Dr. Natalie Crawford: Female Hormone Health, Fertility & Vitality

welcome to the huberman Lab podcast

where we discuss science and

science-based tools for everyday

[Music]

life I'm Andrew huberman and I'm a

professor of neurobiology and

Opthalmology at Stanford School of

Medicine my guest today is Dr Natalie

Crawford Dr Natalie Crawford is a

medical doctor specializing in

Obstetrics and Gynecology reproductive

endocrinology and infertility she also

holds a degree in nutrition science Dr

Crawford runs a clinical practice seen

patients daily as well as being actively

involved in public education both

through social media and through her

popular podcast entitled as a woman

today Dr Crawford teaches us about all

aspects of female hormones and Hormone

Health and fertility beginning as far

back as in utero when we were still in

our mother's womb and extending as far

forward as menopause we discussed topics

such as the timing of puberty and what

the timing of puberty in girls means for

their fertility and we discussed birth

control both hormonal and non- hormonal

forms of birth control and how birth

control may or may not relate to

long-term fertility and different

aspects of female Health we also talk

extensively about measuring fertility

that is egg count we also talk about egg

retrieval AKA freezing one's eggs as

well as invitro fertilization and we

also take a deep dive into the popular

and important topics of nutrition and

supplementation as they relate to

fertility as they relate to pregnancy

but also how they relate to female

hormone Health generally indeed Dr

Crawford provides us with a master class

on female hormones and fertility one

that I know that all women ought to

benefit from and that men would benefit

from listening to as well before we

begin I'd like to emphasize that this

podcast is separate from my teaching and

research roles at Stanford it is however

part of my desire and effort to bring

zero cost to Consumer information about

science and science related tools to the

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always thank you for your interest in

