← Rena Malik, MD Podcast
Rena Malik, MD Podcast
Fertility at 30, 35, 40: What’s REALLY Happening to Your Eggs?
02:04:55
In this episode, Rena Malik, MD and Dr. Natalie Crawford dive into women’s fertility, debunking common myths and revealing how lifestyle, environment, and menstrual patterns impact reproductive health. They offer actionable tips on tracking cycles, interpreting key health markers like AMH, and making informed choices to optimize fertility and overall well-being.
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- [00:00]
Dr. Natalie Crawford
Last night you spent two hours deciding what to wear to the party this morning. It'll take you two minutes to list it on Depop and make your money back. Just grab your phone, snap a few photos and we'll take care of the rest. The sheer dress and platform heels you'll never wear again. There's a birthday girl searching for them right now. Your one and done look is about to pay for your next night out,
- [00:22]
Dr. Rena Malik
or at least the ride home.
- [00:24]
Dr. Natalie Crawford
Your style can make you cash. Start selling on Depop, where taste recognizes taste. Where is Daredevil? I'm right here. Don't miss the return of Marvel Television's Daredevil Born Again. So what's next? I feel liberated.
- [00:41]
Dr. Rena Malik
We're gonna take this city back over
- [00:43]
Dr. Natalie Crawford
medicated in an all new season. Now streaming only on Disney plus. They're hunting us. It's time we started hunting them.
- [00:51]
Dr. Rena Malik
I can work with them.
- [00:54]
Dr. Natalie Crawford
This should be tons of fun. Marvel Television's Daredevil Born Again now streaming only on Disney plus. We know that women who have infertility have a higher rate of stroke, heart attack, metabolic disease, cancer, and earlier death. And the statistic is not just a small amount. It's up to an 80% higher rate of those. And that's a devastating statistic to sit here and say because I had infertility, only 20% of apps that are detecting your ovulation window when you put in your day one of the cycle are predicting ovulation correctly. So getting it wrong the vast majority of the time, that's crazy. If you take insects like Aleve, Motrin, Advil, you will go through the hormonal changes of ovulation, but the follicle will not rupture or release an egg. So you cannot take those or you should not be taking those around ovulation.
- [01:39]
Dr. Rena Malik
I didn't know that.
- [01:40]
Dr. Natalie Crawford
That's crazy, right?
- [01:41]
Dr. Rena Malik
If you're a single woman and you're young and you know you want children, is it better to freeze your eggs or better to go through an IVF cycle with a sperm donor?
- [01:50]
Dr. Natalie Crawford
Oh, it's absolutely better to
- [01:53]
Dr. Rena Malik
want to have a baby. Well, I'm about to share with you the biggest mistakes that women make when they're trying to get pregn. Mistakes start even earlier than when you start thinking about getting pregnant. I'm Dr. Rena Malik, urologist and pelvic surgeon. And welcome back to The Rena Malik, M.D. podcast, your trusted guide for leveling up your health, sex life and relationships with evidence based tools. Today's guest is a good friend, Dr. Natalie Crawford. She is a double board certified obstetrician and gynecologist with fellowship training in reproductive endocrinology and infertility. She specializes in women's fertility, including pcos, endometriosis and hormonal health. She also does inter in reacher fertilization and lifestyle optimization. She's a co founder of Four Hour Fertility in Austin, Texas. She's the host of the As a Woman podcast with over 5 million listeners and author of the Fertility Formula, a guide to hormones, inflammation reduction and reproductive health. In our conversation, we are cutting through common myths about birth control, fertility, hormone tracking, and the surprising red flags your cycle might tell you long before you're thinking about getting pregnant. We're also going to talk about AMH testing, testosterone trends, and five simple lifestyle changes that can dramatically impact your reproductive health. Your cycle could be telling you a lot more than you realize. Dr. Crawford, thank you so much for joining us.
- [03:20]
Dr. Natalie Crawford
Thank you for having me.
- [03:21]
Dr. Rena Malik
So I'm so excited to have you because fertility is a huge issue and I feel like it's becoming more and more prevalent. I'm seeing more and more of my own colleagues and friends. Friends struggling with it and I'm hearing a lot more about it, which partially is because of social media, but also I think it's, it's just so important to talk about because more and more people are deciding to have kids at later ages.
- [03:41]
Dr. Natalie Crawford
That is true.
- [03:41]
Dr. Rena Malik
And so are you seeing, is it a global phenomenon or maybe a developing world or non developing world phenomenon that fertility rates are declining?
- [03:49]
Dr. Natalie Crawford
Fertility rates are absolutely declining. When I first started being a fertility doctor, when I Left Fellowship Over 10 years ago, the rate of infertility was one out of every eight couples. And now in the United States specifically, it's one out of every five. And in some countries it's worse. So that's crazy. In one decade, we've seen a huge shift and increasing the rate of infertility. And yes, we see that women are waiting longer to start their families, people are pursuing careers. But even when we account for age and we take that out of the picture, we still see this global rise in the rate of infertility, meaning it's harder to get pregnant. And this is both male factors and female factors.
- [04:26]
Dr. Rena Malik
So what countries have the lowest rates of fertility and which have the highest?
- [04:29]
Dr. Natalie Crawford
So we tend to see that some of our developed nations actually have the worst fertility rates, which goes two ways. One, is it better reporting so we're getting more accurate rate, or is it the modernization of the world and part of the chronic inflammation, the chronic disease rates are higher. Are we seeing that as well?
- [04:47]
Dr. Rena Malik
Yeah. So obviously, chronic disease, chronic, you know, poor diets, obesity, all those things contribute to infertility. What about things in the environment, you know, that are we being exposed to more microplastics and endocrine disrupting chemicals at a higher rate in the last, you know, 50 years?
- [05:05]
Dr. Natalie Crawford
Yeah, all of these things actually work together. And that's what's so hard if you're a patient sitting on the other end of this. If we use the sperm statistic, in 50 years, we've seen sperm counts decrease by 50% and most rapidly in the past 20 years. In the same time, the world has become more industrialized. We have more toxins, more chemicals. But a lot of the mechanism for how some of these environmental chemicals actually impact fertility can be through chronic inflammation and disruption of the hypothalamic axis. So we see this interconnected network where maybe it's not one exact chemical causing infertility, but when you add together dietary choices, not getting sleep, stress levels, environmental toxins, these things have a profound impact on fertility. And then specifically, male fertility is so much more sensitive. Women do have their eggs in their body their whole life. So we see a greater tincture of time as some time adds up. But because the sperm life cycle is relatively short, sperm are so sensitive. You know, when we freeze and thaw sperm in the lab, we're going to lose 50% of them just in the freeze thaw process. So sperm are made, they have that three month cycle. But that's also an opportunity, especially when it comes to environmental toxins or behavioral toxins, choices we're making, to really change and influence male fertility specifically.
- [06:21]
Dr. Rena Malik
Absolutely. And interestingly, you know, when I was doing some research on fertility, there are certain toxins that are lipophilic, meaning that if you are more overweight, those toxins are going to stick around longer.
- [06:31]
Dr. Natalie Crawford
Yeah, they accumulate in your fat and they make it worse. And interestingly, there's protective mechanisms in your diet that can counter some of these. So folic acid is a great one that actually decreases the rate of BPA in your body. It can help fight it. A lot of these nutrients are found in fruits and vegetables, and they counter some of the environmental toxins. But you're right, a lot of these lipophilic ones make things even worse if you have other health problems as well.
- [06:55]
Dr. Rena Malik
You know, as interesting, I was talking to a patient the other day and he came to me with his box of supplements and literally a box and and then he was telling, you know, what do I, Should I take this? Should I take that? I was like, look, stop spending all this money on the supplements. Take that money. Invest in a personal trainer, invest in nutritionist, because you don't have that together yet. And I think that that's a big take home for a lot of people is like, we're trying to figure out what is the cause of things, but we're not doing the work when it comes to diet, exercise, stress, which is a huge one, and sleep.
- [07:29]
Dr. Natalie Crawford
Absolutely. It's majoring in the minors. So we're focusing on these little things. And it'd be great if there was a magic pill that could make everything better. But supplements should be just that. They are supplemental. We shouldn't even really entertain that discussion hard until we have optimized our own nutrition and all the lifestyle factors. You said because chronic inflammation, insulin resistance, they do a double hit for fertility because they interfere with the brain. So the brain can then not signal hormones directly, but they also directly impair egg and sperm quality and the DNA integrity inside. So when we think of one exposure harms you in two different ways. Going back in preventative care and being proactive is really what we all need to be doing first before we start going down this pathway of spending hundreds of dollars on supplements.
- [08:15]
Dr. Rena Malik
Yeah, absolutely. Let's take it back, though. Let's take it back to, you know, when women start becoming fertile, which is when they start having their period. I've heard you say that your period should be a vital sign.
- [08:27]
Dr. Natalie Crawford
Why is reality is in women, their brain ovary connection is so tightly controlled. Getting pregnant takes a huge metabolic load on the body. And so being in a position where you can have a period and have it regularly is a reflection of a proper hormonal state. So what we want to think about here when it comes to your period is that the hypothalamus is in the brain. And I like to think about that as central control station. Constantly interpreting hormone signals from your body. It then talks to your pituitary, which sends out hormones called FSH and lh, which you're well familiar with and your audience knows these help control sperm and testosterone production in men and in women control egg growth, ovulation, estrogen and progesterone. But the brain is waiting to hear that estrogen progesterone signal back. And so having a cycle at a regular, predictable interval, and more than a cycle, but also when you ovulate, how long each of these phases are, the follicular phase or the first half of the cycle or the luteal phase of the back half that is communicating back, that everything is functioning properly. And it doesn't take much to throw the hypothalamus off. So it can be chronic inflammation, stress, low calorie intake, over exercising, chronic disease, autoimmune disease. When the brain senses that maybe this isn't a great time for you to be pregnant, your protective mechanism is maybe not to ovulate. And for a long time people think about this as an on off switch. Meaning, well, as long as I'm having periods, the switch is on and I'm fine. And if I'm not having periods and the switch is off, and that's a problem. And obviously if the switch is off, it's a problem. But a lot of the red flag warning signs that your body is giving you is in the dimmer switch. It's when you start to see subtle changes, meaning when you transition from a perfect ovulatory pattern to one that's dysfunctional, you will go through very specific changes in your period pattern. So you'll have a shorter luteal phase, then you'll have changes to the follicular phase and it will lengthen out, then you will skip cycles and then you will have amenorrhea or absence of a period. And I would much rather start the investigation when you have a short luteal phase or longer follicular than waiting for things to get so abnormal. And more than that, one alarming statistic is that only 20% of apps that are detecting your ovulation window when you put in your day one of the cycle are predicting ovulation correctly. So getting it wrong the vast majority of the time, because it's crazy. Yeah, they're just using an old school method called the calendar method, using a standard luteal phase and walking backwards. So tracking your cycle for a woman is much more than just marking Your Cycle Day 1 in your app or on a calendar. It actually requires knowing when you ovulate. And knowing when you ovulate can be either through checking your basal body temperature, which is easier nowadays with wearables. Cervical mucus monitoring, which is something that your body is going to change with your estrogen levels peak, you're going to have a change in your cervical mucus. It'll be sticky, stretchy, like an egg white, or actually checking your urinary hormones like lh, which is an ovulation predicting kit. And LH is the hormone that causes you to ovulate. So if you can target when you're ovulating, then you have so much more knowledge and can leverage that period as a vital sign. But when did you learn to track your cycle?
- [11:39]
Dr. Rena Malik
I. I mean, I don't even remember. Like, I don't think I. I just knew, like, okay, it should be around the same day or every month. That's it. Yeah.
- [11:46]
Dr. Natalie Crawford
We don't talk about this when we really have years of our reproductive life. Well, before we want to get pregnant, is the prime opportunity to say, well, what is normal for me? Is my cycle regular? How's my luteal phase? How's my follicular?
- [11:58]
Dr. Rena Malik
When should you. If you're a young woman and you're not yet trying to conceive outside of knowing that, like, hey, my periods are not happening on a regular cycle, which is, I guess, to some degree, obviously, just like, putting it on a calendar. Right. Or maybe I'm having really heavy periods. What are other red flags that, like, hey, I need to pay attention.
- [12:15]
Dr. Natalie Crawford
Absolutely. So what you already said. So absent or irregular periods, if we have spotting in the luteal phase. So that second half of the cycle, if we're having spotting, one day of spotting before your period begins is normal, but more of that is not. And that can represent hormonal dysfunction or structural abnormalities. Heavy bleeding, like you talked about, you should never bleed through your clothes. Painful periods, especially those that keep you home from work or school or activities. If you would cancel going to a movie or dinner, not normal. If you have pain with intercourse and specifically with deeper penetration, then that can be a representation that inside anatomically things may not abnormal or have more inflammation. And then when it comes to the cycle itself, the luteal phase should be at least 11 days in length. So if we're less than that, then that's a short luteal phase. And for any given woman, you'll see people say your cycle should be anywhere from 25 to 35 days. And that's a true statement, but it shouldn't hop around. Meaning for you, if I give you a calendar, you should be able to take your finger, put it on when you think your next period is going to be, and with a day or two of accuracy, be correct. If it's 25 days, one month, 34 the next, that's too much variability. I call that irregularly regular. And that's a sign that your brain is not responding quite as appropriately as it should and warrants an investigation.
- [13:34]
Dr. Rena Malik
So you mentioned the luteal phase should be 11 days. So should young women be tracking when
- [13:38]
Dr. Natalie Crawford
they ovulate in the perfect world, yes, that is a vital sign. That's that fertility key. And your fertility is much more than just getting pregnant. I think culture has simplified it to fertility equals getting pregnant. We know that women who have infertility have a higher rate of stroke, heart attack, metabolic disease, cancer, and earlier death. Like, and the statistic is not just a small amount. It's up to an 80% higher rate of those. And that's a devastating statistic to sit here and say, because I had infertility. But when we think about what it is, it's not that infertility is a disease causing you to therefore have these problems. What really is happening is that the underlying state of your health that might contribute to infertility absolutely can contribute to these other chronic diseases later on. And this is why this discussion that we talked about earlier, metabolic and cellular health is so important. And so not being able to our body earlier is a problem. When you track your cycle, this is the opportunity for you to get those red flags much before it's a problem. And especially if you're a younger woman, you're not ready to get pregnant yet. We're not going to know if you have infertility or not being able to know is my luteal phase normal or not, if it's short, suddenly. We're going to do an investigation and look at your thyroid, look at your prolactin, look at your nutrient status and start to see if there is a reason why. And the earlier you could get diagnosed with hypothyroidism, for example. The earlier you could start treatment and have this not be an issue for you later. But most of the people that I see, most women are not tracking their cycle and learning about ovulation until they are failing to conceive.
- [15:16]
Dr. Rena Malik
Absolutely. I mean, I think in general, there's a big discussion about tracking your cycle because it changes your mood and it changes your how strong you are, how you're going to, you know, act in the workplace. Like, I've been hearing a lot of that, but it's like, now we're talking about more mature things. And when you're young, like, you're really just trying to, like, get through life. And like, I think that's the prime time. And, you know, as you mentioned, I didn't learn about any of this until medical school and, you know, beyond. But no one's teaching women about these things, even in education. Right.
