Fertility 101


Shieva Ghofrany: [00:00:00] All right. Hi everybody. Anyone who is watching you guys are gonna start getting on soon, and we have a treat tonight. So for anyone who is going to be joining us tonight, we have Hi. Lucky. Dr. Shan is joining. She's got a, uh, b request. Hello, doctor. All right, everybody. I'm so excited for everyone to join us and I'm so excited. 

Hopefully, Dr. Hi, how are you? I'm good. How are you? I'm loving the mascara. I, you know, I did put on mascara for everyone. I also, by the way, put on fake nails, which I've never done, but I'm not in the or or in the office until Thursday. They're super not classy looking, but that's okay. I decided to try them and I'm probably gonna take them off too. 

No, I'm loving the almond shape. Wait, are they like press on or you went to a salon to get them done? They, oh no. I don't do my nails at a salon because I never have time [00:01:00] and I am in the operating room so much. They look great. They're press on. They're super chick. But that's okay. My gosh. And I'm just realizing I forgot to put my jewelry on. 

I feel so naked. Wow. You know, I never take my jewelry off. Dr. Ska. I love it. Um, so for everyone who's joining, welcome, welcome, welcome. And I wanna first introduce Dr. Sana and tell you guys we have never officially met. I feel like we knew each other just as Insta Friends. Um, and Dr. Ska knows our new partner. 

Sar Axel, which makes me really happy. But I'm gonna give you all a quick intro. So, am I pronouncing it correctly? It's Secon, yes. Yes, yes. Secon. Secon. I mean it doesn't really matter. . Okay, well whatever you, how do you pronounce it? I usually say Secon, but it depends on my mood. . Well then we're gonna say the appropriate term. 

Dr. Scon. Um, so she is an R e I, which means reproductive endocrinologist and infertility specialist. Although Dr. Scon, I usually like to say R E f, I like to say reproductive, endocrinology and fertility. Mm-hmm. , because I'm a big proponent of language and I feel like it sounds much better to say [00:02:00] fertility. 

Right. People come to you if they have fertility issues and you help fix those issues or, OR questions. Yes. And she is with RMA Reproductive Medicine Associates in New York and she sees patients there and she has an amazing blog that actually I'm so glad I discovered because it's a great resource for my patients, even called the lucky 

So you have to go to the lucky and she has tons of questions and answers, so thank you for coming. Thank you for having me. I mean, this is so great. You know, I love everything that you do on your page, and I feel like an essential part. Women's health education should involve fertility. So that's why I reached out to you to do this talk. 

Yeah. Good. I'm so glad. I'm thrilled that you've reached out to me. Um, I thought that we should start, and we have a bunch of questions that some of the things that you were gonna touch upon were, are going to answer. But I think the first thing we should talk about, I'm gonna touch after you do, about how long should you wait before you see a fertility specialist. 

Let's talk about why does it take so long to get pregnant and what does it take to get pregnant? [00:03:00] Right? Yeah. That's a good place to start because I think it's important to have realistic expectations. A lot of people come to me very scared, automatically assuming something is terribly wrong with them or their partner. 

because it's been X number of months and they haven't gotten pregnant. And a lot of what I do is reassure, right? Because we as humans are extremely inefficient when it comes to reproduction. We're not like certain species of animals that can just look at each other from across the room and have a litter of pups. 

That's just not how our systems work. You know, you release one egg every cycle, and we usually say every month, but not everyone has a 28 day period or cycle. Um, and that one egg is kind of a long shot, right? There's no guarantee that the egg and sperm are gonna meet. There's such a narrow window of opportunity when you release that egg. 

It only lasts for 12 to 24 hours. Sperm can last for about three to five days in the reproductive tract, which is why timing is so important. Mm-hmm , and if even if you time it perfectly in the sperm and the egg are in the right place at the [00:04:00] right time, it's not a guarantee that all of the complex interactions that have to take place will take place to actually fertilize that egg and then grow into an embryo, which takes about a week. 

And even if it gets to the embryo stage, it might not be genetically normal. There's a lot of different typos that can happen along the way. And even if it's a normal healthy embryo, then it, the last challenge is it has to find the lining of the uterus and there's crosstalk between the uterus and the embryo. 

So it's not as simple as what a lot of people think, and there's just a lot of attrition and drop off, which is why it's normal. It's normal. And we say normally it takes, you know, anywhere from six to eight months. And that's, you know, a real generalization. But in general, each month you have like a 15% chance of conceiving for the average person. 

And obviously things like your age and different individual factors can affect that statistic, but that's why you have to try for months and cycles on end for a positive pregnancy test. Right. [00:05:00] Well, and it's interesting because I think that you and I know the guidelines, right? So I'm gonna review the guidelines for everybody. 

So the guidelines that doctors are taught is that if you are under 35, you should try for a full year before you get referred to a fertility specialist. Right? And just to make it clear, that's because it can take 12 months for, we say 80% of our patients to get pregnant, right? Meaning if I had a hundred patients and they tried for 12 months, 80 of those hundred would be pregnant after the 12 months, but 20 of them. 

Wouldn't be pregnant either because they need maybe 14 or 16 months or because they need help. Mm-hmm. . Right. And if you're over 35, we are groomed to say, and we are taught through our American College of OBGYN to say six months of trying. Mm-hmm. , and again, we say timed intercourse like Dr. Sicon said, you do, you should try to have sex. 

We tell patients, and I think you do the same as an R ei. Mm-hmm. every other day around day 10 through day 20, presuming you have a somewhat regular cycle. Right. 25 to 35 days apart, 24 to 35 days apart so that you can leave behind some sperm. So it's [00:06:00] waiting for the egg. Exactly. Now, I think, and I suspect you feel the same, that those are not rules, those are guidelines. 

Correct. Yeah. And it's probably regionally dependent. A little bit, meaning you're in New York City, I'm outside of New York City. We are really lucky to have so many great fertility specialists here in Connecticut and some of our patients who live in New York or really are inclined to go to New York. I have a ton of great people to refer to, so mm-hmm. 

I certainly refer out. Sooner than many doctors. Not only because I have access. Right. And because our patient population is particularly anxious about getting pregnant. Mm-hmm. , due to the fact that many of them have delayed their childbearing because of education and because of work. Right. But also because I myself had many miscarriages. 

Right. And because of that delay, I feel like I really understand the angst. Mm-hmm. . So I see the patients all the time. If you want to see a fertility specialist right off the bat, I will send you, but I don't want me sending you to send a signal that there's something wrong. Right. There's nothing wrong necessarily. 

You might start the workup. Right. And in the [00:07:00] midst of the workup get pregnant. Exactly. Or they might do a workup and not find anything and we'll talk about all the reasons, right. I mean, the number of phone calls and I love when this happens. I'm, we're canceling our appointment because we're already pregnant, you know? 

Yeah. That happens all the time. And I think there's nothing wrong with trying to get ahead of things and being proactive. Um, I think it is regional. I do get dms from patients in the Midwest and in rural areas of the country where, you know, they're waiting a long time to get in to see an r e I. And oftentimes those offices, because they're inundated with requests from patients, will say, if you haven't been trying for X number of months, then you know, call back when, that's when you meet the criteria. 

So I think that's really hard and frustrating. Um, I think especially because. Definitions or criteria of when to seek help don't really factor in individualized factors such as, right. You know, knowing you have a history of fibroids or endometriosis mm-hmm. or someone who knows they have really irregular absent cycles. 

It doesn't make sense to wait the six months or the 12 months and that type of scenario. [00:08:00] Yeah. And also I think, listen, and for everyone listening, if you are one of those people who thinks, I don't understand why hasn't my doctor sent me, I've been trying for eight months and I'm so anxious. The answer is, many doctors do go by what we consider evidence-based medicine. 

And the evidence has shown that if you wait that year, you'll likely be pregnant. Mm-hmm. . And in an effort to not increase the cost to the system or increase your anxiety, some doctors won't refer until they've reached what, again, is considered to be the guideline. And I don't think there's anything wrong with that. 