science and now for my discussion with

Dr Natalie Crawford Dr Crawford welcome

thank you so much for having me I'm

honored to be here well I've been paying

attention to your content for a long

time and I find it to be incredibly

clear informative and for many people

actionable so today I'd like to talk

about both fertility and of course

hormones but as we both know fertility

is not limited to a discussion about

hormones it actually relates to things

like behaviors yes sex behaviors and

other behaviors nutrition

supplementation so we'll get into all of

it but if we could just back up

developmentally and talk a little bit

about female puberty because I think

pretty much everything we'll talk about

today is related to what happens puberty

forward mostly in females but we will

also discuss male fertility and hormones

a bit and the question I have is is

there anything about a woman's timing

or let's just say patterns of puberty

right how frequent

they menstrate early on what the timing

of menstration is uh in terms of their

age Etc that provides hints or maybe

even facts or directives about her

future fertility or how long her

fertility might last this is a great

question and I think defining some

terminology before we begin is helpful

so if we go all the way back to when

you're a fetus inside your mom so when

there's a female fetus inside your mom

you have the most eggs you're ever going

to have at about 20 weeks gestation you

have about 6 to 7 million eggs by the

time you're born you've already lost

more than half of those and you

continually lose eggs all the time so

the analogy that I always use and you do

too is imagining that there's a vault

inside the ovary where all your eggs are

kept and every single month since the

moment you have an ovary you lose a

group of these eggs and when there's

more inside you're losing more so you're

losing all of these eggs throughout

early fetal development and then up

until the time period even of puberty

when you reach puberty you have a

lessening of the number of eggs in your

ovary to the point where it can start to

respond to the signals from the brain so

we think about puberty aret in females

first we have really thearchy which is

the development of breasts so that

happens about two years on average

before you have minarchy which is your

period starting so what happens is the

brain as we know from the hypothalamus

sends out G&R and then we have FSH

coming out which really starts to

stimulate those follicles so fshr

follicle stimulating hormone well-named

hormone for the female of course men

have it too and it's less well- named

for them but it starts to get those

follicles which house the eggs to grow

and make estrogen women have about 2

years of estrogen exposure alone so

unopposed estrogen with no progesterone

because they're not yet ovulating and

that's when you start to see breast

budding and you start to see the

development of some of those secondary

sex characteristics before you actually

have a period what are some of the other

secondary sex characteristics that

precede menarchy um so you said uh

breast Bud development and then breast

development on average about two years

before before you have sexual hair

development so actually adrin Archy is

one of the first usually comes right

before at the same time with breast buds

so two to three years before you'll see

your period And so genital hair underarm

hair yeah genital hair usually first and

then underarm hair um and we're getting

right down into the weeds here which is

good um you know a goal of this podcast

is to normalize all aspects of Health

including sexual health and and

reproductive Health um is that

commensurate also with um the

development of body odor yes you know

because as a young boy who eventually

hit puberty and became a young man and

now I suppose I'm in middle age um 48 um

I can tell you that the the locker room

smelled a lot different um be before

before and after Middle School right

right like the in other words boys start

to smell stinky um right they do yes and

that's usually around that same time of

sexual hair development is when you

start to have those glands around the

hair making some of those odors that

start to produce stink do they reflect

hormones themselves not this like the

smell the actual smell doesn't actually

reflect levels of hormones or anything

like that it is just that your body your

gonads whether it is testes or ovaries

are now starting to respond to those

brain signals the brain is turned on

they're starting to respond and your

body is starting to mature in a way to

get to the point where it can support

reproduction the reason I asked that

question is not to get people thinking

about um stinky smells but um and by the

way some people love the musty smell of

of their own uh armpits or others you

know we're referring to adults um by the

way um but the reason I ask is that

there's a wealth of data in animal

models including cluding non-human

primates suggesting that um exposure to

the odors of others can either um

stimulate or accelerate puberty um is

there any evidence for that in humans so

there's mild evidence and it's murky

because we also know that anything that

could be an endocrine disruptor which a

lot of scents or fragrances are also can

accelerate the onset of puberty by

disrupting part of this system and so we

know that toxins and you know scents and

a lot of the world that we're exposed to

is part of the reason why we're seeing

puberty happening at such a younger age

now in females specifically but in both

but in females than we have before we

have young girls seeing their onset of

menarchy or their period at a much

younger age how much younger I I've seen

the various graphs for different

countries but can we say that you know

10 years ago on average um girls in the

United States and Northern Europe were

hitting menarchy at about what 12 to 13

years of age yeah so you know start

we'll use menarchy for the purpose of

this so having your period you know 10

to 20 years ago you will see most data

would say oh 13 to 15 would have been

kind of the average age and now we're

really seeing it shift to be starting at

10 to 11 and completing by 1314 so most

girls are definitely going through the

puberty change earlier and the other

thing to note is that most girls get

their final height growth right before

they start their period too so not only

are we seeing a change in this getting

starting earlier what we're also seeing

is probably some reduction in height

from having gone through puberty at an

earlier process because once you start

actually menstrating once the ovaries

have really started to learn how to

respond to that FSH and grow the

follicle and it gets to the point where

you can start ovulating so about 2 years

later then that ovulatory period those

high levels of estrogen are going to go

and they're going to close those growth

plates so you've really started to limit

your final adult height as well when you

go through puberty earlier and that's

definitely something that's a huge

concern for precocious puberty or very

young puberty right and we can use

blockers when there are children who

start to exhibit signs of puberty and

one of the main reasons people do that

is to try to get them to a greater adult

height if they're really starting to go

through puberty at a very young age is

that also true for males that it's

happening earlier that earlier puberty

means that your growth spurt uh in terms

of height is going to be uh truncated

not the same and you probably most men

will say oh but I had my growth spur you

know kind of after I started having some

of the puberty change that happened but

because it is this estrogen related

process and women that we see that gross

bird really your final height is within

that year of when your period starts

interesting yeah this uh discussion is

certainly not about me but I was one of

these what I thought was kind of an odd

duck I hit puberty about 13

14 um let's just say I knew I did um but

I didn't shave until I was after college

my growth spurt between freshman and

sophomore year I grew a foot right so I

was like you know grew a full foot but I

was the same weight so I was like real

tall real skinny or pretty- tall you

know real skinny and then it seems like

um you know some people in my life would

argue that puberty is still occurring

for me but it feels like it's very long

and protracted which leads me to a a a

um a very specific question um if

puberty arrives let's again defined as

menarchy um for sake of our discussion

right now if puberty arrives early in a

girl does that mean that her fertility

will shut down earlier as well great

question it does not so the age of which

you start the onset of your period does

not impact how long you're going to have

a reproductive lifespan and that's

because you have the eggs inside that

Vault you're losing them every month

month no matter what so you lost them

all those years before your period

started no matter if your period came at

10 or at 15 it's just about when did

they start allowing your body to ovulate

determined by being able to carry a baby

your body now thinks you can be pregnant

I think this is so important to

highlight because it puts together what

you said earlier about the loss of eggs

even in um as a fetus um I think most

people sort of assume that the reduction

in egg count is due to ovulation and the

fact that you know one egg ovulates

typically but that other eggs are

deployed in that ovulatory cycle and

then those those basically are taken out

of the Vault and out of the opportunity

for fertilization but what you're saying

is that the eggs are constantly being C

From the Vault starting from early

embryonic development and that ovulation

is a distinct step in some sense

unrelated to to to the loss of eggs I

think this is going to be be very

important for our discussion later about

potential egg Harvest yes because I

think some people have it in mind a lot

of misconceptions that you're losing

eggs from your fault and that's not the

case you're just accessing the ones

outside gosh so you're not um so we can

just answer this now perhaps it seems if

I understand correctly that if one were

to harvest eggs for IVF or for

embryogenesis in a dish to set them

aside later or freeze them for later um

if they want to use them eggs or or

fertilized embryos that one is

not reducing the total number of eggs

any more than they would had they just

let their their Cycles proceed naturally

exactly oh that's such an important

point I think that I think a lot of

people believe the opposite they it's

probably the number one thing that

patients fear when they come talk to me

about egg freezing or going through IVF

is I don't want to harm my future

fertility I don't want to cause myself

to run out of eggs earlier or going into

menopause earlier and it's explaining

this process to them that your ovaries

are on a pathway that you can't change

those eggs are coming out of the Vault

regardless of if you're on birth control

pills you're pregnant we do IVF what

we're modifying is one's not going to

ovulate and have the rest of them die

we're going to try to give you

medication to get them all to grow so we

can take all of the ones that have been

released from the Vault that month and

give them a chance for later and the

next month you'll have another group

come out so IVF is not about stimulating

hyper relase or excessive release of

eggs it's about stimulating the growth

of the ones that have been released so

that they can be Frozen at stage either

for later fertilization or fertilized in

addition than Frozen as embryos is that

right exactly and we just use the

hormones that your body normally makes

in a different way the medications we

use are FSH and LH to get the eggs to

grow so people will say I don't want to

take all these weird hormones or strange

medications but we're just manipulating

that normal process that happens in the

natural menstrual cycle in order to say

hey this month let's get all these eggs

to grow let's try to improve the

efficiency

of finding which eggs are going to be

normal or not and help you along this

process I think a good number of people

are now going to uh head to the IVF

Clinic I think again I really want to

highlight this I I think most people

that I've spoken to assume that the

process of harvesting eggs for

freezing for fertilization then or later

is going to diminish their fertility

because they're basically pulling more

out of the savings account so to speak

right okay so you're making the

withdrawal no matter what great well um

such an important point for for people

to know and and propagate um getting

back to puberty uh a little bit later on

I wanted to get into endocrine

disruptors and things of that sort but

since you brought it up um you know I've

heard things such as okay things like

evening primrose oil if Mom is putting

evening primrose oil on or has it in her

shampoo that I've heard of young males

getting um precocious breast Bud

development and keep in mind folks that

some transient breast Bud development is

um characteristic of some normal

puberties in males it sometimes shows up

and goes I knew some kids like that in

the neighborhood they got teased a

little bit and then they stopped getting

teased hopefully nowadays they don't

tease those kids but when I was growing

up those kids got teased not by me but

by other people but it was normal in it

pasted for for some right it occurred um

normally and then ped but I've heard

that things like exposure to evening

primrose oil maybe even just through

contact with Mom can um increase the the

frequency or degree of that male breast

Bud development is it also true

that young girls can undergo precocious

puberty or let's just say accelerated or

exacerbated puberty um through contact

with things like evening primrose oil

which is a I think has some pseudo

estrogen like properties it's important

to differentiate that the secondary sex

characteristics we see like breast Bud

development are from estrogen but it's

not really puberty being initiated when

it's from an endocrine disrupting

chemical so taking you know being

exposed to evening primrose or lavender

or te tea tree oil in a male isn't going

to cause him to start to go into puberty

but it is going to expose him to

estrogen when his body is not and

therefore stimulate some breast bed

development same thing can happen in

young girls meaning they could show some

of those secondary sex signs earlier

than they normally would and this is why

if that's happening at a really young