- [15:44]
Dr. Natalie Crawford
Sexual education, this is not what you learn.
- [15:46]
Dr. Rena Malik
Yeah, you learn how to put on
- [15:48]
Dr. Natalie Crawford
a condom and to double Down. It's not that there's anything wrong with birth control, but what's happening is women in these time period that's ideal to learn and say what is normal for me, what is happening in my body are often put on hormonal contraception, therefore losing that vital sign. And it's not that the birth control is causing harm or doing anything wrong, but you're losing an opportunity to know how your body is functioning. So I think there's one thing to say beyond birth control for a few years, I was on it for more than a decade. I don't have anything against it because it let me achieve big dreams when I wasn't ready to get pregnant. I but in hindsight I wish there'd been an opportunity where somebody had said maybe you should come off of the pill for a few months and see how your cycle is and learn what normal is for you. Because learning all of that later on when I had infertility, when I was struggling to get pregnant, trying to figure out what's my normal, when my doctor said, well, how long is your luteal phase normally? Yeah, I don't know, I don't know. So I think that there's something to be said whether it's in your younger years or at a minimum stopping that contraceptive before you're ready to start trying to conceive. So you can go through this act of learning to track your cycle, getting your hormonal cues and investigating problems that may arise before you feel like you're behind the game.
- [17:03]
Dr. Rena Malik
What is the easiest way for people to track their cycle? For a young girl who's like, you know, maybe in college, maybe, you know, still in school, what is the simplest way for them?
- [17:11]
Dr. Natalie Crawford
Two simplest ways. One, cervical mucus is so easy. People don't talk about their body. So cervical mucus has the word cervix in it. People get really freaked out. Your cervical mucus is protecting your uterus, so it's a barrier so that nothing can get in the uterine environment. Well, it wants sperm to get in around the time of ovulation. So your cervical mucus changes from being creamy or non existent to being very sticky, stretchy with an egg white when estrogen's at its peak level. So when you notice your cervical mucus and this just comes out of your body, you can wipe with toilet paper. Look at it. Should be sticky, stretchy like an egg white. That is considered type 4 cervical mucus. When you see it present, it's a sign of peak estrogen. Last day of type 4 cervical mucus is your ovulation day. So that doesn't require any apps peeing on sticks. Anything crazy from there, I will say. Second, I'm a huge fan of wearables that do connect with an app because that's not just app based technology, but they're leveraging basal body temperature. After you ovulate, your body makes progesterone. Progesterone raises your core body temperature by 0.4 degrees Fahrenheit. So if you detect this shift, you can confirm when ovulation happened. And a lot of the wearable technology is much more sensitive than any one time thermometer use that we had in the past. So 10 years ago I would have said do not check BBT, it's too cumbersome and complex. But now with wearables, it's aware it and not think about it. So I love it. Oura ring with Natural Cycles. I think that's a really easy way to know what's happening with your body and not have to be thinking about it all of the time.
- [18:42]
Dr. Rena Malik
Yeah, that's very helpful. You mentioned birth control. We got to talk about it. In my world, I would say that there are a small subset of women who when they take oral contraceptives, their SHBG goes up, which is their sex hormone binding globulin, which makes their testosterone that's available lower. Yes. And can affect libido.
- [18:59]
Dr. Natalie Crawford
Absolutely.
- [19:00]
Dr. Rena Malik
And I think that's one thing that we don't counsel women on enough when we're starting them on birth control. Right. Another sort of thing that is, you know, we have a lot to do. And I don't blame people. People are busy and they give the advice that they can. And it's a small subset of women that have this, but they're not counseled that. So they don't know now why their libido has all of a sudden plummeted. What are your thoughts on that?
- [19:21]
Dr. Natalie Crawford
Well, you're absolutely right. Of course. There's a greater cultural issue here of going in with any of the above problems that we mentioned. And somebody might say here's a pack of birth control pills and this will fix the problem and it might fix the problem, but doing so without telling the patient what the underlying problem is and the side effects of what the birth control is going to do is a huge issue that we have right now. So the birth control pill, what you're mostly talking about is ethanol, estradiol and a type of synthetic progestin. I think it's really important for people to understand this is different than estrogen and progesterone. Yes, it does feed back to the brain. So the brain senses that there is estrogen and doesn't send out FSH or lh. So you don't grow an egg and ovulate. But ethanol estradiol doesn't even show up on an estrad blood test. It doesn't work across our body and all of our tissues like estrogen does. And to be even more specific, if I have a young woman who has hypothalamic amenorrhea, meaning her brain sending out no hormones and she is low estrogen, even though the birth control pill is one available choice, putting her on actual estradiol is going to benefit her overall health much more, especially her bone health. So we know that estrogen and ethanol estradiol are not equal. This is also really true when it comes to the tissue and the genitourinary tract. And so not just low libido, which due to part of what you said due to decrease in testosterone, but also due to not having estrogen in the genital tissues. I will see women who have, you know, really painful. They have a lot of vaginal dryness. They don't feel like they're as moist as they used to be. Sex becomes very uncomfortable. So not just. So you were doubling low libido plus the fact that it's now much more uncomfortable than it used to be. And you can see why. If you don't know that this could be due to the pill, you now think something's wrong with you.
- [21:13]
Dr. Rena Malik
Yeah.
- [21:13]
Dr. Natalie Crawford
And that's problematic. It doesn't mean that the pill is wrong, but I will counsel patients that this might happen. Maybe we need the pill for XYZ reason. You can minimize it some by depending on the type of birth control. So there are a lot of different strengths of estradiol or ethanol estradiol, a lot of different types of progestin. Some of them work different, some of them are more anti androgenic than others. So you see even more profound changes to libido. I'll also sometimes add in vaginal estrogen on top of the pill if this is a problem. So we have options. But counseling people that this is a real side effect, it's not just in your head or a problem with you. You can explore other contraceptive options or modifications. If being on an effective birth control is a goal right now, we want you to have that, but it doesn't mean that you should just suffer. The pill is not benign, just like no medicine is Right. Any medication that we're taking is going to have some side effects. And certainly it's good to see a culture where we are starting to talk about this, hopefully without fear, so that women can feel empowered to ask the right questions and make the right choice for themselves. K Pop Demon Hunters, Haja Boy's Breakfast Meal and Hunt Tricks Meal have just dropped at McDonald's. They're calling this a battle for the fans. What do you say to that, Rumi?
- [22:26]
Dr. Rena Malik
It's not a battle.
- [22:27]
Dr. Natalie Crawford
So glad the Saja Boys could take breakfast and give our meal the rest of the day.
- [22:31]
Dr. Rena Malik
It is an honor to share.
- [22:33]
Dr. Natalie Crawford
No, it's our honor. It is our larger honor.
- [22:37]
Dr. Rena Malik
No, really, stop. You can really feel the respect in this battle.
- [22:42]
Dr. Natalie Crawford
Pick a meal to pick a side
- [22:45]
Dr. Rena Malik
and participate in McDonald's while supplies last. Absolutely. I think another big concern is that birth control can affect fertility.
- [22:52]
Dr. Natalie Crawford
Yes.
- [22:52]
Dr. Rena Malik
And you disclosed that you were on birth control for 10 years and you struggled with infertility. So I can just see people listening to this. Oh, that's why. So let's set the record straight.
- [23:01]
Dr. Natalie Crawford
Birth control, there's a lot of different types. So let's break down the different types. And before I dive into the statistics on the meech, I think this is a really important analogy for people to understand. You're born with all the eggs you're ever going to have, and I want you to imagine them as in a vault inside your ovary. So from that vault, a group of eggs comes out of it. Every single month, each egg grows inside a follicle. The brain sends out fsh, that follicle stimulating hormone that we talked about, which gets one egg to grow and develop up. That one will ovulate. All the other eggs outside the vault die. Next month, another group comes out. When you have more eggs in the vault, more come out every month. When you have fewer eggs or we start to get older, fewer eggs come out over month. So over time, we start to have less eggs in everybody. And fewer eggs come out of the vault. Well, we can measure these eggs outside the vault, and that's called amh. It's a blood test or with an ultrasound. Now, importantly, when it comes to birth control or being pregnant, being postpartum, you're losing eggs your entire life. No matter what, even before you start your first period, eggs are always coming out of the vault. Just in those time periods, the brain's not sending out fsh, so estrogen is not rising. You're not growing an egg. But all of the eggs that are sent out of the vault just die. And the next month you have another group of them. So birth control doesn't save your eggs, nor does it cause you to run out of them at any faster rate.
- [24:18]
Dr. Rena Malik
So no matter what the stimulus is,
- [24:19]
Dr. Natalie Crawford
those eggs are coming, the eggs are coming out. And when we do IVF or egg freezing, all we are trying to do is get that month's group of eggs to all grow. I can't tap into the vault, I can't get more of them. This is why we're somewhat limited by our own potential, by how many eggs that we have. So we are on this pathway. I mean, since we're born, Puberty is the brain turning on. So you lose most of your eggs actually from birth until you start your first period, where you go from 1 to 2 million eggs at birth to only about half a million when you start your first period. That's crazy. Before you ever ovulated a single one. So this process is happening, you're losing eggs. Birth control does not change this process at all. The birth control pill is really short acting. Single pill lasts 28 hours. That's why we will see women miss one pill and they can ovulate and get pregnant. That's not the most common scenario, but it can happen. That means we don't need months to cleanse our body from the pillow. But as we said earlier, one of the biggest issues with the pill is that you're losing that vital sign of your period. And if it doesn't come for months, you're just spending time and losing that opportunity for earlier investigation. That being said, not all contraceptives are created equally and it's really important to talk about them. So some of the progestin only ones which are long acting are wonderful effective contraceptive choices, but they do have longer lasting effects by their mechanism of action. The progesterone IUD is really great. It's a highly effective contraceptive. Some women will still ovulate on it, not everyone will. But one of the biggest issues that we see is that it is a constant progesterone exposure inside the uterus, which changes both the receptivity of the uterine lining and its ability to grow. And I'll admit my own selection bias, because in my clinic I see people who are struggling. So there's plenty of people who don't struggle, who I don't end up seeing. But what we do know from the data is that the receptivity of the endometrium can be modified for a year after pulling out a progesterone iud. So even though we will sit here and say there's no higher rate of infertility, because infertility is the ability to get pregnant at a year, we can see some lower month to month pregnancy rates, especially in those first six months after you pull out an iud. Also important, the Depo Provera shot. It will prevent you from ovulating in almost all people for three months. So you get the shot every three months. Highly effective contraceptive choice. But one single shot can prevent ovulation for 18 months. So if you got the shot, you didn't know this and you think, well, I want to be pregnant in a year. You might not ovulate. And I've seen this happen to women who had no idea. So we definitely should not be doing the shot if we want to get pregnant anytime in the next two years. So I love long acting contraceptive choices for certain stages of life, but I think it's really important to stop them or transition to shorter acting ones as we are getting closer to our reproductive window and time to conceive. The last thing I do want to say here is that AMH is a hormone, anti mullerian hormone, made from the cells that surround each follicle. Each follicle is where the egg grows. So more eggs remaining, more eggs come out, you'll have more amh. Now these cells are active. This is a hormone that they're making and they can get suppressed. So in prolonged periods of not ovulating, you might have a lower amh. If we are screening your AMH to say, I want to be pregnant someday, but not now, how many eggs do I have? If you were on hormonal contraceptive, it might be artificially lower. That's important. Can be up to 20 to 30% lower if you're on the continuous birth control pill. It can be 10 lower if you're on a progesterone IUD. So it doesn't mean that we don't check it or that we dismiss patients in that scenario. It also doesn't mean that I make all young women come off their contraception if they're happy, but if they're curious about their egg count, what I say is, let's draw a value while you're on your contraceptive du jour. And if it comes back normal, we feel pretty reassured. But if it comes back low, then we're going to have a conversation of should we pull off this contraception for a while, should we recheck it in two months? That's when it should come back to its normal level and not be suppressed anymore? Or is this a real representation of our physiology and that we have a low egg count? That was the longest answer to no birth control in studies. If we look at that 12 month mark doesn't impact your fertility, but I think it's important to know it is masking that vital sign. You're not running out of eggs any faster, you're not saving eggs. AMH might be artificially lowered. It doesn't mean you have lost eggs. It just might be suppressed. And I think the biggest takeaway for me is that if you're thinking you want to be pregnant in the next year, this is the prime opportunity to stop that contraceptive transition to something else. Learn to track your cycle and give your body time to get back to your baseline. So you know what that is.
- [28:54]
Dr. Rena Malik
Let's talk a little bit about amh because people are able to like do these at home tests now. So I think that's really important if they're on birth control to realize that that may be suppressing it. But is it something where you should recheck it if you're not on birth control, let's say in a slow like, is there other things that can artificially lower it?
- [29:11]
Dr. Natalie Crawford
That's a really good question. There's not much that will artificially lower your AMH with the exception of that profound ovarian suppression. Typically that is from contraception, but I'll say postpartum. We're not usually checking an AMH in the postpartum period.
- [29:24]
Dr. Rena Malik
But you how long?
- [29:25]
Dr. Natalie Crawford
Like, well, in pregnancy and postpartum? Well, it depends on when your periods come back. So once your brain turns back on and your ovaries are functioning, then we'll see resume to normal value. So that will depend on your breastfeeding status. But if checking an AMH during pregnancy or in the postpartum when you're still amenorrhea, we can see it be artificially lower than what it can be. I think the bigger point of one of the questions you're asking is if you get a low amh, what should we do about it?
- [29:52]
Dr. Rena Malik
Yeah, yeah.
- [29:52]
Dr. Natalie Crawford
And that's a hard question. In some way the American College of Ob GYN says you shouldn't even check it. You shouldn't even check it unless you have infertility.
- [29:59]
Dr. Rena Malik
Do you agree with that?
- [30:00]
Dr. Natalie Crawford
No, absolutely not. I think that's a very paternalistic, misogynistic statement because they're making the assumption that you can't handle the data and that it will be too overwhelming. To your system, two things can be true at one time. Meaning if I take an average 30 year old who has 20 eggs outside her vault, ovulates, 119 die, and her friend who has low AMH, who might have 10 eggs outside her ball, ovulate, 19 die. Well, on a month to month basis they're both ovulating one egg and if everything else is the same between them, they have the same month to month chance of getting pregnant. So this pulls into a cog saying, not important, causes stress, doesn't impact fertility.
- [30:37]
Dr. Rena Malik
Sure.
