The science of fertility: Hormones, inflammation, and what you can control | Dr Natalie Crawford

Fertility. For some people it's something they don't think much about until suddenly they have to. For others it becomes a long exhausting presence, measured in cycles, tests, losses, and those quiet moments of wondering why. My guest today is Dr Natalie Crawford, a board certified OB-GYN and reproductive endocrinologist. Over her career she's helped thousands of patients navigate fertility from a clinical standpoint. She understands the hormones, the physiology, the treatments, the evidence, and she also knows this terrain personally, having lived through recurrent pregnancy loss herself. And it's that combination that gives her work a rare depth. In her new book The Fertility Formula, Natalie explores how fertility can be supported proactively with evidence, nuance, and without blame. This is a conversation both women and men can take a lot from. Yes, fellas, we do talk about the importance of good quality sperm. I absolutely loved this conversation. Natalie is a wealth of knowledge and genuinely a very pleasant, enjoyable person to spend time with. And with that, let's get into it. I was just saying off air, I've learned so much from reading your book over the last few weeks. And this is a topic that I haven't necessarily had a whole lot of kind of first hand experience thinking about a lot of what you've written about in the book, but I've had second hand experience. And I've close friends who have really struggled with fertility, probably for more than a decade now. And I've kind of been there as a support for them and seen that emotional roller coaster. So firstly, I guess I want to leave with thank you because for me, it's really powerful to have a book written not only by an expert, someone who's qualified as an obstetrician and a kind of gynecologist speaking about hormones and fertility, but also someone who has lived experience and has felt the struggle, the disappointment that often comes with this territory. And to package the science of fertility up with the vulnerability that you opened your book with, that thought was really powerful. Simon, thank you so much. And that means the world to me. This is my lived experience, as you said, as a woman who went through infertility and for pregnancy losses before I had my two kids, how it changed, how I practiced medicine as a physician, and really my perspective about fertility as a field and how it's approached and what it feels like to be on the other side of the table and being told there's nothing you can do. And how the littleing that feels and that loss of control. I love being a fertility doctor, but I also love educating people. And there's so many times when it comes to this topic that the moment you learn about it is when you're struggling. And I wish the truth was we could learn about this basic body system well before and take a more proactive approach because it would help more people. How would you say that your own personal experience has changed the way that you practice? Maybe I should give a little of my story so that the audience knows. I started trying to get pregnant when I was the end of my OB/GYN residency. So that's four years here in the States. And then I had three years of infertility fellowship, which would come after. So very long training program. My first pregnancy loss ended in a miscarriage. And I remember citing statistics to my husband, just, just no big deal. One out of four pregnancies ended in a loss. It's okay. Very medical doctor of me. And then my second loss happened. And I felt more pregnant. I had a lot of pregnancy symptoms. I felt very confident. But I was the chief resident in charge of labor and delivery. Meaning I was determining if we were having a C section, what was happening, helping bring babies into the world, and started cramping and bleeding and miscarrying while I was on shift. And this was more than 12 years ago. And it definitely wasn't the era of where anybody at work knew that I was struggling or pregnant. And so I had to push that away and deliver babies all night and show people their brand new baby while I was losing mine. And I went to the doctor after that and was told, "Well, you have to have three pregnancy losses before we'll do an evaluation." So just keep trying. Got pregnant with my third. Moved to fallitia. I remember picking out the room in the house we were going to live in. This is going to be the nursery. But by the time we moved in, I was losing that pregnancy. Got the Gold Star evaluation and told, "It's just bad luck. You can either keep trying or do IVF. Had my fourth pregnancy loss, which was a tubal pregnancy. Had to get a shot called methotrexae, which is a type of chemotherapy that lives in your body for a while. So then I had to take a break. And I just couldn't accept when I asked questions about am I running too much or what should I be eating or what about different things in the world? Is there anything I can do that can be making a difference here?" And I was told, "No, just do IVF." The irony of being a woman in medicine is that I wasn't at a time in my career where I could do IVF. I was the clinical fellow, meaning I was the doctor and charge of IVF. So I knew I had to wait till the end of that year before I could be the patient, which that's just part of how medicine is. And there's a whole slew of problems with that. But at the time, I accepted that. But I said, "I'm going to enter this stage. If we're going to do IVF, I can only have success with the exit or inside of me, the sperm that my husband has. So I don't believe this narrative that there's nothing I can do. Certainly coming in with the best egg and sperm quality could be impactful." Was that narrative coming from colleagues like other hop citizens and gynecologists? Saying that there's nothing you can do. Absolutely. So that was the prevailing kind of school school? That was the prevailing school of thought that these will call them lifestyle factors really had very little influence over your fertility. And that age was the primary driving factor. And at some point once you don't fit into a certain box and labs come back normal, IVF is the next step. So I didn't love that narrative. At the time, I started doing a lot of my fellowship research because you have to research, publish papers, sit and defend your oral thesis on natural fertility instead of IVF because that was me. And I had questions. So I started researching vitamin levels and endocrine disrupting chemicals. I started looking into period abnormalities and ovarian reserve. And I saw the same word inflammation over and over again. And this was really eye-opening to me Simon because at the time, in medicine, I learned all about inflammation, but in a disease. This disease state causes inflammation, therefore, is bad, but never learned about it as preceding the disease. Or something that could be brewing and causing harm over time. And despite these different topics seeing the same word, that made me start to say inflammation must be bad. And how can I decrease that in my own in-of-one experiment, making different changes to what we eat and what we did, the things in our kitchen, and really paying attention to how I felt, not with the idea that this is going to help me get pregnant right now, but thinking that this surely wouldn't harm me. This is going to give me a little bit of control. Hopefully, we'll help against sperm quality so that when we do IVF, we'll have better outcomes. And I did get pregnant. My fifth and sixth pregnancies got pregnant, did not need IVF, had made a lot of different lifestyle changes, really had learned to listen to my body. And as a woman, as a physician, that was extremely powerful, how giving patients knowledge. How sometimes we don't have to have the perfect study to say that something is impactful, and we have to take the studies that exist and make the best decisions we can. But that, it makes sense. Our bodies are all interconnected. To act like the reproductive system is over here, and everything else is impacted by chronic inflammation and insulin resistance, it doesn't make sense. So it has changed how I approach patients, how I counsel them. I know how hard it is to walk the journey. And one thing that I say every day is I can't control the outcome. You know, there are limits to success, even in the best scenarios. But what I can control is that you have the knowledge you need. You know why we're making the decisions we're making. You know how to advocate for yourself. And you know that you're setting up your world in a way that is going to optimize those factors, egg quality, sperm quality, so that you don't have to sit across and say what a lot of patients have said to me over the years that I felt at one point. If I'd known this information sooner, maybe I would have made different choices. I hate that. I've been using Woop for over six years, and I can confidently say it keeps me on track when it comes to my sleep and exercise routines. The next generation of Woop isn't just tracking your workouts. It's monitoring your sleep quality, your recovery state, and even giving you insights into your biological age. No screen, no distractions, just continuous data on what your body actually needs. And here's what matters. Daily whoop, where is linked to increased physical activity, to better sleep, and improved heart rate variability. I have no doubt that my whoop is helping me train smarter, recover faster, and make decisions that support my long-term health. Head to join.woop.com/simon. That's join.woop.com/simon to get one month off your first subscription. Where are we at today in terms of that this approach being accepted? I feel like it feels like there's been a shift at least in the public and wanting a book like this, almost like demanding a book like this. And you can kind of correct me if I'm wrong there. But has there also been a kind of title shift within the field of medicine that you work in from your colleagues? Luckily there has been. I'll be honest, I was a nutrition major back in college, always been very fascinated by the food we eat. In medical school, I thought it was atrocious, how little nutrition training we got, and how little we talked about it as a physician. But then when I first started getting on social media a decade ago, I was done with my training, and I was on social media, and I would talk about nutrition, talk about some of the things that I'm very passionate about. And people would say, I was just fearmongering patients. My colleagues would say that I was distracting them from getting to treatment and that it was not the right approach that this was harmful. Obviously I disagree with that. But luckily we have seen that public demand has shifted medical perspective, meaning people are no longer accepting that as the public is getting more health informed. And luckily we also see a new generation of physicians as well. And how we approach medicine is also different. So luckily there's more people who are in this camp of knowledge's power, your body is connected. We're seeing chronic inflammation being discussed all over the place. And I think that that is all swaying the fact that it's really not acceptable for most people to sit across from their fertility doctor right now and be told, none of these things matter. There's nothing you can do. You alluded to the fact that at least I think during your second miscarriage that you hadn't really told many people around you that you were pregnant. And I think that's pretty common, at least in my lived experience, kind of watching this with my friends. I feel like after having some disappointment, they're reluctant to kind of let too many people know that they are pregnant again and have that big celebratory high only to kind of be disappointed again, because it almost kind of amplifies the disappointment a bit. Is that something that you see that a lot of women and couples are kind of dealing with this adversity and silence? Simon, this is the number one thing that if I could roll back the clock that I would have done different. I told nobody. I told nobody I was pregnant. Nobody that I was trying to get pregnant. When I lost my third, fourth pregnancy, then it became very tough. How do I tell people the degree of my suffering when I haven't told them anything up to this point? It felt like too much of a burden. And it initially started out like you said. I didn't want to tell people that maybe have to answer questions. However, I didn't give the people in my life who love me, besides my husband, the opportunity to show up and support me. And I'll tell you my fourth pregnancy loss was that a topic pregnancy. That's a tubal pregnancy. My husband was out of town when that got diagnosed. And so for the first time, I was forced to phone a friend and open up a little bit because I needed help. And that was really hard. But what I learned is that my community showed up incredibly. And I really missed out on the opportunity to have gotten that support and not have felt so isolated, so behind, so alone, which compounds the difficulty of infertility. Going through a questioning your sense of self, this life goal that you want, that you don't know if it will happen, sensing this failure of my own body, having pregnancy loss, after pregnancy loss, and then feeling distance between my friends and family, it really set me into a not excellent mental health space, as you can imagine. So I try to encourage my patients to not do what I did, to open up and tell at least the people who are important to them who can show up. You remember when you opened up? What was it in that moment that you needed? Because the other side of this is that-- I feel like a lot of friends, and I've certainly been in this position where I've questioned how to show up here. Because being reactive, I just want to help and fix. But the reality is this is not something that I can fix. And so from your perspective as someone who's lived through that, what is it that you would say you needed from your community? That's such an insightful question. Because often people want to show up and they put the burden on the one's stuff or saying, hey, how can I help you? Which feels like another thing on the mental load of the person who's having infertility or pregnancy loss in that circumstance. The thing that really impacted me the most were the friends who gave a very tangible, this is what I'm going to do. Your husband's out of town. I'm going to pick you up and take you to your appointment. Or I ordered dinner from this place. It's on your doorstep. I'm going to cover your shift tomorrow, things that I didn't have to ask. And whether it's a friend, a neighbor, a colleague, there are different ways that we can show up. I want to bring you by dinner, choose from one of these options. Or I would love to be a person to accompany you to your IVF appointments. Or let's grab coffee this day, this time. Try to take that extra burden of decision making off the person who's struggling in the moment. That's what impacted me the most and helped me and made me feel the most supported. Being thoughtful and trying to make their life easier when everything feels difficult. Yeah, take some of those daily tasks. Yeah. A little off the table or at least out of the mental space of day-to-day life, because so much mental space can be lost to grief. I think that's really helpful. Speaking about agency. Because what I heard in your story, when you were kind of told there wasn't a lot you could do and you should just have IVF, to me, that's a little bit disempowering if there are things that you can do. And it's kind of the opposite of cultivating agency or instilling agency in someone. And when I was reading a book, there was a quote, and I've got it here. And I want to get your thoughts on this because I know how thoughtful you are on this topic. And the quote was, "Fatility is not a matter of luck." It's not about luck at all. It's the net sum of the choices you make throughout your life. Choices that either set you up for a successful pregnancy or impede your ability to conceive. We make choices every day. And some of them are conscious and some of them are not. And this statement isn't meant to be blamed. It's not, I don't take blame for my own pregnancy losses. But looking at our body, our health, and the different choices. We make choices on when we're going to try, if we're going to track our cycle, how much we know, when we seek help from a doctor, how we show up and advocate for ourself. In addition to factors that can increase and decrease inflammation, which is associated with infertility. And so luck is something that there's zero things you do that are going to make a difference. Just happens or it doesn't. But we know, for example, simple fact, if you have, in our course, the day that you are ovulating, you're going to have a 20 to 30% chance of pregnancy compared to a 0% chance two days after. That's not luck, that's science. And knowing that can help you make decisions that make it easier for you to get pregnant. And that statement to me, that's an empowering narrative because solely relying on chance feels disempowering, feels like there's nothing I can do. So why learn about it? Why do anything? Let's just see what happens. Instead of saying, I can't control everything. But there are factors within my control and being in the space to do what I can, that actually, for me personally, that alleviated stress. Once I knew I'm doing everything I can, I'm not going to look back on this fertility journey and wish I had made different decisions. I'm going to make decisions from a place of knowledge. That's an empowering message. I like that. And when I was reading it, the reason I read that quote out was I was imagining hearing that, that it's not about luck. And there's a lot of things that you can do. They affect your fertility. I was imagining the young woman who maybe hasn't started her journey to towards having children feeling really, really motivated and empowered. And then I was thinking about my friend who, you know, often the language-- that I will hear. And this is not to say that it's wrong. I'm just using a says example, because I think people could relate to this often, you know, the languages while other people are so lucky. And so what I'm hearing from you is that this is, it's a perspective, it's a perspective shift at, you know, how you look at the information that you're putting forward in the book. And rather than looking at it as, wow, I'm to blame. I should feel guilty and shame to see it as more as an opportunity to learn and be aware of information that could help. Yes. This is a mindset shift if you're in the midst of fertility, right? If you are young, hopefully it's motivating. Wow, there's things I can do in my 20s that might help me achieve this goal because having kids for many people is a huge life goal. And when do we approach any life goal except this one to say, just don't worry about it until you're ready, because that's the current narrative when it comes to your fertility very often. If you're in the midst of infertility, I wrote that from a place of being somebody who was there myself and feeling that complete loss of control, being one of the hardest things, yet knowing everybody will say smoking impacts your rate of success. Well, that's not random at all. There's a distinct reason why. So feeling like even though you can't cure everything, there's nothing you did that caused it individually. One single factor isn't going to be the make it or break it, but understanding that we deserve to know more about our body. We deserve to show up and ask hard questions of those people taking care of us and all those little choices. They can make a really positive benefit. And I'd rather my patients going through IVF know that ahead of time. I hate the story of so many people who go through IVF. Maybe they have a bad outcome. They don't have as many embryos. And they're told it's bad egress-barm quality, which is probably true. And that there's not much they can do about it. Or then and only them, do they start to investigate what can influence quality instead of being more proactive? Because IVF is expensive, takes time, emotionally and physically challenging. So we need to be entering that life stage if we have to go there from a place of knowledge and optimization. Because then we can be in that mindset of, I'm doing everything I can. We're going to walk this journey knowing that I didn't leave anything on the table, that I'm bringing the best eggs and the best sperm that I can so that we can hopefully get to this outcome. When the sensitivity that exists in this area of health and given it is such an important life goal, like you said, for so many of us, would you say it's a vulnerable population from the perspective of coming across misinformation online and maybe being susceptible to kind of woo-woo science? Absolutely. This is a population of people who've been not educated in the way that they want, often not finding that out until they are struggling. And then there is a ton of misinformation online. There are people selling things. There's even a lot of money coming into tech trying to roll out direct to consumer products and some are great and some the data is yet to be out. And that's hard as a person who's sitting here trying to make their best decisions. So hopefully the book will help educate them earlier. I'd love to give an example here of somebody who even trying to do the right thing fell into this perspective. So I saw patients and I live in Austin. Everybody's pretty healthy. So they had been trying to get pregnant for nine months, went to go see a hormone expert. So they didn't come to me first. They went to a hormone expert. Which is somebody who is not medically trained and reproductive in a chronology. This was not a physician. So if you're lading with the title of hormone expert. Red flag for not using your real medical credentials. Right. So they saw a hormone expert who drew some blood work. And one of the things that I spend, you know, whole chapter going over is your hormones, how they interplay with your body, your menstrual cycle, understanding what's normal. And this couple had a bunch of blood work drawn. And she was told that she had