age kids should go to a pediatric

endocrinologist who are going to check

things like bone age and see if you've

really started the puberty process or

not or is it an outside exposure which

is causing it interestingly about the

young child exposure and development the

other thing to say that's really

interesting and relevant in my field is

that when we think about how many eggs

are in the vault and everybody's born

with this different number and I'm sure

we'll talk about ovarian reserve what we

now know is that the Vault your ovaries

are most susceptible to whatever your

mother does when she's pregnant with you

and that that epigenetic that

programming which is happening is

predisposing young women to probably

having some of them low ovarian reserve

some of them having diseases we

associate with infertility like PCOS or

endometriosis and we haven't yet

characterized what all they are but if

we look at the incidence of some of

these disease that we see now what we do

know is that the time period of which

these people were pregnant the 80s and

90s was not the healthiest time when it

comes to endocrine disruptors and

plastic exposures and chemicals and all

of this processed stuff let's just say

that people have been exposed to that

we're really seeing that those that

ovarian susceptibility to egg quality

and quantity happens in that fetal

development period it's interesting uh

because there are some uh parallels to

male fetal development like the the fact

that you have these or early organizing

effects of hormones like

dihydrotestosterone which essentially

stimulate the growth of the penis but

also then establish a a propensity for

hormones during puberty to activate

growth of the sex organs but also

activate the brain areas they're

responsible for a host of different

things so I only mention that because uh

what I'd like to kind of illustrate in

the background here is that um basically

our reproductive Health

begins really prior prior to conception

really it's a dependent on Mom and Dad

but um certainly to a great degree on on

mom um but then fetal development is

going to be important so sort of um us

uh being able to pick our parents um I I

do have a couple questions about

lavender tea tree oil and evening

primrose oil I was aware that evening

Prim oil oil excuse me can um somehow

bind estrogen receptors or mimic uh some

of the estr or something similar to it I

wasn't aware of tea tree oil or lavender

um here are we talking about oils what

about Aromas and how concerned do people

have to be about this stuff because I

mean you know you'll go into a

restaurant bathroom there'll be popere

uh some people wear perfume I mean we

don't want to set a paranoia but but I

but I think people should know about

this stuff Teo is in a lot of those um

natural shampoos L burn yes the one that

tingle your scalps some people love them

though constant exposure is very

different than a one-time hand washing

in the bathroom and I think that's a big

difference for everything when we talk

about chemicals or toxins or exposures

in the world you can't live in a

toxin-free world but choosing what you

put in and on your body on a regular

basis does set the tone for certain

physiological changes and so you know

using unscented products especially with

children is really an important thing

because we want to make sure that their

lifetime exposure to some of these

things especially during critical times

is much less and so you'll see people

recommend things like your laundry

detergent you know what sensor in your

laundry detergent the shampoo and

conditioner are a big one and the Soaps

that you use on a day-to-day basis in

your house or the oils you put on your

body Lavender is huge because there's

this whole community of people they want

to rub lavender oil on their baby's feet

and help them sleep but really we can

see and if somebody goes and shadows a

pediatric endocrinologist for a day

they'll see some kids come in and this

will be the reason why uh what about

cloth diapers versus non- cloth diapers

I've heard you know that you have your

like very strong cloth drier proponents

right and that because they seem to um

feel or believe that um non- cloth

diapers somehow contain things that can

get into baby's skin and and maybe

there's a bigger question here is baby

skin more permeable than I gu I don't

know that baby skin is more permeable I

don't either I just to me it seems it

seems like it' be hard to imagine it is

but but babies do seem to have this

incredible skin right their skin is so

smooth and and you want to squeeze their

cheeks and all this kind of stuff but um

yeah had the idea they would be more

permeable I think it's more that their

development is this time is very

important and setting the stage for a

lot of what happens later versus in

adulthood those stepwise developmental

processes have already happened so I

think that's why we pay so much

attention to what happens in the you

know childhood period of time because

we're now learning about those later

consequences of what you're exposed to

it's not that you know regular diapers

versus cloth whatever we want to say it

one's necessarily better than the other

it's more honestly a personal preference

babies are exposed to them a lot and

there's been a lot of attention to that

but similarly somebody could use cloth

and wash it with a detergent that then

you know has certain chemicals in it so

there hasn't been a study shown that

this one thing is an exposure for a baby

that somebody needs to be worried about

there's definitely companies now which

are promoting and talking about you know

traditional diapers that they are making

sure have less toxins in them and I

always think anytime you can decrease

toxin exposure to a child is going to be

very

important is there any evidence for um

you know breast milk versus Formula in

terms of impact on future reproductive

development of or reproductive status of

of a child that's a complicated question

because breast milk exposure at least

for the first 6 months of a child's life

certainly helps with the immune system

development and we know that poor immune

development can lead to higher risk of

autoimmune disease later what people

call leaky gut and some of those

diseases certainly are correlated with

fertility so I wouldn't say we've gone

so far to say that if you don't

breastfeed your child they're going to

have fertility issues but we do know

that there's an in between correlation

with things that breastfeeding is

protective against

and how those diseases themselves May

relate to fertility in the female later

on okay okay so if we're um thinking

about a young girlwoman because we're

talking about puberty right so I don't

know what the exact nomenclature is

there you know my experiences I'll I'll

offend and um somebody no matter what um

but a girl who under goes puberty right

so a young woman um who's maybe 13 or so

so she's early teens um under goes

puberty and therefore is contining to

lose eggs from the Vault um but now is

undergoing uh

presumably roughly every 28 days

manarchy but let's talk about this 28

days thing because I think a lot of

people think that um quote unquote

normal menstration is always 28 days and

and we know that's not true so what is

the the range of uh normal durations

between um menstration uh Cycles or

duration of the menstration cycle and

and let's also Define when the

menstruation cycle starts probably for

the males mostly in the audience sure

sure so let's think through the cycle

we'll do a quick one over and then

answer the questions so what we think of

is cycle day one or when you're going to

say this starts is going to be the day

that you start bleeding so that's

actually shedding the endometrial lining

from what grew the last time so any

spotting even would be considered day

one okay so it is we can get back to it

but there's problematic if you have a

lot of spotting before that full flow

starts a day or so can be really normal

just as the body's adjusting to the drop

in progesterone but let's just start at

the beginning day one you have a period

a menes this is when you're actually

bleeding at this time period we like to

think about all of those new eggs being

out of the Vault being susceptible to

that FSH which of course is that

well-named hormone because it stimulates

a follicle to grow and each egg is in a

follicle that egg starts to grow and

makes estrogen that estrogen stimulates

the proliferation of the lining of the

uterus and preparation for potentially

that pregnancy that may come and also

that estrogen makes you feel really

great right that's the folicular phase

name so because that follicle is growing

and it's an FSH dominant phase where you

have a lot of estrogen and people feel

great when they have a lot of estrogen

because women feel good with estrogen

because of the relationship between

estrogen and other neuromodulators like

dopamine serotonin and and is that

happening in parallel or are they

somehow related like is estrogen

controlling the release of Serotonin

somehow and VI Versa or are they just

kind of coincidentally happening in

parallel we definitely think that

there's more of a correlation causation

than just coincidence because we know

there's time periods of people are more

depressed within your cycle correlating

with those low estrogen levels and we

know that when you go into menopause or

you run out of eggs and you're now in a

low estrogen phase we see a lot more of

a depressed mood and you know anadon

lack of response to things which would

normally give you pleasure happens more

more frequently the female brain loves

estrogen and it's protective against

things like dementia so this is a time

period where women are going to be more

energetic they're going to have more

energy more Focus this is the estrogen

dominant phase of the cycle and when you

have seen that estrogen at its high

levels which it's only made from a

mature follicle and it's very specific

200 pams per milliliter for 50 hours

that's the brain's clue okay we must

have a mature egg and it can send out

that surge of LH or luttin hormone and

now you ovulate and when you ovulate the

follicle opens up releases closes back

and then it's the Corpus ludum and we've

entered the ludal phase and the Corpus

ludum as the name suggests a corpus it's

like a body that's basically the it's

Bas it's basically the the corpse of of

what yeah en sheathed the egg before um

and it what I find so amazing I mean

biology is so beautiful right it instead

of just taking that tissue and saying

okay like let's just discard this or um

that becomes the trigger for the next

phase of the it is essential for life

right the Corpus ludum which makes

progesterone opens and closes the

implantation window it is what allows

somebody to get pregnant and for our

species to continue it's so it's

extremely fascinating and that Corpus

ludum gets stimulated to produce

progesterone imp pulses throughout the

entire ludal phase because it's still

controlled by the brain unless you get

pregnant and then in that ludal phase

progesterone is fast ating it's trying

to protect you from things which could

potentially harm your baby so suddenly

now you have less energy you want to

sleep more you want to eat more you

maybe do not want to have sex as much

because your body is suddenly saying

let's just protect this potential

implantation that you're going to have

if that pregnancy doesn't come the

Corpus ludum can only live 12 to 14 days

it has a very distinct lifespan and then

it dies your estrogen and progesterone

both drop you bleed starting over the

next cycle and a new group of follicles

comes out to be released and the reason

why walking through that very succinctly

but is important when you're asking how

long is the normal cycle because the

ludal phase is pretty set at 12 to 14

days the follicular phase can vary in

person to person and what we know though

is for one individual if your menstrual

cycle your reproductive hormones are

working right it should be Rel

relatively constant for you and so if

your periods are every 24 days but

they've always been every 24 to 25 days

then that's not concerning and if your

periods are every 33 days but they've

always been every 33 days then that's

not concerning but we do get concerned

when there's a change in your period or

we get concerned when people have what I

like to say is irregularly regular

periods because what you'll see

textbooks tell you is that your periods

could be as short as 21 days as long as

35 days and that can all be normal but

people will hop between them and they'll

have one cycle that is 24 days in length

from day one to the last day before the

next day one then the next Cycle's 32

and then it's 26 and then it's 34 and

that's not normal that's too irregular

and that can be a sign that something is

not communicating correctly within your

reproductive hormones so what I tell

patients is in general your period

should be less than 35 days apart and

you should be able to look at a calendar

and with your finger put a finger on the

date and within a couple days of

accuracy be able to predict when your

period's coming and if you can't there

could likely be something that is

interfering with the hormonal signals

between the brain and the ovary and one

of the biggest really one of the only

things we see as women start to have

fewer eggs in the vault is a shortening

of their Cycles so you have a regular

period and suddenly now you have less

eggs in the vault so less are coming out

each month and when the brain sends out

that FSH signal now there's fewer eggs

so it's not getting as dilute and you

have one starting to respond sooner so

suddenly you're ovulating shorter faster

in your cycle you're ovulating on cycle

date 9 instead of 14 your ludal phase is

still set but the person who comes to

see me and says my periods have always

been 28 to 30 days but now they're every

24 I just figure it's no big deal I am

have red flags going off everywhere

because I'm now really concerned that

potentially their ovarian reserve has

dropped to a point where we are starting

to see clinical changes now of course

things like thyroid and prolactin and

other hormones can also cause such

changes but that's why you'll hear most

reproductive endocrinologists say your

period's a Vital sign and what we really

mean is the regularity at which it comes

and the predictability of it is telling

us if your hormones are all

communicating in a normal fashion or if

something could potentially be off as we

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claim that special offer let me see if I