- [30:38]
Dr. Natalie Crawford
Although we know that it directly impacts time to menopause. Person with a lower AMH is going to have less reproductive lifespan. She has a lower egg count, will go into menopause earlier. We know that that might impact her family size. We know that she's going to get fewer eggs with egg freezing or ivf, might need more cycles. But also more than that, why is her AMH low? Is it endometriosis, autoimmune disease? Is there an underlying reason that absolutely also impacts fertility? So I think it's one a really simplified statement to say AMH doesn't impact your fertility. I think it's a much more nuanced circumstance. And I also think that we shouldn't make the assumption that you wouldn't do anything about that data. Because I've had women sit across from me who find out they have a low amh, they use that data to change their plan. And you being the one to make that decision versus having time make it for you is extremely impactful and important for your life. You might say, I'll try to get pregnant faster. I mean, I have this partner. We were going to wait five more years because I'm chasing this dream, but I don't want to lose that opportunity because a child is a goal. So we're going to shift our timeline. Or you might say, maybe I'll freeze eggs or embryos if that's available to me so that I can hope to keep this reproductive door open. Or you might start to evaluate underlying causes. Maybe you change your lifestyle, decrease inflammation, get diagnosed with an autoimmune disease. The earlier we start making those changes, we both know the better for you. Or you might do nothing about it, but then you got to be the one to make the choice. And even when I sit across from women, hearing the data, having the investigation done, being the one to say, I don't wanna freeze my eggs, I'm not ready to start trying, I don't have a partner. But I know that these things are open to me, and this is where I sit. It's a part of our biology. We all will run out of eggs at some point. Our fertility will be finite. We won't have endless time. So I don't think it's right to say that you shouldn't be able to check that until you have infertility. In fact, I think it's completely wrong that we make women fail before they even qualify for fertility testing. If we go back to the beginning of the episode we said the rates of infertility are rapidly rising. So in the world where infertility rates are increasing, women are waiting longer to get pregnant. We still want to sit here and say, you've got to fail for 12 months before I'll even draw a blood test.
- [32:54]
Dr. Rena Malik
12 months is too long.
- [32:56]
Dr. Natalie Crawford
Wild. It's too wild.
- [32:57]
Dr. Rena Malik
Especially the reproductive years. It was too long.
- [32:59]
Dr. Natalie Crawford
Long, yeah.
- [32:59]
Dr. Rena Malik
You know, in men, we say sperm health is a biomarker of your overall health. And you've alluded to the same thing for women, fertility and periods are a biomarker of health. Right. That this is a window into your overall health. Obviously, periods is 1. Is AMH sort of. Can we look at it in the same way as like, hey, this is a simple blood test that you can do that might actually give you some insight into your overall health. Like, if it's low, it could be a sign.
- [33:21]
Dr. Natalie Crawford
Absolutely. I think it's a really important test that women should get in their 20s if they want to have kids one day. We don't have the great answer for at what cadence should you check it and what does that mean? Because it does vary month to month. Your body is not perfect. So If I say 20 eggs outside the vault would be average for your age, might be 21 month, then 1722, and I would get a different AMH if I checked it all of those months. But that doesn't mean that the data is not extremely impactful. And to your point, a normal AMH doesn't mean you'll be fertile, doesn't mean you'll have no problems. Fertility is much more complex than that. But a low AMH is absolutely a red flag that something is not functioning as it should. And if we start viewing these different biomarkers as the opportunity for you to take that control over your health, to make changes and learn more at an earlier stage. I do not believe that physicians that our job is to be the gatekeeper of data about your body. And in fact, in today's world, I think we deserve more data about our body. And if it's. Especially if it's a blood test, there's definitely data that's hard to achieve. Endometrial biopsies, I can't see egg quality until I take your eggs out of your body and IVF or egg freezing. So there's so much data for women that's really tough to get. Testing blood is not that.
- [34:36]
Dr. Rena Malik
So I will push back a little bit because there's this emergence of like Dutch testing and. Yeah, and where they're checking your hormones every single day for a month. Right. Is that too much data? Right. Are we giving people so much data they're overwhelmed?
- [34:48]
Dr. Natalie Crawford
You know, I think valid data is really important. So the Dutch test, for example, is salivary saying. And it's not as. Let me reset. The Dutch test, for example, is not validated to be a good replication of your serum hormone levels. And that's one of the issues with it. So when we are trying to say what data is helpful and what data is not helpful, I think it's really important that valid data is where we're going. And this is prevalent in the fertility industry. Right. There's a lot of tech, a lot of money that is coming into the space. So we are seeing a lot of testing rolled out, a lot of direct to consumer tests, a lot of fertility clinics offering things that are not proven to be valid. That's different than saying we're going to get, you know, blood markers done or once a year get a blood panel or I have something wrong with me, I'm not feeling well, or my periods are irregular and getting a blood panel done for some of that. And if you want to be pregnant, similarly, I think men should get a semen analysis before they're 12 months in. I think it's crazy.
- [35:49]
Dr. Rena Malik
So it's so simple.
- [35:50]
Dr. Natalie Crawford
Yeah. I think there's an individualized response to Rena, to your question, meaning everybody's wired a little different and we should never let data put us in a stressful position.
- [35:59]
Dr. Rena Malik
Well, I think that's the issue is that I think it causes stress whether you want it to or not. Because if you get your blood test done every single day. Right. Let's just say. Sure. Let's just say for you, get a good value.
- [36:10]
Dr. Natalie Crawford
Probably shouldn't do that. But yeah.
- [36:12]
Dr. Rena Malik
Let's just say somebody's like, you could.
- [36:13]
Dr. Natalie Crawford
You could go to Quest and get that done every day.
- [36:15]
Dr. Rena Malik
You could get your hormones done at every single day for 28 days, 30 days, whatever your cycle length is. And then you get all this data and you Track it. And now you're like, oh, this one lab doesn't look perfect, or this, this doesn't rise the way it looks like on a textbook that I Googled. Right. And now we're creating more anxiety and stress whether we want to or not. Right. So I think that's the challenge, that's the pushback, is that, you know. Yes. I think these things should be done under supervision with someone who can guide you, who can talk to you about these tests. Whereas, like, more and more things you're able to do by yourself. And you kind of alluded to that. Right. That is not always the best quality. Now, some things, some home tests are great. Right. They are as good or close enough that you can do them at home, and they're good. But it's difficult for the average person to figure that out. Yeah.
- [36:59]
Dr. Natalie Crawford
And I think when you talk about daily hormone tracking versus checking biomarkers, we're really talking about different ball games there. You know, there are urinary based daily hormone trackers that sometimes can be helpful. I think the important thing for your hormones, it is a complex dynamic system. By definition, it's meant to change and respond in accordance to the world around you. And that can sometimes be very hard to understand, whether it's a CGM or a urinary based hormone monitoring system that you're doing. And that is why having a physician or a provider that you really trust overseeing your care, who's willing to look at some of that data and help you interpret it versus going down a rabbit hole can also be very useful.
- [37:40]
Dr. Rena Malik
Yeah. And I'll be honest, I think people can also use that data in a negative way. Right. They'll be like, oh, this is, this is. You're, you're messed up. Right. You go to the wrong person, whether it's a medical person or not. Right. Because there's lots of different people out there and they can use that data to show you, like, oh, my God, you got to do all these 10 things that I'm offering. And so, yeah, there's, there's a challenge there, and I don't know the right answer. I'm just trying to have a discussion here because I think these are real challenges that people are facing.
- [38:05]
Dr. Natalie Crawford
Sabrina, I'll give you an example of a couple that I saw. So a real life couple, and they didn't come to me first. So they went to a air quote hormone expert. So they went to a hormone expert in town. I live in Austin. Super granola, quite common. They had been struggling to get pregnant for nine months went in, they both had big blood panels drawn. She was told that she was estrogen dominant and that she needed daily progesterone and that it's not good to be estrogen dominant and this was preventing her from getting pregnant. So she was put on a compounded daily progesterone. Well, her labs were checked in the follicular phase. So the follicular phase is a naturally estrogen dominant. You haven't ovulated yet, your progesterone should be low. And if we do supplement women with progesterone, we only do it after ovulation is confirmed to occur. So she was essentially put on birth control being on daily progesterone because progesterone opens and closes the implantation window. And this to your point, wasn't even at home testing. This was with a provider who didn't fully understand hormones. Her partner was diagnosed with low testosterone which he actually had. But you can guess what he got given testosterone, testosterone. And I know your audience well knows that taking testosterone as a man suppresses the brain so it can cause azoospermia because it stops the production of testosterone and sperm. So they were equally both put on essentially we'll say contraceptive options after they'd been struggling to get pregnant for nine months under the guise of. This is going to help you get pregnant. So it's not that testing is bad, but I think here's the bigger picture. This is why it's crucial to understand your hormones and understand your body because you cannot rely on the world around you to always do the right thing. Whether it's this test you're doing at home or even the quote expert you're going to. We've got to give our patients a sense of hormone literacy to know, wait a minute, we're checking blood in the follicular phase. Progesterone's naturally low. This is wrong. I don't trust this person anymore. Or you should never put a man who's wanting to get pregnant on testosterone only because that can cause azuspermia. That sometimes is not reversible. Meaning sometimes there's no sperm and the ejaculate and we can never get it back. And that's a scary thing and really a heartbreaking thing to see to patients.
- [40:15]
Dr. Rena Malik
It is absolutely a very scary thing that we see all the time.
- [40:19]
Dr. Natalie Crawford
Yeah. That's why I think it's so important. Right. My book, you have a book coming out. Being in the position to help get that information into consumers hands so that they can show up to Their doctors in a position to better advocate for themselves by not just blindly trusting. Because unfortunately, not all people, you see, are going to always understand the physiology of your body.
- [40:43]
Dr. Rena Malik
Yeah, and I will say, I think that people who are really good sales people are very, very charming and, and alluring. I always take a pause because I,
- [40:52]
Dr. Natalie Crawford
I'm like, but you're so charming.
- [40:54]
Dr. Rena Malik
I don't think I'm that charming. But, like, I think, you know, when you have a discussion, there always needs to be some discussion of risk and
- [41:02]
Dr. Natalie Crawford
some explanation, always nuance.
- [41:04]
Dr. Rena Malik
When people are like, this is the best thing since sliced bread. Your doctors are hiding this from you. That's when you need to be like, wait, wait, why? And my, my like meter is like, hey, if this was something that really did what you're. They're telling you it does, everyone should be on it and everyone should be taking it. It should be worldwide knowledge. Then that's not real. Because if something was really that transformative, it would be in the water, like,
- [41:29]
Dr. Natalie Crawford
it would be somewhere. I say the same thing. If it sounds too good to be true, it is. Right? Nobody. If I could magically give people medication that would cure their infertility that easily, I would absolutely do it. Right. We, we have given our lives to try to help patients live better lives, achieve their health goals. So yeah, your bullshit meter is so right that if this is something that is that obvious, you wouldn't be finding out for it the first time by your salesman, your charming physician or expert or whoever they claim to be. And that's important too, to say, who, who is this person really? And what are their credentials to be the hormone expert?
- [42:08]
Dr. Rena Malik
Right.
- [42:09]
Dr. Natalie Crawford
Because you and I went through a lot of very specific training to sit in these chairs and to talk about male and female fertility. Yet there are a lot of people who don't have that training, therefore don't have all the knowledge. And it's not that they're all inherently bad, but you do deserve to know who you are seeing and if they are qualified to give the advice they are given.
- [42:29]
Dr. Rena Malik
Absolutely. What are some things that back to fertility. Things that, like, simple things that women aren't doing that could actually enhance their fertility.
- [42:38]
Dr. Natalie Crawford
Okay, I call these my five non negotiables. Because this is all coming back to the idea that every single day there are decisions we make, whether we realize it or not, that are either increasing our inflammatory burden or they are improving it. And what I want to say before I dive into them very quickly is that the inflammatory system is tightly linked to reproduction. So Acute inflammation is your body getting a cut, healing from that. Acute inflammation is actually super important in ovulation. If you take incense like Aleve, Motrin, Advil, you will go through the hormonal changes of ovulation, but the follicle will not rupture or release an egg. So you cannot take those, or you should not be taking those around ovulation. But many women are not aware of that. So those are medications, if you take them, only take them when you're on your period and not at any other time in your cycle.
- [43:23]
Dr. Rena Malik
So I didn't know that.
- [43:24]
Dr. Natalie Crawford
Yeah, that's crazy, right?
- [43:25]
Dr. Rena Malik
Yeah.
- [43:26]
Dr. Natalie Crawford
So inflammation is a normal body response that is helpful. However, chronic inflammation is not. So this is when your immune system is constantly turned on because it's exposed to the world or a variety of stimulus. But what starts to happen in a chronic inflammatory environment is it is feedback to the brain interferes with the hypothalamus from interpreting and responding signals, and it actually goes in and is detrimental to the DNA inside the egg and the sperm. And then for the ugg, even more so, because the egg have the mitochondria that get passed on to the embryo, we see that chronic inflammation and therefore insulin resistance, which go hand in hand, can majorly contribute to mitochondrial dysfunction, poor metabolic health, and therefore bad egg quality, bad embryo quality. And even when we do ivf, and I think this is an important way to frame this next part, because sometimes people will be told, we'll just do ivf, and that's all you need to worry about. But even an ivf, I can only work with the eggs and sperm that I'm given. So this is your opportunity to influence that egg and sperm quality before you do a cycle. And I think it's so sad when people go through ivf, which is expensive, takes time. It's emotionally, physically challenging, only then to have a suboptimal result and start down this pathway of, well, what can I do? Maybe it's egger sperm quality. You should go focus on these factors. We should be doing these before we want to get pregnant, while we're trying, if we're going through fertility treatments, because as a human, you deserve to go into this saying, I'm doing everything I can. I can't control every outcome. But just like any goal you're chasing, I'm gonna learn about it. I'm gonna know how to advocate for myself, and I'm gonna know that I'm bringing my best to the table. That's possible. So a lot of these simple Things you can do all counter back to trying to decrease inflamma or to decrease inflammation and insulin resistance. So what are they? Number one thing is sleep. So I. Right, it's not sexy, but only 2/3 of US adults get more than 6 hours of sleep. And that's a low number.
- [45:27]
Dr. Rena Malik
That's really low.
- [45:28]
Dr. Natalie Crawford
It's really, it's really bad. Right.
- [45:29]
Dr. Rena Malik
And which means their testosterone sucks, as
- [45:32]
Dr. Natalie Crawford
is their ovulatory pattern and their egg quality. So women need a little bit more. We usually say seven to nine hours is what people need. And most women need at least seven and a half hours, especially during the luteal phase where your metabolic needs are higher. Sleep is when your body heals inflammation, for lack of a better word. It's when it's going to go and heal up from everything you were exposed to during the day. More than that, sleep's really important to counter insulin resistance. And also when you sleep, your gonadotropins, FSH and LH are released from your brain in the early morning hours. So this benefit of sleep is so profound, meaning if you don't sleep enough, it is directly going to impact your hormone release, therefore your fertility. If you get one hour less sleep per night, you're gonna get sequentially fewer eggs with ivf, even with ivf, so it's going to directly impact the number of eggs that we can get. We also know that circadian rhythm is important. So increased sleep variability for men or women results in a lower monthly pregnancy rate and a longer time to pregnancy. So it doesn't mean it's impossible to get pregnant. But you even said your testosterone is going to suck for men and women. Your body is wired to make sure that you can raise a child in this environment. And sleep is the best feedback mechanism you can give that everything is working appropriately. So quick recommendations. A cool room, set the environment, make it dark, wear a sleep mask, consider a sound machine. Put your electronics further away. Make sure you get in bed with enough time. Melatonin can be advantageous. It's an antioxidant. IVF studies have even shown that utilizing melatonin has been improved egg quality. Everybody doesn't need melatonin. It's not a more is more medication because it can suppress the brain. So I typically recommend people start with 1mg and at most 3mg a night if you're going to try melatonin.