something called estrogen dominance, meaning her estrogen level was high and her progesterone level was low. Well, if we think about the menstrual cycle, which we can dive into in a bit, but the first half is naturally estrogen dominant for lack of a better word. Your body's growing an egg, making estrogen. There is no progesterone. And in the second half, you have ovulated and now your body makes both. So she had our blood work drawn in the follicular face. In the first half? First half the cycle. She was supposed to be estrogen dominant. And what we know about progesterone is that it opens and closes the window for implantation and the uterus. So if you've had too much progesterone, this is how a lot of birth control works. An embryo cannot implant. And what do you think her hormone expert did? Said, well, your estrogen dominant. So here is some progesterone that you can take every single day to balance your hormones while you're trying to get pregnant. He put her on birth control essentially. He put her on a compounded progesterone. He happened to sell. And she for months used this completely impeding her ability to get pregnant. And her husband had blood work drawn. And his testosterone was low. And it was low. But what we know for men is that if you take testosterone, it suppresses the brain, so it won't send out FSA to an LIT. Exactly. So he then stopped making natural testosterone and stopped making sperm. It sounds like it does all stuff. It sounds like it does all. And my probably see a patient who falls into one of these two scenarios every single week. It's scary. That is very scary. And that's why it's really not an option in today's world where there's misinformation online. But also people can call themselves an expert in whatever they want. You have to have agency over your body. You have to understand what should be normal so that you can help advocate for yourself. And this patient and many who I've seen like this say, well, I learned from you. I saw this online or I read this from something you did. And then I learned that this was a big red flag and that I was doing the wrong thing. But I felt like such wasted time. And probably one thing you know walking with your friends through their fertility journeys is time is one of the most expensive commodities we have. So feeling like you've had a 0% chance for all those months, the wrong thing was done. It's just terrible. And the issue there is that that you know that patient just being in a position of a really desperation to have a child, right? Wanted to believe anything. Yeah. That makes them very susceptible to the quote unquote hormone expert who is touting that they have the concrete answer. Yeah, I have this magic medicine that's going to fix everything. And the so in that scenario, I mean, that's just one example of I'm sure thousands, but there's just not a deeper appreciation for the natural rhythm and variation of hormones throughout the woman's menstrual cycle and really just a lack of appreciation of physiology and reproductive health you know, overall. And so that brings me to to being an obstetrician and a gynecologist. What is it about that medical specialty? Because that is a specialty of medicine that really hones in on reproductive health. So what is it that that qualifies like if someone is a hormone expert, to me, it's an obstetrician, a gynecologist and correct me if I'm wrong, but maybe on the male perspective, like a urologist. Correct. Yeah. So I did OB/GYN training and then for your audience to know I did three years after of what's called reproductive endocrinology. So OB/GYN of cetrics and gynecology, pregnancy, delivering babies, and then the menstrual cycle and abnormalities of such PCOS and demetriosis, uterine fibroids. But I did three extra years just studying the hormones of the reproductive system, working with patients with infertility, really learning about the science and the complexity of our hormonal system. And one of my big passions, I'm in is trying to take this really complex information. That's a subspecialty of OB/GYN and break it down in a way that the regular person can understand it because I think we deserve to understand that. And for too long medicine's been paternalistic, assuming that you can't understand how your body works. So I'm just going to tell you what to do. And that does make you vulnerable. So instead, I think it's really important that men and women understand their reproductive physiology so that they could sit across from the hormone expert and call their bullshit, say red flag, I'm not listening to you, I'm going to go get another opinion because I know that's not how my body is supposed to work. The hormones are dynamic. By definition, hormones are communication systems between our endocrine organs and the rest of our body. They are simply telling your body what to do. I like to think about it as your best friend. So my best friend lives in Georgia and I live in Austin. She has no idea, can't see what I'm doing unless I send her a text or I tell her. And this is really what your hormones are doing. Your brain doesn't know you're ovulating. It's waiting to hear the estrogen signal. It's waiting for that text message to tell it to come back. And those hormones in the brain, you mentioned the negative feedback loop that respond, FSH and LH, they respond based on estrogen. So there's this beautiful dance and connection that's supposed to happen when everything's working perfectly. But it It also presents an opportunity for interference. chronic inflammation, for example, can be static on the radio or bad cell service, making it harder for the text messages to get through. And that's why we have to understand that our whole body truly, truly is connected. But checking hormones is complex, especially your reproductive hormones, depends on time in your cycle, time of day, other factors. You have to often interpret two hormones together. And so just drawing a blanket hormone panel can be difficult. And this example shows how it can be harmful if done by the wrong person who doesn't understand. I'm misinterpreted and then lead to an intervention which could be counterproductive or harmful. So I want to get to inflammation into the menstrual cycle and hormones and biological clock and then into solutions and being proactive and what we can do with our lifestyle behaviors. But I think at this point it might be good for us to define some terms. Let's do it. So when we say fertility, what does fertility actually mean by definition? Fertility is really a sense of hormonal health. It is the life stage of the ability to get pregnant. We can use the counter to fertility and say infertility is officially defined as failure to get pregnant after 12 months of trying. And I'm going to present a major argument to you that's against current medical standards. So right now if you were to say my girlfriend, I are ready for a kid, the medical answer is, okay, Simon, go try for 12 months. If you have problems, come see me and then we'll do testing. And I think it's ridiculous. Why should we make people fail before we even do testing to see if you have sperm? If your partner has normal anatomy, what her egg count is, why do we take that most valuable commodity your time and act like it doesn't matter as much? Is that a healthcare access cost issue or what the matter is? Originally yes, right. But the world has changed. The rates of infertility are rising. When I first became a fertility doctor, I would sit across from people and say this was over a decade ago, that one out of eight couples would have infertility. So failure of getting pregnant at 12 months. Now in the United States, that number is one out of five, huge jump. In addition to that, and that doesn't take age into the picture. But if we add to that, women are waiting longer to get pregnant. They are chasing dreams and doing incredible things. Yet they still want to have a multi-child family. So in the world where infertilities increasing, people are waiting longer, does it still make sense to say fail first than call me? We will test these things later and then you learn about your body. I'm going to argue no. Is that why the infertility is that the incidence is higher because now people are having children later or are there other reasons as well that have contributed from the one in eight to one in five? There's other reasons too, because we also see the global rise in chronic inflammatory disorders drop in sperm count, drop in egg count. So it's not just as simple as people are waiting longer. So that is one piece of the puzzle. But really, this is a nuance when it comes to a lot of what we're going to talk about today too, because if I say something doesn't increase your rate of infertility, that means by 12 months, the same percentage of people are pregnant or not. But I can also talk about another word, which will say sometimes your fecundability. And this is your monthly probability of getting pregnant. A condability. And that is our smallest point measurement of your fertility or what we will often say is your natural fertility, your ability to get pregnant without fertility treatment. And the vast majority of people that I talk to, they're really interested in that. How can I have the highest fecundability, the highest chance of getting pregnant per month once I start trying? Perlons five day fasting mimicking diet or FMD is a patented science-backed program designed to keep the body in a fasting-like metabolic state while still allowing you to eat. It was developed by leading longevity and metabolic health researcher and past proof-guest, Dr. Walter Longer, based on more than 25 years of research to make fasting more achievable without asking people to completely stop eating. The FMD has now been used in over 40 clinical trials with findings that include reductions in visceral fat, improvements in metabolic markers, and reductions in biological age, all in controlled research settings. 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This deal is exclusive for listeners of this show, so head to CarawayHome.com/theproof or use the code "Theproof at checkout." What percentage of that kind of one in five couples that are not getting pregnant within the first 12 months? What percentage of that is driven by female physiology? Female infertility versus male infertility? You know, it's 50%. 50% is due to female factors. 50% due to male factors. We're going to be a little more specific. It's one third, one third, one third, meaning a third of people are going to have a combined female and male factor contributing. So a lot of the fertility burden falls on women, but this is really important. I'm really lucky to see a new era in male health, meaning 10 years ago I couldn't even get a partner to show up to the appointment. Let alone be a present supportive partner, be curious and asking about his own health, and we are seeing a generational change in men and how they approach their health, probably because of guys like you. That's incredible. It really is really special to sit on my side of the table and witness them. I'm noticing more friends that are interested in doing sperm samples and understanding what their sperm morphology and count is at and sharing videos on social media about not sitting in the sun off too long. Yeah, but it's incredible because how often prior to that, did I see men sitting in the sauna or using testosterone or daily cannabis use and just killing their sperm count yet no discussion about it and honestly, a lot of stigma when talking about sperm, right? Talking about is your sperm normal? Or do you have normal testosterone? That was something that men did not talk about. And now we see people talking about it on social media, doing their one in-of-one experiments where they're making some change and repeating a semen analysis. I think every couple should get a semen analysis before they start trying to get pregnant because sperm is really interesting, right? It is so unlike eggs, a woman is born with all the eggs she's ever going to have in her body. That means time does add up in a different way because tincture of time, chronic inflammation, there is some inherent change that occurs just from length and time in body. But men make brand new sperm every single day, every single second. They package up DNA into sperm and it has a three-month lifespan. So one singular change that a man makes right now, he'll have new sperm in three months. That's so impactful. So if you are planning and knowing that you're wanting to start trying to have kids in, you know, six months time, then you know you can begin to make those changes, lifestyle changes and your sperm quality will be different to what it is today. Exactly. For both, for definitely for men, but also for women. Your exerence eye to your whole body, but the 60 days prior to when you're going to ovulate, they're the most susceptible to the world around you. And let's consider this trimester zero. This is the time period before you get pregnant, where you have the opportunity to influence your egg and sperm quality. And isn't that a powerful message that gives you something to do to prepare to hopefully have a higher month-to-month for kindability and a lower chance of infertility? Yeah, on the topic and not to digress too much, I'll just say this and we can leave it. On the topic of men being more interested in this, the one area of male health, and it kind of speaks to what you were saying earlier about the hormone expert. The one trend that I've seen that I think is a little bit worrying is this big increase in T.R.T. in men from clinics that maybe are not doing it in a way that's completely responsible as someone is planning to have children. They are doing it completely irresponsibly. Yes, men's health clinics, for the most part, are not taking into account the fact that many men might want to have children. And I think for your audience, it's important to say that sometimes the azuspermia, which means zero sperm in your sample, so your testes stopping the protein is stopping the production of sperm. Sometimes this is irreversible after using T.R.T. And we don't always know who that's going to be. If you want to have kids in the future or right now, you should never be placed on testosterone alone. There are alternatives, like clomid and some similar medications that tell the brain to send out more FSH and LH, therefore stimulating, more natural testosterone and more sperm. Or in some men, if they are on T.R.T., they can take an injectable hormone, typically it's HCG, binds to the LH receptor, but that can help preserve sperm. But that needs to be monitored with a semen analysis and make sure that it is. So we can in a blanket say T.R.T. alone taking testosterone without any other hormonal treatment to try to preserve sperm should never be done by a man who is trying to get pregnant or wants to have children in the future. And in the off case where that is he must do for some reason, we should freeze sperm first. And if a man was looking into this, it would say it sounds like it should be done underneath the guidance of an endocrinologist or. Or a urologist. Or a urologist. But it's often not. Yeah, yeah. Okay. Well, believe that there. That's a topic for a whole podcast. Back to infertility. I found it interesting. You wrote about the fact that infertility rates are significantly higher in medical professionals. They are. They're twice. Is that from stress, from work hours? Probably all of the above. Right? We do know that medical professionals tend to wait longer. But even controlling for age, we see that doubling the rate of infertility. We also see a higher rate of miscarriage. And this is even worse in surgical professions for women. A lot of this is lifestyle. We don't get enough sleep. We work long shift work hours, often eating whatever foods available, highly processed and flimatory food, not working out, building muscle exposed to a variety of toxins. So we're really setting the stage for having an environment that is less conducive to a successful pregnancy. Also surprising to me was that infertility itself is defined, categorized as a disease. It is. And that has been actually a very good thing because the World Health Organization defined infertility as a disease, which means for many people, hopefully we're going to start to see more insurance, being able to cover fertility treatments. So that's a very targeted reason why it's a disease. I will add to this though, that for many people and how I view infertility, it's also a symptom. For me, for example, go back to me. I begged, I asked, you know, what's going on? I had a variety of other vagish symptoms, but pregnancy loss was the thing that got me into a doctor's office. So I was relatively healthy with no medical diagnoses before this. Obviously told everything was right, but a decade later diagnosed with celiac disease. So an autoimmune disease, you know, sensitivity or an allergy to gluten. And when I was my own end of one listening to what made me feel more chronic inflammation, gluten was on that list and it was something I removed from my diet. And so pregnancy's five and six, I was no longer eating gluten. And I didn't get that diagnosis though, till decade later, despite having a variety of vague inflammatory symptoms. And so I think when we look here at what is causing infertility, and we look at the state of the world and the state of our health, for me, my pregnancy loss was a symptom. That was my body's red flag warning sign. And because so many of the different causes of infertility are influenced by chronic inflammation and insulin resistance, I want women to start looking at infertility as a symptom, as a red flag. Is there something more in your body that is going on? And I'll tell you something, the worst statistic of all the ones in the book, is that women who have infertility have higher rates of metabolic disease, cancer, stroke, heart attack, and early death. I sit across from you as a woman who had infertility, and yet I wrote all of that in my book, and why is it? Does infertility, the disease, cause you to later on, have a heart attack? No. It's that the majority of the causes of infertility are really a representation of poor metabolic or cellular health as causing chronic inflammation. And if not treated over time, puts you into a population that is at a higher risk of chronic disease. So in that way, it might be a woman's first early sign. Exactly, because usually in this reproductive age, you haven't developed the full spectrum, you know, high blood pressure diabetes. So if we think about this as your, we'll call it your preclinical opportunity, this chance to change your life, your cellular health, hopefully help you get pregnant, but also have a completely different trajectory for your health journey and your lifespan, that's incredibly powerful. So that's where in your book, I think you talk about fertility being more than just conceiving, but as a marker of global well-being, global health. Okay. Let's move on to some of the main mechanisms, the parts of physiology, reproductive health that could be impeding someone from conceiving. And you've mentioned inflammation a lot of times. I have. So let's start with that at a high level. What, when you say inflammation, what do you mean? When I say it as I do, I guess it does make inflammation seem inherently bad. But inflammation is a normal part of your immune system, and it's actually really important for getting pregnant. So the term that we're really referring to that is harmful is chronic inflammation. The acute inflammation, the activation of your immune system, you know, you get a cut on your arm, your immune system activates, this is a cute inflammatory response, goes to heal the cut. And acute inflammation is really important in ovulation. So I'll give a good example is that when you ovulate, the egg grows inside a structure called the follicle. That follicle is going to grow and develop, and then ovulation is actually rupturing of the follicle wall, releasing the egg in the follicle reforms and becomes a cyst known as the corpus luteum. Well, that process requires inflammation. And in fact, women who take insets, non-cerodal anti-inflammatory medication like Advil, Motrin, Alive, they can prevent the follicle from rupturing and the egg from being released. They might get the hormone changes that occur with ovulation, but the egg actually won't be released from the follicle. So side note, you're trying to get pregnant. You can take those medications when you're on your period and you're having menstrual cramps, but you should not take them at any other time in your cycle because it can prevent ovulation from occurring. But how many people don't even know that fact? Yeah, I mean, I definitely didn't. You definitely didn't. But so many, you might not be the target population for that fact. But so many women don't even know that. So understanding that it's not as simple as let's take a pill and get rid of all inflammation. What we really want to do is try to limit what we call chronic inflammation. And if we view this as the constant activation of our immune system, shunting it into a different response system. And I think to consider this your inflammatory burden, the amount of inflammation, that chronic inflammation that you're exposed to on a daily basis. And as that gets higher, there's more damage that will be done. And your body has less resilience to be able to handle those moments where it needs the acute inflammatory response. And to be able to function normally because it starts to shift all of its effort and energy into trying to combat this chronic inflammation. Many different things cause chronic inflammation. So we have how we set our life up and I know we'll dive into all these a little bit later. But are you getting enough sleep? How you move your body and how much muscle you have? Chronic stress is directly related to chronic inflammation. the exposure to environmental and behavioral. toxins. Also, the food you eat. We know that the gut is a huge component of how your body is going to be exposed to more or less inflammation based on your gut microbiome, the permeability of your intestines, and that's directly correlated with the composition of your diet. But in addition to this, what I want, we also have