Now For A Single Woman. Really? Or 1 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 Abled To Get Pregnant Even If They're Starting Young. So I Think That We Really Have Two Factors Going Into That Statistics You Saw. When It Comes To Spirm, you know, study came out last year looking at sperm counts. And They've Decreased 50% In 50 Years. What's Most Alarming About This Spirm Count Decreased And Men? Is That In The Past Ten 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 Forerifatility 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 Day 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, the started Forer in 2020 with My Partner Amanda Skilland, 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 In 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 My 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 Were Sharing About Their Pregnancies. I Had This Idea I Need A Weight 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 Had Not Even Open 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. So My Fourth Pregnancy Loss Was An Ectopic Pregnancy, Which Is A Tubal Pregnancy. So This Is A Pregnancy That Implant In The Philopian Tube Instead Of In The Uterus.

Those Pregnancies Cannot Grow The Philopian Tube Doesn't Have The Blood Supply To Support A Placenta. And The Philopian Tube Can Rupshure. 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 A Receive A Medication In Order To Try To Stop The Pregnancy From Growing. But There Was Still A Risk Of The Tube Rupshuring. And I Was Force 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. 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 And 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 In The Fear. Especially If You're A Gold-oriented Person. I Have Set So Many Goals And I'm Going To Do This. And Here Is 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 Shateful, So Much Guilt. And I Had Nobody To Share That With Or To Help Aliveate That Burden From Me. Use The Word Guilt There. There's a Complex Set of Emotions That Have Her Described When Someone Finds Out That Their Pregnancy. Or Even There's 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 Sexual Health. And You Almost Observe A Feeling That They Can Often Feel Like They Are Broken In Some Way. Like They're Not 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 Exactly Same Thing.

And 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 Is Citing Across From Me Every Day. Say, 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. You Need To Know That 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's Deep In The Mids To Failed, IVF Cycles Are 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 A Good Good Friend Who's Just, He's Offset At The Age Now Where My Friendship Circle Is Starting To Go And Get Fittility Test 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 Test 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, 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 Is Going To Leave Me. Because I Can't Give Them What They Want.

And All Of That Sort Of Complex. There's 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, If 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, Your Team. This Is A Team. It Doesn't Matter Who's Diagnosis Comes Back As What. We Are Trying To Get Us Pregnant. And Really Refrain 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 Exorly.

And She Had Taken A Lot Of Blame For Not Frazing 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 Fertilized 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 Developed 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 Plane 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 Talk About Fertility. Where Do We Need To Start? I Was Going To Assume Where I Need To Start Here. So I'm An Absolute Muggle An Idea As It Relates To Fertility.

And Female Anna Mell Reproductive Health. So Where Do We Start If We Want To Understand Fertility? I Always Like To Start With The Overy And Understanding The Difference In Eggs In 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 Millions Sperm In A Day. And 1500 Sperm A Second. So Men, 1500 Sperm A Second.

You're Just Like Pfft, Pfft, Pfft, Pfft, Pfft, Pfft, Pfft. So Men In Their Testies Have Germs Sells, Meaning They Can Just Produce Brand New Sperm At Very High Rates Every Single Day. And In The Overy For Women It's So Different. Because You Are Born With All The Eggs You're Over 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 Exit Inside Your Body.

And They Absorb The Where And The Tear And The World Around You, Your Whole Life. Where Your Sperm Life Span Is 90 Days. Takes 72 Days for Sperm To Grow Across The Testicle. And Then 18 Days To Get Out The Ajaculatory System. So You Have Three Months. So You Could Change Your Life In Changes Berm Counts In Three Months. Why Does It Take 18 Days? I Thought In My Little Idiot Head, I Thought That I Make My Sperm Okay Today. And Then If I Jaculate, That's The Sperm Out.