No. But I also advocate for, there's nothing wrong. Being proactive, although we also have to acknowledge that that's certainly from a place of privilege. Unfortunately, Medicaid, for example, does not cover many of these things. Right. And some patients, insurances don't cover everything. If you're in my category, I have a crazy deductible of $13,000. 

So all that stuff should get taken into account. Yeah. But certainly I think those patients who feel that they wanna be more proactive, it's not a rule. Mm-hmm. . So you can go see mm-hmm. , you can see someone. Yeah. Um, tell us the, the things that I want to touch upon with our questions, and then I'm gonna [00:09:00] talk a little bit about, again, outside of how long you should try some of the things you should do mm-hmm. 

as far as getting yourself prepared. But there are a few interesting questions I wanna make sure that you touch upon. So can you give us the statistics mm-hmm. , about what happens after 30 versus 35. Mm-hmm. versus. . Yes. So on the female side, um, we care a lot about age when it comes to trying to conceive and being able to get pregnant and have a healthy pregnancy because the one time sensitive factor, when you think about all of the things that go into establishing a healthy pregnancy, the sperm, the reproductive tract, the uterus, the fallopian tubes, and then the ovaries and the eggs, they contain the one time sensitive factor are the ovaries and the eggs they contain, right? 

Mm-hmm. , we're born with all of the eggs that we're ever going to have. We're not gonna be able to make new eggs or fix our eggs. And anytime I tell a patient this, I can see their body language. Like they just start to get really anxious, right? And I always say, , you know, it's all about perspective and [00:10:00] flipping that perspective instead of us, you, you know, feeling fear from that fact. 

I think we have to embrace that biological fact and find ways to work around it. Find reproductive hacks, right? So we're gonna talk about that later on in the discussion when we bring up fertility preservation and. Fertility planning. But um, when it comes to timeline and how it affects our eggs, it's really two time sensitive factors and they often get confused. 

So I wanna address 'em separately. One is the egg quantity and the other is the egg quality. And I think a lot of people fixate on how many eggs they have because that's the more tangible concept. It's something that you can test at any given time point. You can do two things. You can do blood work and look at markers like your A M H level, anti malar hormone, and it's a hormone that you know. 

The higher it is, the more eggs you have at that snapshot in time. And you can do an ultrasound and see how many eggs there are at the surface of the ovary, which doesn't represent all of your eggs. You can't see all of your eggs at any given time point, [00:11:00] but you can see a limited subset that have been randomly recruited to the surface of the ovary. 

There's always this random recruitment, and then one of them gets selected also at random to ovulate, and then the rest of them die off and go away. The size of that pool is always gonna tell you. an overall estimate of how many you have. And so, because you can actually tell someone their individual egg count, I think that's what a lot of people put the emphasis on. 

Um, you know, but I tell them that the egg count really is only important for treatment, right? Mm-hmm. , every month you're releasing one egg, or every cycle that you ovulate, you release one egg. So whether you have a high egg count or a low egg count doesn't really impact your chance of conceiving. And I think that's a really important thing to know. 

What impacts your chance of conceiving is your egg quality. The reason we care about egg count is cuz if you're doing egg freezing or ivf, that tells us how many we can get from one cycle, how efficient and effective your treatment might be, but your egg quality is what determines your natural fertility. 

The [00:12:00] chance of that one ovulated. at any given time being genetically normal when it turns into an embryo, and that is very much linked to age, there's no way to directly test that. Um, and it's really hard, you know, for patients to understand that. They're always saying, well, my egg count is really high, so that means I have the eggs of a 20 year old. 

And I'm like, no, they're two separate issues. Right? They both just happen to change as we get older. And they both happen to start to change in a more rapid way, in an accelerated fashion at 35 and older. But they're two separate issues. You can have a low egg count and a really high egg quality. And again, we're making assumptions. 

There's no way to directly assess this, but we get a lot of our information about egg quality from all the I V F that we do, which nowadays involves genetic testing of embryos. And we see a really strong relationship between the age of the eggs that the embryos came from and the likelihood of the resulting embryo being genetically normal and having the right number of chromosomes or packages of d n a, um, and the age of the eggs. 

[00:13:00] So, When you're, you know, in your twenties and early thirties, that's as good as it. If I was to take all the eggs from your ovaries and turn them into embryos and genetically test them in our IVF lab, I would presume that maybe about 25% will be abnormal. That sounds like a lot, but that's kind of your starting point. 

You've been holding onto those eggs for two decades, but the majority are normal. And by the time you get to your early thirties, maybe it's creeped up to about 25 to 30%. And at 35, it's like 30 to 35% of embryos coming from your eggs are abnormal, but still the majority are normal, which is why I always tell my 35 year old patients, you're still in a good position. 

Right? At 38, you start to see levels of about 50%. So it's almost like the odds are 50 50. Are you gonna ovulate an abnormal or a normal egg? And at 40 it's like 60%, you know, and and so now the odds have flipped in favor of it being more likely to ovulate an abnormal. , but there's still a good chance you could ovulate a normal healthy egg. 

You can should actually, we should just point out, it doesn't mean, for example, at 38, if it's [00:14:00] 50 50, that if you're pregnant, you have a 50 50 chance of a chromosomally abnormal pregnancy. Correct. Just everyone understands that. Yes, because you're already less likely to get pregnant with a chromosomally abnormal egg. 

Right. So if an embryo doesn't have the right amount of dna, the most likely thing to happen is as it's getting to the uterus, because the fertilization happens in the fallopian tube and then it travels to the uterus. A lot of them stall. They just stop growing because they don't have the right directions. 

They don't have the GPS to guide normal growth and development. And then some of them will. It depends on what's missing, right? It depends on which genes are functional, which ones aren't. Sometimes you can get as far as implantation, and then at some point after implantation, it will stop growing. And that's the number one mechanism of miscarriage, right? 

So that is a really important thing to point out. But all of this is age related, and this is the main driver behind why it takes longer to get pregnant. , the risk of miscarriage is higher as you get older. Mm-hmm. . And, um, it's not something that happens overnight. You know, everyone has the number 35 [00:15:00] like burnt into their consciousness. 

Right. But it's not like overnight it becomes harder. It's just things start to change more rapidly and your odds start to flip in favor of it being more likely to ovulate an unhealthy egg. But it doesn't, it's not all or nothing. You know, I have 41 year old patients who get pregnant on their own and everything's fine. 

It's just less likely to be easy. Yes. Well, and that's what I love. I love, um, talking about this openly, frequently and, um, casually to patients. I always say, because I really do want women to be proactive about their health and about their fertility, but I don't want them to be, like you said, wrapped with fear. 

And so I think, you know, I often say to my young patients, young, 28 30, and they're like, good. Just worried. What if I can't get pregnant? Mm-hmm. . And I actually always start with the end with them. I always say, listen, here's the bottom line. As long as you are willing and open to accept that you might get pregnant on your own, you might need help. 

But either way, you will most likely have a baby. It depends on how far out you wanna go with that help. But start with the end in mind. If you said to me, right, I only wanna get [00:16:00] pregnant on my own spontaneously with no help ever mm-hmm. , then it's a little harder for me to kind of be completely pro, completely optimistic and say, oh, no big deal. 

Mm-hmm. . But at really most ages, we can say to patients nowadays with the mechanisms we have, you can have a baby. Mm-hmm. on your own most likely. There are certainly individual cases where, you know, women's uteruses are just not equipped to be able to carry a baby, but hopefully they can use the gestational carrier or vice versa. 

Versa. They can't use their own eggs, they use someone else's eggs or someone else's sperm. Yes, they can certainly adopt, and I'm a vocal proponent also, by the way of saying, I think there's actually a lot of goodness in choosing to not have children because that's a totally different life. That has a really amazing. 

Um, output outcome with it. Yes. But I do think that continuing to maintain some optimism is something that women really do need. Cuz I think it's really easy for women to say, I'm so scared. What if I don't get pregnant? Yes. And I always say like, why are we so scared? We have, we have things to do to help you. 