have this correct um we've got this

thing that we call the menstrual cycle

the ovulatory

cycle the there's two phases a

follicular phase and a ludal phase here

precedes the ludal phase the ludal phase

tends to be if I heard correctly um

fairly fixed about 14 days mhm um the

follicular phase can vary in duration

maybe 10 to 14 days maybe even 10 to 18

days depending on the person something

about their brain to ovary

communication for those that um aren't

familiar with this um the I always

learned that estrogen primes

progesterone is kind of the really basic

top Contour description of the ovulatory

cycle that you know estrogen is going to

slowly climb toward the the point of

ovulation and then there's a there's a

peak and then a drop and then

progesterone is going to dominate in the

ludal phase the second half you said

that estrogen um is associated with with

a psychological level and a

physiological level more energy um

feelings of Vitality and some of that

estrogen increase is actually coming

from the one egg that got stimulated the

most the the one that got selected right

so picked for the team um potentially

for the team but got picked uh

potentially for fertilization and that

egg sheds its Corpus ludum

which is this piece of the of the egg

that then triggers the progesterone that

dominates the ludal phase do I have that

right mostly mostly yeah please correct

me the follicle in which the egg grows

right when you ovulate it ruptures the

cyst burst a follicle is a cyst a cyst

is a fluid filed structure follicle is a

fluid fill structure that holds an egg

so when you ovulate and you get that LH

surge the cyst bursts it opens up and

the egg comes out of it and then it

reheal and becomes the ludum got it so

just a little bit different in timing

and you're right with estrogen primes

progesterone but really we think about

it the layer of the uterus because

estrogen stimulates the growth of that

lining and then progesterone stabilizes

it and allows implantation to occur but

the sequence of events of when you're

estrogen dominant and progesterone

deficient which is the folicular phase

and people will come in having Labs

drawn randomly and they're all concerned

that they don't have progesterone and

when you talk to them about where they

are in their cycle you say you're not

supposed to have progesterone that's

your follicular phase this is perfectly

normal okay great thanks for that

clarification I get a lot of questions

about birth control but on my social

media handles don't we all don't we all

to be clear

um this it's a vast topic for

exploration but along the lines of what

we're talking about now I've heard and I

suspect it may not be true but tell me

is there any evidence that taking birth

control can disrupt the process that you

just described and when we talk about

birth control we should probably Define

what we're talking about so there are um

hormone-based birth controls aka the

pill there're also hormone-based birth

controls that are not in pill form um

there are iuds that are copper iuds

there are other iuds let's just talk

about hormone-based

contraception in females okay uh if

which many of them as I understand are

estrogen mimics or estrogen themselves

that suppress ovulation do they diminish

or increase the number of eggs that are

taken from the Vault fantastic question

let's talk about what people say is the

pill so let's specifically talk about

combined oral contraception the pill

which has ethanol estrad and some type

of

progestin no contraception does not

change the release of eggs out of the

Vault they are occurring at the same

process and the same pathway you're not

ovulating because that estrogen does

prevent FSH from coming from the brain

so you have the group of eggs still come

out of the Vault there's no FSH they

just all die the next group comes out so

when you are saying are you going to run

out of eggs faster is it going to harm

your fertility does birth control impair

the process the answer is no but there's

a couple important caveats one is that

the birth control pills especially if

you take them continuously or for a

prolonged period of time the the body is

smart and the ovaries start to say we're

not really doing anything and one of

those markers of ovarian reserve we have

is amh and that's antimullerian hormone

and amh is made from the granulosis

cells or the cells that surround every

follicle so in the shortest way possible

more eggs in the vault more come out

every month higher amh fewer eggs in the

vault fewer come out lower amh if your

amh is being suppressed because of the

birth control pill because it's

decreasing the activity of those

granulosis cells you might get a low amh

value when you've been on the birth

control pill for a long time that is

completely reversible but it can be

significant so if somebody is wanting to

get an amh level let's say somebody

comes to my clinic they're not trying to

get pregnant and they're on the pill and

they're considering freezing their eggs

so we're going to check their ovarian

reserve if we draw it I always say this

amh may be up to 30% lower in somebody

who is on the birth control pill so we

can still draw it and if it comes back

in the normal range we feel good but if

it does come back low we're going to

have to make a decision are we going to

stop the birth control pill for a period

of some months use alternative

contraception if you don't want to be

pregnant and then repeat this test to

see if this is a true low because we do

see that young women do have low ovarian

reserve sometimes or was this just

suppressed because you were on the birth

control pill so we see it impact some of

the hormone testing that we can do and I

think that's an important distinction

and we can see that the longer you take

it that

potentially it might actually improve

your fertility if you had underlying

endometriosis or some medical conditions

that we see associated with infertility

so prolonged pill users can potentially

improve their fertility versus people

who are trying to get pregnant that same

age who were not on on the pill those

studies are complicated right because of

selection bias because if you've been on

the pill for 10 years you're a little

bit older so is it that they were

preventing pregnancy and the other group

potentially had some exposure so they

were inherently more infertile than the

group that was on the pill but we do

know that the pill doesn't cause

infertility and I use it all the time

all the time in IVF Cycles we put people

on the birth control pill because we can

actually synchronize that group of eggs

that comes out of the Vault grow

together because your body doesn't want

to have 20 babies at one time right and

what we're trying to do with IVF get 20

eggs to grow if that's what's out of the

Vault really goes against the check and

balance of the human body to not have 20

babies at once why is it that males who

take testosterone synthetic testosterone

it shuts down their own testosterone

production and sperm production but

females who take estrogen in the form of

birth control pills it doesn't shut down

estrogen production by the ovaries so I

love this question you know the answer

so I like it extra because I know you're

asking spermatogenesis is a constant and

ongoing process right so in women you're

born with all the eggs you're ever going

to have and what we're talking about is

if we stop FSH at that moment we're just

impacting the ability to ovulate at that

time but we're not changing this

constant loss throughout the Vault

spermatogenesis right the sperm is made

every single day you're making brand new

sperm so 72 days for the sperm to be

created in the testes 18 days to find

their way out the ejaculatory system and

so exposures that you have that stop the

production of FSH and LH inhibit the

development the creation of new sperm so

somebody who's been on

testosterone will tell the brain the

brain doesn't know it's from your taking

it it says hey we have plenty of sperm

we're good we don't need anymore so the

brain then gets suppressed and doesn't

make that FSH and LH therefore not

stimulating

both further testosterone production

because you don't need that but

testosterone production and sperm

production go hand in hand so therefore

you're no longer making new sperm and in

fact the longer you're on testosterone

the harder it may be to get sperm

production to come back and in 25% of

people they may not get it back if

they've been on prolonged testosterone

exposure so it's really because of what

women will sometimes say is unfair which

is the fact that you're born with all

these eggs and you run out of them they

accumulate the wear and tear of your

life right we see egg quality being a

huge issue in female reproduction yet

men get to have new sperm every 90 days

they get to wash away whatever bad Deeds

they did and can change their lifestyle

and their exposures and have very

different sperm but because of that same

process things that shut off the

production of FSH LH really impact sperm

quite

significantly you mentioned bad Deeds um

for sperm um not by sperm I said for

sperm um and you know we we know that

heat is is a uh you know a pretty

traumatic insult to the um to the

spermatogenesis cycle um saunas and hot

tubs and whatnot and I did receive the

question as to whether or not um heat

exposure saunas hot tubs Etc are they um

detrimental to ovulation or egg

production in any way I mean obviously

things are more internal in females the

ovaries are internal but is there any

evidence for that I mean the body does

heat up yeah there's no it doesn't harm

the ovulatory period or the ovaries and

just like we know the reason why the

testes are so susceptible is because

they're supposed to be at a cooler

temperature that's why they're in the

scrotum outside the body that's why the

testes are so susceptible to heat

changes but the ovaries being inside the

body they're not in the same way now

when somebody's pregnant important

distinction right we know that the

development especially organ development

of an embryo can be more sensitive to

certain things and that heat exposure

that time whether it's hot tub use or

extreme fevers even can make a

difference in development of a fetus but

when it's coming to the ovulatory cycle

or hormone production heat in the female

doesn't make any

difference well I want to be clear

before I ask the next question that I

don't want to be responsible for any

unwanted pregnancies but when I was in

high school they told us that women can

get pregnant even while they have their

period is that true seems like a lie

based on everything you're saying but I

don't want anyone to run out and um test

that hypothesis without having the facts

first so in general if somebody has

extremely regular Cycles then that's a

complete lie you can't get pregnant on

your period the reason why they tell us

this is one especially when you're

younger your period Cycles tend to be

irregular they're not your body hasn't

fully matured to have that regularity

and that we know that sperm do live in

the repr productive tract for much

longer than the egg does so sperm can

live there for up to 5 days so if

somebody did have a shorter period

window let's say their normal periods

are going to be 24 days they're

ovulating on cycle day 10 if they have a

regular period that's five or six days

they could potentially have intercourse

that end part of that period the sperm

could live for five days and be right

there when you have the egg in route so

it's not the most fertile time for sure

and in most people that is considered a

time when you're not going to get

pregnant but especially when you're

younger and you have more irregularity

or in people who have a short cycle

window that might not be the case so by

extension um can we conclude then that

the most fertile time is going to be

when sperm meets egg let's save timing

of intercourse for yep for the time

being but because there's can be a delay

there uh when sperm meets egg um on

obviously day of ovul ation or day uh

day after day of day of the egg lives

for 24 hours so the egg can only be

fertilized for 24 hours while it's in

the fallopian tube once the egg has

entered the uterus it can't be

fertilized anymore so it has this very

short window of time where it will allow

sperm to enter it now sperm can live for

5 days so we'll say the fertile window

is this 5-day period ending on the day

of ovulation you will hear a lot of us a

lot lot of doctors say the day after

ovulation because do you really know

exactly what time you ovulate it on and

if the egg has 24 hours then that extra

day could potentially be helpful but

really it's 5 days ending on the day of

ovulation and people with very regular

Cycles or who cont trct them and they

know when that ovulation is happening

the day before and the day of ovulation

those are the two top hitting days so if

you're kind of not in the mood to have

lots of sex those are going to be the

days you target to have the highest

chance of conceiving and what is the

relationship between estrogen libido and

ovulation in females the higher your

estrogen is the increased liido that

you're going to have and of course you