disease states that can cause inflammation. I have one of those. Right, autoimmune disease. We have other diseases like endometriosis or adenomiosis, which are chronic inflammatory disorders in the reproductive system. But chronic inflammation harms our body in multiple ways, and especially when it comes to our reproductive health. In order to explain them, I think we probably need to ferment it, describe what's normal so we can dive into what's abnormal. So if you let me add, like, to talk about the menstrual cycle. Okay, so when it comes to the female body, let's start with understanding that inside our ovary, we have all the eggs we're ever going to be born as a woman. I like to imagine the analogy of them being an avult. So you're born with all the eggs in your vault. Really interestingly, a woman has the highest account when she is a baby inside her mom. So if you are pregnant, when your little girl is five months inside of you, she'll have six to seven million eggs. By the time she's born, she has one to two million. So lost most of them by that time. By the time a girl starts her first period that numbers dropped about half a million. So we're rapidly losing eggs. Well, what is that? And this is called ovarian reserve. How many eggs you have left from this vault of eggs each egg grows in a follicle, like we talked about, a group of eggs or a group of follicles is going to be released from the vault every single month. Now in the menstrual cycle, one will ovulate and all the other ones sent out of the vault will die and the next month another group. And there's nothing that we can do currently available on the market that's going to change this process, meaning eggs are always coming out before you start your period, when you're on birth control, when you are pregnant, you're constantly losing eggs. That's interesting from an evolutionary perspective. It doesn't make any sense on us, right? From an evolutionary perspective. What's really fascinating is that when the vault is more full or more crowded, you lose more eggs. That helps us understand why we drop more when we're younger. Like to think about it as that gatekeeper says it's too crowded in here and shoves more out. Average is for a woman. If you're 30, you're tend to have about 20 eggs coming out of the vault per month. As the vault gets emptier, fewer eggs are going to come out. So an average 40 year old might have eight eggs outside the vault. Eventually the vault will run out of eggs. We will be in menopause no longer have any available. So that's called ovarian reserve, which we'll talk about some meaning how many eggs do we have remaining. And then we also have the quality of those eggs, which is a component of both genetic normalcy because our chromosomes so fascinating and evolutionary discordant with success. Your chromosomes are held inside your egg at a stage of myosis or cell division called metaphase. So for a woman, 46 XX, our chromosomes are lined up, 23 X, 23 X held apart by proteins called myotic spindles. And they don't separate into what becomes the egg until you ovulate. So this is why you have more genetic normalcy when you ovulate at 25, then at 45 because they've been sitting there longer having more opportunity for proteins to break down and time to add up. But the other component of egg quality is going to be that metabolic health. Your egg have all your mitochondria that get passed on to the embryo. So embryo's mitochondria can exclusively from the egg. Egg controls fertilization and early embryo growth. The male genome doesn't even kick in until day three. So everything is first dependent on the egg. And when we have things like chronic inflammation, this is going to come in and harm our mitochondria. But also damages those myotic spindles and increases the rate of genetic abnormality on a population based level. As you get older, you have fewer eggs. As you get older, you're going to have more genetic abnormality just based on texture of time. But also as a population, people tend to get less metabolically healthy as they get older. So inflammation causes this double hit right inside the egg, impacting both the genetic and the metabolic health of the egg. But what you're saying, the positive news here is that we can intervene on that. And so that DNA damage and reduction in egg quality that you're speaking to that would occur between 25 and 40 is not set in concrete. Exactly. And if we can be more proactive in our approach to this and make some of these anti-inflammatory lifestyle decisions earlier and for a longer time, we are hopefully changing some of this trajectory. I don't want to act like we can undo all of it. Time does have a variable. But simplifying that egg quality only equals age is not reflective of the full picture. How big of a contributing factor to overall infertility, would you say egg quality is? I mean, if that is hard as a fertility doctor, probably half, if not more of all my patients will say there's some component to egg quality. The hard thing for egg quality as opposed to sperm quality is it's really easy to test your sperm. You just have to ejaculate into a cup and I can look at it under the microscope. But to really understand egg quality to get an official diagnosis that something's not working right, we have to take eggs out of the body. This is IVF or egg freezing. Such a much harder process than we have. But I think it is an empowering narrative that if I sit here and say age is the only thing that impacts your fertility and you're listening to your 42, you feel like I'm screwed. So can't rewind the clock, but your biological clock is more than just age ages one piece of the puzzle. But when we understand that your metabolic health impacts it as well, that is an empowering narrative that we can start to make these changes. If this gets me thinking of chronological age and biological age as well. Exactly. Right. That your eggs probably have their own biological age that is impacting how easy or how difficult it may be for you to get to success. Is ovarian reserve something that you would objectively measure and can be measured? Yes. Great question. Ovarian reserve, there is a way to measure it. So the best way is going to be one, I guess there's two main ways. One is going to be an ultrasound. So I can do an ultrasound and count those follicles. The small fluid filled structures that have been released from the ovary vault that month, we can count them. And we have age related averages. We can also draw a blood test called AMH anti-malarian hormone. And AMH is made from the granulosa cells, the cells that surround each follicle. So if we go backwards, more eggs in the vault, more come out, more granulosa cells, higher AMH, fewer eggs in the vault, fewer come out, lower AMH. Importantly, there's some month to month variability. The human body is not perfect. So if you have 20 eggs out of the vault one month and then 17 and then 22, if I did check an AMH each of those months, it would be slightly different. So there's some month to month variability. And I always look at category of AMH versus point value, meaning are we average above average below average or critically low. I like to expand upon a little bit of nuance when it comes to AMH. I am a huge proponent that if a woman especially wants to have kids one day but not yet, we should check her AMH. I have set across from thousands of women who make different decisions based on their reproductive timeline, then they would have without that information. But the reason why I'm bringing this up is currently the American College of OBGYN, big national society, says that we should not be checking AMH values in women who do not have infertility. And I think, yes, they think it will cause undue stress. And they think it is going to make women make decisions that are not aligned with their values, which I actually hugely disagree with. So I'd love to expand upon this for a minute. Yeah, maybe if I throw an example to you, and then I think this will help for expanding. So let's take a 32 year old woman who doesn't have infertility. I'm sure when she wants to have children, what I'm hearing from you is that if you were to measure AMH, is it possible to tell her how much time she has left and when she should begin trying to conceive. In a way, it definitely can alert us to the fact that she's falling off the standard curve. So even though an AMH is not going to allow me to sit here and say, you're going to have no problems getting pregnant. What I can say is that your OVRM reserve is average, meaning I would expect you to go through menopause at the average age, and that person would still have many years of her reproductive lifespan. On the other end, if it's low or critically low, this is a huge opportunity for intervention for her, meaning even if she can't go put more eggs back in her vault, she might make different decisions. And also the bigger question for me is why? Why is her AMH low at 32? The reason why AMH can be low, there's genetic factors, so things you do not control at all. But there's also factors such as autoimmune disease, chronic inflammation, endometriosis, smoking cigarettes, cannabis use, all of these are associated with lower ovarian reserve. And so just so I'm clear, when AMH is low, that's telling you that more eggs are coming out of the vault. When AMH is low, fewer eggs are outside the vault, so there's a lower account outside the vault. When AMH is low, therefore we need to be able to see that. We know that there's fewer eggs inside the vault because when the vault is more, they go hand in hand. They go hand in hand. Valt is more crowded, more come out. Valt is empty or fewer. And is there anything that someone can do to help preserve the number of eggs in the vault? Like is there anything you can do to slow that right down? We know that chronic inflammation, these inflammatory diseases accelerate it. So if you smoke cigarettes, you should stop. If you have an autoimmune condition, it should be treated. So that begs the question that likely by trying to decrease our exposure are inflammatory burden earlier, we can slow down this trajectory some. And then I will say this is a huge area of interest for medical research. Is there a way to change the recruitment of eggs outside the vault and extend the reproductive lifespan or delay the onset of menopause? This is how people are looking at rapamycin, for example, when it comes to fertility studies. But right now for the majority of people, what I want them to take away is that AMH testing is not telling us that you can't get pregnant or you can. It's not a fertility marker per se of your fecundability. Meaning on face value, somebody who has a low AMH and has 10 eggs outside her vault. And somebody who has a high AMH or normal one and has 20. Well, as long as we're still ovulating, we have no other health medical problems. Both those women are going to ovulate one egg. And if they're the same age, the same health circumstance, they're going to have the same month to month fecundability. We're not going to have a difference. Now some important distinctions is that if these two women freeze their eggs or go through IVF, they're going to have very different outcomes. In egg freezing or IVF, I can only get the eggs outside the vault to grow. I cannot tap into the vault right now. Meaning if you have a low AMH, this patient, she can only get 10. Her best friend can get 20. So it does influence when it comes to fertility treatments. The woman with the lower AMH will go into menopause, so has a shorter reproductive lifespan. And then again, to say, but why is her AMH low? Because many of the things that do cause a low AMH be it that they are chronic inflammatory are also associated with a lower month to month fecundability or lower chance of getting pregnant. So that is telling you that it's not quite as simple as AMH impacts, you know, your fertility that you can get pregnant or not get pregnant. But I think it's a very important marker because the women that I sit across from, they may be at a position where they're delaying childbearing, chasing big dreams of career. But they might be with a partner where if they knew they had limited time, they might be able to start earlier. Or she might consider freezing her eggs or freezing embryos if she's not ready. I can put some eggs into the freezer when I have more than I will later. Maybe we do an investigation or hopefully we do an investigation for why it's low. We might under cover a chronic disease like Hashimoto's that we start treating earlier so we can slow down some of this rate of loss. Or she may do nothing, but then it was her choice instead of being in the position where she was taken, that agency was away. Because time will make a decision for us when it comes to our fertility and I'd rather more women be in the position of actively making that choice. Do we understand if so that woman who has low AMH, I'm learning so much, I'm loving this by the way. This is a real trait for me to sit down with a true expert in this space and geek out. So thank you. If a woman has low AMH, do we know if that is low because she's experienced increased loss of eggs in previous years versus starting her life with a lower egg count? Simon, you're brilliant. I tell patients every day that I don't know the difference there. It's like having a graph and I have one data point on it. I can interpret the category we are in, but I don't know where we started. I don't know the slope of the line, so I don't know the rate of decline. So a single data point is helpful because as we discussed, if you find out you're low, you might make some different decisions. But it's not really telling us about where we just born with a lower number and we're running out at a normal rate or are we born with a high number, we're running out really fast. And we have to make the assumption that we are running out quickly that the slope of the line is great because that's the more conservative approach. But in fact, I think there are some women and we know when is the greatest loss in our account when you're a baby inside your mother's womb, meaning the biggest drop in your eggs does occur during your mom's pregnancy. And so there likely are many factors which a woman is exposed to in pregnancy that are influencing her daughter's account. And we know that environmental toxins and insulin resistance directly can influence some of these factors for a female child. I love waking up and feeling light, not puffy, not inflamed, just clearheaded and ready to move, which for me is the biggest sign that I actually slept well. That's why I love ate sleep. The pod five is a smart mattress cover that automatically adjusts temperature and elevation throughout the night to help you reach and maximize deep or stored sleep. When your sleep quality is dialed in, everything just feels different, mood improves, thinking sharpens, joints feel better, energy stabilizers, life just feels easier. And it's not simply about clocking more hours. It's about getting the kind of sleep that lets your body and your brain recover overnight. Use my code, [email protected]/theproof from up to $350 off the pod five ultra. You also get 30 days to try it at home and return it if you don't like it. But I'm confident you'll love it. Your body will thank you for this investment in better sleep. Okay. So, what I'm hearing so far is that when it comes to ovarian reserve and the quality of the egg, inflammation probably matters. To what extent, maybe that could be debated or it would be different on an individual basis. But being aware of inflammation seems really important here from a fertility context. What are the everyday signs and symptoms if someone's listening right now and is thinking, do I have chronic inflammation? Yes. Like, what would that show up for someone? Okay. I want to go over the everyday signs and symptoms and then I want to be a little more specific because I got distracted and talked about the menstrual cycle because that is a big vital sign for us. That was probably my fault. We'll come back to that. No, it's my fault. When it comes to, do you have symptoms of chronic inflammation? I have a whole chart in the book that has over 80 different things you can experience when you have chronic inflammation. The problem, especially for women, is so many of these are vague and women tend to get dismissed when they go to healthcare providers for a lot of these symptoms. Therefore, it's hard to get them taken seriously. The number one symptom of chronic inflammation will be fatigue, a general sense of tiredness, especially in the afternoon. You should not need day to day your afternoon coffee or some energy drink or something to get you through the day. The body is not meant to need that in the afternoon. Other symptoms are headache, brain fog, not being able to concentrate, feeling bloated, having GI distress, having acne, having a runny nose. These are so various in general. I walk through people in the book so you can look at it and read the list. Most of us are going to have some level of inflammation. It's unrealistic for me to sit here and say, "Simon, get rid of everything. You won't have none of these." We shouldn't have the same symptoms every single day or around the same time of our cycle all the time. Those are those little red flags that we dismiss and we put away. The sooner we start paying attention to them, the bigger the opportunity for change. When it comes to women, a huge opportunity for us to learn about our body and especially the impact of inflammation is going to be learning to track our menstrual cycle. Back to the menstrual cycle for a hot minute. We've got our eggs in our vault. They come out of the vault every month. What is going to happen is the brain is going to send out a hormone called FSH. The hypothelamous, that central command station of the brain, is listening to these different hormones coming in and sends out FSH. It actually tells the pituitary gland to send out FSH. FSH is well-named. It's one of the only times in medicine that hormones are named for what they do in women and not men because men have FSH and LH2. But FSH follicle stimulating hormone stimulates a follicle to grow. Gets the follicle growing inside that follicle. That is the chosen egg. That egg is going to mature. As in matures, it makes estrogen like we talked about earlier. It's going to talk back to the brain. It's going to grow the uterine lining. And when the hypothelamous hears that high estrogen signal, and it's very specific, 200 pg for 50 hours, when it knows that estrogen is high enough for long enough, it says we have a mature egg. That whole time period is the follicular phase. The act of growing a follicle, the estrogen dominant phase, estrogen only phase, first half of that cycle. Once estrogen is high enough, the brain will then send out that LH surge, LH is luteinizing hormone. The LH surge is the trigger to rupture the follicle, let the egg be released for the follicle to reform. And that's ovulation. Fun fact, the egg only has 24 hours to go. get fertilized. So if there's not sperm present in that timeline, it's not happening on that. Which can be from a few days before. It can. Sperm can live for up to five days on the female reproductive track. And then after that, you're going to enter what's called the luteal phase. And the luteal phase is the second half of the cycle. Also well-named because now you have the corpus luteum, that same follicle that released the egg is now a corpus luteum, which makes both estrogen but also now progesterone. And it makes it at the direction of LH pulses from the brain to the brain, sending out signals of LH, telling this corpus luteum to make progesterone. And the corpus luteum can only live for about two weeks. So if you don't get pregnant, the corpus luteum will die. Progesterone levels will drop. This is the signal to the uterine lining to shut off. Pregnancy didn't happen this month. And to the brain, start to grow a new egg, send out some more FSH. So really beautifully coordinated cycle. To clarify, when you get pregnant, a pregnancy is going to implant typically around a week after ovulation. Fertilization happens in the fallopian tube. Early embryo growth and development all happens in the fallopian tube. Embryo enters the uterine cavity about five to seven days after you've ovulated. And if you start to implant an fetus, an embryo, HCG is the pregnancy hormone. And HCG and LH share a receptor. So HCG goes binds to that receptor on the corpus luteum and now stimulates a constant and increase in progesterone as HCG levels rise as the pregnancy grow. And this rescues the corpus luteum. You keep making progesterone. And this is where all the pregnancy symptoms come from from high progesterone. Feeling tired, sore breasts, feeling nauseous, morning sickness. So in the absence of a pregnancy, that corpus luteum can only live for two weeks and then the cycle starts over. Now, really importantly, is that tracking your cycle and truly what I mean by that is tracking ovulation is a skill that women are not taught. That is a huge opportunity to understand how their brain and ovaries are communicating and the influence that inflammation can have. And what I mean by that is that our body goes through a very distinct set of changes as we go through the ovulatory spectrum. Meaning if I have textbook perfect cycles on one end of the spectrum. And on the other, I have what's called amenorrhea or absence of a period. It's not just a light switch on and off. There's stages of dysfunction that your body goes through. And during the first two, you'll still have a regular cycle. It's just slightly different. Meaning the first stage of ovulatory dysfunction is a shortening of your luteal phase. Your luteal phase should be greater than 11 days. So when it is not, you're going to start to have this shorter luteal phase. And that's the first sign that you're not ovulating or you're not ovulating, let's say optimally. How would a woman determine that? Because we're going to track our ovulation. Okay. And I walk through how we do that. The second phase of ovulatory dysfunction is going to be a longer follicular phase. So now it's taking a stronger or longer FSH signal to get an egg to grow. We're not responding as early as we should. And then we're going to get