I am only scared or anxious or worried about things that I [00:17:00] cannot find and I cannot fix. Mm-hmm. . And so because we have fertility specialists, I understand that a lot of people don't wanna invoke the rights to use them or need to use them. But at least if we have that opportunity, it's so good. Yes. Um, and I love that you said about 35, cuz I do think I have, I have a lot of patients who say, well I'm 33 and I have to get, have a baby next year because I just have to do it before 35. 

Yes. And we have to really explain, it's not like your fertility dives off a cliff. It does decline slowly, but it doesn't dive off a cliff. Right. It's not as though your risk of down. exponentially goes up at 35. It does not. Right. Those are all things that you should consider. Right? Yeah. Um, I wanna quickly say what you should do before you get pregnant in general. 

Mm-hmm. . And actually I have a question for you about this. So we televisions before they get pregnant, ideally, of course you're in good health. You know, I always have to put in the disclaimer, of course we should be in our best weight, which is like really hard for me to say. Cause I'm never at my optimal weight or health ever. 

Yes. Um, but in a perfect world that would be ideal and get any chronic medical issues under control if you had high blood pressure, thyroid disease, diabetes. Mm-hmm. , get those in good [00:18:00] control. Mm-hmm. , the question in the general world comes up about what tests should you do before you get pregnant. Right. 

There's the ideal. Mm-hmm. And then there is what I would say is more common. Mm-hmm. most commonly in our practice. And we're in a very, you know, an educated population of patients. Right. They come to us already pregnant, and then we do the routine blood tests, like routine panels of genetic tests. That patients carry on their own, meaning genetic, um, the recessive genes that we all are born with and carry mm-hmm. 

So that's when we typically do those, that's when we typically look for things like, are you immune to rubella, for example, and what is your blood count in your blood type? In an ideal world, and I think in New York City, again, there's a bit of a difference. So New York City patients, by and large I see. 

When they come out to us in the suburbs, they've already had all that testing done before they've gotten pregnant, they have had pregnancy test, they have had all of the genetic tests to make sure they don't have any recessive genes. Mm-hmm. , they found out whether or not they're immune to rubella, for example. 

Things like that. So first [00:19:00] I just wanna put out there that that would be ideal. Yeah. But that's not standardized throughout the country and at least even where we are in Connecticut. Mm-hmm. , the insurance companies will not always pay for the genetic testing when it's pre-pregnancy, which is, that's crazy. 

Ridiculous. Right. Because the minute make it pregnant, they're gonna pay. . Um, but I think it's an important thing to point out that if you have the opportunity to go to your doctor and do your genetic test ahead of time, every now and then, we do catch them ahead of time. Who has a genetic abnormality, for example, cystic fibrosis. 

And if we found that out ahead of time and if we found out about their partner, then they could avoid a lot of the concerns that happened in a pregnancy that happens to have two dab damaged genes for cystic fibrosis. Those patients can come. Yeah. City. Explain city. Do you city people do it. Yeah. And I explain it as a risk assessment. 

I'm like, it's just to see if you're the two to 4% of couples that walk through my office door that just happen to match up. And a lot of people have misconceptions. I'll [00:20:00] have patients that are, you know, couples that are different ethnicities, like completely different backgrounds and they'll be like, but, and, or, you know, we don't have anything in our family history. 

Right. And I have to explain to them that none of that matters anymore. Right. You know, like I'm a carrier of K acts and I'm definitely not Ashkenazi Jewish. Right. So go figure. Yeah. Um, it doesn't really matter. And, and I think, you know, anyone who's done 23 and me can attest to the fact that I think all of us have like mixed ancestry, so you can't just go by your background. 

Um, but yeah, I definitely do that testing. Preconception or push it preconception just because it might change your management. And I tell patients, cuz some patients will say, well, even if I was a joint carrier, we were, you know, carrying the same recessive mutation and there's a one in four chance of having an affected child, we still wouldn't do I V F to genetically test embryos to avoid that situation. 

And I say that's fine, but at least you'll go into the pregnancy mentally prepared saying, all right, I'm gonna wait till the end of the first trimester and there's this one in four chance that this pregnancy [00:21:00] could be affected. At least you can be mentally prepared and informed and you just never know. 

Maybe you'll change your mind once you have new information. Yeah. And at least you can get educated so that you know which pediatricians are gonna be discussing it with maybe to deliver in a different hospital than where you are. So I definitely, I mean, I'm a huge proponent of wanting patients to do it. 

The hard part is, again, when they've seen the fertility doctor, all of our patients have done. . Right, right, right. And I think when you enter into a fertility space, you're already Yeah. Understanding that you're gonna do more. But in the generalist office it would be ideal. Right. But just so all the, everyone listening knows it is not the standard, meaning the American college guidelines do not say that you have to do it, but it's certainly something that you could do. 

And I think, like I said, ideal is different than what happens on a daily basis. Mm-hmm. . Mm-hmm. . Um, so I know we're gonna talk about some treatment options and I do wanna touch upon on embryo freezing, but there were a couple of questions very specific that I think are actually extrapolate to everyone else. 

So, for example, if someone, and these are something I'm gonna tell you the questions, cuz then you can pepper [00:22:00] them in. Okay. Um, getting a woman says she's not getting her period at all at age 44. Does the fertility treatment work, um, if she's possibly menopausal. So I think we can talk about that with egg freezing. 

I mean with, um mm-hmm. with donor egg. Mm-hmm. , um, This is a funny question, so I'm just curious, does drinking cold water affect fertility? I've never heard that. Please educate us. Mm-hmm. . Mm-hmm. . And when you talked about we're not able to really change the quality of our eggs, talk to us about coq 10 mm-hmm. 

and whether or not that really has been debunked or is there still anything that we really can, um, do about the egg quality? Mm-hmm. , I think you had said that. Really not. So those are, so those are like themes that there's a bunch more questions, but those are some themes. So within the discussion of what could happen and how can we fix it, weave those in for us, will. 

Yeah, definitely. So I think the most important place to start is thinking about what it takes to get pregnant. Yeah. And then we can talk about things that could get in your way. So tests [00:23:00] that you should think about generally, and then ways to get around the inefficiency. So feel free to interrupt me if there's anything you want me to focus on or any specific question. 

Um, but basically, you know, and some of this is gonna sound really obvious, but I guarantee you're gonna learn something that you didn't know. So we were talking about that recruitment of eggs, right? So you have a random assortment that get randomly pulled to the surface of the ovaries, and then your brain, your pituitary gland in your brain, actually sends hormonal signals and at random they pick one dominant. 

that will mature and grow and eventually be released or ovulated into the fallopian tube on one side or the other. And there's no rhyme or reason. It doesn't alternate. It's very random. So you could ovulate five times on one side, you know, you can't predict it. Um, and when that egg is ovulated, it has that short window of opportunity for the egg and sperm to interact and then grow into an embryo that will then implant into the uterine cavity. 

So you can have structural things blocking [00:24:00] the sperm and egg from meeting, like having the tubes blocked on one side or both sides. Mm-hmm. , you can have problems with implantation because of things that are interrupting that smooth contour of the uterine cavity, like fibroids or polyps or scar tissue or a septum. 

You can have male factor issues and up to 40%. Couples that have been trying for a year and haven't been able to get pregnant. There's some element of sperm quality issues and then there are egg quality issues or problems with ovulating an egg regularly. If you're not getting a period, it means you're not ovulating. 

Or if you're getting really infrequent periods, you're ovulating infrequently and you're not in the game. So that's just, and let's, I'm gonna interrupt you one sec cause I do wanna highlight, I hope everyone heard that because I think women take too much shame and blame on their on themselves. But 40% of fertility issues are male. 

Right. So that is a really important and impressive number that I think that people need to really pay attention to. Right. And men are always making new sperm every 72 days. So I have couples who come to me and the male partner sometimes will [00:25:00] just be, I don't know what it is, if they're, you know, just reluctant to enter the doctor's office and do any testing or if it's a pride link, yes. 