see those Peak estrogen levels which are

going to trigger that LH surge so the

body is made to get pregnant you're

going to have that Peak estrogen that

Peak libido right before and right at

that ovulatory time period so that

hopefully you also want to have

intercourse and get pregnant I've heard

before let's just say that some people

be careful here um uh can sense the

literally the deployment of the of the

egg the the ovulation they they report

that they can feel yeah that this let's

just say the the departure of the of the

uh egg um is that an imaginary thing

mean I always liked I always like that

image that people can know when that

happens after all men generally know

when when their um when their sperm are

leaving their body let's hope they do um

but but um why wouldn't that there be an

internal sense for for women also of

what's going on I mean we have

interoception there's a ton of nerve

inovation of that area it doesn't

communicate to the brain excellent as

far as tracking to where that sensation

is but you're right I already said

ovulation is the rupture of a cyst right

it is rupturing and the egg is being

released and those follicular fluid is

also exiting and going into the paranal

cavity and so there is a group women who

can feel that especially people who are

very in tune with their body and it has

a name it's called middle schmerz the

pain almost feels like a crampy pain

that happens in the middle of the cycle

and that is your ovulatory pain oh

interesting what is it called middle

Schurz okay we'll put that in the show

note captions and whoever does it is

going to have to get the spelling right

middle Schurz amazing amazing um amazing

and foreign to me but for obvious

reasons uh but amazing

uh I'm always astonished in the um how

incredibly well orchestrated this whole

process is it's it's just such an

incredible feat of biology just I mean

the number of things that have to be

timed correctly and the use and I don't

want to say reuse but the the

repurposing of tissues for different

things and like it's what a what an

incredible dance it's just amazing it's

beautiful I mean I'm so nerdy because I

just love how everything has to

communicate just perfectly it makes you

in awe of the pregnancies that just

happen just all the time because really

things have to synchronize really at the

wonderful time period And even though

this isn't what we're talking about I've

heard you say this so I want to say this

people always ask every single day well

how much sex should you have when should

you have sex is there too much sex and

what we know is that you definitely

should not decrease your sexual

intercourse interval so if you are in a

relationship and you are sex everyday

people have sex every day you will 100 %

hit intercourse throughout your entire

fertile window on the day that you

ovulate you're depositing the same sperm

there because you're not generating new

sperm it's whether the load went half

and half and half and half or if it went

in you know one big group but if you're

constantly putting more sperm out there

you have a higher chance and so studies

go back and always say daily intercourse

associated with the highest chance of

fundability especially during the

fertile window

however for couples who are not sex

everyday people that idea can cause a

lot of stress stress of course impacts

the system in a lot of different ways it

can also cause sexual burnout where they

no longer feel like being intimate or

having sex on the day they're actually

ovulating because they've been doing it

this whole time leading up and that's

where the time period of saying have sex

every other day throughout the fertile

window so starting five or six days

before you think you're going to ovulate

and and then try to Target having

intercourse on the day before and the

day of ovulation and the reason why

people said every other day or a few

days prior to kind of get some sperm

exposure there in case you ovulated

early but really to try to prevent some

of that increased stress that can happen

when you're trying to conceive

especially if you have programmed or

timed intercourse that needs to happen

on an everyday interval but the odds of

getting pregnant by saving up sperm for

two or 3 days that's not higher I'm

curious then why if let's just say

hypothetically someone is um donating or

freezing sperm or doing IVF why they

instruct the male to um not ejaculate

for 48 to 72 hours prior to um let's

just say depositing sperm is such a

funny word um but it works so two points

one if we're doing a seen analysis now

we're trying to evaluate the sperm and

any test has certain normal parameters

and these are all based bed on a 48 to

72-hour abstinence period so yes if you

ejaculate more frequently you're going

to have less sperm and that can be very

normal but if we're looking at a test

with set normal parameters that are

based on two to three days of not having

intercourse that's why we want you to do

it for that if we're doing let's say IUI

or uterine insemination also known as

artificial insemination or where we take

the sperm and put it in a catheter and

put it in the uterus

we're trying to get more players further

down the field and in that case I know

when you ovulate because I'm timing it

perfectly and I am trying to get as many

possible in this process because we're

not just having them deposited in the

vagina we're trying to get them further

so we want more because that's part of

that treatment process and similarly

with IVF I want to have as many sperm as

possible to sort through and pick out

the best looking the most modal the most

normally shaped ones so we're trying to

get just a better sample and by having

these normal guidelines we're able to

judge this is low for what it should be

which can also be a clue to other

problems I definitely want to talk about

chemistry both um sort of interpersonal

chemistry and literally uh ejaculate and

vaginal chemistry but before we do that

um I'm curious whether or not we can

just touch on a few of the things that a

lot of people wonder about in terms of

egg quality and if they touch on sperm

quality maybe we can also just mention

that um but for instance um does

cannabis either by edible or by smoking

cannabis impact Ed quality in either

direction uh alcohol would be the next

and then I'm going to assume and I have

to do this strictly because of what I

understand about you know drugs of abuse

like cocaine and amphetamine

methamphetamine that none of those can

be good for systems of the body because

they provide they create so much stress

for the body um but let's just say

alcohol H in cannabis um I read a

statistic when researching the episode

on cannabis that shocked me which is

that 15% one

five% not 1.5 15% of American women at

least in this one study survey reported

having consumed or smoked cannabis

during known pregnancy which is wild

wild unless of course I'm just naive and

THC is not harmful to fetus but I have a

hard time believing that so what gives I

mean here we and and there I actually

just threw in fetal development so is

cannabis is Al alcohol bad for egg

quality so they're different things and

they're the same thing in one so let's

answer them each individually so we'll

go with the one that everybody knows and

has accepted now that they wouldn't have

accepted 40 years ago right smoking

cigarettes so that's obviously bad

decreases the number of eggs you have in

the vault smoking cigarettes actually

gets into your Vault decreases is the

number that you have you have a higher

chance of going into menopause earlier

and it increases the risk of having

abnormal chromosomes which is what we

really think about when we think about

egg quality right impacting those myotic

spindles inside the eggs which hold the

chromosomes in their perfect position

they are associated they get wear and

tear from things that cause inflammation

or are toxic so cigarette smoke we know

decreases egg quality egg quantity

increases miscarriage and then of course

has fetal impacts could I just ask you

because when we talk about um there's

nicotine which itself is not

carcinogenic and then there's the

smoking process which brings in a bunch

of other things the the question I know

is burning in everybody's mind is vaping

yeah right because vaping is I'm I'm

very bullish on this I mean it's very

clear that the chemicals associated with

vaping are just oh so bad for

Everybody's Health but it's distinctly

different from saying that nicotine is

bad for one's health and it can be but

um without doing too much of a deep dive

is are there any data that show that

vaping is bad for egg quality of course

there's not as much data because it just

hasn't been around as long but yes

vaping definitely has chemicals that

looks like it's associated with poor

success rates in IVF cycles and that's

really kind of one of the most finite

measures of egg quality we can see

because we're really testing the egg at

a level in a lab versus just are you

getting pregnant naturally and sorry to

interject again but anytime a

conversation like this comes up

especially between two people in the

health science space um there are these

shouts because I hear them literally

where people say well listen I Vaped

every day and I've had three healthy

babies and I think that my response is

always okay there's going to be a

distribution of responses and then of

course how much healthier could your

babies have been had you not Vaped

during pregnancy or Vaped prior to

pregnancy or I mean I think these are

the the key issues that like you can't

you can't rewind the clock as far as I

know right in the absence of a Time

machine you can't rewind the clock so um

I mean basically everything you're

saying is that smoking cigarettes or

vaping nicotine just can't be good for

egg quality we know that we know that

it's not good for getting pregnant we

know that it's not good for sperm and

therefore we also know it's going to

impact pregnancy rates you know things

like cannabis right decreases sperm

production decreases sperm motility

changes sperm morphology the shape of it

changes the DNA it increases the

fragmentation of the DNA

if your partner uses cannabis and you

get pregnant you have a higher chance of

miscarriage because of the sperm

association with the Cannabis now edible

cannabis as well as right because you

can't study something that's illegal so

a lot of this data is just more new and

a lot of it's going to be observational

and in States like Colorado and

California where you know canvas is

essentially legal um yeah I I'm assuming

that there are more data but okay so um

smoking

Endor vaping nicotine cannabis either

edible or smoked very likely detrimental

to egg quality and sperm quality which

is not to say that one can't conceive it

just means that the quality of your baby

your child will not be as high as the

quality of that baby if you didn't do

that is that right yes and I'm and I'm

not trying to demonize anyone that did

did do this during pregnancy a lot of

people didn't know but this is this is

really about people trying to make

choices in anticipation of future

pregnancy yeah and when you're trying to

set yourself up for Success because we

know infertility becoming more common we

don't always know who is going to have

it and when you find yourself in that

position specifically you now want to

optimize everything you can so if

there's something that is going to make

the sperm quality worse and the Egg

quality worse and your success with

treatment lower and your miscarriage

rate higher we're going to recommend

that you not do it if you're trying to

get pregnant naturally all these things

correlate over but of course there's

always going to be outliers and

exceptions I'm going to sit here and

tell you that the odds of getting

pregnant at age 43 are less than 3% per

month and every single person is going

to be like but my Aunt Barbara or I know

this person who did because 3% is not

zero and you're talking about natural

pregnancy there by by uh interc old

fashioned way yes right but yes so

people will get pregnant people will

have healthy children who do have

exposures to nicotine to cannabis even

to alcohol even though we know that

alcohol can cause fetal alcohol syndrome

0% of alcohol should be the acceptable

level in pregnancy and then does alcohol

impact fertility such a complicated

question and this is probably due to the

amount you consume and the frequency of

which you consume it alcohol is a toxin

that your liver must filter out and We

Know It causes inflammation anybody

who's had a fun night with alcohol knows

they can wake up the next day and they

feel different

their body is processing that alcohol

and that inflammation especially if it's

chronic chronic

exposure we know chronic inflammation is

one of the things that we see impacting

egg quality and sperm quality so

certainly if you enjoy alcohol it should

be something that is done in moderation

one or two drinks a week at the most and

you should not do it at all once you

find out you're pregnant I'd like to

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we were talking about birth control I