into more irregular cycles, which are more obvious jumping around, skipping months, and amenorrhea. But these first stages, a woman is still having her period, quote, regularly. But the actual phases are not optimal. And this is why if you are simply using an app to track your ovulation, marking cycle day one in an app, and this app doesn't use any of what we call fertility awareness methods, which are your body's physical signs that we're going to go over. An app is only accurately detecting ovulation 20% of the time. 20%. That means 80% of the time, if you're putting your period into an app and it's giving you the ovulation day, it's wrong. That's wild to me. Because many women say, yeah, I'm tracking my cycle. I am putting it into my app. And yet they're actually not getting the opportunity to really understand all the data their body is giving them. And is this a just to double click on the importance of this? What I'm hearing is that this is kind of foundational and perhaps ground zero when it comes to understanding your base kind of hormone health in inflammation before going into any type of lab tests and things like that. It's just being aware of whether or not your menstrual cycle is normal. Is it normal? Are you ovulating appropriately? Is it optimal? A couple important concepts before we go over fertility awareness methods really quickly is that one, you will read in my book and in other books, people will say the average menstrual cycle length. So from day one of your cycle till the last day before the next should be between 25 to 35 days. But it should not be hopping around in that interval, meaning for any one individual woman, her cycle should only vary by one to two days per month, meaning 28 days, one month, 29 the next, 28 days, 27. She shouldn't have a 25 day cycle than a 34 day cycle than a 25 day cycle. That's too much variation. So that's not normal. So if I give you a calendar for your woman, I should be able to say, put your finger on when your next period's coming and you should be within a two day interval of being able to get it right. So that's an important concept to just understand about what type of variability is acceptable and what type of variability is a sign that something's off. And if that's not acceptable, say 35 days, it's the hop. Right. Because I feel like, I feel like some women that I know, maybe in that context would say, oh, my period is just late this month. Like when is it okay to just kind not neglect it? That's probably the wrong word here, but just to kind of overlook it and kind of continue on with life versus going and seeing a specialist. Everybody's entitled to one off period, meaning this month is weird. If next month gets back to baseline and every month is normal, they're on not a big deal. That makes us highlight the importance of understanding your own baseline. But also to drive that home even more and to tie this back into the chronic inflammation discussion. The reason why some of this is is you don't sleep as much. You get really stressed, you get ill. This is going to interfere with the brain's interpretation of estrogen progesterone and how it sends out hormones. Chronic inflammation directly impairs the hypothelamus, control center in the brain from interpreting what it needs to and sending out hormones directly. So ovarian response, egg quality aside, when you have chronic inflammation, you are going to be at risk for ovulatory dysfunction or not ovulating your best because the brain is having a harder time hearing the signal and your cell phone service is really bad so it can't respond as well as it needs to. So that's really important for us to say the period really is a vital sign and one of the ways that our body evolutionary is trying to give us insight to how we're doing, how is our health, are we getting enough calories, are we running too much, are we too stressed, but when do women learn how to track their cycle? They don't. Instead, most women learn to track their cycle only when they are failing to conceive and having infertility. The number of people who don't learn it before they want to get pregnant is extremely high. And then even when people are first trying to get pregnant, so many of my patients say, well, we're not trying, but we're not preventing. We're just having unprotected sex and seeing what happens, trying to make it be, quote, low stress. But again, this is just opportunity of time. We're learning this about our body is a lost opportunity for intervention a much sooner time. So how do we track our ovulation? Because that's really what I want people to take away from this, which is then trying to get the timing of spumb to the release of the egg. Exactly. So tracking your ovulation is going to be important to just one, understand your period is a vital sign. So even if you do not want to get pregnant, if you do not have a normal ovulatory pattern, you should get that evaluated. There could be a thyroid problem, could be prolactin, which is a pituitary hormone. You could have insulin resistance, you could have PCOS, you could have an autoimmune disease. So it's a sign of your health. We should understand it earlier. Two, to your point, yes, we already alluded to the fact that sperm can live up for five days. The egg can only be fertilized for 24 hours, timing in our course in regards to ovulation, allows us to have the highest pregnancy rates per month and the shorter time to pregnancy. The best ways to track your ovulation are going to be with what we call fertility awareness methods or those signs from your body. These are going to include your cervical mucus, your basal body temperature, and you checking your own hormones. You want to dive into these. So cervical mucus. Your cervix is the entry, the gateway into your uterus. Servical mucus is supposed to protect the uterus so that nothing is going to get into the uterus, no infection, nothing from the vagina is going to get inside. With the exception of when you're ovulating, we would like sperm to get in. That is the pathways sperm take. They swim through the uterus into the philoping tubes where they fertilize an egg. So your cervical mucus changes directly in response to estrogen. When estrogen levels are low, you're not going to notice any cervical mucus on the outside. It's going to be very scant at the level of the cervix. It's a very thick barrier. As estrogen gets higher, it's going to change and be a little bit of creamy, but at pink levels, cervical mucus becomes sticky, stretchy like an egg white, clear. In this This will come out of your vagina. So if you go to the restroom, you wipe, you look at it. A woman will notice type 4 cervical mucus when estrogen is at that peak level of 200 kilograms. So if you have multiple days of that type 4 cervical mucus, ovulation is the last day. If you just have one day, ovulation is that day. So if we track our cervical mucus as a woman, that is free. It doesn't require any tech. We're able to say, "Okay, this is my ovulation day. If I then know my total cycle length, I'm able to gauge how long is my follicular and luteal phase?" And if your luteal phase is, for example, nine days, and I said it needs to be at least eleven, we now know that there's probably some interference at the brain, not sending out LH long enough to keep this corpus luteum alive. So that's that first stage of ovulatory dysfunction that we should investigate and then optimize before we want to get pregnant. So that's cervical mucus. Everybody should do this. It's not hard. You're just monitoring. The one key there is to wipe before you go to the restroom because cervical mucus can fall into the toilet. So if women are trying to track this, sit down on the toilet, wipe first. To see. Go, John. Yeah. Second is going to be basal body temperature. Fun fact, does that progesterone completely changes the metabolism of a woman? And one of the things that it does is it raises your corbody temperature. And this is in preparation for a pregnancy, right, progesterone, the progestational hormone. And so your temperature will rise once that corpus luteum is making progesterone by 0.4 degrees Fahrenheit. So if we know what our baseline temperature is and we can detect this shift, we can now know when ovulation occurred. This has, this is where I love tech because it has changed the game here. This used to be extremely cumbersome. And when I was struggling and trying to get pregnant and I was trying to track my own basal body temperature, I had graph paper, a special thermometer, marking it down, very cumbersome. Now wearable technology combined with the right app has made it such that we can have a more sensitive and accurate measurement of our body temperature, multiple data points throughout the day. And this can be a way where you can know when you're ovulating without having to check it yourself. So this is low hanging fruit. If we have the resources, of course, we have to be able to afford it. But these are things like or ring, whoop, apple watch, natural cycles. They all have options for long term wearables that can measure your basic body temperature. Yeah, my, my whoop will pick up an increase in body temperature before I, if I'm going to get sick or something like that. Yeah, it's really incredible. I have my or ring on. It's one of those things that humbling at times, right, when you're not taking care of yourself or traveling or not sleeping. So that's a way that's easy to do your base body temperature. If you have the opportunity to use a wearable, which many people do. And then the third option is going to be a urinary hormone measurement. There's a couple different on the market. The original ones were called ovulation predictor kits or OPKs. This is very much like a pregnancy test. You would urinate on it and it's an LH detection system. So you're trying to detect the first time LH is present in the urine reflecting that surge. And because the surge occurs the day before you ovulate, you can say a positive OPK would be the day before ovulation and then you can track your different cycle links. There are now some other options on the market that are more complex urinary hormone systems that also can monitor progesterone metabolites and FSH and LH. And those are great. They're probably more expensive and a little more detailed than the average person needs, but they are an option as well. So we can see that any of these can help you determine when you're ovulating. And if you're trying to get pregnant, the data shows us that they all improve the odds of getting pregnant per month so that monthly fecundibility overdoing nothing, yet none of them are better than the others. And in fact, if you use two, pick your two favorite. You have even higher month to month fecundibility rates because you're just more accurately detecting ovulation and targeting intercourse. But even if you're not getting pregnant, I think this is a powerful tool that we're not taught about how we can learn to see these different cycle patterns, what our baseline is, and the opportunity to get an investigation or get to the root cause of what's going on well before this problem is so much worse. What changes here in terms of monitoring the menstrual cycle and then using it as a window into your hormone health and reproductive health if a woman is on the pill or any type of kind of oral contraception. You lose all of this. And this is, to my opinion, one of the biggest downfalls of the birth control pill because on the birth control pill, you're using a synthetic hormone that's ethanol estradiol, so it's a different type of estrogen that the ovary makes and a type of a synthetic progesterone or progestin every single day. And then when you stop the pill or you go into the placebo pills, your uterus has that same reaction, progesterone is taken away because you're not taking the active pill and you will get a hormone withdrawal bleed. But it's not a bleed that's reflective of these symptoms and you cannot track ovulation while this is happening. So you won't have cervical mucus, you won't have a shift in your body temperature and this is because you're exposed to progesterone every single day. And similarly, if you check that your urinary hormones, FSH and LH will be near undetectable while you're taking the birth control pill. That's how it works. Does that make a woman hot on when she's on oral contraception in terms of body temperature if progesterone? It does change your metabolism because it's a different type of progesterone than your body makes normally, it's not quite as noticeable, but it does change your body. And your brain is not sending out FSH and LH, estrogen levels if we check them are going to be extremely low. And I've had women sent to me for hormone abnormalities because they're well-meaning PCP to hormone labs while they were on the birth control pill. And I can tell you right now, if you're taking the birth control pill, FSH, LH, estrogen, progesterone are going to be near undetectable levels. That's how the pill works. It's why it's a highly effective contraceptive choice. But that's an important thing to know if you're on the birth control pill for 10 years, that you just lost the opportunity to understand your cycle for 10 years of your life. And when you stop the pill, it's not that it takes a long time to get out of your system. Single pill has a 28 hour half life. That's why missing one pill can actually result in a pregnancy, right? So the pill doesn't live in your body for a really long time, but it takes a while to see what your new baseline pattern is because the normal cycle is relatively a month. So if we take the pill up until we want to get pregnant, well, now we can't really accurately track our cycle for at least a few months. Well, what if it's not normal and then we're getting an investigation? And you can see how really quickly we're six to 12 months in from when we wanted to get pregnant instead of stopping it well before we want to conceive, getting an understanding of what's happening with our body, getting an evaluation. If it's not normal before the clock is ticking for lack of better, for lack of better words. But I'll be honest, I mean, one of the hardest things that I see, some of my hardest, most heartbreaking cases, I had a 25 year old come see me. She was a nurse and she stopped her birth control pill and her period didn't come back. And she went to go see her doctor at a few months of being off the pill and they said, this is normal. It can be normal not to have your period back at three months off the pill. That's false. It should definitely be back by that time. Told her to just keep waiting. At six months, she went back and said, this is, I still don't have my period, I feel terrible. And he sent her to me. And it turns out she was in a very inferior. She was an early menopause. And she was low estrogen all of those months. She wasn't going to start ovulating again. And the saddest part of her story is that in college, she stomped the pill for a few months and didn't get a period and thought it was weird and went to a doctor and said, I don't have my period. What's going on? And they dismissed our saying, this can be normal. Don't worry about it. Just start the pill back up. And had they done an investigation at that time, had they checked an AMH level? She likely was at the place where she would have had some eggs left, even being critically low and given the opportunity to consider egg freezing or at least know that this was what was going to happen to her body. She ended up getting pregnant, but she had to use donor eggs to fight me and so young. And so I think it's really important. And she was one of many people I talk about in the book who sat across from me saying, I just didn't even know how to advocate for myself and that your period is that true vital sign. And so the pill can in some ways like mouse or obscure you from understanding that there's something that you would want to look into. Absolutely. You're not changing. Importantly, you're not changing the rate of loss of the eggs outside the vault. Right. We've already established that eggs are coming out of the vault. No matter what. No matter what. So the pill is not going to cause you to run out of eggs any faster. Similarly, it's not going to cause you to be able to keep them longer. What it's doing is we'll say your 20 eggs are coming out of the vault. The pill binds to the brain and prevents FSH and LH release. So no egg is going to grow and ovulate. Therefore, you're going to lose all of these fertility awareness methods. The ovary goes into a state where it's no longer responding to the brain because there's nothing to respond to. to. It's just waiting for a signal. All those eggs die and the next month another group comes out. So it's not changing the rate of loss of eggs in that way. It's not going to long-term armure fertility, but it is changing our ability to learn about our body and see these signs that it's trying to give us. Does the pill being used long term? Does it affect fertility? In the same way that we were talking before the testosterone? Kind of think about these. Similarly, some people will refer to testosterone as male contraception, but testosterone, you know, taken exogenously, kind of, it turns off the signals from the patruchy gland down to the to the testes. And in a similar way here, you're saying the pill is essentially shutting down this part of the brain, sending signals down to the female reproductive system. If used in a prolonged basis, is there any risk of the kind of that system sort of weakening over time and not firing back up? The answer's no, but I love that you're asking the question. The testes are so much more sensitive than the ovaries when it comes to this longer term suppression. Because since they're generating sperm, they're packaging up. It's a different process than just stimulating an egg to grow. And that's why the ovaries do have more resilience after they've been suppressed. We'll say, coming back and responding to ovulation. We do see that not all long term contraceptives are created equal. And I think that's worth saying, meaning studies looking at the rate of infertility at one year of discontinuation show no higher rates of infertility for these different contraceptive options. However, the depot-prevare shot, which is the birth control pill shot that is progesterone only, a single shot is going to prevent ovulation for three months in all women. That's how it's a contraceptive. But a single shot in one woman can prevent ovulation for 18 months. It's a really long time. So we should not be using the depot-prevare of the birth control pill shot if we want to potentially get pregnant in the next two years. Okay. So that's really important. Luckily, that's not as common. We also see progesterone IUDs, which are a progesterone only contraceptive put locally into the uterus. These typically suppress ovulation at the very beginning of their lifespan, but not at the end because progesterone levels do drop over time. So women lose these signs because progesterone antagonizes the endometrial lining and daily progesterone, you thins it out and makes it so that women may not have a period at all. The important fact here is that progesterone IUDs have been shown to change the receptivity of the endometrium from this really prolonged progesterone exposure for potentially up to 12 months. That's really impactful, meaning if you have an IUD and you want to get pregnant soon, I would like you to remove it at minimum six months before you want to get pregnant, ideally closer to 12 months. Of course, if you're not ready to get pregnant right now, we have to switch. You could switch to the pill or use condoms or some other type of contraceptive choice, but this discussion that we really should be changing our contraceptive before we want to get pregnant or coming off of these hormonal contraceptives so that we can track our period, learn when ovulation occurs and make sure the environment is the best that it can be for a successful pregnancy. Is that the same for all types of IUDs? Copper IUDs are very different. Copper IUDs cause localized inflammation that appears to more readily go away as soon as the IUD is removed. Okay. Back to your own personal kind of journey here. You mentioned earlier that when you were told that there wasn't a lot you could do and that you should go down this route of IVF that you began kind of looking into this a little bit more deeply and realize that chronic inflammation is kind of often a significant factor when it comes to successfully conceiving. What were the main behavior changes that you made that you did with the idea being that it would help lower inflammation or improve chronic inflammation levels in your body? To frame it, I consider these my five non-negotiable categories and then I might tell you exactly what I did and what I recommend, but this is going to be sleep, stress, movement, diet, toxins. Those are going to be my five categories that I like to think about and break this down. I'm very often, I get asked about lots of little tiny specific things, but before we ever go down any of those rabbit holes, these are the majors. This is what we should work to master across the board to have optimal health. These are the exact same things people are talking about when it comes to having better health and parimenopause and menopause or longevity these are core components of how you can make positive impact in your metabolic health. So let's start with my number one which is going to be sleep. Sleep is number one on that list. Sleep is number one. For many reasons, from a patient perspective, there's a lower delta to get into change. I mean, you get high impact from behavior changes only. It feels less scary and we can get better compliance and give people on board. For me personally, this was a hard one because I was in fellowship and in training, but I realized the importance of trying to set a more regular sleep schedule, prioritizing that and with the understanding that I could be more productive when I got more sleep versus staying up late, trying to accomplish different things. And of course, I mean, I was in medical training, so there's times you don't control your sleep. That only makes it more important to do so when you can. Sleep is when your body is going to heal inflammation. The