But they'll say, I have a child from a previous marriage, so like, I'm good, right? This is not a me problem. And I'm like, well, your quality can fluctuate over time and things can change with your health. So, you know, it's really worth getting this checked out, even if it's been a year, like a couple has had a child and now they're coming back to me for baby number two, I'll retest because things could have changed for sure. 

So that's, and you wouldn't necessarily even go forward with some of the more aggressive fertility treatments if you don't know that the sperm quality is good, I think. Right? No, for sure. I never wanna be surprised on the day of an egg retrieval for an I V F cycle that there is no sperm, right? There's no way to know unless you actually. 

Look and see what's in the sample under the microscope. So that brings me to my next point, which is, you know, what are the tests? Semen analysis is easier. Just getting a sample. And that's the thing. It's like, it pains me to, you know, beg people to do this test. I'm like, this is something you do for recreation, I'm [00:26:00] assuming. 

Yes. Anyway. Test. It's nothing like what women are gonna go through. Let's face it, man. Right. And anyone is watching an extensive test for the most part either. Um, but anyhow, so there's that. There's also, um, an H S G, which is like a two for one test. It's basically where they put dye that lights up on an x-ray into the cervix. 

It enters the uterine cavity. and we'll give you a nice silhouette of the uterine cavity so you can make sure there's no lumps or bumps interrupting the lining. And we'll fill the fallopian tubes and hopefully spill from either side so you're making sure that the entire reproductive tract is patent. 

You can do the egg count, like I said, with the AM m H level. And, um, on the ultrasound you can get an actual account. Can't test for egg quality, but we make our assumptions based on age, which is something I never like to do. I don't ever wanna reduce patients to numbers and categories, but unfortunately our hands are tied when it comes to egg quality. 

And, and that's basically, you know, the overview of the basic workup. There are other hormonal things we look at, like your thyroid function, other pituitary hormones, [00:27:00] um, and that, you know, that's, that's what I would do for any patient coming to me for a fertility workup. There might be some specialized things. 

on, you know, a case by case basis. Now, let's say everything comes back normal, then you're not really pushed in one direction or the other because there are situations where you're like, okay, the sperm count is low. We have to do I v f, we have to inject the, this egg with sperm to make this happen. You know, or if the tubes are blocked, we have to do I v IVF to bypass them. 

But if everything comes back normal, we call that unexplained infertility. And it doesn't mean there isn't an actual explanation, we just don't have the tests and the know-how to figure out what's going on. It could be, and you know, and I'm gonna interrupt again, one sec. Yeah. So, so just for everyone watching the test that Oxycon has just mentioned, other than I would say the follicle count and ed and ed count, so the HSG test, the semen analysis, and the blood. 

those are all tests that your general OB GY might do on her own before sending. You used a lot of the time that more, and then in my kind of [00:28:00] older age where I was really busy, I would say to patients, I can do it, but I'd rather send you to the fertility doctor because they can do it in a much more concerted way. 

Yeah. Your entire office and lab is groomed towards women who are trying to get pregnant, whereas the generalists are seeing nine year old women, 12 year old women, everyone in between. Yeah. So again, you can talk to your doctor. Some patients don't wanna see the fertility doctor until they've had those tests. 

Mm-hmm. , some doctors wanna do those tests first. Mm-hmm. . So it's, again, there is no rule, but just so you know, those tests may have been done before you even see your reproductive endocrinologist and the doc, the patient, the doctor might have not found anything. So that's just an FYI for everybody. No, that's a really good point. 

And for me, I have no preference. Like if I have all the information up front, it makes for a more informative first meeting and conversation. But if not, that's fine too. We're just starting with a blank slate. And in some ways it's easy to just have all the records in one place. Right. Um, so that's the basic workup. 

And if everything comes back normal, it's really going to be a decision that is based on what your main priorities and objectives are, [00:29:00] and also your age and your family building plans. Because there are really two different buckets of treatment. And the treatments when you're not really targeting a specific problem, are just aimed at overall trying to make this whole process more efficient. 

Right. And so there's the first bucket of treatment, which are things like taking Clomid or Letrozole. These are ovulation induction medications. Mm-hmm. . And even for someone who has a regular cycle and they're ovulating on their own. we're inducing the ovulation sometimes of more than one egg because it's almost like, okay, well if one egg seems kind of like a long shot, maybe releasing two or three eggs is going to improve the chance that at least one of them is normal and we'll make it past all of those different barriers that it has to get past. 

And we don't just focus on the eggs because we don't know what's holding you back. Um, if anything, we also do something on the sperm side. So we give you, you know, these medications, which are pills that you take for about five days. We bring you in for a scan to make sure we know how your body [00:30:00] responded. 

We can trigger the release with an additional medication, which is an injection to make you release the eggs in a time fashion. And then we can say, okay, let's get sperm. From your partner or from a donor, and we're gonna spin it in a centrifuge machine, concentrate it, wash out the dead sperm, optimize the sample, and inject it at the top of your uterus in a procedure that is going to feel like a pap smear for you. 

Um, you know, it's, it's basically called an intrauterine insemination where we're getting the sperm past the cervix and injecting it at the top of the uterus, and then we let it do its thing. And it's like gambling because you're just trying to get a higher odds of a good interaction between a sperm and an egg. 

Now, the downsides of this type of treatment are the, it's not gonna get you that much further than just trying on your own. It's going to maybe bump up your chances marginally by, let's say 5%, because a lot of people will think, oh, if you're doing the insemination, you're injecting it like right next to the egg. 

No, it still has to swim to the egg and all of the other things that we talked. downstream of [00:31:00] ovulation have to happen on their own. So it's not gonna go from that 15% chance to like 75%, right? So if you're doing this, the name of the game is persistence, where you have to keep trying because it's not like your, you know, per cycle. 

Odds are that high, but it could be the extra push that gets you there. The other potential downside is, , you're at an increased risk of multiple pregnancy or twins. Right? Because you are releasing multiple eggs and it's not precise. You can't really, uh, know in advance which ones are gonna implant and which ones aren't. 

So you make judgment calls and that's why we bring you in for the ultrasound to make it safe. And I know some OB GYNs, some generalists will just do this in their office, and some of them will do it with ultrasound monitoring. Mm-hmm. , sometimes they don't. Yeah. Sometimes they just do blood tests. So there's a lot of different ways to go about it. 

But in my practice, I'm a little bit of a control freak because I will maybe cancel the cycle if there's too many follicles. Right, right, right. Three to 8% is what we quote. So it's not the most likely thing to happen. Right. But we say risk because while twins are [00:32:00] cute, there's like a six times higher risk of preterm delivery and other types of complications. 

Yeah. So let me just reiterate that for everybody. So sometimes again, just like the generalists may take on the workup of the fertil of the fertility issues to see what's going on. Some generalists will give Clomid or Femara, which is lectures. All these oral medications, just like Dr. Scon said that most of us generalists would not do insemination in our office, at least anymore. 

I mean, back 25 years ago, I feel like we did, but now we don't. Right. Um, and I don't wanna speak for people across the country because some doctors, even if they're generalists, have specialized a little bit. So there is not something wrong with your generalist potentially saying, listen, I can give you chlo, I can give you letrozole without insemination. 

Once we've done the workup, at least to make sure your tubes are open, cuz you don't wanna take that medication if your tubes aren't open. , but just like Dr. Scon said, we do it as general is much differently. It's kind of like, here's your medication, take it for five days. Come in your middle of your cycle maybe to look at your mm-hmm. 

lining and look and see if you've ovulated or sometimes just take your medication. Cause if you're pregnant, again, it's very doctor dependent. I no longer [00:33:00] do that because like I said, I didn't have the time to do it and I knew we had great fertility specialists and my patients were actually pretty groomed to wanna go to, to see the specialists. 