No, Yeah, Those Spurn Were Made A Couple Months A Go. Really? Yeah, They're Like In Storage Lockers, So That You Have Some For Every Day. So They Kind Of Get What? 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 Weighted Three Days, 600 Million. The Catch Here Is Sperm Are So Fragile. They're So Fragile. They Like To Die, They Get. Ted Pulse. Those Little Ted Pulse. So If You Weight Too Long, You're Just Kind Of A bunch of Dead Guys. And Then They're Going To Inparre 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 You're Sperm Counts Normal. If You're Having Very Long Absinence Periods In Between Your Inner Course 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. Top To Minds Your Fertilize Your Chances Of Fatsalizing an Egg.

Yes. I Didn't Know That. 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 Seeds Your Fancy. We See That Longer Than Seven Days For The 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 Egg. So Is That Sperm Covered Off? Is That Sperm? Okay. And Sperm Counts As You Said Earlier Have Been Reducing Over The Last 50 Years By 50% Which Is Her 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 Makes Sperm. Like If You Have High Collestral, 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 Access From The Brain To Your Gone Out. Your Goneouts Are Either Your Testes Or Your Overs.

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 Play Going Around? Then It'S Say This Is Not A Good Time To Have A Child Right Now. It Is. Because You Can'T Support Your Own Body. Or The World Around You.

Your Drenal Clans Are Making Cortisol Because It'S So Stressful Or Your Calorie And Take 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 To 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 Spurm. Like To Make Eggs Grow Or To Be Making Spurm. And The Hormones That Are Associated With Them.

So Estrogen and Prudestrone 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. There'S More Inflamation. 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 Tuxons In Our World. From The Foods We Eat, From The Air We Breathe, From The Type Of Kitchen Wear Of 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 Spurm Counts And A Reduce 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 Bird In.

So Smoking Marijuana And Smoking Sigurettes Are No Knows If I Have That. Absolutely No Knows. So I Think Sigurettes Most People Are Pretty Where Sigurettes Are Pretty Bad For Your Health. If We Talk About Reproductive Health In General, Sigurettes Smoking For Women In 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 Spurm Count, Your Spurm Motility, And The Quality, The Shape Of The Spurm, 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 Spurms Head. Okay. I'm Giving Up Bad Spurm. You're Giving Up Bad Spurm.

What About Vaping? We Don't Know As Much About Vaping. But It Appears In All The Preliminary Studies To Be Similarly Very Bad. What Is In What You're Breathing With Vaping? Might Even Be More Harmful Than Cigarettes, Potentially. What About Fones 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 Amid It From Them. So, modern phones Actually Amid 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 use 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, the heat of the testicle is, of course, something very, very different.

I do think you talk to Rina about this. So, when it comes to the testicles, they live outside your body for a reason. We know that men who have an undistanded testicle, even if it's surgically removed, sorry, what's an undistanded 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 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? We're having lots of hot baths. If it's daily, and you sit in there for 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 there 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?

Steve, and 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 azure sperm, 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 is a chance that I might not be able to get sperm to return to your ejaculate. It might be permanent. Let's talk about X. Let's talk about X. 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, they look like this about, how many marbles do I have 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, no, you're counting. That's different than guessing. No, no, no, no, no. I'm not, I'm not, just go ahead and have a guess how many marbles you win there. We'll count after we'll see who's right. Okay, I said 200. Okay. Anyone in the comment section below or so you can, you guys can also guess, Brent Sheets, don't skip the end. I think there's about... He is counting. That is not guessing.

Well, I can't count the more, can I? Because I can't say the more seven times. Nobody else can see them all in count then. 140. Okay. This is the analogy. I'm going to pass them over to you. I'd love you to use this as an 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 and men, testes are making brand new sperm every single day. And 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. You're 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. 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 vaults and tout all of these small eggs in 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, follicle stimulating hormone from the brain will come and stimulate one of these eggs. Why any 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. 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. proportionately. Okay, there's 20 or 30 in there proportionally to a jar that has 200. These numbers are obviously ratioed. And then one of them is basically selected. So ovulate. At random. At random. So. Okay. 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, 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? What age am I now? So we can say that you, you know, were 30 at one point and now we're starting to get to about age 34 at this point. 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 40, maybe about 8 to 10 per month, 44, closer to three to four 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. Indomie triosits, 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 these, 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 kindergarteners 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 they'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. Your chances of getting pregnant per month are going to be approximately 10 to 15% per month.