immune system is meant to go drop some of that inflammatory burden. So that's an important component that can happen in sleep. If you get less sleep, you will have higher inflammatory markers. We know that melatonin is a natural hormone your brain makes. It's a potent antioxidant. In fact, supplementing with melatonin can be advantageous to equality even in IVF studies. So this sleep is really critical when we want to go real specific to fertility. The gonadotropins, FSH and LH are released from the brain in the early morning after you've gotten a set amount of sleep. So if you're cutting your sleep cycle short, you're not going to be able to send out your hormones that control your ovaries to the degree they need to. So we can start to see, okay, this is important from a few levels. And then also we have that sleep is one of the top ways to fight back against insulin resistance, which I'll go into in a minute. My really bad analogy for that. But when you get sleep, what we show that we need is that, well, only two-thirds of adults are getting six hours of sleep or more. Meaning that 30 people get less than six hours of sleep. And we know that women need at least seven to nine hours of sleep and really closer to seven and a half, especially in the luteal phase when the body has a greater metabolic need to make progesterone. So a huge area for impact here in fertility studies, if either partner is getting bad sleep, we have a lower rate of pregnancy per month. If we have increase in sleep variability, so we can talk about the importance of the circadian rhythm. So we're not going to bad and waking up at the set time. Ideally, this is close to what the sun does. It is going to be associated with a higher rate of infertility, either partner. Men who get less sleep have lower testosterone levels, lower sperm counts. Women who get less sleep, there's a direct relationship. For every hour of sleep, you get less. You have fewer eggs retrieved with IVF. Okay? So there's many different metrics across. We just talked about natural fertility, IVF, sperm counts, egg counts that are directly related to the amount and the quality of sleep you get, which it makes sense from an evolutionary perspective. Totally to me. Like if it's asleep, given that when you sleep, you're so vulnerable to radiation, it speaks to how important it is. And if you're not getting it, you're not getting that recovery and rejuvenation, then it would make sense that reproduction is not the priority. Especially for a woman, having a pregnancy is a huge metabolic demand on the body. So if your body isn't getting the sleep that it needs, this is causing chronic stress because you're telling your body, I can't predictably give you sleep and it's going to be less enthused about you carrying a pregnancy right now. So the hypotherlemic response in women is extremely sensitive for a reason. If we evolutionary are in a famine, there's no food, we're migrating, those are not great times to have a child. And so the brain is looking for different signs that you are cellularly healthy enough to support your well-being and a child's well-being at the same time. And sleep is one of those big feedbacks that it's looking for that you can get enough of it. I know myself, if I get six hours, I will literally feel inflamed. I'll have the brain fog. And it's a very acute experience for me because I do normally get eight hours, but I have to imagine if you're someone who's getting six hours chronically, maybe you almost set a new normal. You directly have more chronic inflammation. Your inflammatory markers are higher. This hungover feeling that you're feeling that becomes your new baseline. And then somebody may say, "Oh, it's just get it. getting older, there's nothing you can do about it. But it's because you're not setting the right foundation. If we can get more sleep, we're directly changing that. And I used to be one of those people, like a badge of honor. I only need five hours of sleep. I'm so productive or so busy. I'm looking back on that and cringe. Because I definitely need seven hours of sleep tonight. And when I do not get it, exactly like you, as I'm in, more brain fog. I'm not thinking as quick. I'm not as productive. I feel puffy and bloated and icky. And it's showing me so clearly that when you learn to listen to your body, it's telling you in a lot of ways what it needs. Totally. Right? I could be sitting in a conversation like this and my level of attentiveness to the word you're saying is down. Yes, exactly. So when it comes to sleep, here's what I recommend. We want to make it accessible. And here's what I started trying to change when I could. A set sleep schedule when you can. We don't want to sleep and really late and stay up late on the weekends. We really want to have a good, similar circadian rhythm, going to sleeper on the same time, waking up at the same time, aiming for at least seven and a half hours, making the room dark, wearing a sleep mask, if you need to, making the room cool, consider a sound machine, putting your electronics further away. And I think one of the really biggest pieces of the puzzle here is that if you sleep with somebody in your room, you have to be on the same sleep schedule. Absolutely. I see so many pairs. One of them is going to bed early. The other one's coming to bed later. One of them's getting up early. But that is interrupting both of your sleep patterns. So fertility is a team sport. If we're trying to have our best optimal health now and in the long term, talk to your partner. He got to sleep together. So talk about when are we going to bed, when are we waking up? And if that is not realistic, maybe based on your line of work, consider a sleep divorce. You can have a loving relationship and have the bedroom for sex and other fun things. But maybe we need to sleep in separate rooms. And I say that because sleep is so crucial to health. OK. Number one. Number two is I want to talk about stress and muscle. But actually, before I talk about those two, I'd like to talk about insulin resistance and give my really bad analogy. OK. And just before you get on to that, one other thing I'm thinking of there that I've introduced-- so Tony and I, we use a different comforter. We have separate like we're-- I call it a doona. I call it a doona. But I think you guys call it a comforter. Yeah, we have our own. So that when she ends up stealing the whole thing, I still have mine. I still have my own comforter so that I'm not freezing cold. My temperature is kind of optimized and there's not like a tug of war happening. And that has actually-- that's been a huge game changer. OK. If Jason's listening to my husband, he's about to get his own comforter. He's the cover hog in our family, so get my own space. Yeah, because I think we had the discussion about sleeping in separate rooms at one stage around optimizing sleep when we're like now. Let's try and say in the same bed. Yeah, I think there are some positives to that as well. And so cultivating Simon, what I love is that you had a discussion. You talked to your partner, what do we need to do to have our own best sleep possible and come together to go to bed at the same time, make the changes we need to to our bedroom. And that's really what I would encourage more people to do. Right, yeah. That was our happy medium, but it's going to be different for every couple. OK, insulin resistance. So I said, one of the ways the sleep can help is because it helps decrease insulin resistance or improve our insulin sensitivity. So let's talk about what that means. Insulin's another hormone. It's one that's made from the pancreas. And this is a very simplified analogy, but it really helps my patients think about this because so often, I hear patients say, I don't have diabetes or prediabetes. So insulin resistance does not affect me. But we know in fertility studies that women who have higher rates of insulin resistance have a higher rate of pregnancy loss and a lower rate of success with IVF, even without a formal diagnosis. But when we go and we look at optimal versus normal levels, we can see that there's a difference. So it is so important when it comes to your fertility. So let's say you're going to eat some food. This food is going to get broken down. And glucose is one of the components that's the fuel for the cell. So every cell in your body wants to have glucose come in. And I'd like for us to think about insulin. It's the hormone that's released when glucose is in our blood stream. And insulin is going to help glucose get into the cell. Let's consider the salesman walking glucose to the cell, knocking on the door. You answer the door. Glucose can go in the cell and insulin goes away. So this is meant to work really beautifully. You eat, glucose goes up, insulin released from pancreas, glucose goes in cell and lowers, insulin lowers, Latina. Well, for a variety of different reasons, we're going to go over glucose levels are higher in our blood and staying higher for longer. Well, what are you going to do if a salesman comes to your door every day? What are you going to do? Probably not open the door. That's what your cells do. So your cells says, I'm so sick of seeing that guy. I am not opening the door today. And what that does is actually sets off this very interesting cascade because the cell's hungry for glucose doesn't like the salesman. The liver starts breaking down glycogen, which is where glucose is stored, putting more into the blood stream because your cell is hungry. Glucose levels raise more. So now more insulin is released from the pancreas. The salesman's now banging on the door. And now you finally say fine. And you open the door and glucose can get in. This is insulin resistance because now you require such a high insulin level to allow glucose to get into the cells. But insulin is a growth factor. It is causing you to make visceral fat deposits so that a nominal fat inside that can be so problematic because it's a better long-term storage system. So you're putting some fat on. Insulin is also extremely toxic to the ovarian environment when it's persistently elevated. It is going to change how the ovary will respond to those brain hormone signals. So it starts to shift the hormone production in the ovary. In addition to having this act of insulin resistance, insulin's so inflammatory, your inflammation markers are going to rise, which we talked about is going to impact mitochondrial health and egg quality itself directly, also coming back and interfering with brain function. So having insulin resistance is also going to impact the brain's ability to send out those gonadotropins like we talked about. So it's essentially as a trade-off. So evolution has decided we have to increase insulin because you need to get glucose into the cells. That's primarily survival. But with that, it's not a free lunch. You get these kind of off-target effects. And really it's because of the modern world, because evolutionary, when would you not get glucose into your cell? It wasn't from eating foods with a high glycemic index or from not sleeping necessarily or from chronic stress. And those could contribute some. But a lot of times it was because you were having a hard time. You know, your body was shifting into storage mode. So putting that fat viscerally that is a better long-term storage option helped you stay alive. So insulin resistance was survival-- Like a protective mechanism. Exactly. But the things that cause us to have that scenario now, a lot of them are things that we control over and that modern world has made worse. Not necessarily how our body was made defunction. And understanding that is really important because I will leave people are really smart. And one of the biggest problems with our health is that we, as physicians, as medical experts, haven't provided information in a way that people can really understand it. Therefore, impact real change. And that's also empowering knowing that if you have insulin resistance, it's actually not your physiology broken. Your physiology is doing-- What it's supposed to do. It's supposed to do. It's that there's a mismatch between the environment now and physiology. And as opposed to our ancestors not having those exposures, then going through periods of famine, where we're exposed to a completely different set of variables. Exactly. So we have to break that cycle. And that's where living, quote, anti-inflammatory, a lot of this is trying to break this insulin-resistant cycle because that is so prevalent in the modern world. OK, so we said sleep helps improve our insulin sensitivity. You're not eating while you're asleep. Your blood glucose can go down. This can help impact how yourselves can respond when it sees insulin come back around. When it comes to stress, OK? Chronic stress and movement are really intertwined. I'm going to do movement and come back to stress. Fun fact is the skeletal muscle has a transporter called glute 4. And glute 4 is helping the muscle get what it needs. I like to think about it as giving glute posts a key to unlock the door and not need the salesman anymore. So if you use your skeletal muscle, glute posts can get into those cells without needing insulin. So building and using skeletal muscle is one of the best ways that you can fight chronic inflammation and insulin resistance. And you can utilize this to your advantage when we circle back to stress in a moment. Yet for many women specifically, movement is all about aesthetics or being a certain body size. And building muscle hasn't entered the discussion for a lot of people until it comes to parrymenopause. But I tell everybody you need to build muscle. This is resistance training picking up weights three times a week before you want to get-- pregnant when you're trying to get pregnant. If you have infertility and you're going through fertility treatments during your pregnancy and then when you're cleared again postpartum, there's this idea that we should stop exercising when we're having infertility or stop when we're pregnant. And of course, we've need to listen to our body. There's always different methods we shouldn't be pushing ourselves too hard at different life stages. But picking up weights is one of the best tools that we have in our toolbox to build more skeletal muscle, to therefore give the keys out to glucose and not have to rely on insulin because if glucose lowers, then we're going to see that insulin is going to lower. And then your cells, throughout your rest of your body, are going to be more sensitive to insulin and we're breaking that cycle. The same thing is really intertwined with chronic stress. So again, like inflammation, acute stress has a purpose. Chronic stress does not. So acute stress, my favorite analogy like most people is a bear. If Simon sees a bear, what do you want to do? You want to run away from it. So your body is meant to when quarters all is released, that's your stress hormone known to be inflammatory. And the reason why is part of your survival mechanism is to go back and break down glycogen from the liver and put more glucose in your blood. Because it's not going to rely on the fact that you ate recently enough to fuel your muscles, your heart and your lungs. It says, oh my gosh, a bear very quickly activate more glucose should go into the bloodstream. And if this was a long time ago and you did run from the bear, in fact, your muscles would use up that glucose. It would lower back down. You get back to baseline or homeostasis that well since you would survive the bear and metabolically, that's how your body is meant to function. Well, realistically, that's not what's causing stress now, right? It is the world around us. It is our person-to-person interactions. It's social media, bad doctor's appointments, politicians, the world around us, financial times. There's many factors, some of which we control, some of which we don't. And I don't ever sit here and try to act like I'm telling somebody to just be less stressed because that's an extremely unrealistic thing to say. But I think we have to acknowledge that we live in a stressful world and that we encounter stress every day. And the more that this happens, we need to learn how to create the resilience within our body and how we're going to process it. So I like to think of this threefold. Number one, obviously cut out what you can. So if you do not need to, do not do in school or maybe you don't watch the news as often, maybe there's a toxic person in your life that is causing you stress, maybe you're saying yes to a lot of projects you don't have to. So that's not everything, but there usually are some boundaries most people can set that can be a little bit protective for what we're exposed to. And we should do those to the extent that we can. Number two is going to be give your body moments of opportunity to have cortisol substantially lower. And this means in building into your day, sitting across from me, Simon, saying today we'll be stressful in some way. So I'm going to make sure there's at least 20 minutes of a cortisol release for me. And this is going to look really different person to person because you and I are wired really differently. Maybe it's sitting outside hearing the birds going for a walk, talking to a friend, meditation, mindfulness, journaling, acupuncture, yoga, a variety of different things that we can do. They should not involve your phone and they state the obvious. They need to be a release from what is constantly activating that cortisol response. And we should proactively build that into our day to the extent that we can to know that we're going to get that moment of release. And our body will start to know that we're going to get that when we make that a habit. And then we have more resilience when we encounter stress. But the last and what I don't see people talk about the most and what I think is the most impactful is that when we experience acute stress regardless of the cause. And most of us know it because we feel it when you get stressed, you feel like your heart racing or pressure, anxiety, whatever you're feeling. If we think, okay, my liver is breaking down glycogen, putting glucose in my blood. I need to leverage this to my benefit. I should use my muscle because now that's how my body is meant to be. I can get glucose into the cell. I can lower it faster. I cannot have this insulin-resistant cycle because chronic stress causes insulin resistance. And in fact, instead of doing something small, tens squats at your desk, a small walk outside, something to leverage that skeletal muscle that you've now built, what do most people do when they're stressed? Eight. Right. And do they eat broccoli? No. They eat comfort food. Comfort food. You know, food that has very little nutritional value is inflammatory to the gut in your intestines, but they're searching that dopamine hit instead of thinking about how is my body functioning right now? And how do I leverage this to get back to baseline and stop this inflammation loop? Yeah. I mean, that's so important because, and I like that sleep and stress throughout the top of that list because if you're not getting those right, it makes it very difficult to get these other ones right. Exactly. And yet, the narrative, there's nothing you can do. Almost everybody who sits across from me can make improvement in one or all of these. These are the foundation of your day, whether you realize it or not, we're making little decisions on the spectrum that influence our chronic inflammation and how much insulin resistance we have. I think that's in, you just said, whether you realize it or not. And I think so many of these behaviors are so innocuous and mindless scrolling without being aware, doing something that's very normalized, unaware that it is causing these little bits of micro stress and anxiety every single time, which is feeding into two inflammation, feeding into home and levels, feeding into menstrual cycle, irregularity or regularity, feeding into fertility. That, those, the connecting of those dots, I, I think there is a huge, you know, lack of awareness on that. There is. And it's really interesting. We start to realize it that again, this is why I can say it's not one single decision making or breaking it. But starting to understand that the sum of these decisions, they do add up and can be impactful. And again, to this idea that your body is meant to respond to things around it. So lowering that inflammatory burden allows you to have more resilience so that you can travel and not get as much sleep one singular night and not have that impact you in such a negative way because you're controlling all of these other factors. And you mentioned speaking with a friend, but I have to think and I've become increasingly mindful of this, I think as I've gotten older, the importance of having really some quality relationships and quantity doesn't matter so much. But people that you can confide in and, and just share openly. Yes. And not having to like wear the, the mask. No expectation. Right. Because if I know if I'm bottling something up, even if I do all of the yoga and the breath work and like this is me speaking, so other people could be different. But I'm still going to rest my head on the pillow at nighttime and not feel great about those things that I have been spoken about. I have to get them out of my brain too. And I, you see, they're talking to someone or also journaling. I'm a big proponent of brain dumping it out. And that helps me have more clarity. And I think decide how you're wired. But we shouldn't let these thoughts get trapped inside us and then contribute into the cycle. Are you getting them out of your brain whether it's sharing with a friend, a therapist, journaling, that is all really helpful to survival to the world around us. Like we are all living in this experience together and learning how we can optimize our own experience of the world around us and feel our best and be our healthiest. Like that's what we're all searching for. Right. That's a good point. There's, there's, there's multiple avenues to kind of working through those thoughts. Nutrition. Nutrition. Yeah. Let's talk about it. You know that we were going to get there. Starting high, high level, when I was reading through your recommendations, I guess I would summarize it as recommending a very