Mm-hmm. . But across the country there might be people whose generalists are really welle equipped to do it. And those medications are relatively safe, relatively inexpensive. And sometimes that's all you need to kind of get that boost. Like Dr. Ska said before, you have to see a fertility specialist. The downside is that if you've already done it for two or three cycles with your generalist mm-hmm , then that means if it's not working, you really do need to see the specialist because you might need something more like ibm. 

Exactly. Yeah, exactly. And I should also touch on, cuz we haven't really talked about this, , there are patients that have really irregular ovulation. Mm-hmm. . And these are the same types of medication that are basically helping that signal through your brain to be strong enough to get through any communication blockages at the level of the ovary. 

And so it can work really well to get you on a regular pattern of predictable ovulation. So that's another way that it's used. So that's that first, you know, treatment bucket. Um, it, it's also only addressing the [00:34:00] here and now, like we're trying to help you get pregnant. Now. It's not really thinking about baby number two or three if you're interested in having a larger family. 

So that's something to really think about, especially if you're in your mid thirties and that's when you're starting your family building journey. Um, it, it's not wrong to go with ovulation, induction and insemination as a first step, but I might have a lower threshold to move on to a more aggressive treatment option like I V F just because. 

If your goal is to have multiple children, it might make your life easier to think about doing something like ivf, where as a byproduct of IVF, you can have extra embryos frozen for the future. Right. So as I mentioned earlier, the only thing that ages when it comes to your reproductive system are the eggs. 

Your uterus really doesn't age, which is fascinating, right? And they have done you as the vessel. I always say, you know, you could be 15 in great shape and you as a vessel might be very good, but Exactly high quality might not. Yeah. Even if you went into early menopause, we could give you the hormones that are [00:35:00] necessary to allow implantation of an embryo and to support that early pregnancy until the placenta takes over between seven and 10 weeks. 

So it's really not dependent on the age that you are when you're trying to get pregnant. So IVF can be an attractive option. I actually went straight to iv. when I was 34, because again, I'm very proactive. I'm also a fertility expert, right? And I want the option to have a big family, right? So that was kind of a decision I made. 

So I always talk to my patients about that. But sometimes patients, it's not even about that. Maybe they have tried that first treatment option, and it is a laid back approach with laid back success rates. And if at a certain point it's not working, you know, and usually the study suggests past six rounds of that if you're treating unexplained infertility, you start to have diminishing returns. 

Yes. Like if it hasn't worked after that sixth round, it's less likely that it's gonna work thereafter. So I usually say, okay, time equals eggs. You know, let's maybe think about moving on to I V F, which is that second treatment bucket. It's much more precise, it's much more controlled. The downsides. , it's a lot more [00:36:00] work. 

It's obviously more expensive, not always going to be covered by your insurance. Sometimes your insurance will dictate you have to do six rounds or three rounds of that lesser efficacy treatment before they'll even cover it, right? So there's, there's a lot to be said about, you know, just the work and effort and the finances behind it. 

Um, you're expected to come in a lot more frequently. The burden of treatment is higher and you have to have a procedure to remove your eggs. It's basically eight to 10 days of taking injectable medications, not just oral pills. Right. And you're coming in for frequent monitoring. Um, and, you know, you get a lot of support in teaching and the injections are small, short, thin, uh, needles that you're placing yourself in the lower abdomen. 

So it's not the scary long ones that you see in the movies. We don't do intramuscular anymore. Um, but basically, , we're trying to get all of the eggs to grow, not just one, two, or three. We're trying to get everything that was recruited at the surface of the ovaries to grow and be extracted. Cuz guess what? 

If we don't take them out, they're gonna be thrown out anyways, right? So [00:37:00] one of the number one questions or fears I have from my patients about IVF is, is this going to lower my egg count? Are you gonna be taking all my good eggs? And I'm like, no, I'm just salvaging. I'm just accessing whatever I can get to before your body throws it out. 

Cause this is a process that's happening on its own all the time. And so basically we're ringing you in for these monitoring visits and we'll see a picture eventually that. , you know, makes us feel like we're not gonna get anything more out of the cycle, we call it and say, stop your medications, let's extract the eggs. 

And that's done while you're asleep for five to 10 minutes. Mm-hmm. , this is the vaginal canal. You're ovaries sit on on top of the vaginal canal on either side. And we basically go through the vaginal wall with a needle under ultrasound guidance and we drain those. Have my little, I love that. So this, that, Dr. 

Shan would put an ultrasound probe in here with a needle that goes basically through like that little side part and your ovaries, imagine right there. And then she just with a little aspiration, she suctions out all those eggs. Yes. Asleep. It's 16, I did 16 this weekend. And you know, it takes [00:38:00] literally minutes. 

It's a very simple procedure, but you are being put to. and it is a procedure and so that's different, right? Um, you go home the same day and that day we take sperm either, you know, we thaw out donor sperm, or we get sperm from a partner who's coming to pick you up from the retrieval and we'll inject the sperm into each egg or inseminate the, the eggs with, you know, tons of sperm and let them do their thing in the dish overnight. 

And then we'll grow them in the lab into embryos, which takes about a week. We have the option then to genetically test those embryos if we, if you want to. Um, basically an embryo separates out into two cell types. Some become the baby and the ones that sequester out to the periphery become the placenta. 

So you can very safely remove a few of those placental cells and send them off for genetic testing. And it's really interesting. You can count how many chromosomes there are, and that's really important in light of the fact. , all of us. No one makes perfect embryos. All of us are capable of ovulating abnormal eggs. 

And you know, having eggs turn into abnormal embryos so you can [00:39:00] identify which ones have the wrong amount of DNA and which ones have the right amount of dna, and select the healthy one before you put something back inside the uterus. And that's why ivf, when you're especially doing genetic testing and you're selecting really healthy, Really high success rates. 

You can have live birth rates of around 60 to 70%, which is incredible. Considering that 30 years ago when I v f was first, you know, coming uh, to primetime, it was like single digit right percent success rates. So my mentors who like saw that time are just like, you have no idea how lucky you are cuz you can give that happy phone call to your patients. 

Right. More often than just like you had said, then you can freeze the other embryos that are correct deemed to be chromosomally normal and healthy. Yes. And then even if you're 34 with your first 35, with your first 38, with your first, yeah. You have those embryos frozen in time and so that does give. and the amount of time they're frozen have no bearing on the reproductive potential. 

Right? Like, it really doesn't matter if they're frozen for two years or four years, which is another amazing [00:40:00] hack. Um, you know, to, to help you expand your timeline or your window of opportunity to have kids. Right? Um, and we now put back one embryo at a time, which is a huge shift from even 10 years ago. 

You know, I v f when it wasn't as successful and the protocols weren't as tight, we would put multiple embryos in the uterus because, you know, this was expensive, labor intensive, and we weren't really that good at even freezing the embryos. So we were like, we have them, let's just use them. And that's why twins and triplets. 

Happens so much more commonly. And that misconception is still so strong. Patients are like, well I don't wanna talk about IVF cause I don't want twins. I don't want, I'm like, yeah, it's actually the opposite. . Yep. We probably lower your risk of twins by doing I V F. Right. And and the misconception, like you touched upon before, even though we delivered dozens of twins in the vast majority end up being healthy and you know, close to full term, if not full term, but fertility doctors do not purposefully put in more than one embryo. 

Especially when they have good [00:41:00] quality ones. Despite patients thinking it's so fun and cute. I'll get two for one. If you have to have twins or triplets, of course you will likely be okay. But we know Yeah, the risks again, diabetes, hypertension, preterm deliveries, so it's not something that we purposely look for. 

Right. Yes. Yeah, yeah. I get that request a lot. a lot. Right. Um, okay, tell me cuz I have my questions for you. Well, I do wanna find, I wanna hear about Myo. Osat had a question and coq 10. Mm-hmm. . Um, and I really do, even though I always say it's like one of those challenging things to talk about, I think emotionally and, and scientifically and, um, from a perspective of just society. 