- [47:19]
Dr. Rena Malik
But I will just add about melatonin. There's some data that melatonin, when you look at the labels on Supplements versus what's in the supplement is extremely variable. So definitely, if you decided to use melatonin, if that's right for you, make sure you're getting a supplement that shows third party testing that is reliable. You know, I, I don't know all the data in melatonin, but I do know that, yeah, I'll give a plug
- [47:40]
Dr. Natalie Crawford
because I'm a medical advisor for Subco, which is a company that you can look up the supplements you're taking and you can see their scores. They independently test them, they give you all of that information. So if you're just trying to say which one might be better or it's less quality, you can investigate that on your own. Because it is tough when it comes to supplements. As we said earlier, I think one of the biggest things that I see with sleep, I'll be interested to see what you say is partner discordance. One person goes to sleep, sets the stage, goes to bed, and the partner jumps in bed three hours later. Usually this is the woman going to bed earlier. The man is coming in later saying, I'm a night owl. But that's very disruptive to both people's sleep patterns to not be sleeping together.
- [48:20]
Dr. Rena Malik
Well, I will say I just had a patient the other day who, her husband wears a sleep mask and every time he moves it makes noise. So her sleep is terrible. And I find that sleep divorce, which is a term, actually benefits those couples because they both sleep better and, and then they can be together and still have time for intimacy. But it's like you're, when you're in bed together, you know that that's like sort of on the table. Whereas you, when you go to sleep, like you sleep and you're not bothered and you have better quality sleep and then you're happier and you're more, you
- [48:48]
Dr. Natalie Crawford
know, then your libido's better, then your whole relationship's better.
- [48:51]
Dr. Rena Malik
Everything is better when you sleep better. So I think that it is something people do and they sort of are embarrassed about it. They hide, oh, we sleep separately. It's okay. If you need to sleep separately, by all means, sleep separately. Like when I was a resident and my husband was not, I would sleep in the basement because he would wake up every time my pager went off and, and he was a light sleeper. And I was like, okay, I'll just sleep separate when I'm on call. And for me, I would fall right back asleep. It wasn't an issue. But like you, you have to do that sometimes and that's okay. It doesn't mean that you don't love each other. Like you don't have to sleep in the same bed.
- [49:22]
Dr. Natalie Crawford
Yeah, I think we just sat here and said, sleep number one. First, first place you should start to move the needle doesn't cost money. It's a behavioral change. And it's that important that if you have to remove yourself or your partner or create a different environment, it's that important to your health, your hormones, your fertility right now, but also your long term health in the future. It's truly one thing that our bodies need. And I can't even believe that. You know, I used to wear that like honor badge. I only need five hours of sleep.
- [49:50]
Dr. Rena Malik
We all did.
- [49:50]
Dr. Natalie Crawford
Oh, you know, it was just, I look back on that, like, how did I even function? Because now if I don't get enough sleep, I feel terrible the next day.
- [49:58]
Dr. Rena Malik
Eczema is unpredictable. But you can flare less with epglis, a once monthly treatment for moderate to severe eczema. After an initial four month or longer dosing phase, about 4 in 10 people taking EBGLIS achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing. Empglis Lebricizumab LBKZ, a 250 milligram per
- [50:20]
Dr. Natalie Crawford
2 milliliter injection, is a prescription medicine
- [50:22]
Dr. Rena Malik
used to treat adults and children 12 years of age and older who weigh
- [50:25]
Dr. Natalie Crawford
at least 88 pounds or 40 kilograms
- [50:27]
Dr. Rena Malik
with moderate to severe eczema, also called atopic dermatitis that is not well controlled
- [50:31]
Dr. Natalie Crawford
with prescription therapies used on the skin or topicals or who cannot use topical therapies.
- [50:35]
Dr. Rena Malik
EBGLIS can be used with or without topical corticosteroids. Don't use if you're allergic to ebglis.
- [50:39]
Dr. Natalie Crawford
Allergic reactions can occur that can be severe.
- [50:41]
Dr. Rena Malik
Eye problems can occur.
- [50:42]
Dr. Natalie Crawford
Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine
- [50:46]
Dr. Rena Malik
when treated with Eglis before starting Ebglis.
- [50:48]
Dr. Natalie Crawford
Tell your doctor if you have a parasitic infection.
- [50:51]
Dr. Rena Malik
Ask your doctor about ebgliss and visit ebgliss.lily.com or call 1-800-lilyrx or 1-800-545-5979.
- [50:57]
Dr. Natalie Crawford
Dying from sleep. I always say the next two pillars are going to be muscle movement and muscle and then also how we manage stress. And for both of these, I'd like to give the fastest explanation possible for insulin resistance, if I can.
- [51:10]
Dr. Rena Malik
Sure.
- [51:11]
Dr. Natalie Crawford
Okay. So you eat Food. Food gets broken down into its different molecules. Glucose is the fuel for your cells. So you eat. Glucose is in your blood because it's broken down from your food. And your pancreas is going to send out insulin. Insulin is a hormone. And what it does is, I like to think about it like a salesman going up to the cell, knocking on the door, allowing glucose to go in. So when life is functioning perfectly, glucose levels rise. Insulin comes out, knocks on the door, glucose goes in, they both lower lati da. You go back for a variety of different reasons. What starts to happen with insulin resistance? Glucose levels in the blood get higher and therefore insulin is released more and more frequently. And this is the really terrible analogy that I like. What are you going to do if a salesman comes to your door every single day?
- [51:57]
Dr. Rena Malik
You're going to stop.
- [51:58]
Dr. Natalie Crawford
You're going to stop opening the door. So when you stop opening the door, this is what's happening in your cell, saying, no, thank you, like I've seen you before, insulin, I'm not going to open the door. Well, inside your cell, it's really hungry because it's not getting the glucose that it needs. And so then a process starts where the glycogen or the storage in your liver starts to break down and more glucose gets into your blood, and then more insulin is released. And then insulin's like the salesman banging on the door. So finally, cell opens it, allowing the glucose to go in. And that's insulin resistance. It takes a much higher insulin level in order to get the cell the glucose that it needs. Yet high insulin, as you know, is a growth factor. So it's causing fat distribution in our abdomen, more inflammation, and even more than that in the ovary. Specifically, insulin resistance changes the ovarian response to FSH and lh. It's directly toxic to mitochondrial function and to egg quality. So we see this direct relationship between insulin resistance and reproductive outcomes. Higher rates of recurrent pregnancy loss, poor outcomes with IVF cycles. And that's even in patients who don't have pcos. All of that to be said when it comes to muscle. A lot of times I get asked about exercise, and we grew up in a culture or a timeline where exercise was to look a certain way, to achieve a certain aesthetic. And even the medical recommendations were so cardio focused for so many people. But if we simply wanna look at fertility and hormone health, building and using skeletal muscle is one of the best things you can do. This is for men and for women. Inside your muscle is a transporter called Glute4. But what I like to think about it is the key to the door, meaning glucose no longer needs insulin to get into the cell. When you are using that skeletal muscle, glucose can easily get in. Therefore, glucose lowers, insulin lowers, and you can break this cycle of what's happening. So movement. You should lift weights, build muscle three times a week. If you're a woman at all stages of reproductive life, so you are. Don't want to be pregnant yet you're young, three times a week if you are trying to get pregnant, if you're going through fertility treatments, if you are pregnant, when you're cleared postpartum, when you're in perimenopause. This should be the core of what we do, because using that muscle is going to be key, and we've got to build it to use it to its full potential. That doesn't mean that other activity is not helpful, but that's something that I didn't learn till much later. That wasn't explained to me in that way. When we were in medical training, I
- [54:24]
Dr. Rena Malik
don't think we even really talked about resistance training. It was just like, you know, maybe a line on a slide resistance train. Right. Is good for you.
- [54:31]
Dr. Natalie Crawford
And now it's, you know, when we start thinking about things that people aren't doing that they can move the needle on themselves. This is a huge one for the majority of my patients.
- [54:39]
Dr. Rena Malik
And I don't know if it's exactly the same for females, but for males, the data on the testosterone would say that using large muscle groups going close to failure, meaning using high volumes of.
- [54:50]
Dr. Natalie Crawford
Of.
- [54:51]
Dr. Rena Malik
Of muscle groups, is actually beneficial for hormone health, for testosterone production. Yeah, I don't know if that's similar.
- [54:58]
Dr. Natalie Crawford
It's similar for women, too, that, you know, really going to failure on one muscle group is much more important than compound exercising all over. And so really kind of targeting. Trying to go to the extreme. It builds the muscle the best, but it also utilizes it in such a way that is the most hormonally healthy, for lack of a better word. Yeah, chronic stress, you mentioned this earlier, and I think it's something that so many physicians dismiss, and especially in the infertility space, because infertility is stressful. It's terrible. I walked that road. I walk it with patients every single day. It is very stressful by the process itself. But we have to not let that kind of keep us away from the discussion about what's happening in your body when you experience chronic stress. Chronic stress is so abnormal, but the stress response system is normal. So your Body releases cortisol to stressful events. And cortisol is known to be an inflammatory hormone because it changes how your body's working for a purpose. The bad analogy of the bear. If you see a bear, you want to run away. Cortisol is going to increase and one of the things it's going to do is go back to that liver process, break down glycogen, put more glucose in your blood because you need the glucose to run, survive, get away from the bear. And if we did run from the bear, all that glucose would get used up by our skeletal muscle. It would go back to normal, we would recover and get back to homeostasis or baseline. But that's not what causes us to be stressed nowadays. It's not bears, it is having a bad conversation. It's a work meeting, it's a bad doctor's appointment, it's an email. Doom scrolling. We're sitting here and we experience chronic stress. So our bodies raise our cortisol, we feel it, glucose goes into our bloodstream. But then what do we do? What most people do, they stress, eat
- [56:45]
Dr. Rena Malik
or they stress, they do some maladaptive
- [56:49]
Dr. Natalie Crawford
behavior and do they stress, eat, they, you know, they drink, they look on their phone more like we worsen this process us because we don't understand truly what's happening inside our body when we're feeling this way and we're searching for some short term, you know, dopamine hit to make us feel better. Because being stressed is not a good way to feel. Well, the advice of just don't stress about being stressed is so passive aggressive I can't even handle it. But let's just say a few different things. I like to think about this. 3. Yes, when it comes to stress, cultivating a life that has less unneeded stress is going to be important. Whether this is cutting out toxic people, saying no to things, how you schedule your day, we should always pay attention to that. But that's not the only answer. Two is going to be moments where you give your body release from that cortisol. 20 minutes a day, if you can, is going to be ideal to reset the system and make it more sensitive. You and I are wired really differently, so this is probably different things, but it can be going outside journaling, meditation, mindfulness, acupuncture, yoga therapy, it doesn't really matter all of those things. Exactly. So having moments to let the cortisol drop without your phone is going to be really important to build into your day. And I like the mindset of the world is Stressful. So what can I do about this? Let me kind of build in those protective mechanisms because I will encounter stress today. But third, and probably most important is when we do encounter those stressful situations that are pushing us over the edge of we should think about how our body works and fight to get back to baseline. So instead of stress eating Sour Patch Kids, we should go for a five minute walk or do squats in place. Understanding that glucose has just been shoved into your bloodstream and then allowing you the opportunity to try to use it up to recover from this stressful event is going to make you feel better the fastest yet. We don't really hear that advice for dealing with these acute stressful interactions. So when we think about these three things, sleep, stress, exercise, they really all work together to fight against this chronic inflammatory burden and lower that down so that your body has more resilience and the day to day inner counters and then the next two buckets are going to be the foods that you eat and the toxins that you're exposed to.
- [59:03]
Dr. Rena Malik
What is the optimal diet for fertility?
- [59:06]
Dr. Natalie Crawford
I think the optimal diet is obviously when there's mostly going to be whole foods that are unprocessed.
- [59:10]
Dr. Rena Malik
List.
- [59:11]
Dr. Natalie Crawford
The number one most important thing is gonna be high in fruits and vegetables. They're high in fiber, high in nutrients. From fertility studies, couples who ate more servings of fruits and vegetables, got pregnant faster, had better egg and sperm quality, had less miscarriage rate. But we see a lot of people maybe not eating very much fruit or being very selective about what they are eating. So I don't restrict any types of fruits and vegetables. 2 servings at every meal time is going to be the fertility recommendation. That's what should go on your plate first. From there we want to build it out with things that are less processed. And I'll admit some of the nuance here. Fertility studies group all foods together. So if we look at red meat, for example, you know, they're putting a grass fed steak and a hot dog in the same category. And then they look at what's called quartiles for a lot of nutrition studies, right? So people, they put them into groups, lowest exposure, highest quartile of exposure. And then they compare those two groups. Groups. And we're trying to see an effect, but sometimes it might be overemphasizing one without understanding the nuance of everything in that category. Not the same. But the red meat data for fertility tells us that if you consume the highest quartile of red meat, you have fewer embryos, develop with IVF and you have an increased stage of endometriosis going to laparoscopy. We also see that for every serving of meat that a plant based protein is put in place of an animal based protein. Women ovulated better and had higher fertility rates. So I think that a diverse diet is going to be the key here. We really want to make sure we are incorporating some of those plant based protein options. Beans, lentils, those have great fiber benefits as well. Fiber is the food for your gut microbiome and your gut is your first line of defense. So in the gut, if you are eating foods that do not have fiber, you are not supporting your gut microbiome. This there worsens inflammation. For the very shortest, just one sentence of what the gut microbiome does puts
- [61:03]
Dr. Rena Malik
and puts you at risk for colon cancer.
- [61:05]
Dr. Natalie Crawford
It does.
- [61:05]
Dr. Rena Malik
And this is my biggest concern with people who do very extreme diets is they don't get enough fiber. Yeah.
- [61:10]
Dr. Natalie Crawford
I mean, we're really worried about the carnivore diet, for example, because it is so low fiber. It does. If we're looking through the globe of fertility, the gut microbiome is really important in estrogen metabolism, hormone signaling, it's its own endocrine system. But we are living in a colon cancer crisis right now. Right. And yet we're also seeing a lot of people eating well under the fiber recommendation. So I think it's important for people to know that, you know, animal meat does not have fiber in. It doesn't mean that it's bad for you, but it does mean that having good fiber sources is important and having a diverse diet is really advantageous. Fish up to three times a week, it is a really great, you know, source of omega 3 fatty acids. Eggs look relatively neutral on the inflammatory scale, but they have some really great nutrients in them. Choline, B12, that can be really helpful, especially for people who are vegetarian. So recommend those. The dairy data is whole fat dairy in limited amounts, not skim because it's more processed and you're losing some of the nutritional benefit from it. But just like we're seeing across the board, we want to limit sugar added sugars, non nutritive sugars, we want to limit the ultra processed foods. It's not that it's a never, but those things should not be consumed on a day to day basis. And the way I frame it for my patients is your day to day. You should be eating lots of diversity, lots of whole foods, things that are less processed. We really want to try to eat the rainbow, really improving that Fiber, because fiber is going to fight inflammation the best. And then we're able to have more resilience and recover if, if you want to eat cake at dinner, at this special occasion. But when we're constantly eating those type of foods, it's increasing that inflammatory burden. Your glucose level in your blood, that glycemic index is going to be elevated, more insulin will be released. It's going to be very hard to break the system if we are not really focusing on our dietary change and optimizing that on a day to day. So we want to make the majority of the choices that we do in the best way that we can. It's not that every decision has to be perfect. And I really want to get people away from the. This is the diet for fertility, because that seems like a short term thing, yet everything I'm sitting here saying, I know you recommend also because this is an anti inflammatory diet. This is the best for your body's health, for hormonal health. And it makes sense because if fertility is a health marker, then of course the diet recommended is going to be the one that's going to decrease inflammation and insulin resistance and help your cells at a metabolic level the most. Yeah.