unfortunately moved us forward and and

forgot to ask about iuds oh yeah so my

understanding is that the copper IUD

works by creating a sort of um not

actually electric but a kind of a

electric um fence that kills sperm like

sperm don't like copper sperm don't like

copper copper likes to kill sperm um

there's some interesting uh history I've

been reading a lot on the history of

Medicine of um people who you know for

whatever reason were forced into or

chose to be in the sex trade prostitutes

using um inserting copper coins into

their vaginal tract to try and uh kill

sperm but to varying degrees of success

obviously there's a whole um

socioeconomic landscape around that so

um I think it's obvious what I'm

referring to but um very interesting but

that's just one form of IUD right there

there are some other iuds and then

there's of course the ring we didn't

talk about that so maybe we just touch

on a few of those in within the context

of whether or not it Alters egg quality

Andor future fertility when one takes

the ring out takes the IUD out this is a

great question because a lot of people

don't know this and and I'll roll

through a few of the top birth control

methods and just thinking through copper

IUD as you already said no hormonal

involvement it causes inflammation and a

toxic environment inside the uterus

isolated does cause sometimes heavier

periods but they should still be regular

if they are irregular that's a sign of a

hormonal issue because you still ovulate

with the copper IUD is it literally a

copper wire woven into the so the I well

the IUD is a is a little T and the arms

are have copper wires wrapped around

them and they and those are they grow

into the uterine lining they don't grow

into the uterine lining the IUD just

sits in there and just the presence of

that copper causes that inflammatory

reaction in that toxic environment and

is it toxic to the environment in ways

that are detrimental to the woman or or

just a sperm both I mean implantation is

not going to

occur likely right I mean no nothing has

100% successful but it's much harder for

an embryo to implant within that highly

inflammatory environment to me amazing

that people figured this out before

fting Laboratories right let's just put

some copper in some uteruses and see

what happens right you know it I it

really speaks to the the urgency that

must have existed to preventing

pregnancy and they just how costly

biologically and a pregnancy is

pregnancy is and pregnancy is not Health

neutral so it is something that somebody

needs to be in of right health or it can

be a deadly circumstance when we get

back to other iuds so iuds that more

people are more familiar with are the

progesterone based iuds this is going to

be your Marena Kina liletta they have a

bunch of different names based on the

amount of progesterone and how long they

last for these work mostly by thinning

out the uterine lining as we already

said progesterone

compacts the uterine lining to prepare

it for implantation in a normal cycle

but if you have constant exposure to

Progesterone what is going to happen is

it's going to prevent the uterine lining

from growing and it gets it very very

thin not all iuds in fact most of them

don't prevent ovulation only in about

50% of people do they actually prevent

ovulation so their main mechanism of

action is this endometrial effect when

you remove the IUD

especially if you're already ovulating

no problem the problem we do see in some

people with progesterone iuds that maybe

isn't talked about as much is that this

prolonged progesterone exposure because

people are putting iuds in for 5 to

seven years and not having a period for

that length of time because the

endometrium has become so atropic or

non-existent that you're no longer

bleeding despite the fact that you may

be

ovulating it can take a while for that

lining to grow back and so it's not

uncommon to have an IUD in place and if

you have no period you're going to say

this is great I don't have a period

wonderful you get it removed and now

your period hasn't come back and that

leads people to sometimes be concerned

that the IUD is causing them not to

ovulate or they have

this infertility caused by the IUD but

really what it is is that the Linings

become so so thin that it can take many

months of that unopposed estrogen

exposure in the follicular phase to get

it thick enough to finally bleed when

you're ovulating so I do tell people if

they have a progesterone IUD to get it

removed 3 to six months before they want

to get pregnant use some other form of

contraception but give their body time

to make sure they have that regular

period pattern back important

distinction if you're still ovulating

and having a period on an IUD then this

is going to be less of a concern because

if you're growing enough of a lining to

then shed it we're less worried about it

but if you are amaric or have absence of

your periods with an IUD we need to

think about removing it for a period of

time before you get pregnant so that

your body can grow that lining again

when it comes to some of the other

things that you mentioned one I you

didn't ask that I want to mention is the

Depo pra shot the Depo pra shot is a

high dose of progesterone high enough to

actually prevent ovulation so in that

circumstance you are not ovulating and

therefore if you don't ovulate at you're

not going to get pregnant Depo pra is

proven to prevent ovulation for 3 months

so when you take it you need to get it

every 3 months to have a proven

contraceptive benefit however it can

last in your system for 18 months and

prevent ovulation for up to 18 months so

I will see people who liked that option

for contraception and now they haven't

had a period in a long time but their

last Depo shot was 6 months ago and

there are all frustrated by the fact

when I tell them well you still may not

have another period for a year plus

because this high level of progesterone

that you've already injected into your

system can last a substantial amount of

time so that is a contraceptive option

that I tell people to discontinue a year

and a half to two years before they want

to get pregnant which sometimes people

don't know that yet and so that's

something that can be a contraceptive

option from if you're very remote from

wanting to have a child but in people

who are in their childbearing years

contemplating family building

soon that is not my favorite option so

you haven't mentioned because I haven't

asked um any negative consequences of

birth control of any kind and I'm not

encouraging you to if you don't believe

in them I know that this is a very

controversial um topic but um you know

one of the more popular studies

discussed on social media is one that I

I've spent some time with the paper um

and a few of the papers that stemmed

from it um not a huge study but

describing that how women rate the faces

of men as either more essentially what

happens is there there seems to be at

least in this study a there was a a

statistically significant um bias uh for

women to select particular male faces as

attractive and those male faces tended

to be of the more you know square jaw

AKA masculine features right in a quotes

right this is what the study um found um

but that when women were on oral

contraception presumably estrogen

progestin type oral contraception that

that effect um was smeared they had a

not a statistically significant tendency

to uh choose the quote unquote more

masculine faces I have to be very

careful with my language here because

you know it's easy to get description of

a study like this wrong and that has led

a lot of people to think that birth

control is going to throw off their

partner choice

um now of course it's a small study um

studies like it are not always so well

controlled um but is there any evidence

that birth control oral oral estrogen

progestin based birth control just to

keep it specific can increase rates of

cancers can decrease rates of cancers

can lead to um any sorts of disruptions

in um bodily uh function or health

that's really like a rock solid result

that's been seen by mult multiple

studies clinical trials um or are we

still just in the dark about a lot of

this stuff okay so nothing is without

risk getting pregnant is not without

risk taking the birth control pill is

not without risk we do see that there's

been a lot of not informed consent and

people who are taking the birth control

pill meaning maybe they weren't educated

about what all of their options were the

positives and the negatives about each

one of them if we're going to reference

the combo to the pill estrogen

progesterone pill important to

understand that neither the estrogen nor

the progesterone are the same estrogen

progesterone that your ovaries make

right it's ethanol estradi which your

brain interprets as an estrogen but

other parts of your body may not and

then it's various types of progestins

some of which have even androgenic or

male hormone likee properties and some

of which do not so there's a ton of

variation even the amount of ethanol

estrad that each pill has with your low

low and your low low pills having less

and even with the modern-day average

pill having a lot less estrogen than it

used to when you're on the birth control

pill your ovaries aren't making

estradiol and that estradiol is

important in growing the uterine lining

but also for the genital structures and

so we think about vaginal health and

bulvar health we certainly see that

especially with continuous use so if we

distinguish you take the P for 21 days

and you have a 7-Day break where you

might bleed or you take sugar pills and

then you take them again a lot of people

now are taking continuously where you

have exposure to these compounds every

single day H so in in like the the um

the wheel the little little pouch with a

wheel of different colored pills um may

have seen these on the on the countertop

in previous relationships um and then

there's the ones that sometimes people

just opt not to take because those are

the not the placebo like there's no need

to take estrogen during that phase and

then and then they repeat is that

exactly okay but some people are taking

estrogen all way very common right now

so people and they're not wrong they say

oh well why have a period in these

little breaks it's not really a

reflection of my hormone status which is

accurate and so they're taking them

continuously you also have less pill

failure pregnancies so if you're using

the pill for contraception that can be a

great strategy but the longer you take

them we do see some vaginal involv art

changes right and so atrophic vaginitis

people who notice increased sensitivity

decreased elasticity increase discomfort

with intercourse increase in like yeast

infections that can sometimes be see

because that environment is different

now that's just one thing that can come

from the pill we also see the pill be

life saving for other people they have

terrible you know PMS or premenstrual

dysphoric syndrome where their mental

health when they change from from high

to low estrogen it's always the change

in estrogen that interferes can cause

some people to really have mental health

issues that are so severe that having

that stable hormone level is helpful and

so the pill can be extremely beneficial

for some people when it comes to mental

health it can be beneficial for people

who have issues with very heavy periods

and anemia instead of getting blood

transfusions you know taking the birth

control pill might prevent the lining of

the uterus from growing so much that

they bleed so much same with fibroids

people with PCOS PCOS is polycystic

ovarian syndrome if we want to put it

very simply you have a lot of eggs in

your Vault so you release a lot of eggs

every month and what this does is the

FSH signal gets diluted and so you're

not responding to the normal signal and

you don't ovulate and because the ovary

is a hormone making factory it gets

really bored when it can't make estrogen

because that egg's not growing so it

starts to make testosterone so you start

to see this Androgen dominant

environment associated with lack of

ovulation and having a lot of follicles

inside the ovary that are not really

responding an androgen excuse me

androgenization of other tissues like

like body hair deepening of voice body

hair typically the level of testosterone

made in PCOS isn't truly deepening voice