But I really think we should talk about egg freezing and whether or not we should be encouraging more people to do it. Mm-hmm. . So let's do first like the very pure just egg quality. Can't we do anything about it? Yeah. Coca and my nossal, any of those things. Well, MYOS stall is really for the cervical P mucus, I think. 

Right? No P C O S, um, right. Oh, my myo Nossal. You're right. I'm thinking what's the one for cervical mucus? Um, yeah, a [00:42:00] different one. But I think a lot of people feel apprehensive when they ask me this because they know like I'm very evidence based. Right. And anything that they think might be like, woo, you know, they're like, oh, I don't wanna ask her about acupuncture or supplements. 

And I'm like, I'm actually all about that. I think whatever you can do, That may or may not contribute, but as long as it's not harmful, doesn't have major adverse side effects, I'm okay with it. You know? And acupuncture, I thought there is evidence, there is some, there is some evidence. And I also, I love acupuncture. 

Yeah. I do acupuncture and I don't know how it works as a western medicine doctor, but I do think there's something to it. Mm-hmm. , you know, we know when you put a needle through the skin, it does release endorphins. So if anything, it might help with the stress of treatment. It might help to alleviate some of the side effects. 

I don't know how it works, but my patients love it. And, and you know, they believe about it. There's, yeah, exactly. So, and there is some data, um, so, you know, I'm all about doing things that could be helpful but aren't gonna be harmful. So, [00:43:00] coq 10, there is some data, um, you know, and it's mixed, but it's been studied particularly in women who are older with lower ovarian reserve and in some studies has been shown to improve response to treatment. 

There's some suggestion that it, it could. help improve egg quality. Now I think it's not necessarily reversing egg quality changes that have taken place that are age related, but I think that lifestyle, uh, makes a huge difference. You know, having a healthy diet, like a Mediterranean style diet, not smoking, taking some of these supplements could probably help to slow down that accelerated process. 

Right. The attrition of the quality. Exactly. I think it definitely can affect how fast you're losing your eggs and how fast these age related changes in quality are happening. So it's not that you're repairing because we don't really have any proof that the body has these repair mechanisms. 

Unfortunately, you can't really undo the effects of age, but certainly leading a healthy [00:44:00] lifestyle and you know, having a diet high in antioxidants and maybe that involves things like coq 10, which is an antioxidant, can help to slow down that process. Just like. , you know, doing, taking care of your skin can help slow down aging. 

Um, I think that the same is true with your eggs, right? So I think it's just a different way of thinking about it. Yeah. And I think I agree with you. There's, there are enough other benefits to any antioxidants it seems. Yes. Yeah. That it's a heart health supplement. Yeah. I mean, you can't go wrong. So I tell my patients to take Cocuten. 

Okay, good. Yeah. Um, and then my acetol sensitizes your body to the effects of insulin. And that's a problem for a lot of women with P C O and a lot of us will prescribe metformin for that, which is a better proven therapy for insulin resistance in P C O. Um, as S rm, the American Society of Reproductive Medicine doesn't really say there's a lot of evidence to support the use of my own acetol, but I do have patients that will want to take it on the side alongside the metformin, and I'm [00:45:00] fine with. 

And no harm as far as you. Exactly right. Exactly. Okay, so, um, let's talk about egg freezing because I think, you know, that is on everyone's mind. Anyone who knows. Me and my story about my business partner Jenny Hayes Edwards, she, do you know this? She froze her eggs. 10, she's 46. Her baby is about to turn one. 

Wow. This week she froze her eggs at 35. Okay. Out in Colorado with Dr. Schoolcraft. She was 35, she was single. She happened to have a little bit of extra money and she thought, let me just do it. And she was at the place where he had just started vitrification or he was one of the plane, I guess, right? Yeah. 

Um, I think he, she was first, their sixth patient at the clinic in Colorado froze her eggs and then about three or four years ago, turned them into embryos with her hus, with her now husband. And then a little bit over a year and a half ago, well no, two years ago she got pregnant with that. Wow. At age 45, she's now 46 and her baby's a year. 

Wow. Um, and I think that that really was [00:46:00] an amazing, cuz that was, Yeah. And freezing really being what it is now. Yeah. So, you know, I think the perennial question I always struggle with as a generalist, especially as someone who really feels strongly, that of course, like being a mother is wonderful and I love having my children, and it's part of my career is to deliver children, but I still don't want women to constantly feel the stress and anxiety of procreation. 

Yeah. It's not what defines us, I don't think. Right. So there's a hard balance as a generalist between how do I gently dip my toe into bringing this up with my patients without it feeling like I am. , you should be thinking about fertility because it's so important. And I, you know, I think that there's, it's irresponsible to not address it because someone who really don't know that their fertility might change over time. 

I know. And then I think it has to be done in a very delicate way because it's a hard message to Yeah, it's a hard, and so I never wanna ignore it for patients, but I also don't wanna be the first one to kind of pick up, bring up at like a 29 30 year old, like, Hey, what are you thinking pro creatively? 

Mm-hmm. . And have you thought about freezing your eggs? Because I think there is a lot of [00:47:00] anxiety involved with that as well. So I think that we, we do have to figure out better ways and be more open about it. And like I said, if we could be more open casual, frequently talk about it, then it wouldn't have to feel like such a big deal. 

But give us some of the data about freezing eggs. For sure. So I think obviously egg freezing and fertility preservation are great tools that one can use to just have a backup plan. It's like an insurance policy. Um, and it's, and I say that, Very carefully because it's not a, a for sure insurance policy, right? 

It's not a guarantee, but it could set you up for success. It could set you up for a better chance of success if and when you ever need to do IVF to get pregnant. So a lot of patients will say, well, if I freeze my eggs, does that mean I have to now do IVF when I do wanna have a baby? And I'm like, no. 

Mm-hmm. , we're just taking whatever eggs we can get to now, which is probably a larger number and a higher proportion that would turn into normal healthy embryos at this age than what we would [00:48:00] be able to access doing the same amount of work. , you know, five to 10 years from now. So it's just having those eggs as a backup plan if and when, or should you ever need ivf, whether it's because your partner has issues with their sperm, you find out you wanna do genetic testing or anything, any reason to do ivf. 

And so I don't think there's any downside to doing it, aside from the financial cost. A lot of employers are starting to cover it now, and I hope that starts to become a more universal thing. Yeah. Um, ironically, I feel like none of the hospitals or large medical organizations cover it and doctors, female doctors are the big, one of the biggest groups, right. 

We've all, we all delay our fertility in our pregnancy and our child, you know, or child rearing because of re and things like that. So yeah, I think it will be, I mean, this is a huge area of advocacy that I have been involved in, in trying to educate my peers because, you know, I don't think that I would've done what I did at 34 had I not been in this specialty. 

And it was top of mind, right? When I first entered medicine as a medical student, I had it [00:49:00] in my mind that. , if I was going to have kids, it was going to be around age 40 because I'd already delayed living my life for training for so long that I would wanna be, you know, if I got married, I'd wanna be married for some time. 

I don't wanna like be, you know, bogged down with kids. And only once I was an r e I fellow was, I like, oh, maybe that's not a good plan. Right. You know, and I moved my timeline up. Right. Yeah. So a lot of my peers who are in other specialties, you know, aren't thinking about it. They know about it, they understand the medicine, but it's almost like repressed because it's like you have other things going on, you're distracted. 

Well, you're right, you're busy. I mean, the thought, by the way, as a resident, the thought of going to a fertility doctor I know and getting injections and getting monitored, like, I don't even know how someone would do it. Yeah. I mean, it's so many things, but, but I do think, and I wanna circle back to what I said for anyone who's starting. 

Yeah. I think it's the most pervasive, um, feeling I want everyone to leave with. , these things all sound really technologically advanced. And they can be expensive. They can be invasive. Yeah. And stressful and anxiety provoked. You walk into a fertility doctor and they're gonna ask you a lot of questions and all of a sudden you're told all of these different [00:50:00] options and it will definitely seem overwhelming. 