Not very high, 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.

As you were saying here talking to me about this, the opposite of confronting the truth is regret. And I can't imagine how much regret you've seen. I wanted to ask you about 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 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-malarian 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 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 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.

It's 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 X 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 account 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 X 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 you 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 OK again having a good account doesn't mean you're going to get pregnant your chances 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 eggs you have and how many eggs you have to have a chance of getting pregnant.

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 and have to worry about this my grandparents and 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.

I 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 and my early 30s had I wanted to meaning would you check it if you really can't offer somebody things to intervene or 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.

Now it's accessible and 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 and a vote 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 counselor 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 etc. 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 is not that it's pulling them out give 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 very 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 going to 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 there like that's not studied as well but we know moderate to high drinking levels.

As associated with reduced egg quality what's moderate to usually considered for drinks a week for drinks a week so five for glasses of champagne a week. Yep so you're for glasses tonight at dinner you've hit moderate. That is I mean most people especially in Britain.

Oh well here to 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 plastic in the microwave of the dishwasher you shouldn't use teflon on your pans. You shouldn't touch.

Thermal paper receipts like if the airport if they print off a ticket for you or receipt from the grocery store that has chemicals in it itself take out food so when you order your take out 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 take the plastic and you microwave it. Shouldn't do it.

How do we know this have they 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 that your regular cycles there's so many different variables you can look at at an end point 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 when 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 health is 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 prostate landings 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 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 saying 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 things somebody can do to try to improve their reproduction and how their hormones are made and that's a lot more urgent. 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 bear you have the stress of every day 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

that 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 court is all be made is not going to allow your brain to 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 them.

What that comes down to is that you've got a modified 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 court is all drops that's important so 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 hugeest things that people can make a change in process foods refined sugar process 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 process 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 equality 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 and might be types of meat so we have to take it with a perspective of the limitation of the data we know that process 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

that means 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 right everything in moderation nothing in excess we know that the healthiest fertility diet high and fruits and vegetables fruits and vegetables are fiber sources they're 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 substitute in some of those other sources of protein that are good 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 three fatty acids in it and

ultimately eating more fish and less red meat is such a great substitute. What about skinned milk and fertility I heard I've had you speak a little bit 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 or steroid hormone 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 for dairy consumption I say that if you do meatless Monday the rest of your meals for the

week you should have one serving a 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 process foods sugars process meats all those refined carbohydrates all the package things that are totally fake that should be very rare those are your occasion type of foods not your everyday foods

and at the other thing we didn't talk about regarding lifestyle choices is exercise now 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 all 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 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 eggs in the follicle where he 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 less 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 at bursts it ruptures and follicle so 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 not can't see yes holding one of the little eggs and 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 eggs 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 pg 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 philopean tube so it'll be sucked up into the philopean tube but that follicle reform so the egg is gone 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 what we're going to do the 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 philopean 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 okay that's where fertilization happens okay so the sperm comes through the philopean tube it meets the egg which is chilling there

chilling there and then what happens then well hopefully fertilization happened which is like the sperm which is like the tadpole's head hits the egg and 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

the fastest 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 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

and that's the 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

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 and 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 plus and a

second point of thinking about that which is a lot to go into about optimizing intercourse and trying to get pregnant is that things that disrupt the brains 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