plant rich high fiber, whole food kind of like Mediterranean style themed pattern. Yes. That is rich in colorful plant foods and you know, may have some animal foods in there and in particular like fish being preferable over other types of meat and very low in kind of ultra processed hyper palatable foods. Is that a, is that a pretty good, I guess, summary of the overall summary? Right. And as I was reading that given we sit here right now at the start of January and the new dietary guidelines came out, I thought it wouldn't be great to get your opinion on the new guidelines what they got right. What maybe you don't think is, is great. And just overall, overall, I guess first thoughts on the new guidelines. Overall, I think there's a lot that's right. with the dietary guidelines. I wish, and what I'm a huge, just proponent of, is that if we were gonna talk about our upside down pyramid, that the top, the biggest category, to me, should just be fruits and vegetables across the board. That should be across the entire top. Because that is what, especially if we're looking at this through the lens of hormone health and fertility, having more fiber, having more phytonutrients, this is what is going to feed the gut microbiome. And to take a minute and think about our gut microbiome, I know you love this and you talk about this all the time, so we won't go into tons of detail for your audience, but you have a beautiful, diverse network of bacteria and signed urine testin. And what I think is important for people to understand is that they are hormonally active, and that they are very important in their metabolites, the short-chain fatty acids, actually impact endocrine signaling, signaling from the brain, they metabolize estrogen in your gut. So if you want to not think about the gut microbiome, we're bringing it into because it impacts your hormones and your fertility. In addition to the fact that your gut microbiome is your first line of defense, they help counter some of that inflammation, protect it from getting absorbed by those intestinal cells and from intestinal damage. So we want to think about the important of the gut lining and think about that gut microbiome. A healthy gut microbiome is essential to optimal fertility, to lowering chronic inflammation, to fighting insulin resistance. It all goes hand in hand. What truths do we know? Number one, your dietary choices influence your gut microbiome. Right? Number two, the full composition of your diet influences your ability to make hormones. And number three, what you already said, ultra-process foods do not play any beneficial role to your health, especially when it comes to your fertility. The gut microbiome is fed by fiber. So fiber is their food. Fiber is really highest in fruits and vegetables and then in your whole grain carbohydrates. But fruits and vegetables contain a lot of nutrients that can be hugely beneficial to egg and sperm quality in addition to lowering inflammation directly, having fiber. I think it's also very important to know it's not that meat is inherently bad, but I'm concerned about people who consume a carnivore diet because animal meat does not have fiber in it. So when we start thinking about the importance of fiber and how we're composing our plate or our upside down food pyramid, I don't love having animal meat as high from a fertility standpoint. The biggest category should be plants, fruits and vegetables. And that is what all the fertility literature supports as well. Increased fiber intake is associated with lower time depreconancy, improved outcomes with IVF, better sperm parameters, lower miscarid rates. So consuming fruits and vegetables, every single meal, every single day, is the number one recommendation for the fertility diet, therefore the biggest ring on the food pyramid. When it comes to proteins, protein is important. Fertility literature is really specific that for every plant-based serving of protein that you consume over animal-based protein, you have higher pregnancy rates. Echnology, the difficulty with nutritional studies is always important here because they're observational. And a lot of the red meat studies specifically group all red meat together. Is it a marker of die quality versus red meat? So there's nuance there that I'm absolutely going to acknowledge because it's probably a hot dog and a high quality red meat serving. They're probably not the same. And that's what if someone was here who was a proponent of animal-mates, that's where they would probably push back and they would say, well, those studies are looking at people eating hamburgers. They're looking at people doing both and that's what we should acknowledge, right? That it's hard to study diet when it comes to some of these variables. But they also put red meat and quartiles. So lowest exposure divided all by four to highest exposure. And people in the highest exposure group had fewer embryos with IVF cycles, lower live birth rates, worse stage of endometriosis, and lower sperm counts. So what we can say from a fertility standpoint is it's not going to say red meat's inherently harmful, but we shouldn't be living in highest quartile world, right? So I tell my patients that a variety of proteins can be good. Plant-based proteins should always be incorporated. Lentils, beans, tofu. Those are always going to be really healthy options to learn how to incorporate into your diet. And then when you have animal-based proteins, it shouldn't be red meat all the time. Quality of meat probably matters. And as you alluded to earlier, fish is really high in omega-3 fatty acids. It has a lot of other nutritional benefits. And so that is one that I like people to lean on up to three times per week. What is hard talking about diet to patients and even looking at a food pyramid is that we're so habitual in our choices. And the barrier to change feels very, very high. So I try to lessen this to people, especially if they're going through infertility, saying that to start, not forever, but to start, I'd like you to drop your meat to one meal per day. And the reason why I recommend meat serving in only one meal per day is it forces you to try new fruits and vegetables to learn what plant-based protein options are out there and start to craft a more diverse diet than the average person consumes. And that can be helpful when it comes to change, especially to change in line with what's been shown to be best for fertility. So I would say the food pyramid, I would not have the steak up here on the tallest row. Proteins are really important. I'd like to see more plant-based proteins or some included at all on the food pyramid. And then I'd like to see that we have also healthy fats, because we do know that fat cholesterol-- we'll say this cholesterol is the backbone for steroid hormones. Your body cannot make progesterone if you do not have fat. So especially leaning on those unsaturated fats, the olive oils, the nuts, the avocados, those are going to provide hormone backbones that you need. And of course, I'm from the era of the low fat world. And there's so many people that by choice lean to lower fat products, and they may not even realize it. But that is something they just habitually do. And those products are often labeled as low fat, but very high in refined carbohydrates, and sodium, and other-- Exactly. The dairy literature, it will say, is relatively neutral. What is consistent for fertility is that whole fat dairy sources are recommended over your lower fat ones. So in line with guidelines right now, and we want to have more complex carbohydrates-- ones that are less processed, less refined. They're going to have higher fiber and nutrient composition. We never want to avoid carbohydrates in general. And so it's a really balanced diet. We're leaning towards whole foods. We're avoiding the non-nutricious foods, the ultra-process foods. And I think for my patients, some things that I say is even healthy foods, in quotes, can be non-healthy for you when they're highly processed. Doesn't mean we never eat. Some of those will use a protein bar as an example. But if you're in your home with a kitchen and a pantry, you should not be eating a protein bar. If you're on a plane, that's a different scenario. So there should be some foods that maybe you leverage because it's better than other options. But when you have the ability, you should stock your home with foods that are providing nutritional value, therefore our anti-inflammatory. And this is what we're going for. An anti-inflammatory eating approach, foods that are going to nourish you and provide nutrients and prove your egg and sperm quality, but also help fight against these inflammatory patterns that contribute to insulin resistance. I think that was beautifully summarized. And I think the most disappointing part of the new guidelines-- and I do think there's a lot of good in there-- is when giving guidelines and telling me to be able to eat less of something like ultra-processed foods, which I think is amazing-- Yes. --and needs to come with a very clear and science informed when eating less of that, eat more of this. Agreed. That's swap. Like what you're talking about as you talk through with your patients and you're saying, we want to eat more fruits, and vegetables, and legumes, soy, and lentils, and all of these. It is very clear on a just a meal basis when you're at the grocery store, OK? Not going to eat as much of that. I'm going to eat more of this. And when that's not there, like we saw with the low fat phase, people would talk to eat low fat. Really, it should have been, hey, let's eat less of these foods that are rich and saturated fat. And eat more of these foods than up to seeds of all the avocado. Yes, they're still-- They contain fat, but they contain healthy fats. And then maybe we still would up because of the food environment. But maybe we wouldn't have seen as much of an increase in ultra-processed food intake. I think it's an important point. And it's one thing I worked really hard to do for my patients, but also in the book, is cultivate a how-to plan. How are you going to start to incorporate this in a way that feels attainable? And I always want to stress, we're never shooting for perfection. Every little decision matters. This is good news, meaning if the majority of your choices, most of the time, are in line with a lifestyle that is anti-inflammatory. Your body has the ability to have you eat cake, handle it, go back to baseline. And that's really what we're cultivating here is that resilience where you can be exposed to a stressor of a variety of different types and not have it be the thing that tips you over the edge because your burden of inflammation is already so high. Quickly you mentioned soy. I did. And I did too. There still is probably a pretty widely held understanding out there that soy foods are problematic for hormones. So if someone's listening and thinking, "Well, I've been told that I shouldn't have tofu or tempeh or soy milk because that's going to negatively affect my fertility," what would you like to sort of draw their awareness to? There is robust data that then more soy you consume, the improved outcomes you have when it comes to IVF and natural fertility rates, that fecundability. Populations that consume more soy and even looking at individuals who do so have less inflammatory markers. They have more resilience to environmental toxins like BPA, for example. It counters the effect that BPA can negatively have in our cells, highly anti-inflammatory. So eating soy, this concern comes from the fact that it can be a phytoestrogen, but there's been no associated relationship even in men, and I want to state this clearly. There's been no relationship seen with eating soy and decreasing testosterone levels or worsening sperm counts. So only a positive when it comes to fertility studies and metrics with soy consumption. Outside of the general dietary pattern that we've been discussing here, are there any specific nutrients or specific supplements that you would really speak about with your patients or recommend that they take? Absolutely. So if we're trying to get pregnant, there's a few that are really important for us to think about. One is going to be folic acid, and this is in most prenatal vitamins. Folic acid, we won't have at least 400 micrograms, so MCGs a day. This is an important step in cell synthesis, so you cannot grow in human. If you do not have high enough folic acid levels, and the recommendation is to start supplementing with folic acid at least three months before you get pregnant so that you can have high enough levels for long enough time, so you're not deficient. So we always want to say, let's take a prenatal, make sure it has folic acid in it, start at least three months beforehand. Second from that is going to be vitamin D levels. So vitamin D deficiency does create an inflammatory state within the body, and we've seen a multitude of fertility evidence, whether it's with IVF or natural fertility, the vitamin D levels are correlated with success. So it's an easy recommendation for across the board to say that everybody should have a vitamin D of at least a thousand international units a day if they're trying to get pregnant. Most prenatals probably have less than this, so the vast majority of prenatals have 600 to 800 IUs, so this typically means an additional supplementation with vitamin D. If you're trying to get pregnant, we also think Colleen should be an essential part. Colleen can be received from the diet, you know, eggs are a great nutritional source of it, but because it's so essential in brain health of a fetus, we want at least 450 milligrams of Colleen, and it's not in every prenatal. So we really do have to look and see if the prenatal does have Colleen in it because it's so important. And I can't imagine many would have 400 or close to 450 is that because you're going to presumably get some from the diet or is 450 what you want from a supplement. 450 is what's been studied for optimal fetal outcomes, and in fact, there was a study came out that even showed higher levels in that was associated with better neural function later on. So if we're trying to live in the state of doing everything we can because diet is often inconsistent on a day-to-day basis, this is something that's easy enough to supplement with that doesn't have negative benefits. And so that would be even more important if someone's not consuming eggs. Exactly. So if we definitely do not consume eggs than even more important, go check. And then the last one there's going to be omega-3 fatty acids. So many prenatals have added these like DHA and EPA into their recommendation, but if your prenatal does not have added omega-3 fatty acids, then please consider taking a supplementation for this. Is there an amount of DHA and EPA? I usually like a combined amount of 1000 milligrams, which is pretty high. 1000 milligrams. Yeah, and this will vary a little. If you do frequently consume fish, algae, chia seeds, flaxseeds, walnuts, you are getting some good omega-3 fatty acids. But if that's not something you regularly have in your diet, then even more important. And I'll have a fun fact on this one. I was a nutrition major. So back in college, all of my classmates went on to become registered dietitians and I went to medical school, but always loved nutrition. But I did research when I was in college with rats looking at their response when you fed chow to the pregnant ones that had omega-3 fatty acids supplementation and then how they performed in a metric maze with different brain tests for bowel function and other things. And those that were consuming higher doses of omega-3 fatty acids in their chowel pregnant, their offspring performed better. So this has been something that I don't know. We hear recommendations all the time, but when you personally see it too, even in an animal based model, it really drives home the fact that this is a modifiable factor that we can do that can impact our child's health as well, in addition to being good for egg quality and egg health. Yeah, I think I remember reading something as well around the importance of DHA and having a normal term pregnancy. Is that also true? That is true. Yeah. Okay, so follow the casted vitamin D, calling omega-3s. And there's one more I want to add if you're trying to get pregnant. It's going to be co-ins MQ-10, which is an antioxidant, important in mitochondrial health, important for both men and women with no downside to this and potentially advantageous in studies for fertility, which of a lot of other supplements don't have the evidence behind them to maybe fully endorse when it comes to fertility. The co-Q-10 dose for women is a little bit higher than men, so we recommend 200 milligrams a day for men and 600 milligrams a day for women. Okay, 200 milligrams for men. 600 for women. 600 milligrams for women. Yeah, there's mitochondria there, a few in the entire embryo, so we want to give them the support they need to function appropriately. On folic acid. Yes. If someone has heard that folic acid increases rights of cancer and that they should be getting a methyl folate version or form, is there any truth to that or folic acid completely find? All the available evidence supports that folic acid is completely fine and safe and is the only version of folate that is protective against neural tube defects. So a neural tube defect is a defect in the brain and the spinal cord of your baby. And in fact, if you do have a baby with a neural tube defect in your next pregnancy, we're going to recommend folic acid at 10 times the dose. There's a lot of misinformation about folic acid. I want to say a couple things about it. One is people will say methyl folate is a downstream metabolite of folic acid. That's a true statement. So your body is going to take the folic acid, metabolize it into methyl folate. There have been studies done showing that if you take methylated folate supplementation, you have similar blood levels as somebody who takes folic acid. Also true. There's a variety of different response to these medications. So some people may individually feel better on methylated folate on their day-to-day life. That being said, this is fear mongering for somebody to say that if you take folic acid, it's going to build up in your body, causing harm, causing miscarriage, that's not a true statement. And what I want people to hear is that when it comes to pregnancy, your body is completely different than it is when you're not pregnant. And when it comes to taking in something that is meant to solely support your child, it has to be able to get through the placenta, has to be stable enough in your blood long enough and pass through the placenta. And folic acid has been shown to do that and methylated folate is less stable in pill form, has not been proven to cross the placenta and be at levels where it can be protective against a baby. This means very clearly for us that at the current moment, taking folic acid in its folic acid form is important for protection of your baby's brain and spinal cord development, and there is no evidence showing harm. If you want to take both, there's also no harm in that. So if you want to take methylated folate and folic acid, that's fine. And I have some patients who love a prenatal that has methylated folate. And I'll tell them, just go by a single ingredient, 400 microgram folic acid pill, take that in addition if this is the prenatal that you love. There is no study that shows that methylated folate does the same and there's probably not going to be. Because today's world of medical research is not going to allow us to put pregnant women at risk for a birth defect to do a controlled study. There is research going on right now looking at second trimester. Now in real transparency, the neural tubes are already developed. That's why they can't do a first trimester study. Looking at in the second trimester, if you take a methylated folate version versus a folic acid, does it cross the placenta the same and how does it give blood levels? So that will be an important study to help guide us and there may be no difference. But the reality is we don't have that data right now and sitting across from women who do have a neural tube defect. I have patients who babies have grown without a brain or their spinal cord is extruding from their back. And some of these are incompatible with life. And when you sit across from them and you tell them the recommendation, the next pregnancy is to take 10 times of folic acid. If they look back and find out that they were taking a prenatal that didn't have folic acid and only contain methylated folate, they may ask, did that contribute? And at this moment, we can't assuredly say no, it didn't contribute at all. So I think that this is. is just really important to say sometimes what we do when we're pregnant is different than what we may want to do when we're just taking care of ourselves. And that's the truth for all of pregnancy. The placenta is a complicated, beautiful organ, but we can't make the assumption that everything crosses across it because we know that's not true. And so in terms of if you're planning a pregnancy, so you're not pregnant, you know that you're going to be trying, presumably you could stop that fallic acid earlier than someone who just finds out they're pregnant at like six weeks. Yeah, because by the time you're six weeks, the neural tube is the first thing that develops inside the baby. So you know, you have an embryo, every cell is toticotin at the beginning, meaning it can become anything. They start to separate in groups. And the first organ system that aligns is that of the neural system. So that's before many women know they're even pregnant. So at what stage would you recommend a woman would begin supplementing with, was it 400 milligrams? 