I try to prepare patients for that beforehand. But if you keep in mind that if your end result is, you know, I always say to my patients, if you tell me I wanna be a mother no matter what, then here's what I'm gonna tell you. Yeah. Rather be a mother. But it might be on your own. It might be with oral medication, it might be with injectable medication, it might be IVs, right? 

It might be donor egg, donor sperm, it might be gestational carrier, it might be adoption. Right. You have all these tools. So rather than look at it as, oh my gosh, it's so scary and too much, look at it as, these are my options. Let me be calm in, in the idea that this will help. Right. If I need it to, to right. 

And, and something I wanna say is, you know, it's not a guarantee and I think something that gets left out of the conversation all too often, especially when I have patients come to me for a second opinion. It's like all this other information that I have to give to them that they've never heard. I'm shocked that they've never heard it. 

when you come back to use your frozen eggs, what happens? Right? So just like we talked about the inefficiency of human reproduction in your body. When all of these things are happening inside of you, that happens in the lab, that all plays [00:51:00] out. It's, except you're starting out with more than one egg. 

Hopefully you have, you know, at least a good number of eggs frozen, you'll haw the out, right? You give us a a roundabout. What's a good number? What are you guys? It depends on your age. Yeah, it depends on your age. And I'll explain why. Think about it like an inverted pyramid, right? Mm-hmm. , you start out with the number of eggs, you froze and you come back to thaw them. 

On average, we say, you know, maybe like 85% will haw out successfully. And I say an average. , you know, with an asterisk that it depends on things like your age and your individual egg quality. But for all comers, that's kind of our average. I would say the younger you are, it might be closer to like 90 to 95%. 

If you're freezing egg, well survive the thaw. Correct? Yeah. So you're gonna lose some in the thaw, and that is normal and expected because an egg, when you're freezing, it is a single cell filled with lots of water. It's very vulnerable to damage from the freeze thaw process. So don't expect a hundred percent to thaw out. 

It could. , but you may lose a few at the beginning. Right. And then only about 80% on average will [00:52:00] fertilize successfully. That's just standard across the board, whether using frozen or fresh eggs. With I V F, we don't really see a hundred percent fertilization rates across the board. Mm-hmm. , and that's because it's a complex set of biologic reactions. 

And even when we're trying to force it to happen, it's not gonna happen. So majority will fertilize, but you're gonna lose some there. And then the biggest attrition point is going from fertilized egg to an embryo. And it's because along the way, the embryo. Is extinguishing all of the programs, it's inherited from the sperm and the egg. 

It's gonna turn on its own genes. It's a very labor intensive process. And not every embryo is gonna make the cut. 60% on average will actually get to that stage. So these are percentages of percentages of percentages. Right. And then the reason I said how many eggs you need to feel comfortable and confident about your ability to come back and use them successfully depends on age is because at that last part, when you get to the embryo stage, what proportion of those embryos are going to be genetically normal versus [00:53:00] normal? 

And that is directly related to your age, right? So if you freeze your eggs when you're younger, like early thirties, even mid thirties, hopefully the majority of any of the ones that turn into embryos will, the odds will. Favor of them being normal, right? But if you freeze your eggs at 38 or later, you could be in a situation where the majority will be abnormal, but there could still be some normal embryos there, but it becomes more tenuous. 

So the drop off happens at each of these stages. And then the last point of attrition is not every normal embryo will implant and the result in a successful live birth, it's like two thirds. So that's the part that I feel people don't always remember. I don't know if they block it out because it's like scary so much. 

Yeah. Or I think it's just really overwhelming and not everyone goes through those exact numbers and some centers don't, you know, maybe have those numbers. But if you work at a place that has done a lot of egg freezing and therefore has had a good proportion of patients come back and use their frozen eggs, they can actually speak to their [00:54:00] own data. 

That's basically what our numbers look like. So when you factor all of that into the equation, on average, I would say if I was. talking to a 35 year old, it would be great to have around 15 eggs frozen. 15 because one five. Does everyone hear that? 15? Yeah, but that doesn't mean if you got 12 eggs from one cycle, you have to do a second round. 

It depends on how conservative you wanna be. It depends on, you know, what margin of error makes you feel comfortable. That is acceptable to you. It depends on how many children you wanna have. Another thing I always tell patients is you are not necessarily going to be in a position where you need to have all of your frozen eggs to have all of your children. 

This might be for baby number two or three, right? Mm-hmm. . That's statistically the more likely thing. The more likely scenario. Mm-hmm . The other thing I say is cause a lot of patients will come to me and they've never even thought about embryo freezing cuz they're single. And I say if you're older, like if you're coming to me at 40, 41 and you're thinking about freezing your. 

you can freeze your eggs, but we're gonna talk about all that drop off and realistically, based on what your egg [00:55:00] count looks like on that ultrasound, how many eggs we're gonna get from one cycle and how, you know, sure we can be about getting something useful out of that cycle. And I say to patients, you could also, you know, know upfront what you have. 

If you are willing to turn those eggs into embryos upfront and genetically test them then and there the advantages of embryo freezing. , you'll already get past all of that attrition. You'll be able to genetically test them as embryos and embryos thaw out like 98% of the time. And it's not really dependent on age or the egg quality that the embryos came from. 

Right? So, so wait, lemme just interrupt for a sec. So everyone here who's listening understands what Dr. Sana is talking about is freezing eggs alone that have not had a sperm attached to them is different than freezing the embryo. The embryo means it was an egg and sperm together. So if you are a single young woman who doesn't wanna pick a sperm donor to kind of be the father of the baby for the future, then you would, you would be freezing your eggs. 

But if you have a partner [00:56:00] or a sperm donor that you like, or if you're planning on doing this alone, regardless, or with your, your female partner, Is this correct to say yes, you will have better odds freezing embryos than right, and that's really important for everyone to know. And I don't know if it's better odds, it's just more confidence because you know upfront what you have, you've already gotten past all the attrition. 

That inverted pyramid still happens, all that drop off still occurs, but you'll know then and there, oh, maybe I need to do another cycle. I didn't get any embryos right, or I only got one embryo. What's not frozen are hopefully, Already genetically tested healthy embryos as opposed Correct. To eggs that still have to go through, right? 

Yeah. So you know what, you have the thought survival rate is better, but the downside is you're locked in. You can't go backwards and un ize that embryo and use that egg, you know, you can't reverse the process and then ha you know, use what you froze with another partner, right? So medical, legally it can be tricky as well. 

Um, you know, because if you break up, what does that mean? [00:57:00] Right? So sometimes I'll have patients that will do a round of egg freezing and or do a round of embryo freezing just to kind of cover all bases, right? But I'll say to patients who are, you know, older and they're like, I'm worried about egg freezing being very tenuous and not assure thing, maybe I would consider a sperm donor. 

I'm single right now. Maybe I would wanna just make embryos, but I'm not sure. And I say to them, and I think this helps them in the decision making process. Is it more important for you to be able to come back and have a pregnancy that you carry that. , you have a partner who's, you know, sperm contributed to that pregnancy, so they're involved. 

Or is it more important for you to have a child using your eggs? What's your priority? Right. If the answer is it's more important to do this with a partner using their sperm, then freeze your eggs. And if God forbid it doesn't work, then the backup option could be a donor egg. Right? Right. If you're not able at that age, when you come back to do another cycle for whatever reason, right. 

Um, you know, if your egg count or your egg quality is beyond a certain point, then you could use a, a [00:58:00] donor egg and use your partner's sperm. But if the priority is I would only really wanna have children if they're linked to my genetics, then maybe that is going to push the needle towards embryo freezing up front so you know what you have. 

Right. No, and I think that's a great point. I mean, that's kind of what I always start with the end when, when patients say to me, should I try another six months before I go see someone? And my question is always, if you tell me a hundred percent you wanna have a baby yes. And you're already having a little bit of trouble, then go now. 

Like as long as you don't mind that it is going to be a more interventionist process, but it will give you the feeling that you're being more proactive then go now. So I do think that is really important for every woman and her partner and her doctor to have that discussion because we each have different feelings and values about it. 