it can if there is an ovarian tumor

making testosterone or certain other

conditions but typically with PCOS you

see increase in body hair increase in

acne

and you can see some even like male

pattern balding some temporal balding of

women so some hair loss temporal B so

like the the WID yeah the Widow peaking

and then thinning out in these two areas

and then we see an increase in body

composition towards a male level so if

we think about a male body holding your

fat in your abdominal region and if we

think about the traditional female body

holding more fat in the hips and thighs

area we see that when this hormone

shifts in PCOS you tend to get more

abdominal fat distribution which then

leads to further insulin resistance and

metabolic syndrome but in PCOS because

you're not

ovulating

and those ovaries each little follicle

makes a tiny amount of estrogen we'll

say each little follicle when it's not

responding will make you know one to two

peagrams of estrogen but if you have 50

of them each month you're having some

constant estrogen exposure so that

lining of the uterus is being constantly

stimulated to grow and you're never

getting the progesterone to stabilize or

the progesterone withdraw to bleed so

endometrial cancer is much higher in

people with PCOS who don't ovulate and

the birth control pill can prevent that

any unopposed estrogen situation because

the body is made to have both estrogen

and progesterone so we see an immense

decrease in endometrial cancer an

immense drop in ovarian cancer ovarian

cancer comes from the remodeling of the

ovary so every time you have a follicle

grow and it ruptures and it makes takes

the Corpus ludum and then it heals up

those are opportunities for those cancer

cells to go away in that remodeling

process and lead to ovarian cancer and

because you're not ovulating on the pill

your incidence of ovarian cancer drops

dramatically 10 years of pel use has

dropped the chance you get ovarian

cancer by more than 90% And of course

ovarian cancer is super hard to diagnose

because the inovation to the peritoneal

system is is poor and you don't have any

outward signs often to late stage

disease that being

said could you potentially have an

increase in breast cancer in some people

by taking the Pill by taking the pill

that that's a concern especially in

people who might be predisposed to this

for some other reason they might have

braa mutations or something like that um

and then is there a situation where the

pill certainly masks what's going on

with your menstrual cycle and I really

think this is where where Women's Health

had has a huge history in paternalism

meaning doctors would just tell people

this is what you're going to do so your

periods are irregular here is the birth

control pill and they're not explaining

why or the pros and cons to it and what

happens is people are not being taught

how their bodies work and now they are

because of your podcast amongst others

and now they're able to know that my

periods of Vital sign and I don't know

what it is because the pill is producing

a different environment the pill's also

been associated with potentially

development of things like leaky gut or

IBS and so there is a definite change in

your environment when you're on the

birth control pill increase risk of

blood clots because of how it's

processed in the liver increasing your

clotting factors can I just interrupt

there you know I'm aware um that a a

fair Fairly high percentage of people

have um mutations in Factor 5 lien a

clotting Factor um few where people are

as we say homozygous have two deficient

copies or mutant copies I should say um

but there are many people out there that

have one mutant copy of factor 5 lien

and my understanding is that oral

contraception in females um can really

exacerbate the factor 5 lien mutation do

you suggest that people get um get their

Factor five lien um genetics analyzed I

mean it's pretty inexpensive to do right

I think on a standard blood test you can

just ask for the factor 5 um analysis

and it's not like a a really in-depth

thing you don't have to fly to yeah you

don't have to fly you don't have to fly

to another country you know like you do

for many things um it's important to say

that's not the norm right like that's

not the recommendation when you're

talking about putting somebody on the

birth control pill you want to make sure

they don't have high blood pressure

because it can increase their blood

pressure you want to make sure they

don't smoke cigarettes because the

combination of the pill and cigarette

smoking can increase the risk of a

stroke but the recommendation is not to

screen them to see if they have any

inherited clotting disorders that said

if you ever have a blood clot on the

birth control pill because you're

traveling on a plane or you're just on

the pill or you're living your life

you're now going to get this extensive

work up to find out if you do have that

it's by no means wrong and specifically

you should if anybody in your family has

ever had a DVT so a deep vein thrombosis

so blood caught in their leg or a

pulmonary embolism or a PE so anybody in

your family has had one of those you

should have 100% get worked up for

clotting disorders and if you have

something like you carry Factor 5 you

should no longer take the birth control

pill and specifically the pill because

it's an oral pill and how it's

metabolized in the liver is actually

what is causing the change in those

clotting factors because that's where

they're made as well so it doesn't mean

you can't take any form of contraception

but we do want to make sure that we

counsel you appropriately I never think

it's wrong to be an advocate for your

own health or to ask questions it's

important to know that screening I mean

I'll get on my soap box because we'll

talk about screening for ovarian reserve

and it is 100% not recommended even

though I think it should be yeah my next

question was going to be about testing

amh levels and um and we'll return to

that for those that hear that and it

sounds cryptic as well as getting an

ultrasound just seeing basically how

many how many eggs are are in likely to

be in in the Vault on on both sides okay

so we have to remember that screening

recommendations come from at what point

in the population does it make sense to

spin the money to test for a disease

based on the likelihood of finding it so

if we think about right that's what your

papsmear guidelines and your colonoscopy

and your mammograms everything is all

based on when are you going to find

enough cases at some age to make it

worthwhile testing which is a crazy

principle especially in the US because

the government's not paying for our

health care so why should these

guidelines be based on when is it coste

effective to do testing well I I'll put

in a this is going to sound sound a

little bit conspiratorial but it's not I

mean I think that given that for people

who have insurance private paid

insurance or through their work um that

there's a cost to doing these tests of

any kind colonoscopy amh Etc and they

must have figured out the you know

optimal point on the graph with which

they can reduce their payout to people

who for instance get colon cancer if

they didn't get the colonoscopy at 45 as

opposed to 50 as opposed to 60 as

opposed to 25 I mean this is I mean the

reality we know is that

the more information you have the better

choices you can make I mean the only

caveat to that would be that uh for some

not all but for some people sort of of

the hypochondria type sometimes more

information leads to more anxiety which

leads to more problems but that's a rare

instance that is I always think that in

general data is always good age having

the information at hand about your body

and being able to make educated choices

versus being in a position where you say

I had no idea that I had Factor 5 Li in

and I had this terrible blood clot

because pulmonary emms can kill people

we all know that right so we talk about

this rare thing but it can happen but

this is really where it can be tough it

can be tough to find even a doctor who

made like we said Factor five is a blood

test and relatively inexpensive so that

one is not hard but Physicians live in a

weird world where you know they have

recommendations based on screening based

on the likelihood of finding disease

that they follow and when they go off of

those they start introducing themselves

to why are you not following medical

guidelines but for an

individual this is really tough to

advocate for yourself and the one thing

that I'll say too this is why paying

attention to your body is so important

right understanding your stool habits

and what's normal and what's not so that

you can catch early signs of things and

present for that colonoscopy earlier the

current screening guideline for should

you get your ovarian reserve checked is

that you should not ACOG the American

College of OBGYN has an entire practice

bullettin situation saying there's no

utility and screening for amh okay I

mean I totally disagree but I'm glad you

disagree I mean to me it just seems nuts

I mean um or ovaries rather I mean the

um the amh is a blood draw amh is a

blood test it's a blood draw it one

could opt to do the um ultrasound as

well which is of course more invasive

but but women who are seeing their OBGYN

are probably familiar with with with um

pelvic exams yeah I mean it's a FAL

ultrasound but it's not painful not

painful um but different than a blood

draw just just for in full disclosure so

um and you know I've heard of women in

their early 30s going in getting their

am levels checked getting their

ultrasound and then going oh my goodness

they're down to like you know I I don't

want to throw out numbers cuz this

actually can get tricky it um you know

they'll say oh you have whatever you

know four follicles and then someone in

their early 40s will have 20 follicles

and then people start to is it sort of

becomes a scorekeeping thing and and of

course follicle quality there a bunch of

other things um and then you can tell us

more about those but let's say someone

did not have insurance or or Insurance

permission to um to get this paid for

what is the approximate cost of getting

one's amh levels and analyzed $79 $79 to

find out essentially where your ovarian

reserve is at so let's talk about this I

already said this in my soap box so ACOG

says you shouldn't screen it because amh

does not predict your fundability right

your body's ability to get pregnant in

that month is independent of your amh

and for the most part that's true right

because let's say you have a person and

they're both 30 you have two people one

has low ovarian reserve they have five

eggs coming out of the Vault and this

one has normal ovarian reserve and they

have 20 eggs coming out of the Vault and

we should probably clarify that the

number of because you said this earlier

but the number of eggs coming out of the

vault is an indirect measure of how many

eggs is in the vault when that number is

going down it means the number of eggs

in the vault is likely going down down

corre sort of like your body starts to

take smaller withdrawals as you start to

run out of the Vault wants to be at like

equilibrium right it really wants to be

in this Middle Ground so when you have

too many it shoots out more every month

it's too crowded it doesn't want that

and then when it starts to get low it

gets scared about being empty and sends

out fewer per month so what you see

outside the Vault and that is called an

anal follicle count or an AFC it's an

ultrasound based measurement of how many

eggs you have outside the vault at one

point in time and on the ultrasound if

one looks um this is going to show up as

so what look like um little Hollow

spaces like so not gray stuff but but

Hollow Bodies I say chocolate chips and

the chocolate chip cookie if we can

imagine the over yeah like looks like a

chocolate chip cookie the chocolate

chips

small little dark fluid fill follicles

each one of those houses an egg some

bigger than others because they're more

mature than others based on when you

check in the cycle so if you're looking

in that early follicular phase when

somebody's on their period they're they

all should be small because nothing's

been stimulated if I'm looking per

ulatory I'll see that dominant follicle

that's about to ovulate and then