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

going to be expanding 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 and a

lot of the things that you 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 in the part of the brain that controls if FSH and LH release from the pituitaries called the hypothalamus so we call this hypothelamic dysfunction I like to think about the

hypothelamic dysfunction because the you know airport control station they're watching the planes come in and sending out other signals it is interpreting what your body is giving it and then it's directing what is happening estrogen is also made from fat and the reason 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

that you're going to get 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 is 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 and 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 Stevens gains 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 is 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 hit 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 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 an interfere with our brains interpretation of our hormones as well

so we see that both over exercising 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 signals it's also a great way for stress coping and lowering your cortisol levels so exercise we should put they right up there with the top thing somebody can do get more sleep exercise every day

so I 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 she I think she had a couple of diet she changes she had some struggles with eating and that resulted in her period basically stopping for I think 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 what is quote unquote normal as it relates to a normal healthy healthy menstrual cycle into people that are struggling what 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 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 use 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 you explain this to me like I've never heard of a menstrual cycle before what is it what happens so the menstrual cycle is essentially what we've talked about with our whole

period of the week and the next right so you have your group of eggs come out of the over each eggs and a follicle brains and so follicle stimulating hormone that eggs 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 loodial phase because the corpus lewdium is always set at two weeks and then when you're not pregnant you're going to bleed so

that's the setting of the lining that's your period your ovaries are doing something different throughout that process so while you're bleeding in 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 setting 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 when you 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 is the signal for your body to believe

you should exactly so you either problem a I didn't ovulate so that is either I'm out of X I don't have any X to ovulate or my brain didn't send out the signals like we said hypothelamic ameneria that's often that over exercising or that calorie restriction or chronic illness stress sometimes I like to think about that one often more as hypothelamic 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 you're ovary and your brain have a miscommunication and so when we talk about your regular 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 Suzy

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 to 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 track 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 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 link 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 leuidium 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 right because now 35 days minus 14 is going to be 21

yeah go 21 so your fertile window or 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 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'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 the first thing I wanted to say the first thing I wanted to just to ask is how long on average do different age groups need to try before they hit the bull's eye

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 that doesn't doesn't that just ruin the fun you know what I mean because I have this one friend who's 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 a chore I don't know there's something about that I'm like oh gosh

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 38 and now it's 5 to 8% per month

if you're 40 it's 3 to 5% 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 and you're trying to do what you can understanding your cycle tracking for a woman is a reflection of our full health

how is 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 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's 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 100% and sometimes it's situational truck drivers pilots they're 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 your intra-yudarin 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 in the uterus wait so I could just ejaculate in a petri dish get a little pipette and pst 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 centrifuget and get just the sperm we can then put the sperm into the uterus and avoid having all that protective ejaculate sample with them you must hear couples doing this kind of thing people do the craziest things

people do crazy things I mean definitely people are having intercourse and then they're putting their 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 basers right this what people call it and try to pull up sperm and put just put 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 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 to 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 so purchasing a vialis sperm itself is about a thousand dollars and then each cycle with a clinic to get the sperm inside

is typically going to be one to two thousand dollars so that's for each month you're going to look at two to three thousand 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 and one so they now split custody with their sperm donor and I think that this is why he changed his mind he had no well he didn't get he didn't get paid for this right so it was out of the goodness of his heart he just met them and gave this sample so part of the issue two is that it's not an exchange of a service for for a fee or a good right it's just 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 ex donor sperm gestational carriers donor embryos even and there's a whole world to go into there but protecting somebody's parental right 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 PC OS yes I've got a very close friend of mine that struggled a lot with PC OS 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 PC OS 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 PC OS are undiagnosed so much higher than either of those numbers you're I said is going to be the real number and what is PC OS there's a couple different ways that PC OS presents so how I like to describe PC OS 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 PC OS 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 6 to 7 million at 5 months to 1 to 2 million at 9 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 eggs like food for the egg okay it's the thing that selects the one egg and gives it water is it like a plant exactly so you have the same amount coming but there's more eggs eating it okay so nobody is 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 it'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 it's real job it's 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 just to emulate any of them the ovary is not making estrogen and it gets bored so what happens is the pathway to make testosterone becomes up regulated