400 micrograms of fallic acid per day? Three months before they want to try to conceive. Okay, clear. In this space, are there any woo-woo-style supplements that are being marketed to women to improve their fertility? There are tons of woo-woo supplements that are marketed to women to improve their fertility. I'll say this, there are some supplements that will be different based on your medical circumstance. So if you have endometriosis or PCOS, there might be evidence-based guidelines that you should do something different. And acetylcystine can be helpful for endometriosis and myonacetal can be helpful for PCOS. And I do some tables in the book breaking these down. What are some harmful ones? And I'd love to mention these really quickly because I think that's more important in this woo-woo. Number one, a lot of supplements have high levels of biotin in them. And this is really important for people to be aware of. Biotin is a B vitamin, but importantly, what it can do in the lab is actually combine to the sex steroid hormone assay. So it's not change anything in your body, but if I draw your level to check your estrogen for your testosterone or your thyroid and you're taking high levels of biotin, it is actually going to give me a false result in my lab. So this makes it really hard when we're trying to understand our things normal or optimal or we're checking different hormone levels. These are pervasive and different hair skin and nail supplements. Some of our greens powders have high levels of biotin in them. And so always flip it over and look. We want to make sure that if you see biotin and it's over the daily recommended value, if you see it's higher than 100%, that's a hard pass if we're trying to check hormones at all. And I've had patients who have had very difficult IVF cycles because they are taking high doses of biotin and we can't monitor or measure their estrogen effectively. We're just getting very false values. So I think that's important to know because biotin is in a lot of different places. How long would someone need to stop taking that supplement before getting there? We know that taking it for only seven to ten days is enough to make a change in sex steroid hormone assays. So probably the similar. I take patients off at least two weeks before we'll check blood labs. Okay, so that's important. I think another few things fall into the category of herbs. And it's not that every herbal preparation is harmful, but a lot of supplements should be nutritional supplementation that we're trying to make sure we're getting nutrients that we're not convinced we're getting from our diet. Herbs in a lot of different ways can mimic different hormones. And this might be advantageous at certain life stages, but if you're trying to get pregnant, we don't want to mimic any hormones. We want that really pure brain overrecommunication system. We want to ovulate when we can. The notable ones here are going to be vi-tex with this chase berry. It's so profoundly modified some of your hormone levels that they usually give it to monks because it would increase prolactin, therefore decrease testosterone and drop their sexual desire. It can be utilized in PCOS to some of the same benefit, drop testosterone, make someone with PCOS might feel better, might improve some of their ovulatory pattern. But again, not if you're trying to get pregnant because we don't want to be modifying our hormone response or potentially not making enough progesterone that we need. And then Maka and Ash-Gawanda are other ones. And those can be in a lot of things too. So Maka has estrogen-like properties combined to the estrogen receptor. We don't want to confuse the brain. Ash-Gawanda can similarly work at the brain levels. And so it's very frequently added to promote relaxation, not saying that that's bad on a day to day. But again, if you're trying to get pregnant, we're relying on your brain to properly interpret the signals coming in. And we don't want to modify that spectrum because we're taking herbal preparations. Also when thinking about affecting these signals from our brain to specific organs, this is where endocrine disrupting chemicals and toxins enters the conversation, which was fifth on your list. So let's go there. Firstly, what is an endocrine disrupting chemical toxins by definition? You just defined it really well. It is something that interferes with our endocrine system or one of our endocrine organs. So it can interfere with the ovaries, the testes. Most of them interfere at the brain level. They also can interfere with the thyroid. So for some way, they either bind to a receptor, they upregulate, downregulate, they mimic an actual hormone itself, but it modifies how your endocrine system or your hormonal system is functioning. And then in addition to that, very obvious response, because we can sit here and say, that makes sense. If you're exposed to an endocrine disruptor, that's obviously going to impact your hormones. Endocrine disrupting chemicals also cause inflammation within the body. So again, it's a double hit. You're directly changing hormone function based on how this chemical interacts with your body, second increases level of inflammation within your body, therefore worsening all the things that we've spent so much time reviewing. If people are wondering, how do we study this? Like at a high level. How a science is thinking about exposures to chemicals and toxins and reproductive health. So I did a study when I was in fellowship working with the Environmental Protection Agency. And what we did is we looked at PFCs or perforated chemicals. One of the classes of endocrine disruptors. And these are those forever chemicals often can be found in nonstick cookware and different food wrappings and coverings, but they also can leach into the water and the soil. And we can draw blood and look at levels of PFCs. And that's what we did in the study. Looking at PFC levels, time to pregnancy, menstrual cycle characteristics, ovarian reserve and thyroid function. And there's a clear association with higher levels of exposure and change to our reproductive outcome and longer time to pregnancy. So profound that when I was a fellow I came home and started saying, this is wild. This was more than a decade ago. But wild that at a time or at plastics in my kitchen and we cooked on nonstick cookware, the evidence that these things accumulate in your body forever chemicals can so severely impact your reproduction. And that I didn't know about this. And I was a fertility specialist and at the time nobody was talking about this. And my husband came home from work that day and I was cleaning out our whole kitchen. The whole pile of things like no more of this. There's often this mentality from people that well, we can't avoid all of them. So we should just not worry about it at all. The all or nothing effect. And we really need to get out of that mentality and go back to this whole every decision matter. And the sum of the exposures matters more than just one singular exposure. But we can start to make impactful change when it comes to inter-condistrupting chemicals. And the big three categories specifically are going to be those PFCs like I talked about. You're going to have your BPA, which I think most people are aware of. And then also phallates which are often plasticizers but also in fragrance based products. And so where I encourage people to start with these is let's start in our kitchen, our food and our bathroom. And the things that we use every single day are going to be much more impactful than something you're rarely exposed to. So we want to eliminate all plastic from our day to day life. We don't need to put food storage in plastic. We do not need plastic water bottles. Our children don't need plastic baby bottles. We don't need plastic dishware. We don't ever want to have plastic. If we do have to eat from it, heat it. We don't want warm food, warm drinks, put it in the microwave, put it in the dishwasher. So we want to change those things out for glass, stainless steel options that are not going to have as much of an exposure risk as we know that plastic and specifically heated plastic is. That's pretty well known now. So me saying that I think a lot of people are a little bit more aware of that. Yeah. But a big level of exposure I want to note here is going to be DoorDash. A lot of your food comes to you packaged in, we'll say, toxin rich environments, whatever the packaging may be. So it's really important if you do order food to go, you take it out of that packaging, eat it off of a plate. Or if you're still waiting to eat that maybe you put into a glass container or something else, if you're keeping it warm, putting it in the oven, take it out of what it's coming in. And then the wrappings for a lot of processed foods do have endocrine disruptors in them. And so paying attention to again, this idea that wrapped packaged processed foods shouldn't be the things that we're consuming day to day, things like the protein bars and other more processed foods. How do you feel about, like, take away to go coffee cup? helps. I feel like whenever possible, we should be trying to put it in a stainless coffee mug as much as possible and not even that not drinking through the plastic lid, right? Even your beautiful stainless cup often has a plastic lid. So trying to go to better options, again, the majority of the time. I mean, I've traveled to LA. Have I had coffee out of a cup with a plastic lid while I've been here? I absolutely have. But in my day of life, even if I put the plastic lid on to transport it, I'm taking it off to drink out of it. And even though I might not be having zero exposure, that's a lot more than it would be. Yeah, it's choosing a viable, potentially safer alternative when you can and it makes sense. Exactly. And not living your life in fear. Exactly. This is not fear, but knowledge it empowers you to make choices. And especially if we step back, especially in the world of infertility where there's so much lack of control, we don't obsess over these things every day at all. But understanding them lets you make a life shift so that I don't ever think about, oh my gosh, the plastic lid on my coffee mug. I don't even think about it anymore. I don't stress over these because I have cultivated a life where I'm avoiding them the majority of the time. And that gives my body the ability to have that resilience and to have that piece of mind that I am controlling the factors I can to have optimal hormonal health and fertility. Outside of the kitchen and food. Yes. What are the other kind of main behavior changes that you think would yield the biggest kind of bang for buck? Yeah. Let's talk about in the home and then behavior. In the home, we're going to say the bathroom, especially for the products that you're using every single day. So if there is something that you use once in a blue moon, I'm less worried about it. But lotions, soaps, shampoos, things that go on your body that are in part of your routine. We need to investigate these to see what chemicals are in them. This can be complicated. So I have a chart in here of things you should look out for and things that are more okay. You can also go to the environmental working group to skin deep. You can put in your exact product and you can see if it has any harmful toxins in it. And one thing I do want to say when it comes to phallate exposure, a lot of those can be from fragrance that there's a lot of deceitful marketing, which makes it really hard to be a consumer, meaning unscented and fragrance free do not mean the same thing. And we should be searching for fragrance free products over unscented because unscented can be a scent. I'll say you kind of just mask it. Exactly. To make it scent neutral versus having no added fragrance to it. Well, it's good to. Yeah. So it's just one little tip that we can start to look at when we are trying to choose products. So that one is something that it can be expensive. It's hard, especially for women to say, I need to go change all of my beauty products. But when you're getting low before you just reflexively buy, this is the shampoo we get or this is the hand soap we get. Take that moment to look it up, see if there's a better alternative and just start making smart decisions when it comes to those. I'm pretty sure the laundry detergent we use at home says fragrance free. Okay. So you're going to check it. Make sure it doesn't just say unscented. Now, other things in the home I want to mention is water and air. And there's a lot of this that we don't control because it's based on where we live. But we can look up our air quality and our water quality. We should be drinking filtered water. And we can use an activated charcoal filter or a reverse osmosis. These are ones that take a little bit more investment, but the payoff pays long term. You also should consider getting an air purifier in your home, especially if you live in a city-based area. And again, you can look up some of these things of the EPA website. You can actually look up that your air quality and your water quality. The water one is great because you can see what type of filter will filter out the toxins that are in your area. So it's actually not just a scary website, but it says for you living here, this type of water filter will remove if there's heavy metals or endocrine disruptors or what could be in the water there. So it's the least worth investigating and making informed decisions. I find the air purified doubles as a way to actually improve my sleep as well. The noise. It sounds machine. Yeah, we love it. And then also my kids is really cute because they'll realize when they use something, you know, our air filter turns like red when it gets louder. And it's real easy for them to get in the habit of, oh, like that's not necessarily good for me. That's changing the air around me. And so that's really great at a young age to start being aware of how these different things that we do can impact our overall health. And we can't talk about toxins without talking about behavioral toxins as well. Simon, I'll tell you the number one thing that I see in clinical practice right now is cannabis use and its impact on fertility. I see more men specifically using cannabis under the idea that it's a healthy option because it's normalized or that it's a non-harmful option without understanding the detriment that it has to sperm counts. And this isn't just theoretical, well proven evidence. Regular cannabis use is associated with changing the hypothalamic axis, meaning you're going to have less sperm produced lower testosterone levels if you use marijuana, especially consistently. What we also see is that marijuana exposure changes the quality of the sperm, increases the fragmentation of the DNA. So causes inflammation, it's toxic right inside the DNA, changes the motility of the sperm. Male cannabis exposure is associated with miscarriage in the female partner, even if the female partner is not exposed herself. It's that important. And when I see patients who have, we'll say, a bad IVF outcome because in the IVF lab, I'm in a unique position to be able to hopefully get your pregnant, but also learn more about your eggs and sperm and how they work together. So I told you earlier the male genome kicks in at day three of embryo life. So if you go through IVF, if you get your eggs out there, fertilize, and all your embryos stop growing at that day three, I can then say there's a male factor involved here. And more often and not when I sit down and review these factors with a couple, he will then admit to cannabis use that he previously declined. And if we stop that behavior, wait three months for a new sperm cycle, we will have a completely different outcome when it comes to our IVF outcome directly. It is that important. And for women who are using cannabis, they get 25% fewer eggs in embryos when they go through an IVF cycle, one fourth less. That's a huge number. This includes like CBD products and THC like gummies and those things. In most studies, yes, some studies are just looking at marijuana, some are looking at all cannabis based products. What we do know is we can say THC does cross the placenta. So we definitely want to be avoiding it if we are trying to conceive because we don't want to be crossing the placenta. We don't know exactly all the impact that can have on a growing fetus. But we do know that any cannabis exposure is associated with poor pregnancy outcomes as well, like preterm birth, growth restriction. So to me, we're trying to live our hormone healthy life, decrease inflammation, be in a position where we're taking control on that agency back. All cannabis based products are not it if we are trying to get pregnant. Another trend kind of goes hand in hand with the baggie jane's baggie pants, a back trend is that I've noticed it seems like younger kids are starting to smoke cigarettes again. I know what is that. And it's become a trendy thing on social media to be seen with cigarettes, which really was not trendy. When I was in my 20s at all, it was kind of frowned upon as a behavior. What do we understand about smoking cigarettes or vaping and fertility? Absolutely one of the worst things you can do for your fertility and your hormone health for men and for women. So we know that smoking cigarettes for women, cigarettes smoke gets into that vault. It's actually going to decrease the number of eggs that you have, women who smoke cigarettes go into menopause earlier and it negatively impacts their egg quality. So they have more DNA damage inside their eggs. So hugely impactful. Similarly for men, lower sperm counts, poor sperm quality, lower pregnancy rates. From a fertility standpoint, the smoking recommendation is exceedingly clear that it is harmful. There's less data on vaping, but all data that exists puts it as a absolutely terrible thing for your health. And so these are things to me that we make choices. I don't say here to control your behavior. But when you want to say that there's nothing you can do, well, that's not a true statement. These are decisions that we are making that in all cases we should avoid if we want to have our body function and it's appropriate way. And if we can't avoid it completely, we should limit to the extent of our ability. I think most people realize that binge drinking is not great for their health. But I wonder, is there is there evidence that links more moderate drinking to sperm quality or fertility? I'm talking kind of like the nightly glass of wine or a few drinks on the weekend. Is that going to affect a woman's fertility or a man's sperm quality at that level of intake? What's so interesting about alcohol being a doctor this long is seeing the cultural shift. If I were to try to say the data that I'm about to say 10 years ago, huge social pushback, now we're having much more acceptance that alcohol, of course, causes chronic inflammation. It changes how your body is functioning on a cellular level and it's not good for your health. The best amount of alcohol is no amount of alcohol. That's very, very clear. When it comes to what you describe as moderate drinking, what I would say is that the cutoff levels are much lower than most people think moderate drinking is. Two drinks a week for a woman and four drinks a week for a man. And again, these are actual drink size drinks, not the American standard, the extra large generous poor. At levels more than that, very clear associations with worse outcomes, lower sperm counts, poor egg quality, but at any level, we see harm to our hormones and fertility versus none. So again, you make the choices you make. I think we can take that data and say, if I want to have a glass of champagne on your birthday, especially if you're living a really anti-inflammatory life, your sun meter is going to be low, your inflammatory burden is going to be low, you're going to be able to have that glass of champagne and your body will process that inflammation. It will be less impactful than if you are a nightly, heavy, nay glass of wine because then your body is never recovering from it. In addition to the fact that alcohol is a carcinogen, it's also going to impact this insulin resistance pathway because it doesn't hold nutritional value, but does impact your body's cellular health. Okay. So on the topic of improving our chances of conceiving, I kind of like you get out of here without talking about six. Let's talk about it. Okay. So we've spoken about the timing in relation to ovulation. I think we covered that pretty well. There are all sorts of other ideas out there around positions, time of the day, position after sex. What does it matter when it comes to sex and conceiving? Let's talk about some of the top myths I see and separate myths from fact when it comes to sex and getting pregnant. Number one that I'm actually going to say is that people should have less sex if they're trying to conceive because they're saving up sperm for ovulation day. And I actually see patients do this a lot, meaning we've been abstaining because we want to put all the sperm there when the time is right. That's actually detrimental for a couple of different reasons. A man makes 1,500 sperm per second, millions of sperm a day. So if you are abstaining and having infrequent ejaculation, that sperm is just backing up and getting damage in the ejaculatory system. And in fact, prolonged abstinence intervals decrease available sperm quality. And I like really bad analogies as you know. So if we imagine a highway and I just want all my cars going, if you have a long abstinence interval, you're going to have a lot of stalled cars on the highway, making it harder for the good sperm to get where they need to go. It's going to take them longer. There's going to be a traffic jam because of all these stalled cars. So there's absolutely no reason that we should ever have less sex if you want to get pregnant. So first of all, don't back up. If you have sex every day as a part of your life, perfect, great, wonderful. If you don't, that's when we're trying to bring in targeting to that fertile window with the highest yield days being the day before ovulation or the day of ovulation. Those are the two best days that you're going to have the highest odds of getting pregnant the highest fecundability if you can target intercourse on one of those two days. And as we said earlier, sperm lives for five days in the reproductive tract, the egg lives for 24 hours. So the five days before and the day of ovulation are the only days that you can get pregnant in your menstrual cycle. So we don't want to have ejaculatory intervals of more than four days. So even if you guys are in a relationship where you don't have sex every day or every other day, we want to make sure you're ejaculating. Clearing the pipes, getting