everything else will be small and is

there a a graph that people can look at

or that we could link to that says okay

the the average with a distribution of

you know standard error on their side

for let's say a 28-year-old woman or a

37y old woman or a 45y old woman of the

number of follicles on the right and

left side and as I understand

asymmetries are common yeah um tends to

be you know like if someone goes in and

they you got six follicles on the left

side and 12 on the other side are they

how do how do people gauge what what

fantas points one because their doctors

should tell them but that doesn't always

happen but yes we we add these counts

together to get your anro follicle count

because there is often asymmetry but

what we should expect let's say in

somebody who's 30 is you should have in

the 16 to 20 range of total follicles

per month right and left side combined

comined okay when you're 35 that number

is closer to like 14 to 16 so starting

to drop it's still pretty good when

you're 40 it's 8 to 10 when you're 44 2

to 4 right so you start to have this

immense drop that exponentially starts

to increase really around AG 37 so

things start to kind of get into this

severe Zone really after age 37 and we

didn't really talk about ages 18 to 25

but there are people who get pregnant in

that age bracket are is the follicle

count very very high is there sort of an

a is a nonlinear drop off or yeah their

follicle count would be higher and I

mean I occasionally have patients who

are very young but have infertility or

want to freeze their eggs I've also had

patients in that age range who are in

premature ovarian failure right right

because there can be things that go

wrong even early but we should probably

highlight again something that you said

earlier but gosh I you know this like

contradicts so much of what's out there

which is that even if you have low

follicle count if you collect eggs

you're not changing what's in the vault

you're not pulling From the Vault you're

not you can't right that those eggs are

spent you you you now have the

opportunity to turn them into potential

pregnancies correct I mean side note

right we haven't even dove into IVF but

that's the next wave of technology is

what we call IVM in vitro maturation are

trying to figure out how can you get

eggs from the Vault and get them to grow

in the lab because that would open up

possibilities for people who have fewer

eggs to have a higher efficiency of this

process because one of the limiting

factors when you're doing fertility when

you're doing egg freezing or IVF is how

many eggs can you get per month and

that's why some people have to do cycle

after cycle because they can only get

five eggs or five eggs but if we Circle

back to what we were saying when we got

off on this beautiful tangent is that no

no matter if you have five or you have

20 eggs outside the Vault you're

ovulating one so you're trying to get

pregnant naturally that's what

fundability is probability of getting

pregnant per month naturally you have

the same chance if you're the same age

regardless of if you have five eggs or

you have 20 eggs and that's why ACOG

came in and said well amh doesn't impact

fundability it doesn't predict your

ability to get pregnant or who's going

to have infertility and who's not going

to have infertility so there's no

utility and screening for it

in people now for once I'm speechless I

mean that that argument makes sense

through the lens of just probabilities

of

pregnancy um through natural conception

um but it completely erases the very

very very real situation where people

are making choices about for instance

whether or not to stay with a given

partner whether or not to leave a given

partner whether or not to accelerate the

process of building a family my egg

should I have a baby now goodness like

there's so many

this American College of whoever whoever

is like

completely but they're crazy and that's

what I say they they argue in their

statement that finding that you have

sorry I'm like reeling it in I mean

think trying to think of an analogy that

doesn't fail but it's like if you can

it's like saying okay if you can walk

now great there's no reason to test for

this inevitable paralysis that's going

to happen at different rates in

different people and there are things

that you can do to offset in other words

you could like take a little bit of some

tissue that will allow you to walk in

the future but we're not going to do

that because if you can walk now you can

walk now it's good now that's absurd and

that's really what it is and they say

well finding out that you have low

ovarian reserve at a young age is going

to cause undue stress that is

unwarranted because most people don't

have infertility and so they're purely

putting it through the lens of your

likelihood to get pregnant but it's

actionable stress exactly right if it

were just stress like hey guess what and

you know I know people who have family

members with Huntington mutations and

some opt to not know whether or not they

themselves have have the Huntington

mutation and and it's a very personal

choice right sure but here that whereas

unfortunately there still isn't a a cure

for Huntington hopefully someday there

will be malom would but in the meantime

there's essentially a a cure for this

situation which is the Harvest and

potential fertilization there at least

an opportunity and this is what I say

and of course you and I feel similarly

education and data like being the one to

make the choice way is an extremely

important distinction versus having it

happen to you so if you're young and you

find out you have low ovarian reserve is

that going to make a difference and it

very well might you might now freeze

your eggs when you wouldn't have

otherwise you might now start to try to

get pregnant if you're partnered when

you otherwise were just waiting but

change the conversation with your

partner too right because a lot of

people think they can just wait I you be

like because of age right we're in

totally wait but if you have a low

ovarian reserve then that you may lose

the opportunity for Parenthood and for a

lot of people this is a life goal and

this is what's Wild to me when on earth

besides reproduction do we have life

goals that we take the approach I'll

just wait and see if it's a problem

later never right if you want to become

a doctor you want to become an athlete

you are constantly working towards that

goal or understanding what it's going to

take to get there but why does the goal

of Parenthood the attitude is completely

I'm not going to think about it until

later and then I'll deal with it if it

becomes a problem because you can make

change choices you could freeze your

eggs you could try to get pregnant

sooner you could evaluate for reasons of

low ovarian reserve do you have a

genetic mutation or an autoimmune

disease why is it low it's not just

always a big unknown there can be some

actual things that potentially might be

impactful for your health long term so I

think it's it's wild that this is the

current conversation and I will say I

know personally a lot of OBGYN who 100%

will draw an amh blood test if you're at

your annual and you ask and I recommend

all of my OB friends because I see

people at a different stage right when

they see me they're struggling to get

pregnant or they want to freeze their

eggs but when we talk about this I say

hey just like you say are you trying to

get pregnant now and if somebody says no

and follow-up question is well do you

want to be on birth control the same

question should be well do you want to

be pregnant at some point and if so

should you consider freezing your eggs

or getting this blood test checked and

very often people will make a different

decision with that information well I'm

so glad that you're highlighting this

because my understanding is at least in

the state of California I don't know

about other states or if it even varies

by state that the opportunity to harvest

eggs uh and freeze them um there's a

hard cut off at age I think it is 42

prior to age 42 they'll do it um after

42 they'll do it if and only if you're

willing to do invitro fertilization to

actually fertilize and then they'll

freeze embryos but they're far more

reluctant to collect eggs after age 42

yes yes and no so when you think about

egg freezing and IVF are really the same

process right when you're going through

the exact same thing you're taking the

eggs out of the body and then you're

either just freezing them as an egg or

you're fertilizing them in the lab and

that's IVF and making an embryo right

away egg freezing has changed

dynamically over the past 10 years

whereas 10 years ago survival rate of

eggs in the lab was 40% really terrible

and so we really didn't offer it to many

people it wasn't something that was

talked about and now it feels trendy

almost but it's really just the tech has

gotten so much better and cheaper yeah

90% of eggs now survive the free thaw so

90% is not a low number by any means

embryos are much stronger right an egg

is a single cell it's a single cell an

embryo when we freeze an embryo that's

day five or six is 300 plus cells so

it's so much stronger and those embryos

survive the freeze thought 99% of the

time so yes there's a 9% difference that

being said making embryos is a lot more

expensive eggs is cheaper you could do

two rounds of eggs and have just as many

eggs or have more eggs than if you'd

made them into embryos right away so I

never recommend that somebody commits to

a sperm source that they don't want to

have a child with unless that that's the

sperm Source they want to have a child

and this has changed because when embryo

survival was so much greater than egg

survival especially if you had few eggs

or you were older making embryos was the

only option what we do know is that egg

quality decreases immensely as we get

older and we've touched on this but we

haven't really mentioned it so not only

do you have fewer eggs as you get older

the chromosomes inside start to lose

their positioning and so we think about

egg quality we think about genetic

normaly and we know that the rates of

anupy or abnormal chromosomes increases

proportionally to your age which um for

people that aren't aware are going to

predispose not always um to miscarriages

if they're implanted or potentially even

uh the formation of a of a fetus that

carries for instance tricomes so CH

chromosomal repeats or um lack of lack

of certain chromosomes these could be

deadly or they could be um capable of

carrying to term and then but have

undetectable Demi to severe

developmental um abnormalities correct

correct and this is this is why it you

have a lower probability of pregnancy

per month as you get older so if we look

at your natural fundability it's not

because you have fewer eggs because we

already said your egg count per month

doesn't impact your probability of

getting pregnant it's because the

normaly of those chromosomes has changed

so dramatically that the odds that your

body's randomly choosing the good one to

ovulate become so low and that's why

those natural fertility rates are so low

because most genetically abnormal eggs

do not fertilize or implant but if they

do they have a significantly higher

chance of miscarriage it's 40% at age 40

right so you have a much lower chance of

seeing the positive pregnancy test but

then your chance of losing that

pregnancy is significantly higher as

well so when we are counseling somebody

about egg phrasing what we know is that

not every egg is going to fertilize with

sperm going to make an embryo going to

be genetically normal or even implant

when it is genetically normal there is

huge loss in human reproduction meaning

the more eggs you have at a younger age

the better the ROI on this process is

going to be it doesn't mean you you

don't do it when people get older but

every Clinic does have a cut off and

every Clinic is going to be a little bit

different a lot of different reasons why

we actually probably have an older cuto

off so we will let somebody go through

IVF or freeze their eggs up to age 45

and it's a lot about informed consent

and

having the approach that you're smart

enough that if I give you the odds and I

walk you through how many eggs you are

and the likelihood of them making into

embryos you can say yeah but for or 10

eggs is way more than zero based on my