- [63:40]
Dr. Rena Malik
And I would say that a low fat diet is also not necessarily. We were, we were raised in this era of that diets being very important, but having a diet that has some healthy fats is actually very, at least for male fertility, very beneficial fat.
- [63:54]
Dr. Natalie Crawford
Cholesterol is the backbone for all sex steroid hormones. So absolutely we need fat. You know, we love to see it from olive oil, nuts, avocados. Healthy fats are a amazing source, source of that cholesterol backbone. But your body cannot make progesterone if you don't have enough cholesterol in your diet.
- [64:13]
Dr. Rena Malik
Absolutely, yeah. And then toxins. I don't want to spend a ton of time fear mongering people about toxins, but I think it's important to give maybe some advice on things people can change, like small changes they can make that can make a big difference.
- [64:26]
Dr. Natalie Crawford
I think you're asking the question about endocrine disrupting chemicals, but I like to start by answering it with behavioral toxins. So the number one thing that I'm seeing in my practice right now impacting fertility is cannabis use in men. So cannabis use, either by men or women, drastically impacts your fertility. So women who use cannabis have 25% lower rate of getting eggs in an IVF cycle and 28 lower live birth rates. That's, that's wild.
- [64:50]
Dr. Rena Malik
Yeah. You Know one in four.
- [64:51]
Dr. Natalie Crawford
Yeah. Men who use cannabis, we see profoundly lower sperm counts. We see increased fragmentation of DNA. We see increased miscarriage in the female partner when only the man is using cannabis. And so this is a modifiable factor that's been normalized by society.
- [65:07]
Dr. Rena Malik
Yes.
- [65:07]
Dr. Natalie Crawford
So just because something is normalized or socially acceptable does not mean it's healthy. And there's a lot of people who think that it's healthier than alcohol or healthier than other behaviors, but it's quite detrimental. So I'm really want to give that plea that I think it's so important that we look at these behavioral toxins. Alcohol is. Is not helpful either. It causes chronic inflammation and insulin resistance. Smoking cigarettes obviously can be detrimental to hormonal health across the board. But these behavioral toxins we have to include in the discussion to the question you actually asked me to endocrine disrupting chemicals. These are chemicals that directly impact our endocrine system. They both cause chronic inflammation, they harm the gut, they cause increased gut permeability, but they also can impact different endocrine organs, and they all work a little different. But it could be your thyroid, your brain, your ovaries. So when we think about endocrine disruptors, the big categories here are going to be paying attention to what's happening in your kitchen, the food you eat and the products in your bathroom. And again, the attitude is the things that you use most commonly, the things you use every day, that's really what I want you to start to pay attention to. So your favorite water bottle should not be plastic. We really should remove plastic from the kitchen. Plastic should never get heated up in the microwave or the dishwasher. So we really want to be looking at different options to put our food in, both for storage and consumption. A big one right now is everybody doordashes food. Right. It can really be an easy option in a busy life, but that is usually coming into go containers that can be full of different toxins. And you can't change what they're putting it in. But what you can do is if it comes to your house and you're not ready to eat it, you know, don't eat it out of the takeout container. I know we often want to to save dishes, but put it onto a plate if you're not eating it yet, put it into another dish. If you're going to put it into the oven so you can at least reduce that exposure. And then back to a lot of our processed foods. A lot of them are put into packaging that Actually has a lot of these endocrine disruptors in them. So even healthy foods in quotes, protein bars and things like that, the packaging is not always the best. So whenever possible, you should be relying on, you know, whole foods as opposed to those that are processed and packaged, and leaving the protein bar for when you have to have it because you're traveling or you're on the go. But when you're in your house, that should not be what you are leaning on because you have a refrigerator and a pantry and options for more food and then for your bathroom products. This is so nuanced in the book. I have a whole chart to make it easy. But don't obsess over the things you rarely use, meaning you have a special perfume you use once a month. Like, I'm, well, less concerned about that than the shampoo or the body lotion you're putting all over your body. And yet it's really hard when it comes to products because we have ones we like, and our body reacts different. Our skin reacts different. So take the time to figure out. Like, one runs out, it can be expensive. Take the time to figure out what you want to replace it with. You can go to the environmental working group and look at skin deep, and you can put in your product and see. So the. Just start by knowledge. Does the thing that I currently like, does that contain chemicals that can be impacting my hormonal system and my health? You search it up and it does. Okay, we'll flag it when it's out. Now it's trying to change that one. And you have the opportunity to research and figure out a better one. And the last thing I want to say here is that fragrance free is different than unscented. Okay. Unscented can be a scent. So we really want to search for things that say fragrance free and not unscented.
- [68:39]
Dr. Rena Malik
Yeah, it's very complex. We had a chemist on the podcast once, and basically she's like, a lot of these large companies, they do, you know, tons of testing on their products, but also, even the packaging is. So when people try to transfer it to another package, they're actually destabilizing or potentially, like, maybe it's light sensitive or
- [68:58]
Dr. Natalie Crawford
maybe whatever the case may be, oh, so interesting.
- [69:00]
Dr. Rena Malik
And so putting it. Keeping it in the packaging it comes in is actually safer for the product and for you because you're using the product all over you. And two, some of these, like, things that you put in the products in, they're flagging things that are not really toxic, like scent, not Necessarily toxic, you know, like. But depends on what it is. Right. And so, so I think it's really, it's thoughtful to think about, but I would generally recommend safer to buy from larger companies because they will do a lot more extensive studies on these products.
- [69:29]
Dr. Natalie Crawford
They have more resources.
- [69:29]
Dr. Rena Malik
Yeah. They have more resources, whereas a smaller company may not do as many. And there's less regulation, you know, in that, in that space.
- [69:35]
Dr. Natalie Crawford
It's a really good thing and it's tough. So we acknowledge that there's a zero percent way to avoid every toxin that's in this environment.
- [69:42]
Dr. Rena Malik
Yeah.
- [69:43]
Dr. Natalie Crawford
Yet the world is becoming more toxic. Therefore we owe it to ourselves to pay attention to what is happening and at least make the decisions that we can. Not to stress about it every day. But really all these things we're talking about are to cultivate your day to day life in a way that you do have that body resilience so that you can handle when things are off.
- [70:02]
Dr. Rena Malik
Absolutely. I want to talk about something important that I've been seeing a lot of. So a lot of women are now taking testosterone.
- [70:09]
Dr. Natalie Crawford
Yes.
- [70:10]
Dr. Rena Malik
For the purposes of increasing libido or the. They've heard that it may be beneficial for other purposes. Right now it's only off label for a low desire in postmenopausal women. But you know, I, I think that's a nuanced discussion, but I'm seeing a lot more perimenopausal women taking it as early as in their 30s and they still want to have children. And I don't think there's enough discussion about how that affects fertility. Now I looked at this a little bit and I understand that sometimes using testosterone for short periods of times may be beneficial for infertility. But in general, I would assume that the response is similar to men where it would affect fertility. But I'll leave the answer to you.
- [70:47]
Dr. Natalie Crawford
You should not take testosterone if you want to get pregnant. If you're trying to get pregnant, we'll say that specifically. So you should not be on testosterone if you are actively trying to get pregnant. Testosterone can change the uterine lining, can thin out the uterine lining itself. It also, of course, if you do get pregnant, it can viralize a female fetus and we're highly concerned about that, about if you don't know that you are pregnant and you are on testosterone. We use it sometimes in very small doses in very specific times in the cycle for ivf. And this is what you're alluding to.
- [71:13]
Dr. Rena Malik
Yeah.
- [71:13]
Dr. Natalie Crawford
We call this testosterone priming sometimes because it is like A different hormone. We can get an improved response from the ovary by giving it just a little touch and then taking it away. When you get to the lower end of your egg count, androgen production does start to become important in the ovary. So in the postmenopausal ovary, making testosterone is really important. So when you have a really low egg count, you're not responding to stem the way we want you to. We will sometimes see if a small course, less than two weeks, very low dose testosterone can get an improved ovarian response because the ovary gets really stubborn as you get older. But that is very different than I'm on testosterone every day for my libido as a part of my hormone replacement therapy because I'm in perimenopause. So I think this is a really big plea if you, if you want to get pregnant, your hormone replacement therapy would look different in perimenopause than somebody who is not wanting to be pregnant anymore. Similarly, if you are on testosterone, we should make sure that you cannot get pregnant. Has your partner had a vasectomy? Are you also taking daily progestin and a high enough dose that it can prevent you from getting pregnant? So there's a lot of nuance here with this one. And I love seeing more access to hormone replacement therapy. I love hormone replacement therapy, but I think that's a really big thing. And as an individual woman, we have to know. I've seen really young women place on testosterone. It's also, as you know, in women, not an easy thing because some of the side effects from testosterone can be quite problematic. And given it too high a dose, some of them are irreversible, like clitoromegaly. So we want to re in voice deepening and we tend not to see those when used appropriately. But not all hormone experts are equal.
- [72:57]
Dr. Rena Malik
And I would say a lot. There are women getting pellets.
- [73:01]
Dr. Natalie Crawford
Oh, I hate pellets.
- [73:02]
Dr. Rena Malik
And pellets will last for a prolonged period of time and there's higher risk of getting those side effects because you can't control the dose.
- [73:09]
Dr. Natalie Crawford
Exactly. I think there's. There are people who like pellets and who have benefited from them. And I think this was really in the era before HRT became more accessible. With what we see now, I don't see any reason why in today's world we should be giving somebody pellets because we cannot change them, cannot remove the dose, cannot track it and modify it. I've had young women go to some of these providers, get pellets and do not ovulate, obviously. And then we are following their hormone levels to try to figure out when they get low enough for us to try to get them to ovulate. And it can take months and months and months. So I absolutely would say that that's a red flag in today's world. If somebody's trying to give you pellets, there are better and more available options for HRT if you're in your perimenopausal years or still want to conceive, receive.
- [73:53]
Dr. Rena Malik
If some women right now who are listening are on testosterone and didn't know because I actually had somebody reach out to me and they said, well, I was, I've heard that transdermal testosterone is okay. And I said, no, not necessarily. They're all, they're all doing the same thing. Right. I don't, I mean, like, I understand hormone therapy, that giving estrogen progesterone transdermal is safer for side effects. And that may be true for testosterone that we haven't necessary. It depends on the side effect you're looking at. But in terms of how it functions in the body, your body still sees it a. As does testosterone. Yes. So I think it's really important for anyone listening if they're on it right now, even if it's just daily transdermal testosterone, what should they do if they're on daily testosterone right now in terms of fertility, if they still want to get pregnant?
- [74:33]
Dr. Natalie Crawford
So absolutely, one, we should find a provider who understands this, who can help you navigate it. Two, you should stop testosterone. A lot of these people, if they're still symptomatic, would benefit from just a higher estrogen dose. If you are trying to get pregnant via fertility treatments is a little bit different story than if you are in the, the camp that I usually see, which is I'm perimenopausal, I'm symptomatic, but I, if I ovulated and we got pregnant, I still wanna have a baby. Like trying naturally hormone replacement therapy is be very different in that situation. Meaning we have to give low enough estrogen so that we don't prevent the brain from sending out fsh. Because estrogen talks back to the brain. If I put you on high enough estrogen levels, you will not ovulate. We utilize that to our benefit at times. So I have to give you low enough doses. So I'm just raising your estrogen baseline without suppressing the hypothalamic origin. So that's difficult. And then I cannot give you daily progesterone I have to give you progesterone after a confirmed ovulation. So your doctor who maybe prescribed you HRT and who gave you testosterone may not understand that or feel comfortable with that. So you just may have to find a provider who is experienced and understands how we do HRT and perimenopause if you are trying to get pregnant.
- [75:45]
Dr. Rena Malik
So stopping testosterone is not that simple.
- [75:47]
Dr. Natalie Crawford
Right. Women are usually at lower doses. So it's not.
- [75:49]
Dr. Rena Malik
They're at lower doses, but when you stop it, you're going to feel bad because for a short time.
- [75:54]
Dr. Natalie Crawford
Yeah, I take men off it all the time. They get really mad at me, it's really miserable.
- [75:57]
Dr. Rena Malik
So in men, we will often do things to bridge the gap. So try Clomid or hcg. Is there anything like that for women so they don't feel so crummy when their body is starting to sort of make its. Its own testosterone because it's sort of been shut. Shut off?
- [76:10]
Dr. Natalie Crawford
Yeah. Usually you can change the ratio and give a little bit more estrogen while you're coming off the testosterone. I've not seen anybody who's on T alone who's not also on estrogen or progesterone therapy. I think that would be a very interesting HRT regimen for somebody in the perimenopausal year time frame. But that would be an option if you're not on estrogen, then to swap it out to see if that can alleviate some of the symptoms that you might potentially be.
- [76:33]
Dr. Rena Malik
Well, I guess I'm saying if you're taking it for, let's say, low desire, you may just be just on testosterone. You may not be on estrogen, progesterone because you're not having other symptoms.
- [76:41]
Dr. Natalie Crawford
I mean, estrogen will help low desire for most women who are also having it too. So it's often a safer option in this perimenopausal timeframe. I think we see a lot of postmenopausal women who are trying to avoid estrogen and they're just on testosterone. But often if you do have low desire and you're still trying to get pregnant, we see that there's a lot of dysfunction with not making enough estrogen, and that's part of why you're sensing a change from where you were 10 years ago. And even though testosterone and estrogen convert back and forth, so when you have low estrogen, you have low testosterone too. We usually, as women in our brains, can get the symptomatic relief from just more estrogen.
- [77:17]
Dr. Rena Malik
Got it. Okay. You did mention earlier about mitochondrial health and how your lifestyle affects mitochondrial health of the egg and may make it more difficult to get pregnant. But if someone had has poor egg quality and they are able to get pregnant, how does that affect the fetus and the baby? Like, are they going to have poor metabolic health because of that?
- [77:38]
Dr. Natalie Crawford
This is a really beautiful, complicated question, I think, for somebody to understand. Is having poor mitochondrial health inherited into the embryo itself? We don't necessarily know what that exact thing is doing, but if we're taking generalizations, what we do know is that epigenetics play a huge role in development of your child. And epigenetics mean that we'll say the baby gets its genetic code from you, but the decisions of which genes are turned on and off, the overall risk for disease is influenced by the maternal environment. How much of that comes from the egg itself? How much of that comes from the maternal environment during pregnancy? We think a lot of it comes from that time period during pregnancy. But I don't think we have the answer to say it's one or the other. And there's probably some combination of both.