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 of 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 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 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 let result 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 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 at 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 androgen 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 are always to my patients it's 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 extras stressors like the court is all 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 PCOS are overweight you can 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 it's 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 an intervention to try to help them get pregnant

and those interventions are freezing their eggs IVF those kinds of things you have ovulation induction freezing your eggs IVF when you scan the ovaries can you see PCOS hmm PCOS is diagnosed by having two out of three criteria so number one seen a lot of eggs on ultrasound yeah 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 your regularity or absent periods so two out of the three of them so if you have your regular periods and acne you've met the diagnostic criteria what causes PCOS you talked about maybe it's something your mother might have done but 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 influence a lot of how your ovaries going to function later

and there's a huge correlation between different exposures or whether it is insulin resistance and pregnancy and then women being born later in life with a higher risk of PCOS certainly you come back into PCOS by by being overweight and what I mean by that is often patients will present they'll be diagnosed with PCOS but the etiologies a little bit different if you're very obese

that fat is going to make estrogen the brain is going to 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 ovary syndrome for some people yes but have you seen that yes I have seen people but most of it correlates with 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 R.H. 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 an ovulation so that irregular periods or lack of having a period all together

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 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 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 know have an increased risk of heart disease, stroke, osteoporosis, dementia, all timers 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 while 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 times do you know what endometrium is?

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 shutting 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 and some other 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 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 in 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 within her course is another one especially in certain positions

so not pain with like insertion or penetration but deep pain so he'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 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 scars you can have destruction of the internal anatomy and total blockage of the phylopean 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 and 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 into 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 is approaching it in a certain way because by the time that you can even diagnose it the damage is done and if you're having a situation where you're 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 the treatment 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 infertility clinics patients with infertility is 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 you're over communicating

with your brain pattern so you're still having regular periods and you're having sex even if it's painful but you're not getting pregnant that 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 against Burmese is to allow them to meet a phlegm, drop your inflammation and treat your endometriosis and then put an embryo back inside because I don't need 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 of time when you're in 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, ten years and then come off it when you want to get start getting pregnant?

One thing that's very interesting so a good example of one medication not a 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 seen estrogen and that's not the same estrogen that the ovaries make so it's not the type of estrogen that stimulates this endometriosis cells 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 ten 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 medications 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 endogate worse and then you do have higher rates of success when you come off of that then 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 it gives them all 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 de-stroy is the eggs inside the vault so you're going to run out of eggs faster I want four kids how old do you I'm 25 so when do you want to start trying to have them let's say 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-ed count now now is the time to intervene egg freezing or embryo freezing

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 endopation 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 philopian tubes open? how is your partner 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 endopation is a hundred percent 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 you 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 today like in terms of the use that word family planning

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 no family and then oh my god I want to have a family I want for life here's what I say to somebody who has we'll say PCOS or Indomie Trio says

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 in 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 the most firm grow out embryos and I can do genetic testing to see which ones are chromosomely normal and they can stay in the freezer until you're ready for them what?

well I can I can 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 till 32-33

because now naturally having that fourth baby becomes statistically very unprobable 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 the 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 while 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 going to 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 egregious 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 thought 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 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 thought we were trying it but they are so fragile it just took a while to get the tech there eggs now survive 90% of the time going through the freeze thought 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 and chuck 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 is 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 of 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 life birth and what a 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 chemilatively after two embryos are put inside not at one so I put one transfer or you're not pregnant and then you do the second one

88% of people have had a life 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 you 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 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 ten 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 then 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 chat GPT is telling us that on average IVF in the UK is about 3500 pounds and in the US it's about $10,000 IVF is $20,000 which genetic testing yes freezing the eggs 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 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 and I Instagram and with that couple over there they just had sex and then little Bernie was born 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 I had this conversation in my partner but I was scared to have the conversation because turning to my partner and going, hey babe I think we should freeze your eggs

and I should, it's like loaded with a bunch of feelings 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 have 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 and 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 3% is not 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 3% 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 unappreciated 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 running a business today is more challenging than ever before especially with rising costs in every direction

as a business owner I've seen first hand how crucial it is to streamline operations and reduce expenses wherever possible that's where our podcast sponsor next week comes in next week is the number one cloud financial system integrating accounting, financial management,

inventory and HR into one platform one source of truth it's been a game changer for us no more juggling multiple systems everything unified improving efficiency and slashing manual tasks and errors you can join over 37,000 companies that have made the move