rid of the stalled cars so that when the moment is right, you're putting the best sperm possible. In that two day window, given that a man is making 1500 sperm per second. Crazy. Which is wild. Would you be increasing your chances of successfully fertilizing the egg by increasing the frequency of sex on those days? There's no reason to have to have sex multiple times the day if that's the question. It's going to be no difference the way I like to think about it is the rate of sperm turnover. It's essentially the same. I'm just putting it there at two different time periods or at one. And enough sperm live in the female reproductive tract, especially those first 48 hours for that to be a negligible difference. Do whatever works for your sex life. Position. There's no position that makes you more likely or less likely to get pregnant. So choose what works for your relationship. Of course, ejaculation is the key. I wish it were true that female orgasm was associated with higher rates of pregnancy. We would have an increase in the need to focus on female orgasm. But the reality is it makes negligible change. So always ago, let all men should shoot for. Right. That was a little subtle dig at the man this man did. But doesn't change. Come on, come on, let's lift out again. Right. It doesn't change odds of pregnancy. So whatever position is for lack of a better word, going to get the job done. sperm through the uterus, through the philopian tubes quite quickly. And if they encounter the egg, they're drawn towards it and attracted towards it. That's where they're going to go. But if there's no egg in the pathway, they are swimming out of the tubes and entering the parotoninial cavity quite quickly and some of them are staying behind in the cervix and inside the uterus. So you don't need to trap them inside the vagina anyway. I know a lot of people who will ask, do I need to elevate my hips and put my legs in the air? Don't you need to put a diaphragm in or something to try to trap the sperm inside. All you are doing in those circumstances is trapping the ejaculate inside. So the vagina is very acidic. Therefore the ejaculate, everything that is in the ejaculate that's not sperm is alkaline to help protect the sperm. So the sperm quickly swim out of that, swim through that stretchy, egg white cervical mucus and enter into the uterine cavity. So if you are trying to "trap the sperm inside", you're just keeping the ejaculate inside longer and you're increasing your escapherinary tract infection. Could it be a problem for the sperm, which is now the woman's responsibility, if she was to go into the sauna? No, that's a great question. We know that the testes are outside the body because sperm are created. Remember that sperm are packaged, the DNA gets inside the head, they grow and develop. It's actually fascinating. They grow and develop across the course of the testes. So at one side of the germ cells, packaging DNA into a head, growing and developing, getting a tail added till they get to the other side and then they migrate through the ejaculatory tract the next 18 days. So 72 days to develop, 18 days to swim out. The testes need to be at a lower core body temperature for this process to happen. And when they are not, testicular function is impaired. And this is why if you're trying to get pregnant, we want men to stay out of externally hot environments like the hot tub, like the sauna, like a laptop on your lap. However, the female body, especially around this time, is anybody's body, but your body has a higher core body temperature than your scrotum, which is outside your body. So we're not worried about sperm. They're already created and developed at that time. They're not going to get harmed once they're exiting the system. So that's sex. That's sex. Let's finish here with a tiny bit more on infertility. Okay. If someone has really been struggling with this, what are the options other than making these lifestyle changes and kind of hoping for the best? What are the kind of handful or few options that exist to help someone successfully conceive? Simon, there's many fewer than we'd love for them to be, to be honest. The field is amazing and incredible, but let's think about the different options that I have and how they may help. We have medications that can help with ovulation. So if you have some of this ovulatory dysfunction, a short loodial phase, a long follicular phase, irregular cycles, we can give medications that work to try to improve that process. So these are things like clomid or letharzole. They work a little bit differently, but in essence, they lower your estrogen levels. For the brain says, "I need more estrogen, sends out more FSH," and hopefully that's a strong enough signal to get you to ovulate. We also have what are called gonadotropin, some cells. These are injectable hormones that are FSH and LH directly. These medications can help you ovulate if you are not. We then also have options for men, we should talk about if your sperm counts are low. So not testosterone, but we can give clomid for men. Similarly, works at the brain level, binds estrogen receptors, the brain sends out more FSH and LH, hopefully this drives more natural testosterone production. gonadotropins and HCG can work similarly just more expensive. So we have hormones that if your sperm count is low, we can try to give to men to improve sperm count. If your ovulatory pattern is not ideal for women, we have ovulation induction medications that we can utilize. We then have something called an IUI or an intrauterine insemination. And this is when we want to take your players and put them further down the field. So if I try to explain conception rates to somebody, your rate of getting pregnant per month and your peak reproductive years late 20s, going to be about 20 to 25% per month. Pretty good, but not 100%. As we get older, that metric drops. So at age 35, if you're trying to get pregnant for the first time, your odds of conceiving per month are going to be 11 to 12%. And at 38 to 40, it's 5% per month. None of those numbers are zero, but it gets less easy to get pregnant as we get older. That's for a woman or a man or a woman. Those are female ages. We do see an impact of male ages as well, but it is an older age, 45 and older. We start to see a stronger impact of male age on fertility. But so we look at our monthly rates of getting pregnant, and we say not everybody's going to get pregnant every month. But I like to think about these numbers as I've got all, you know, my players on one end of the field, they're trying to kick the ball into a goal on the other side. So if you're 38, like it could happen, 5% is not zero, but that's not the highest odds, right? So an IUI and Intrigutor Ninsimination is when a man is going to ejaculate, into a cut, we're going to process that sperm sample and get the sperm isolated from the ejaculate. And then we put this highly concentrated sample of sperm into the uterine cavity. We will want to think about the vagina being a hostile environment because of the acidity and the cervix being the most truturous part of the journey. Like it's a windy road and the uterus is the open highway. We want to put this sperm there so they have an higher odds of making it to the egg. So this is taking your players and putting them further down the field. What I tell my patients though is if your players all suck, they still suck at the 50 yard line. The idea that we can make a goal with people who are injured, really terrible at their game, still not going to happen. So an IUI doesn't do everything, but it can be helpful in certain conditions, especially if the motility is low. They don't move as well. We call this a mild male factor. And it's utilized sometimes in what's known as unexplained infertility when we combine it with ovulation, specifically ovulating more than one egg. So like to think about this as well, if I've got two goals and I put my players further down, like hopefully somebody can make a shot. We're maximizing it. Exactly. So we're not treating maybe what's underlying in that instance where we're trying to improve the odds of making the shot. From there, we have surgery. So reproductive surgery is an option that sometimes can help people get pregnant. There are certain anatomical scenarios that can make it harder to conceive for the woman. Udorin polyps, which are benign, gross of the endometrial tissue. They're Udorin fibroids, which are gross of the muscle component of the uterus. Both of these can present with abnormal bleeding patterns. So again, going back to your periods of vital sign, abnormal bleeding can be a clue to get some of these diagnosed. An interesting one that many people don't know that they have is a uterine birth defect. So the uterus actually forms from two buds of what we call mullerian tissue. Little tiny buds in the embryo, they grow in a longay, they fuse together, and then the midline portion reabsorbs. And this tissue becomes the upper one third of the vagina, the cervix, the uterus, and the fallopian tubes. Overseas have a different origin. Lower vagina has a different origin. And you can have failure anywhere along this process. At its extreme, it's called mullerian agenesis being born with no uterus. You can have just one half develop, have half a uterus. We call that a unicornuate uterus. You can have two different uterine cavities that are not connected at all. Call that a uterine-dyed elfus. But one of the most common ones is called the uterine septum. So the uterus fuse together, but that midline portion did not reabsorble of the way. And there's a piece of avascular tissue that is dangling inside the uterus. Uterus septums are associated with an 80% chance of miscarriage. And that makes sense if we think about it. The embryo is going to come into the uterine cavity from the fallopian tube. And if there's this dangly piece of tissue, really attractive that it tries to go implant on, there's not the vascular blood supply that the rest of the uterus has to get a full implantation. Is that diagnosed with an ultrasound or? It can be diagnosed with a very specific type of ultrasound. So the problem with regular vaginal ultrasound, which is what we do for women, is that the uterus is a potential space, meaning these two walls are put together. And if I do an analogy and I put my ring inside, you don't know that always on vaginal ultrasound. So we can do an ultrasound where we put water into the uterine cavity and distend it a little, and then you can see that there's something abnormal inside. So to diagnose any of these uterine abnormalities, we actually have to do a more specific type of exam. And that's for polyps, fibroids, or for a uterine septum. So these are scenarios where uterine surgery can actually fix the problem. So we go fix this and then you can go and get pregnant. Surgery also plays a role for endometriosis, which we didn't touch on much, but to put it in one sentence. Endometriosis is a chronic inflammatory disease that has an autoimmune origin, meaning your body responds abnormally to a normal process. And some of your endometrial cells, the lining of the uterus is what women bleed off when they have their period. They're going to migrate out those fallopian tubes. And that's not problematic. In a normal non-endometriosis patient, her body would say Natalie's on a period, no big deal. But in somebody who has endometriosis, your body then acts like that's foreign material, activates your immune system to go fight the foreign invader, walls off this endometrial tissue and creates implants in your paratoneal cavity. And they get stimulated by every estrogen cycle. So every month as you ovulate and you make estrogen, estrogen grows the endometrial lining. You're going to stimulate these little patches, causing chronic inflammation. And over time, can obstruct anatomy as well. So endometriosis is a very terrible disease. You can cause severe pain due to chronic inflammation, pain with your period, pain with intercourse, GI distress, bloating. It also can take seven to 10 years to diagnose on average, because it's so hard to diagnose. You don't always see it on ultrasound or imaging. It's what we call a surgical diagnosis for the majority of people. Meaning you have to put a camera in your abdomen and not see endometriosis to know that you don't have it. If you do have endometriosis and we do surgery and we take out these lesions, we excise them, your inflammatory markers will improve. So your inflammation will drop and you will see a benefit to your natural fertility rates. But after about six months, this inflammation is going to come back. Unless we suppress your body and prevent you from ovulating, which is a different circumstance, but assuming for the sake of this discussion that you're trying to get pregnant, that is a temporary solution that helps some people. And my big plea is that before you do that, please test everything else for your fertility. Make sure your tubes are open, know your ovarian reserve, have your partner check a semen analysis. So before we do a game plan that might temporarily aid us, be ready to go as soon as you're done with that so you can make the most of those six months. So those are ways of the surgery can be one tool that we have. And the biggest tool that we have is the only thing that's ever going to exceed natural conception rates. Meaning ovulation induction, IUI or surgery are trying to fix a problem to get us back to our baseline rates for our age because our rates are lower because we have infertility. So if you're 35, I'm trying to get you to a 12% chance of success. I'm not getting you higher than that. IVF plays in a different camp. It's apples to oranges. When we get a genetically normal embryo, you have a 65% chance of a live birth rate. 65 is incomparable to 5%, and to 10%, and to 20%, right? We're playing a different game. IVF, if I want to put it simply, is getting one month's group of eggs. So whatever eggs have been synodied at the vault that month, giving good natotropins, so higher doses of FSH and LH than your body would normally make to try to get that entire group of eggs to grow. This is hormone shots, coming in for ultrasound, and then we take the eggs out of the body with a procedure called an egg retrieval, which is a large needle attached to a vaginal ultrasound. It takes two weeks to grow the eggs, so it's not a really long timeline there. It feels uncomfortable to grow the eggs, pelvic pressure, bloating, but it's not acutely painful. The egg retrieval, we always do it under anesthesia. So very long, that would be painful if you didn't have anesthesia. And then the eggs are outside your body, fertilize in the lab, and then they can grow out in the lab until that implantation stage. Importantly, especially for this discussion of chronic inflammation, for somebody who can't modify their inflammation or who is doing everything, or who has endometriosis or autoimmune disease. When I take your eggs out of the body, I am now able for the most vulnerable stages of human development to have it in a non-inflammatory environment. Fertilization and early embryo growth is when the greatest loss happens in the reproductive timeline. Only about 75 to 80% of eggs will fertilize, even in the perfect scenario. Only about half of those that fertilize would make it to an implantation stage embryo. So if you have endometriosis, and maybe you had surgery and you still didn't get pregnant, you're going to see us more quickly go to IVF because now I can take the eggs out of that inflammatory environment and grow the embryos in something that is "perfect" with no inflammation, all the nutrients that an embryo needs. The rate of genetic normalcy will depend on partly your age, so a person to person at varies. We'll say an average 35-year-old has about 50% of their eggs genetically normal. This is somewhere where for all the reasons we discussed, we do have some agency over this number. We need to be more metabolically unhelpful. whether it's choices we're making or chronic disease, we're gonna have less genetic normalcy than people who tend to be more metabolically healthy. But if we use really rough numbers really fast just to make this make sense. If I get 16x at a 35 year old, let's say 14 of them fertilize and that would be average. About half of these would make it to an implantation stage embryo, which is day five or six called the blastocyst, so let's call it seven. And then 50% of these would be genetically normal. Let's round down and call it three. So this 135 year old who had average across the whole board got three genetically normal embryos. A single genetically normal embryo has a 65% chance of life birth, but cumulative rates are high after multiple transfers. So after a second transfer, so people either got pregnant in the first or the second one, it's about 85% of people will have success. And after three, then it will be 95%. So most people will actually have success with IVF, asterisk if you get enough embryos. And to quickly give the contrast, if you're 40, and let's say you have a really great cycle and you got 10x and eight fertilized and four made it to the blastocyst, but the average rate of genetic abnormality at age 40 is 25%. You got one embryo, so you have one tri. So for the same woman, a cycle at age 35 might give her three times as many embryos to work with, how she's gonna get at age 40. - So age is the biggest kind of risk factor for IVF not working? - Exactly, and we have to look through the lens though that as we get older, the population tends to get more metabolically unhealthy as well. So there's that doubling impact. But for all of us, we can't escape the fact that we will run out of eggs, eggs won't get lower, making this mathematical equation harder, and time does add up and our chromosomes will become abnormal at some point. And just to say egg freezing is the first part of IVF. So if a woman says, "Should I freeze my eggs?" What we're doing is getting that one month's group of eggs to grow, taking them out of her body and freezing them at the egg freezing point. She still has to do IVF or in vitro fertilization, fertilization in the lab, once she's ready to use them. We'll thaw the eggs, fertilize them with sperm, and then pick up into the second half of the equation. Egg freezing is not a guarantee. It is not an insurance policy. So many people will say that, and I think we are overgarenting. Egg freezing is an investment. It's like putting your money in the stock market. Like is it usually good to invest your money? Yes, does it usually pay off for many people? Yes, is there risk involved? Is there a guarantee of your outcome? The return on that investment is determined by factors we do not know, your health later on, your partner's sperm. So we make a lot of assumptions when we freeze eggs. 10 years ago when I entered this field, egg freezing was still experimental. And the reason why is that egg freezing technology was not as good, and only about 40% to 50% of eggs survived the freeze thaw. That led to a lot of women who were doing egg freezing at that time being pushed towards fertilization with sperm, trying to make embryos because they survived so much better. I'm happy to say that egg freezing has advanced. Survival rates of a single egg in the lamp are 90 to 95% on average. That's incredible. A single cell filled with mitochondria, DNA, mostly cytoplasm, we can freeze it and thaw it with a 90 to 95% survival rate. So in today's age, it's a very rare scenario where a single woman should be fertilizing eggs with donor sperm, unless she is actively trying to conceive. We should feel confident in egg freezing. And for the same cost of making embryos fertilizing with sperm, she could do two rounds of egg freezing. Like to think that's the first half of the process. Ultimately, have more eggs that are frozen and keep this door of opportunity open longer. - I could keep talking to you for hours. We're at three hours. I think I told you we were gonna run for about 90 minutes. - You said six weeks. - So clearly this has been a conversation that I've thoroughly enjoyed. And you have such a breadth and depth of knowledge for this area of science. And just to kind of sit with someone and see that ability to recall the information, to apply it and then communicate it to how listeners has just been really inspiring. - Thank you so much. - Let alone all of the very, very helpful information that is gonna reach listeners, men and women that can drastically change their life and help them with things that they may be struggling with. So thank you so much for being with us and hanging out with me today. I hope that everyone goes out and gets a copy of the Fidelity Formula and shares it with their friends and share this episode with your friends if you were to leave people with a single, the most important perspective shift about Fidelity today. What would that be? - Honestly, the one I wanna say is one thing we didn't is that you're not alone in a process that feels very isolating. There are many people who struggle either trying to understand their body, trying to get pregnant or even in the depths of infertility. And hopefully this episode is coming to you from a place of knowledge, helping you advocate for yourself, know what to expect, but also seeing all the things that you can do that can make a positive impact on your fertility and taking control of those factors does put you in a place where you can have that peace of mind. I always say, I don't achieve every goal that I set out to do, but it's not gonna be for lack of trying. I'm gonna do everything I can to have the peace of mind that I set myself up for success. And I want everybody who's on the side of the table trying to get pregnant, the shoes that I was in once, to not have all these questions and searching the internet, but to have that guidebook of knowledge that they need. - Beautiful, thank you so much for being with us today. - Thank you, Simon. - There you have it, friends. I hope you enjoyed this episode. If you did and want to stay up to date with future episodes, be sure to hit that subscribe button on YouTube and follow on Apple or Spotify. Finally, thank you for showing up and the effort that you're making to take control of your health. I look forward to hanging out with you again in the next episode.