- [78:22]
Dr. Rena Malik
Both.
- [78:23]
Dr. Natalie Crawford
I think that means that in the perfect world, we want to go into this. If you're trying to get pregnant doing what you can ahead of time, do we see that women with poor egg quality have a higher risk of birth defects or abnormalities like that? Absolutely not. So we tend to think it just makes it harder. The egg is so sensitive in the body, early embryo growth is so, so sensitive that we tend to see this huge attrition in IVF enough, because when these eggs don't have the metabolic capability to come to a baby, we tend to see it drop off in the lab. And that's why every egg is not going to fertilize, develop into an embryo, or be genetically normal. On the other end, because in, in
- [79:02]
Dr. Rena Malik
sperm health, we do see those epigenetics. There's some data that the epigenetics in the sperm affect how the. The baby outcome. The baby's outcome is going to be
- [79:10]
Dr. Natalie Crawford
not just fertility and maternal health during pregnancy as well. So I think for women it's more complicated since we gestate the baby as well. But I think we know now that what we can easily say is that the child's health is starting to be programmed well before that child is born. And the sooner that we can start to pay attention to the building blocks, we're going to have the best outcome for our children that we can.
- [79:31]
Dr. Rena Malik
I want to just talk about in terms of Fertility as you age now, I think it's not as simple, and you've alluded to this before in other interviews, is that it's not as simple as. As you age, your egg quality declines. There's obviously all the factors that you. You talked about that also affect the health of the egg. But what does it look like? Is it that your fertility is going down and down and down, down slowly over years, or is it like you hit perimenopause and it drops off precipitously?
- [79:55]
Dr. Natalie Crawford
Egg quality, if we want to think about that, because it is tightly tied to your ability to get pregnant, as we've said before. But just to reframe what we're about to go into, I like to think about it as the combination of genetics and metabolic health. Takes two to tango here. The genetics of your egg are so interesting. Unlike sperm, they get packaged up with their 23x, their 23y. Your eggs are held in metaphase of meiosis, meaning 23x lined up in a row in their perfect match, held apart by meiotic spindles. These are proteins that do break down over time. Even if you're super healthy, we can't avoid the tincture of time that will happen. I like to use the bad analogy of imagining kindergarteners standing in a line of alphabetical order. Simply, the longer I ask them to stand there, they're going to get out of line, even if everything around them is great. Now, if I bring in distractions, if we think about inflammation like distractions, and there's puppies and kitties, well, then they're going to get out of order even faster. So inflammation has this double hit. And as a population, as we get older, we also as a population, get less metabolically healthy. So inside your eggs, you're going to see that you're going to have more chromosomes in the poor position and poor functioning eggs as you get older. If you follow the normal trajectory of metabolic health with a age. And that's why it's so important and to me, empowering to say, well, what can we do for that metabolic health standpoint? Because we can't roll back the clock on the time standpoint. But the biological clock is more than just your age. Although age is absolutely an essential component and we can't avoid having that discussion. I also do want to say I think it's wrong that so many fertility doctors specifically simplify your ability to get pregnant to solely be your age. I don't think that's the right message. It feels very hopeless if that is what you're hearing. And I think people are smart enough to understand that one variable can be very important, but not everything. That being said, we all will run out of eggs at some point. All your eggs will be genetically abnormal. There is an end to when you can get pregnant. We tend to see the highest rates of conception when you are in your 20s and your early 30s. At this point, you're going to have about a 20 to 25% chance of getting pregnant per month. Month. Starting around your mid-30s. And on this is going to start to change. So if you're trying to get pregnant for your first time and you're 35, 36, this number drops to be about an 11 to 12% chance per month. As you're 38, drops to be 5% per month. And if you're 40 and older, starts to be 3% per month or less. Now, that is not zero. And I tell people bad statistics all the time because for one individual human who gets pregnant, it's a hundred or zero.
- [82:31]
Dr. Rena Malik
Right? Right.
- [82:32]
Dr. Natalie Crawford
But we use this to frame, okay, 20 to 25%. If I'm at age 30, I might not get pregnant in the first month, but 72% of people will be pregnant by six months. Only a small number get pregnant in that next six months. That we make them fail before they get their evaluation. So we start to see that.
- [82:50]
Dr. Rena Malik
So realistically, it should be like four months. Realistically, six months at the most.
- [82:54]
Dr. Natalie Crawford
I think. I think six months at the most. I think there's a huge argument, depending on your age and your goals, that, that we could do this testing ahead of time, be more preventative about it. If you found out you had aspermia before you went through six to 12 months of trying, you're gonna have a very different journey than feeling like you wasted that year.
- [83:11]
Dr. Rena Malik
Absolutely.
- [83:12]
Dr. Natalie Crawford
And I've said across some of those people who've waited years tracking cycles, trying, and then they found out he had obstructive asus spermia, had no sperm, and a zero percent chance of getting pregnant that way. And that's devastating, especially as the female partner's getting older. But we digress. So we see that the rate of pregnancy per month does drop. Drop as we get older. And we see this more profound drop after age 37 when you're in perimenopause. Perimenopause, by definition, is a lower egg count. So we start to see that the ovary doesn't respond as appropriately to the brain's hormones. I always like to say it doesn't want to run out of eggs, gets a little more stubborn, tries to hold on to them. So you see some unpredictability, but it doesn't mean that you can't ovulate. And in fact, we see an increased weight of, of twinning as you get older, meaning older women who are in perimenopause who conceive naturally have a higher rate of fraternal twins than the general population because their brain sends out more fsh because the ovary was being a little stubborn. There's fewer follicles, so that's a stronger FSH signal to those follicles, and they have a higher risk of having two of them grow and ovulate. So we should start to understand, though, once you're in this perimenopause phase, if we're learning to track our cycle, when we start to see these cycle changes, the first cycle change you're going to see as your egg count starts to drop is going to be ovulating sooner, shorter follicular phase, less eggs, stronger signal, they grow faster. So if you sit across from me and say, you know, my period used to be 30 days, but now it's 24, 25, I would sit here and say, you have low ovarian reserve unless proven otherwise. That is the first thing that I'm thinking about. So if you start to notice that's happening, that's a really good body sign that, that. Welcome to perimenopause. Now, we should get it tested and make sure it's not your thyroid or prolactin. But that is likely what is going on. And then when you see other cycle changes, when it goes from being closer, it'll then start to go longer. So wait, now it's 35 to 40 days. Oh, now maybe I'm skipping months. We start to know we're in the latter reproductive years. Menopause is one single day defined as not having a period for 12 months and having certain lab values. So you're an ovarian failure and you've not had a cycle for 12 months. That's such a weird definition because you're an ovarian failure for a whole year before you get to qualify for that menopause definition. So we can start to sense this based on blood values. And this is why, if you are not having a period, you should go in and seek help. You are most likely symptomatic and beyond from fertility. But just from a hormone replacement standpoint, like we talked about earlier, starting hormone replacement therapy earlier can have a profound impact on your life and That's a whole nother discussion.
- [85:47]
Dr. Rena Malik
We've had a few experts on the podcast. Mary Claire Haver, we've had Shen Parish, we've had Lauren Striker. So check out those podcasts if you want to learn more. But I want to talk about IVF. So if you are 38, 40, how much does doing IVF, what does that increase your likelihood of getting pregnant? From 3% or 5% to.
- [86:06]
Dr. Natalie Crawford
It's apples and oranges. But it's not as easy as saying 65%. So the rates with IVF, we have a 65% live birth rate per genetically normal embryo in a bucket. That sounds really incredible. It's higher success rates than 25 year olds have trying to get pregnant naturally. The big asterisk there is per genetically normal embryo. And what we do know is that it's harder to find genetically normal embryos as we get older.
- [86:31]
Dr. Rena Malik
Right.
- [86:32]
Dr. Natalie Crawford
Due to the fact that you have less eggs per month. Right. As fewer eggs are in the vault, fewer come out in ivf. I can only get the eggs outside the vault to grow. So an average 40 year old, I'm probably going to only get 8 to 10 eggs to be able to grow. In addition to the fact that the tincture of time, we know that an average 40 year old has about a 25% rate of genetic normalcy. So if I give rough math really quickly and things are perfect, IVF cycle for a 40 year old and I get 10 eggs, we tend to see fertilization rates of 75 to 80% in the lab. So let's say eight fertilize half tend to make it to an implantation stage embryo called the blastocyst. This. So Now I'm at 4, 25 rate of genetic normalcy. I got one and then I have a 65 chance of success, which is way higher than the 3% you started with that month. Because I got the opportunity to get all 10x to see which ones could be there. We grew them in the lab, which is a non inflammatory environment. So we really changed the early embryo growth environment. Hopefully we challenged the sperm a little by putting them through Zymon, which helps select maybe higher functioning sperm versus some of the randomness that might happen in the body. So we're manipulating the system in a way to try to achieve these optimal results. But that's still no guarantee. And that's drastically different than when you're younger. Even if you're only 35 and you have an average of 16 eggs, but 50% are genetically normal, that math is drastically different. So if you get 16 eggs and 14 fertilized and seven grow out, let's just say you fell low, but you had three normal embryos for the same cycle that you might do at 40. Now, cumulative success rates with genetically normal embryos are quite good in ivf. This has really changed the game. To be able to do some genetic testing, meaning two consecutive embryo transfers is going to put you at about an 85% chance of success. And after three, it's almost 95%, meaning I only have a 5% rate of recurrent implantation failure and most people will have success. But a 40 year old just had to go through through three cycles. So three different months, this month's eggs, next month's eggs, the next month's eggs, to have the exact same odds of success that a 35 year old did just one time. So we really have to look at cumulative success and individualized potential based on what your ovarian reserve is, what your egg count is. But it's a different ball game than 3 to 5%, where we're really looking at things differently. And what I really want to stress to women, especially if we're in the 38 and older stage here, is that this becomes even more profoundly important if you want more than one child at this moment. So if you are just starting your family at 38 and you want to have three kids, it's always been your dream, but you met your partner later, we really should understand all of our data before we make a decision. Because getting pregnant is taking you out of the game for a year and a half essentially to be pregnant, have a baby and recover. So there's circumstances where I might find that somebody has low ovarian reserve, they haven't started trying to get pregnant. We might go through IVF and freeze embryos, and then they may try to get pregnant naturally, achieve baby one right now, but when they come back and they're older, have many fewer eggs, we already put those embryos in the bank from when they were 35, so we're gonna have an easier time now. So that's such a personal discussion, but the point is that you can't make decisions on data you don't know and you can't make a lot of assumptions about your own fertility. So going in earlier, getting an evaluation done, having conversations, especially if you want a bigger family size and you're starting later, nobody's going to force you to do ivf, but it should be a tool in the toolbox that you're able to use and leverage if that's a goal that's important to you, I mean,
- [90:11]
Dr. Rena Malik
I think it's, it's, it's incredible. I think the technology has advanced so much that these success rates are so much higher than even when I was in training.
- [90:17]
Dr. Natalie Crawford
Yeah, yeah, it's, it's wild. It, it's progressed immensely in the past 15 years since I've been in the field, which is beautiful to see. Makes you really excited about where we'll be in another decade or two. But in the same breath, there's so much nuance. And it's not all good, it's not all bad. You should never be forced to do something or feel like you are yet you should be able to sit with somebody who can accurately say, these are the different options. And this is why I recommend this one. And who really cares about what your goals are.
- [90:46]
Dr. Rena Malik
If you're a single woman and, and this is probably not a clear answer, but if you're a single woman and you're young and you know you want children, is it better to freeze your eggs or better to go through an IVF cycle with a sperm donor?
- [90:58]
Dr. Natalie Crawford
Oh, it's absolutely better to freeze your eggs. And the reason why you're asking this question is because when we were in training, that was not the answer. Egg freezing was experimental until about 2013, 2014, and crazy how recent it is. I know. So when people say, oh, egg freezing, so trendy, I say it's just accessible and available now. Enough people can do it. Technologies improved of lab personnel are trained. And that wasn't the case a decade ago. So at that time period when we started to first do egg freezing, we used an older freeze thaw process, which is called the slow freeze. And when you did that, you lost almost half of the eggs in the freeze thaw process. And so you can imagine the financial investment to try to go through and freeze eggs knowing half we're not going to survive is especially if you had cancer and it was your only shot or you had a low egg count or you were older. We had these discussions a lot trying to push women towards considering at least donor sperm. That is completely different. Now. In modern labs, the average success rate of freestyling and egg is 90%. In our lab, it's 95. I'll use 90 though. Cause it's the national average. Meaning if we freeze 20 eggs, I'm gonna have 18 or 19 of them survive that freeze thaw. There's no reason that I should force them to be fertilized with donor sperm. The argument to Fertilize eggs if you have a partner. So we could use that discussion. You're with your partner. Should you freeze eggs? Should you freeze embryos? The reason to do it is I said the attrition earlier is that you understand that final number. Because just having 10 eggs in the freezer versus knowing you have no embryos or one embryo, when do you know if you have enough? Right. We make a lot of assumptions on just that, eggs. The counter argument is that for the majority of people in this country, we don't have insurance coverage for this process. The cost of freezing your eggs is about half of making embryos. So I could simply for the same investment, do two cycles and have double the amount of eggs. And if I'm an average young woman who's single and let's say I get 16 to 20 eggs instead of worrying that I might fall below average, because I might, I can now just do a second cycle and now have a. Have 30 to 40. And I have covered the basis so that if I happen to want to procreate with somebody who has less than optimal sperm, I still have put enough eggs in the freezer to have an optimal outcome, then you've really played the odds in your favor. I hate when people say freezing your eggs is an insurance policy on your fertility. It's probably one of my least favorite things that I hear patients sit across from me and they've been told, and they say this because an insurance policy is always going to pay off.
- [93:32]
Dr. Rena Malik
Off.
- [93:32]
Dr. Natalie Crawford
How I like to look at it is this is an investment. It's like putting your money in the stock market. It often pays off. It can be smart to invest your money. In fact, most people are encouraged to do so. But the roi, like a bond, Right. The ROI on that, though, is going to depend on the environment when you withdraw the money. Factors you don't have control over right now. And so it's an investment in yourself and it's an investment in the opportunity to have a child in the future that has your genetics.
- [94:01]
Dr. Rena Malik
If you're a couple and you're sure you're going to stay with this person, that's a whole other discussion. But if you're a couple, there is some data that suggests that men's sperm quality is better before 45.
- [94:11]
Dr. Natalie Crawford
Absolutely.
- [94:11]
Dr. Rena Malik
So in that circumstance, if that couple is pretty sure they want to have children, would you steer them, say they're, you know, say the husband or the partner, male partner is like 38. Would you steer them then towards embryo versus egg freezing?