NetSuite has extended its unique flexible financing program for a few more weeks if you head to netsuite.com slash Bartlett that's netsuite.com slash Bartlett B-A-R-T-L-E-T-T you can check that out it's also an unavoidable reality of the world we live in

I was reading a time magazine and it says that in 1970 the average US woman had her first baby age 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 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 and 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 in a recent podcast you did that studies tell us that if you're not ready to have a family

by 20 sorry 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 count inequality 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 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 and 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 modernized we are taking one month group of eggs growing them to embryos and doing genetic testing and we're freezing them when 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 5-8 cell sample from the embryo biopsy to make sure they're healthy we'll use healthy

well 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 we call aeuploid embryo a genetically normal meaning it has the right number of chromosomes importantly i-v-f 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 foreuploidy 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 biopsy 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

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 have done genetic testing on them I would know that she has one normal and 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 worked 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 20th rate but even without transferring two embryos a single embryo transfer

significantly increases the chance of identical 20 now overall it's still very low but identical 20 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 a count of two maybe it's 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 20 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 yeah 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 or any of these things true there's so many myths when it comes to trying to get pregnant the good old fashioned way within our course 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 an 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 in a few 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 upon 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 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 feet up, lay in bed you can go and do whatever you want to do

and in fact we know that you're an 18 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 implant eggs fertilized when you are up and living your life it's 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 fill 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 if 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, you know, your contractions help get the sperm to the eggs faster so we do know that so 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 phlobeantops we'll just say that we don't have a causal factors 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 links so we tend to see different vaginal links 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 you don't need to as small or penis or bigger penis as long the sperm doesn't need to get closer to the cervix a lot of people obviously think that yeah no no we need to calculate like it goes it gets right where it needs to go crazy

it's super interesting I've learned so much about all of this stuff today and there's lots of conversation at the moment as to whether birth control is healthy or not and this 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 reframen 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 go start on the pill you took it for 15 years and 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 and 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 vault 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 it's like pre-menstrual 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 are thinking 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 that you can understand are your periods coming regularly

and 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 world that I learnt 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 they'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?

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 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

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 the 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 and the most difficult conversation 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 sort of miscarried 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 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 while 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 and I'm 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 every, they're meant to be my children

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 heard 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 wise it's to keep going and knock it up you must see so much of that pain how do you know you know how does that not come out with you

oh it comes home with me and I live it in the moment 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 for you you know that I'm going to give you the truth it's going to be hard to hear sometimes it's going to be hard to believe that you have a 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 if you 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 you know every week this plan's not going to work anymore 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 life 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 in 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 and obstetrics, you know, fetal death, stillbirth, loss of a highly desired, I mean, loss of any pregnancy, loss of life. I, I, those screams of those parents, you'll, 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. That's Lee, thank you. Thank you so much, Stephen. Thank you so much. It's, 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, 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, you know, a doctor or a fertility expert and sit down with them because of the country that they're in or their, 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 of millions of people that you'll never get to me. 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 are, that want to express their gratitude to you.

And I'm sure that they will message you to do such exactly that. I want to say thank you on behalf of all of them as well. I've learnt so much, I've learnt 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 things. 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. Running a business today is more challenging than ever before, especially with rising costs in every direction. As a business owner, I've seen first hand how crucial it is to streamline

operations and reduce expenses wherever possible. That's where our podcast wants a next week comes in. Next week is the number one cloud financial system integrating accounting, financial management, inventory and HR into one platform, one source of truth. It's been a game change for us. No more juggling multiple systems, everything unified, improving efficiency and slashing manual tasks and errors. You can join over 37,000 companies that have made

the move. NetSuite has extended its unique flexible financing program for a few more weeks. If you head to netsuite.com slash Bartlett, that's netsuite.com slash Bartlett, B-A-R-T-L-E-T-T, you can check that out.