Right. And that's okay. Exactly. There shouldn't be one rule about all of this. Exactly. Okay, we're getting to the end of an hour and I figured we would probably do this where we could probably talk for like two hours. There's still so many. Okay. For everyone out there who sent questions because there were about 15 questions before you even started or here Please, please, you can DM them to me [00:59:00] or to Dr. 

Sahan and Yeah, we will get to them. She might get to them before I do because I'm not great about my dms, but we will get to them. So, um, but is there any other little thing? Cause I do wanna talk about one other little thing, but do you have anything else you. . Um, I think we've covered a lot of the points here. 

Let me see. I had a list of things I wanted to talk about. I don't think, I think we've hit on most of my points. Yeah. What did you wanna talk about? Well, and this is not related to fertility per se, but this is what you have posted about, and I'm so glad that you did. Um, along with Chan Dr. Shannon Clarke for babies after five about folic. 

Versus methyl folate. Yeah. So I just want everyone to understand that in back, I mean in the last like decade I would say, and certainly in the last three years, there have been a huge number of very expensive, fancy vitamins that have used methyl folate with the idea being that at least 50% of us have this damaged gene called the M T H FFR gene. 

If you had a damaged gene, we, in the we in the me western medical community used to think based on data that it might [01:00:00] decrease the ability for your body to, um, absorb the folic acid in the its regular form. And so you would need methylated, folic, folic acid. But all of our evidence-based medicine has shown that despite over 50% of us carrying one or two damaged genes, Me included, it does not lead to the problems that we had thought that it did. 

Right. A, that means you don't need the methyl folate necessarily. B, what has come out even more importantly is that American College of OB gyn, A S R M, society for Maternal Fetal Medicine has squarely come out saying that because we know that folic acid will decrease the risk of neural tube defects, spina bifida and things like that, we can't kind of accept this alternative, which is methyl folate is probably as good as, and I have to admit that up until recently, I would've been one of those people who said, well, I don't know that you need, it's different. 

No foul. It must be as good. Right. I think we should be clear, because I'm getting legions of DMS and frantic people writing me saying, but I've been taking that and now I'm on it and I'm pregnant. First of [01:01:00] all, if your past 12 weeks you're, and you've had your 12 week ultrasound, and certainly by your anatomy ultrasound, they will know that you do not have a neural tube defect. 

So take a deep breath. . Mm-hmm. . Second of all, I think I'm correct and I need your clarification on this. Mm-hmm. , there is a chance that methyl folate is as good, but Right. We just don't know. We just don't know. I have had people send me data where they say, but look, this study showed that the methyl folate was absorbed in just as good amount, if not better than folic acid. 

That might be true, but we still don't know That Absorption implies that it will work on the end organ and and prevent neural tube defects. Right. And that's the whole point. Right. That's the whole point. So all that said, I want everyone to understand where we're coming from. Mm-hmm. , it might be as good, but the American College has been very clear. 

That might be as good, is not enough in something where we have such a clear cut intervention for something that can be so detrimental. Correct. We do not want people, we don't want babies to have spina bifido when it's something we can easily, easily, easily prevent. And I think fertility and miscarriage is a huge distractor in all of this. 

Mm-hmm. , because a [01:02:00] lot of people aren't thinking about. Preventing neural tube defects. They're really fixated on, I've had a miscarriage, or I've been trying, and you know, I have infertility and I happen to be in the 50% of patients that have this M T H F R variant or mutation. So that's what they're focusing on. 

And really as a fertility specialist, I'm here to say that there is no evidence that having an M T H F R mutation causes infertility or even miscarriage. Like it's not part of the recurrent pregnancy loss workup Right. At all. And that's important for everyone to know. It has, has been removed from the recurrent pregnancy loss workup. 

Right. So people don't do it, but it's not considered what we should be doing. Yeah. I mean, sometimes it'll get sent off inadvertently if I send off a thrombophilia panel to look at blood clotting factors like the ones that are actually indicated and proven to. Sometimes a cause of recurrent pregnancy loss and if it comes out positive, I just ignore that binding, right? 

Like I'll tell my nurses and my patient, we're not doing anything about that. Right. But I think that's gonna, I think that's [01:03:00] gonna be a long time and a lot of education because there's still a lot of chatter about it. And so I think the really important thing for us to discu, to us to highlight is that the reason ACOG really has come out so, so strongly is because there are so many vitamin companies, they are incredibly good about marketing and the, the majority of these vitamin companies. 

I kind of, kind of did what doctors did as well. Like, oh, it's probably as good as, but that is not our gold standard. We cannot do that. And so these companies really should not have been supplanting the folic acid for methyl folate. And now millions of women are buying these. And I've always said to the patients about all those fancy vitamins, like, I don't care what vitamin you take, take whatever vitamin you're actually gonna swallow every day. 

Yeah. Don't spend money on it unless you want, if you wanna, I don't care. Yeah. But now it's really, it's the, it's the psychology of feeling like you're spending more money, so it must be better. Right. And it's got better marketing and packaging. So that's something important that I just wanted to point out because I think it's, no, it's so important. 

I posted about the other day and I was shocked. about the uproar that it caused, like Yeah, I was shocked. Yeah. I was like, it's just prenatal vitamins. Like I thought this was a [01:04:00] non-controversial post. I know. Well, actually, I think it's actually one of the most controversial, because think I know of women have, have actively taken it, and again, in their defense, many of us as generalists had said, why not take it? 

I mean, right. You, you don't know if you need M T H ffr rather than spend money on an expensive test, just take the methyl folate. Right? Yeah. But I think what you said was so important. It's not necessarily harmful, it's just, it's not a proven benefit. It's not a proven mechanism. Right. And you need to be very clear and very, um, a hundred percent As much as we can be on this. 

Okay. Well honey, well I love talking to you. We could talk for 10 minutes. I know. I hope we can do a part two. This was really fun. We have to do part two and like a part five. This is gonna be a lot fun. I love that. Yeah. Awesome. Um, and I see that, I think that tribe called V Jenny had joined, but I think she joined right after we talked about it. 

So Jenny, if you are still on, we talked about you and your egg freezing and that little baby girl who's gonna kill Congratulations. Yeah. It's an amazing story. Yep. So for everyone who's there, like really that, my, my parting words would be be, um, open and [01:05:00] optimistic. Be proactive and not paranoid, which is what I always say. 

And remind yourself, just cuz you're going into a fertility specialist doesn't mean, oh my God. Like when patients say to me, what if I can't have a baby? I'm like, wait, you mean you don't have access to a fertility doctor? You're unable to do? And some people again, don't have access or don't have insurance coverage. 

And that is a very real concern. And I don't wanna speak from a flippant place of privilege and act like no big deal. Yeah. Um, but again, for, for the majority of the patients that we do see, You will be able to get help if you're willing, right? Mm-hmm. . So you just have to be open to that, right? Yeah. I think it's all about empowering yourself with information and walking through the door of my office does not mean you're signing up to do IVF and all the scary things. 

Right. I think you're just getting information. Yeah. You're getting educated about your body and how it works, and filling in the blanks for all the things that health class didn't teach us. Yeah. And even if you end up with ivf, it's, you know, it's not the end of world what it's world Exactly. We sick. 

None of us really had our life going according to the plans that we thought it was gonna. As long as it works out. Yeah, exactly. We're here to help. [01:06:00] Yeah. All right. Well, thank you. Thank you for having us. Thanks everybody. So fun. Have a great night. You too. Bye. Bye. How do I end this? I, oh, here, . Okay. Oh, wait. 

Lemme take Lucky. I'm gonna take a quick screenshot. Oh, do it. Okay. And then hopefully I'm gonna be able to save this. But my IG glitches all the time, so if I save it, I was, oh, I hope not. That's so devastating when that happens. There is a place they get saved. So if that happens, let me know. Oh, I know. I found out Shannon Clark actually freaked me. 

Oh my God. It's so good to know, doctor. Okay. All right. Goodbye. I'll talk to you soon. Bye.