- [94:26]
Dr. Natalie Crawford
Anytime I have a Couple, we always are talking about both to try to understand really how committed are we, how far away are we from childbearing and where are our resources? Meaning if you sit across from me with your husband and you only have enough money to freeze your eggs, we should just freeze your eggs. Or if you only have enough money for one cycle, and we're concerned there's any reason why this isn't the person forever, but sometimes that you don't have control over that. I mean, people get into accidents like life is super dynamic. And for women specifically, tying up all of your fertility to one partner is not always optimal. Embryo banking though, gives you so much more information, allows you to make more in the time decisions. Because if you are 35 and you didn't have three normal embryos, if we found out you only had one and sperm quality was playing a role, we have the opportunity, because we know this, to, to do more cycles or change your timeline. So I had a couple in this situation who went through and they froze embryos and they were getting married. They weren't ready to get pregnant yet. So they decided to make embryos and they had a much lower outcome than we would expect for their age. And we talked about what this means and should they do another cycle. And they actually decided to do another cycle and they froze them again as embryos. But then they started trying to get pregnant sooner because they wanted a really big family. So they shifted their whole timeline because of what they found out in the lab. So sometimes we say ivf, yes, is therapeutic, but it can also be diagnostic. So I think there's benefit to making embryos if you're with a partner. But if you're really remote from wanting to conceive, my meter, to consider counseling you to have just eggs or if you have the resources. My favorite is going to be two cycles, one of eggs, one of making into embryos. Because we get the understanding of how your eggs and sperm respond in the lab. Therefore, we can, can make more informed assumptions about how those eggs will do. But I haven't put all your eggs in one basket, for lack of a better word.
- [96:23]
Dr. Rena Malik
I want to ask, is there a role of the vaginal microbiome? So we talk about the gut microbiome, the vaginal microbiome. You know, we talk about this a lot, like don't douche, don't do these things that will alter your vaginal microbiome. But what are you seeing in terms of the science between how that affects fertility and, and potentially even natural conception
- [96:42]
Dr. Natalie Crawford
in the past two years we've seen emerging research on this, and I think in the next couple years, we're going to see even more. A couple things can be true. Yes. We know that the microbiome of the vagina, the uterus, and the gut are all different. So it's not quite always just one thing. We also know that when you have an abnormal microbiome, we'll use bv. For example, when you have bacterial vaginosis, which is associated with an overgrowth of the wrong type of bacteria, you can have lower pregnancy rates, implantation failure, and even preterm birth and poor birth outcomes. So the vaginal microbiome is really important. There's a lot of overlap, though, in people who have a poor gut microbiome who also have a poor vaginal microbiome. And so back to our earlier discussion about majoring in the minors. It's not that we want to not pay attention to our vaginal microbiome, but we got to get our gut microbiome in check first. So versus is taking fancy tests and buying suppositories and all of these things. I'd rather us start by going back. Are we eating 30 different fruits and vegetables a week? Are we having a diet high in fiber and making sure that we are making those foundational decisions to have a good gut microbiome first? Because this we're not truly going to be able to, quote, fix our vaginal microbiome if we have gut dysbiosis itself.
- [98:00]
Dr. Rena Malik
So.
- [98:00]
Dr. Natalie Crawford
And that's what the fertility data shows the most, that a gut microbiome that's abnormal is much greater associated with infertility than an abnormal vaginal microbiome. But just saying that doesn't mean that a vaginal microbiome is not important and that there aren't cases, especially when we start to look at, we're having infertility or unexplained infertility or pregnancy loss, where we want to pay more attention to the vaginal microbiome. So I think it's one of those things where it's an individualized thing. It plays a role. But I would compel most people, before we start fully going down that pathway, to start back at the basics and make sure we're healing our gut and probably more targeted.
- [98:34]
Dr. Rena Malik
Right?
- [98:34]
Dr. Natalie Crawford
Exactly.
- [98:35]
Dr. Rena Malik
Have a discussion with a fertility specialist or at least a gynecologist about your particular, you know, exposure.
- [98:41]
Dr. Natalie Crawford
Yeah, there are testing that we can do and target a little bit more directly when it comes to that.
- [98:45]
Dr. Rena Malik
And in terms of women, like, say, when they're Younger, they've had lots of genital infections. Right. And that does dysregulate your vaginal microbiome and potentially put you at risk. Risk for. Right. Scarring in the fallopian teeth and things of that nature. Are there things people can do to sort of, you know, it's done, they can't change it now. Are there things they can do now to improve those things?
- [99:03]
Dr. Natalie Crawford
I think the biggest thing for people to know if you did have an infection when you were younger is that one of the greatest associations we do see with chlamydia and with tubal factor infertility is that your time to make decisions becomes even more important. These are women that I would want to make sure you feel like, no shame, like this is a, so, so common that you tell your provider this. When I find somebody who's had, you know, a prior infection. We have a much lower sensitivity to do a tubal evaluation much earlier. So a good example is an HSG or a histosalpingogram known as an X ray dye test. So we can see if the fallopian tubes are open or if they are blocked. Unfortunately, if they are blocked, it's not as simple as go and block them. There's not anything we can do, although. So I do think it's important to know that information the earlier we can start the IVF process or put eggs in a freezer. Knowing that you're not going to be spending one to three years just trying naturally when you don't have an opportunity to conceive is really important. But it was to the same breath like you had something that caused a lot of chronic inflammation inside. And I have the similar advice to anybody who has endometriosis or autoimmune disease or any known thing that caused inflammation is that your body is sensitive to inflammation now and really paying attention to those factors that you can are more important. Probably the most common scenario that I see is history of chlamydia. One blocked tube, one open tube. And in that case you can still get pregnant with one tube. Naturally the tubes move around in the body so you can get pregnant even when you ovulate on the other side.
- [100:33]
Dr. Rena Malik
Oh really?
- [100:33]
Dr. Natalie Crawford
They move around?
- [100:34]
Dr. Rena Malik
I didn't know that.
- [100:34]
Dr. Natalie Crawford
Oh, I always like to think, you know those little blow up things that are like by the car place.
- [100:38]
Dr. Rena Malik
Yeah.
- [100:38]
Dr. Natalie Crawford
That's what your fallopian tubes are like and they're attracted to the egg. Eggs. So even if one's missing, the other one can move around towards the ovary for where the egg is because the egg is released into the peritoneal cavity and then gets almost like suctioned into the fallopian tube. Fimbria.
- [100:53]
Dr. Rena Malik
Yeah, because surgically, when I look at tubes and like we do hysterectomies for prolapse.
- [100:56]
Dr. Natalie Crawford
Yeah.
- [100:57]
Dr. Rena Malik
It doesn't.
- [100:57]
Dr. Natalie Crawford
They're just kind of.
- [100:58]
Dr. Rena Malik
Yeah. They're just sitting there. Yeah.
- [101:00]
Dr. Natalie Crawford
They're not, they're not on. They're not doing anything, but. Yeah. When they have an egg in place, they move around so you can get pregnant with just one. And in that circumstance, I say it's so important to really pay attention to some of this chronic inflammation because the fallopian tube environment is the same as your peritoneal cavity. And that is where all embryo growth happens at the early stages. So fertilization occurs in the fallopian tube and the embryo grows and develops for the first five days in that fallopian tube. So if you have endometriosis, for example, higher inflammatory markers in your peritoneal fluid, you're going to have that same thing happen in your fallopian tube. And that's one of the many mechanisms how endo can be harmful for embryo development because of that inflammation.
- [101:39]
Dr. Rena Malik
Yeah, I, I saw one paper before we talk about endo, which I do want to talk about briefly at least, is that they look. They did like ozone therapy.
- [101:47]
Dr. Natalie Crawford
Yeah.
- [101:48]
Dr. Rena Malik
For improving the fertility rates for women with chronic infections. Is there, is there any. Is this like, is this something that we're excited about or something that's still really too early to say?
- [101:57]
Dr. Natalie Crawford
It is really too early to make mainstream, but we're always excited about potential opportunities. So I love that people are elite, least looking at it as, you know, women's health largely underfunded. This is. Interest is often coming from industry, but we take interest where we can get for research. So it's something that I'm excited to see where it goes, but too early to tell at the moment.
- [102:17]
Dr. Rena Malik
So endometriosis is something that I see a lot in my patients too, because it affects the bladder and it is often obviously very delayed in diagnosis. Right. These women are suffering for years of super painful periods. No one's really, really caring about them. God, it's so sad. From a fertility perspective, first maybe explain what endometriosis is and then how does it affect fertility?
- [102:37]
Dr. Natalie Crawford
Endometriosis is one of my least favorite things to all the reasons you alluded to. Takes seven to 10 years to get a diagnosis. Women get dismissed and gaslit. The primary symptoms are so subjective at first pain, pain with intercourse, GI urinary symptoms. That these are so frequently dismissed and,
- [102:56]
Dr. Rena Malik
and they're sent to different doctors, they
- [102:58]
Dr. Natalie Crawford
write different specialists for all of those and speaks to a greater discussion. Because what I hear so often from patients is, well, yeah, my periods were debilitating, but I just thought I had a poor pain tolerance or I didn't tolerate it well. So conversations like these are so important when it comes to endo because we have to know what's normal to know what's not. The endometrium is the lining of the uterus. So when you have a period, the endometrium is going to shed. That's what you bleed out. And then we'll regrow and regenerate the next month.
- [103:23]
Dr. Rena Malik
Month.
- [103:24]
Dr. Natalie Crawford
My easy analogy for endometriosis is it's truly an autoimmune disease where your body is responding abnormally to a normal process. And what I want you to think about is that uterus, that triangle shaped uterus with the tubes, it's contracting when you have a period, and that's normal. But what happens is some of those endometrial cells will get pushed out the fallopian tubes. That does not cause endometriosis. But I'm using it to highlight the fact if I went and took your appendix out when you're on your period, I would see some menstrual blood in your abdominal cavity wild. But your body should say, I'm just on my period, no big deal. La ti da. And in a patient who has endometriosis, your body says foreign material, attack, attack. This is not normal. And so your body activates that immune system, goes and walls off these little implants and they become this implanted endometrial tissue that connects to your blood supply. And just like the endometrium in your uterus, uterus, it's hormonally responsive. So one of the biggest problems here is that all the treatments for endo try to suppress hormones so that these lesions don't grow. Therefore, you cannot get pregnant if you're suppressing the hormones because you're suppressing ovulation. So with every ovulatory cycle, we tend to see worsening pain of these lesions, lesion, growth. And it has a really complex physiology. So it goes from just this chronic inflammatory environment into the fact that over time it can actually obscure environment completely. So just like if you had a, a scab and you scratched it every day, you'd eventually get a scar. We can see destruction completely of all pelvic anatomy. When it comes to endometriosis. So you can get tubal blockage, you can get the ovaries can be totally encased. It can be such a devastating disease. So it impacts your fertility in multiple different ways. And it's so hard to get to a diagnosis. Severity of symptoms, all these pain symptoms does not necessarily correlate with disease. So that's one thing that's hard. We also see that it's not always able to be visualized on ultrasound or with mri.
- [105:20]
Dr. Rena Malik
Yeah.
- [105:21]
Dr. Natalie Crawford
So surgery, putting a camera in and looking around is one of the only ways to confirm somebody does not have endometriosis. Sometimes we can get to a diagnosis with ultrasound or mri, but not always. So this really leads you to be in a place where women wait seven to ten years for diagnosis. Terrible pain, diseases worsening all of that time. And we know that 50% of patients with unexplained infertility probably have endometriosis.
- [105:46]
Dr. Rena Malik
Well, and the challenge with these patients is like endometrial surgery is very difficult when it's very aggressive and insurance doesn't pay well for that. Right. So you're going to do this really long six hour surgery potentially. And so a lot of endometrial surgeons that I've spoken to who do high volume end up having to charge for their services because they're spending six to eight hours doing surgery on people and not getting reimbursed first, like, you know, nearly to the rate of someone else doing six to eight hours of surgery. And so now it's become an issue where, you know, people who have less financial means can't get care.
- [106:20]
Dr. Natalie Crawford
More so than that too, that one expensive, long surgery improves from a fertility standpoint for about six months. We see inflammatory markers rise for six months. So this doesn't mean we never do surgery. It can be good for a diagnosis. I think a couple points I always want to make is if you are going to have it, it, please, please, please do all of your fertility testing ahead of time. We want to know that we have everything else optimal. Do not go have endometriosis surgery when you're trying to get pregnant and your partner's not even had a semen analysis. Makes zero sense. We want to really make sure we're timing that surgery in a way so that we come out of it. We're really optimizing our time to get pregnant and that a lot of that comes from having the data ahead of time. We know that because this inflammation starts to come back. This is why a lot of people end up needing to go to IVF enough, especially as the disease is more advanced. Endometriosis is so destructive, it's associated with a low egg count. It can destroy part of your ovarian tissue. When you get endometriomas, those cysts in the ovaries, it gets even worse. So you just get this multiple hit all over the place. One thing I want to say about it when it comes to IVF because I think it's important for people to understand IVF can be so impactful for endo because we're taking the eggs outside the body and we are growing that early embryo stage stage in the lab, which is non inflammatory. So if the fallopian tube is the same as the peritoneal environment, if that's highly inflammatory and endometriosis, I'm changing the environment of the early embryo growth by having the lab environment, which is non inflammatory. We also can suppress endometriosis prior to an embryo transfer. And again, I can't do this in nature because you won't ovulate. But once I have that embryo in the lab, I can now come in and really suppress this disease, stop you from ovulating, decrease inflammation, and then grow the lining with estrogen and put an embryo back inside. And I've completely changed your environment when it comes to your inflammation and your endo.
- [108:09]
Dr. Rena Malik
Is the preparation for IVF more challenging because of the hormone exposure to create the like sort of the follicles?
- [108:15]
Dr. Natalie Crawford
Not necessarily. I would say for the average person it's not because we are tending to use medications like Lupron to suppress in addition to the gonadotrop happens to stimulate. The caveat would be a woman who is endo who also has a high egg count is in the unique position where she might experience worsening pain during the stimulation from high estrogen because we can't use that same type of suppressant in her. So we do want to look at IVF and personalize each phase, meaning we heard the math earlier. As many mature eggs as we can get, the equation is going to fall better. But there are cases with some patients who have really bad endo that I sacrifice quality for quantity. And I say, well, we might use lower doses and not try to get every egg we can, but try to do this in line with a suppression so we can keep inflammation lower. IVF protocols are not a one size fits all, nor should they be. If your clinic ever says this is the protocol that we do, Red flag, Red flag. Red flag.
- [109:12]
Dr. Rena Malik
Yeah, that sounds like a red flag. And I. I mean, this is just. It sounds. So Lupron would be. Sorry, this is probably way too above most of our listeners, but Lupron would be the same. Suppress the inflammation. Yeah.
- [109:23]
Dr. Natalie Crawford
So Lupron is a GNRH agonist. So if we want to go sciency for like one minute, GnRH comes from the hypothalamus to talk to the pituitary.
- [109:30]
Dr. Rena Malik
And we use it a lot in neurology.
- [109:31]
Dr. Natalie Crawford
Right.
- [109:31]
Dr. Rena Malik
Understand. Yes.
- [109:32]
Dr. Natalie Crawford
So it is going to. So usually it can increase or decrease the amount of the pituitary release of FSH or lh. So it's an agonist. So what it actually does is causes the pituitary gland to release all the stored FSH and LH it has, but then it suppresses any further release.
- [109:50]
Dr. Rena Malik
Correct.
- [109:50]
Dr. Natalie Crawford
When we use it in really long term and you have no FSH and lh, therefore absolutely no estrogen production, we see that those endometriosis lesions suppress and inflammation lowers.
- [110:00]
Dr. Rena Malik
Yeah.
- [110:00]
Dr. Natalie Crawford
And so it is known when we use it for a two or three month period, very different than how we do it for IVF or for other things. But when we use it for that longer time period, we see inflammatory markers drop and we see the same outcomes for embryo transfer as we would for surgery. So sometimes surgery is not always the answer, and this is what's so hard for patients is, yeah, we love trying to get to the root cause, for lack of a better description. But a lot of my patients, I might say, we have presumed endometriosis. Does it make sense to try to pay an endosurgeon out of pocket, all the money, wait for months to get on their list, then get a diagnosis and move forward? Or we could, when we do ivf, treat you like an endo patient and just do a longer suppression for that. That presuming you do have it, many patients will lean that way because the outcome is the same as doing the surgery, the little different. I do want to say, though, for pain, if pain is impacting your life, repeat surgery can be advantageous for pain, and we always want to. Having good quality of life is so important. So I'm saying this from the lens of fertility only because I don't want somebody to hear this say, oh, I shouldn't have repeat surgery.
- [111:03]
Dr. Rena Malik
Sure.
- [111:04]
Dr. Natalie Crawford
Secondary surgeries, though, do not improve fertility rates. So that's a pickle sometimes to be put in that one.
- [111:11]
Dr. Rena Malik
Sorry, just to clarify, you mean secondary surgery means the first surgery is the look around and the second.
- [111:15]
Dr. Natalie Crawford
No, the first surgery, if, let's say you look and you excise. So the first time that you take out endometriosis, you're gonna see the biggest fertility benefit.
- [111:23]
Dr. Rena Malik
Got it?
- [111:23]
Dr. Natalie Crawford
Drop in inflammation, remove more. If we go back to remove more, we go back because you have worse pain. We don't see a fertility benefit in those circumstances.
- [111:32]
Dr. Rena Malik
Got it. Got it. Okay. So the reason I asked about Lupron is because it's basically shutting everything down. So you are then supporting them with other hormones to maintain their quality of life and to stimulate ovarian, you know, follicle production.
- [111:44]
Dr. Natalie Crawford
We usually actually for a month or two, don't we? We get them in a very highly suppressed environment. It sucks.
- [111:51]
Dr. Rena Malik
Yeah, I can imagine. Okay.
- [111:52]
Dr. Natalie Crawford
So we warn them like, this is not going to be fun. But then we come off of it with higher dose estrogen to grow the lining and we feel much better. And we really manipulated that body environment. But it's not long term. But it is typically a couple months of.
- [112:06]
Dr. Rena Malik
Yeah, that's why I was, I, I guess I didn't know that. But it is pretty alarming because we give Lupron for prostate cancer patients and they feel horrible.
- [112:15]
Dr. Natalie Crawford
Yes.
- [112:15]
Dr. Rena Malik
Because we've suppressed all their testosterone basically to castrate levels. And so they are really low. Low testosterone and they feel miserable.
- [112:22]
Dr. Natalie Crawford
Yes.
- [112:22]
Dr. Rena Malik
And so that's why I was curious
- [112:24]
Dr. Natalie Crawford
to learn, I should say that Lupron is a treatment for endo outside of trying to get pregnant. And I'm speaking from an embryo transfer fertility standpoint.
- [112:31]
Dr. Rena Malik
Correct.
- [112:31]
Dr. Natalie Crawford
If you are on Lupron for just endo treatment, you do get add back therapy with hormones. So you're not going to be on Lupron for years feeling terrible. When we use it in the circumstance, it's typically one to two months. So it's very short term, not years of this.
- [112:45]
Dr. Rena Malik
Yeah. Okay, helpful. I just want to talk a little bit about your experience because I think one, it's really brave to talk about it. And being a physician who was sort of in training at the time, learning, wanting to be an infertility specialist, what was that like for you?
- [113:00]
Dr. Natalie Crawford
I mean, it was terrible, as you can imagine. So we started trying to get pregnant. I was at the end of my OB GYN residency. So you do four years of OB GYN and then three years of reproductive endocrinology as a fellowship. And I had four pregnancy losses before my two kids. So I had my first pregnancy loss. You know, in residency I quoted statistics to my husband. One out of four pregnancies end in law. Not a big deal. I lost my second pregnancy when I Was chief resident on L D in the bathroom. Nobody knew I was pregnant, bleeding. It was definitely not the era of I could go home. So I, you know, delivered four babies by C section while I was miscarrying that whole night. I remember pulling over on my way home, having to pull over the car and throw up because, like, the cramping was so intense. And I remember sitting there thinking, I'm an obgyn in my last year of training, and I didn't know a miscarriage would be this painful. And I sat across from women who'd had miscarriages all the time, and yet the pain was so intense. It was terrible. And I went to my doctor at that experience and was told, there's nothing you can do. It's just bad luck. Just keep trying. And. Which is really hard for me because I had a lot of questions. I'm a very controlling person. I will admit that. And so I was like, well, what about, you know, what I'm eating? Or what about. I was a big runner at the time. Was that playing a role? Or are there. Does sperm quality matter? Is there anything my husband should be doing because he's just living his best life while I'm a resident? And I got told none of that stuff mattered and just keep trying. And then lost third pregnancy, and then my fourth was an ectopic pregnancy. And at that time, I was in fellowship, and it was profoundly difficult to sit in the position of saying, this is what I have chosen to do for a living, and if I can't get myself pregnant, what does that mean for my chosen career? Like, how can I be a good fertility doctor if I can't even stay pregnant myself? Which was this extra layer of difficulty that I was so unprepared for. And at the same time, I got the golden evaluation. I had all the resources, and I was told just IVF was the next step. Yet you're the clinical fellow, so we'll do IVF in the summer. Like, this is your clinical year. In hindsight, it always feels funny to say that, but you know this when you're in training and you're a fellow. Yeah. This is your time to learn. So I was just like, okay, great. So that's a timeline. I can roll with that. What. What should I do in the interim? What should I do? Prepare. And I was told, nothing. Doesn't really matter. And I just had a really hard time with that. Just really had a hard time that being on the side of helping people do ivf. And some people had better and Worse outcomes. And we talk about egg and sperm quality. That that was just a randomness and not a variable that we could implement four times, especially over and over.
- [115:45]
Dr. Rena Malik
Right?
- [115:45]
Dr. Natalie Crawford
We're beyond just bad luck, bad luck, bad luck. So at that point, most people do their research project. We have to do a year and a half of research and we do a thesis and publish it and sit for oral boards and defend it. And most people do an IVF project, which is fine, there's easier to control. They like look at one medium variable or something small. And I remember going to my program director saying, I want to study natural fertility. I want to know why some people get pregnant, others don't. I want to look at ovarian reserve and short luteal phase and vitamin levels and environmental chemicals. And that's what I did. That was all of my fellowship research. And I was told, well, you'll have to get a master's of clinical research if that's what you want to do, because those are hard projects to defend. I said, great, sign me up. I'm not pregnant right now anyway, right? So, like, sign me up. I will learn all the things. And that was the first time that I really started on the journey. This has me sitting here right now because despite all those different things, environmental chemicals, vitamin D levels, low amh, short luteal phase, the paper sitting in front of me all mentioned inflammation as a mechanism for how these things were harming fertility. Yet in medical school and even in training, we really only talked about inflammation on the disease pathway. Like endometriosis causes inflammation, therefore bad had, but we didn't really talk about inflammation, predicating disease and being there beforehand and this low level inflammation and how that burden can influence your world. So I came home and said, I'm gonna be my own N of one experiment. I was still on this IVF train, but really said, if I gotta do ivf, we're gonna have the best eczema sperm possible. I didn't really believe the narrative. There was nothing we can do. So I got rid of all the plastic in the kitchen, change the foods we were eating, changed our sleep environment, we started lifting weights. And luckily my husband was a good sport when he came home and saw all the Tupperware piled up in the kitchen. And this was 12 plus years ago. I mean, this was well before it was cool to, you know, drink away plastic. Yeah, to throw away plastic. And he was like, okay, whatever, whatever you want. But I was just convinced after going through the research that it had to make some difference. And more than anything, really learning are what are those symptoms of chronic inflammation? They're the things that women get dismissed from. Headache, fatigue, bloating, brain fog, neuropathies, gas. There's a list of 80 plus of them. But what are those for me and what makes me feel worse and what makes me feel better and titrating life to that. And in dietary changes, what I did do was I ended up cutting out gluten, had very whole food, kind of plant based diet. But I noticed I felt more sensitive to gluten and conceived my, my two children without needing ivf. I got pregnant my daughter in that year. I was so I kept waiting for something to go wrong. You know this as a physician, just kept waiting for something to go wrong. I didn't even believe it till I held her in my arms and just sobbed, feeling like I couldn't believe that that really happened. And then got pregnant with my son really quickly, postpartum, kind of living the same life. And that to me was so profound because it really told me what it was like to be a patient. And I've always approached patient care differently. How we have to individualize what data exists and what the individual is going through, but also understanding that we don't know everything. And we have to look at scientific evidence to take the evidence that exists and make the best decisions we can. But one of the most important things we can do is give autonomy to people to make those decisions and not be paternalistic in our approach in medicine. And that was crazy. I got diagnosed with celiac disease 10 years later. So even though I felt like I was sensitive to gluten, I had had a ton of testing. I didn't have primary GI symptoms per se, just had your classic inflammation symptoms and then ended up getting diagnosed with celiac disease, which absolutely can be associated with recurrent pregnancy loss. So it's not that, oh, everybody should just go cut out gluten, but it really is, is showing us how these individualized choices all do add up and how collectively trying to pay attention to them can make it better.
- [119:47]
Dr. Rena Malik
Well, anything experimenting, right, like if you have a hunch that something's not working,
- [119:52]
Dr. Natalie Crawford
like not accepting the, like just try
- [119:54]
Dr. Rena Malik
to try to exclude it or try to change something.
- [119:57]
Dr. Natalie Crawford
Like control what you can and learn to listen to your body. So often, because women are specifically women are gaslit, dismissed. We start to not trust our own experience or our own body. And learning to trust your own body truly is such a tool that you can leverage for your own health and your fertility.
- [120:15]
Dr. Rena Malik
So I'm so excited about your new book.
- [120:17]
Dr. Natalie Crawford
Thank you.
- [120:19]
Dr. Rena Malik
The fertility formula. It's beautiful. So tell us where can people find out more about you, your new book, your practice, your podcast, everything you're doing.
- [120:27]
Dr. Natalie Crawford
Thank you. The book is really, you know, everything we've talked about, but in much more detail and it is broken up into multiple sections. All the facts about your body. I wish you would know, know how you advocate for yourself when things are wrong or when you're trying to get pregnant or have infertility. And then whole half of it is about all these lifestyle factors but bringing back in the data and explaining how we really make actionable choices so that it's not overwhelming. I'm on Instagram at Natalie Crawford md. You can buy the book anywhere books are sold. It's available April 14th and if people pre order it before then, then we've got some pre order bonuses as well. They can learn@natalie crawfordmd.com book and then clinically, I practice in Austin, Texas at Fora Fertility. We have a boutique fertility practice. There's two physicians and we really believe in personalizing the medical approach to try to help patients the best.
- [121:14]
Dr. Rena Malik
Amazing. So we end our podcast with four questions. We ask everybody. They can be about your life. They can be about anything. Doesn't be related to your expertise. What is something you know now that you wish you knew earlier?
- [121:24]
Dr. Natalie Crawford
That my health is worth prioritizing because especially as a woman, as a mom, as somebody who had these other goals for a really long time. I was the queen of putting my health last so often and being that martyr and really sacrificing and knowing now that when I take care of myself, when I get enough sleep, when I eat better, that I can show up in all those other avenues as a much better person and I have more resilience for what the world's gonna throw at me.
- [121:51]
Dr. Rena Malik
Yeah. What is a non negotiable something that you have to do every single day?
- [121:57]
Dr. Natalie Crawford
Sleep. Enough. Enough.
- [121:58]
Dr. Rena Malik
Yeah.
- [121:58]
Dr. Natalie Crawford
Yeah, absolutely. I will not work out one day in order to get enough sleep. I will leave the dishes in the sink so that I can go to bed early. It is something where I will now not complete the to do list to get enough sleep and modify what the daily schedule is going to do.
- [122:12]
Dr. Rena Malik
That's good. What's a life hack or health hack you'd share with us?
- [122:16]
Dr. Natalie Crawford
I think an important life hack is going to be really to learn to write things down as a method of therapy. I have told my followers for a long time I have a word document on my computer that if anybody ever hacks into. I'll be so mad.
- [122:27]
Dr. Rena Malik
Called.
- [122:28]
Dr. Natalie Crawford
It's called life planning. I don't know why it's called that, but it's literally a journal.
- [122:31]
Dr. Rena Malik
Well, now you've told me.
- [122:32]
Dr. Natalie Crawford
I knew that I'm gonna find it. So now it's. It's a journal, for lack of a better word, where you can brain dump and plan. But even when I was going through this process of trying to get diagnosed with celiac, tracking things down, putting the thoughts from your brain onto paper allows you to more clearly see, you know, what's going on with your health, but also your goals, how you're prioritizing your life and lets you structure it better. So find a good way to get the. The words that are in your brain onto paper. And then when you read back on that, that can help give you a lot of clarity.
- [123:02]
Dr. Rena Malik
Yeah. Figure out whichever. I. I do this too. I have a journal I write in and I will sometimes orate on my phone, but I think, figure out what works for you. Like, I love writing in an actual, like, physical journal because I think.
- [123:14]
Dr. Natalie Crawford
And you can't hack it, so probably good.
- [123:15]
Dr. Rena Malik
Yeah, well, someone could steal it.
- [123:17]
Dr. Natalie Crawford
Scary.
- [123:20]
Dr. Rena Malik
Okay, last question is, if you couldn't be a physician, what would you be?
- [123:23]
Dr. Natalie Crawford
Well, you know, if I couldn't be a physician, I always want to be an author. It wouldn't have been a non fiction book. It would have been a fantasy author. But, you know, life is still short. Maybe that'll be like the next version.
- [123:33]
Dr. Rena Malik
Yeah. Amazing. Well, thank you so much.
- [123:35]
Dr. Natalie Crawford
Thank you so much for having me, guys.
- [123:36]
Dr. Rena Malik
Wasn't that a great episode? I could have talked to Natalie for another two hours. If you guys learned something from this episode, if you found it helpful, please subscribe. If you're watching or follow, follow the podcast wherever you're listening, because it makes a huge difference for people around the world to be able to see our podcast and get access to it. So, as always, take care of yourself because you're worth it.
- [123:56]
Dr. Natalie Crawford
Every act of change begins with a neighbor, with someone saying, we take care of each other. Here in food banks and food pantries, neighbors pack fresh food and dignity into every box, moving food from farms to families through Food Feeding America's nationwide network.
- [124:12]
Dr. Rena Malik
So when that box reaches a home, it carries more than food. It carries a promise that together, we can end hunger.
- [124:21]
Dr. Natalie Crawford
Feeding America, led by neighbors, give now to endhunger@feedingamerica.org.