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She's So Lucky
Should You Freeze Your Eggs? Everything You Need to Know About Fertility with Dr. Amanda Adeleye of CCRM [Bonus]
00:52:43
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- [00:01]
A
The following podcast is a dear media production. Dr. Amanda, welcome to the show.
- [00:12]
B
Thank you for having me.
- [00:13]
A
I am super excited to have you here to talk more about reproductive health, about fertility, about your work with ccrm, as well as just helping black women in particular kind of take control of our reproductive choices. We have a lot to get into today.
- [00:29]
B
Yes, we do. Thanks for having me.
- [00:31]
A
Absolutely. I would love to start by learning more about your journey and what got you into reproductive health, what made you want to focus on this.
- [00:40]
B
Yeah, so I grew up in Illinois, and I've always loved science. I knew wanted to be a doctor probably in elementary school. I thought it was probably what I was going to do. And then I started to kind of see the injustice in women's health, and I just wanted to fix it. You know, it's just my personality. I just saw that there was really this imbalance, and it was unfair, and so what could I do to help? And so obgyn as a field seemed like the best way to do it. I also dabbled in breast cancer research for a while. I'm pretty passionate about that as well, you know, So I got through college, went to med school, was pretty sure I was either gonna do ob GYN or possibly general surgery, and then specialize in breast surgery and treating women with bre cancer and ultimately decided on ob gyn just because I really love the idea of being able to take care of women and people that identify as women across the kind of entire spectrum of their lives and really build those relationships. So then I got to residency, so I was a doctor. I went to Columbia, got my medical degree, and then you have to do training afterwards. And so I did ob GYN training for four years. And in that time, I got exposed to reproductive endocrinology and infertility, which is a subspecialty of ob gyn. And I just love the idea of, like, the science of helping people to build their families and that idea, that concept of relationship building over time. And also, really, it's one of the few parts of medicine where you can make people really happy. A lot of medicine is kind of rectifying a problem, and here there's really an opportunity to just elevate and bring somebody joy. And so joy's my middle name, literally. So it just really felt like the right fit. So that's how I got into the field.
- [02:26]
A
I love that point that you just made about reproductive healthcare being the kind of the one area of medicine that helps people potentially feel joy. I never thought about it that way.
- [02:36]
B
Yeah.
- [02:37]
A
Because a lot of areas of medicine are kind of doom and gloom, or oftentimes there's something wrong or you know, just maybe not the happiest of circumstances. But it is an opportunity to really help people build the lives and the families that they desire. I'm sure that's rewarding.
- [02:55]
B
Exactly. Yeah. Yeah, exactly. And having context as an ob GYN is really great. I mean, although I like obstetrics, you know, it's hard as a physician, you know, to do. I realized it wasn't really quite my calling. But there's still, like, really no bigger joy than kind of being in a delivery room delivering that new baby to, like, a healthy parent and a healthy family. And just seeing that emotion in the room, like, I can still see it in my mind's eye, you know, And I haven't done a delivery in almost 10 years. It's really so. It's so incredible to get to be a part of that really special moment in people's lives. And so now I'm on the other side where I get to really help fix it for people so that they get to experience that joy. And it's great to kind of know what they're up for and all the excitement and challenges of parenthood. And so, yeah, it's such an honor and an opportunity to be able to do that for people. People.
- [03:49]
A
Definitely. Definitely. I would love to talk a little bit about the definition of, I guess, fertility versus maybe infertility. So what constitutes as healthy fertility, or if someone is experiencing fertility challenges, what is the definition of infertility? How do they differ?
- [04:08]
B
So fertility is really, you know, if you are somebody who wants to build a family and you try to get pregnant and have a baby, and you can. And that definition is pretty coarse and makes a lot of assumptions. Right. Like, that would presume somebody identifies as cisgender and has a heterosexual. Is in a heterosexual relationship having, you know, penile vaginal intercourse. And that's not everybody. Right? But typically, if we're talking layman's terms, that would be, you know, fertility. The. The ability to get pregnant when you want to and have a baby when you want to. An infertility does have a medical definition. It's, you know, for cisgender heterosexual people who are having reg intercourse at least, you know, a couple times a week. The inability to get pregnant after one year of trying if you are under the age of 35, the inability to get pregnant after six months of trying if you're over 35. And really, anybody who's 40 and over who's trying to get pregnant should be seen right away by a reproductive specialist. And so that's kind of the medical terminology for infertility. Although recently the American Society of Reproductive Medicine, or asrm, has expanded the definition of infertility to really include anybody who needs assisted reproductive technology or assistance to get pregnant and have a baby. So that does more broadly include our, you know, folks in the LGBTQ+ community, people that want to be single parents by choice and more. So that's kind of the longer answer to what's infertility?
- [05:36]
A
Got it. Got it. So for people who are maybe in a hetero relationship, maybe having, trying to have or conceive naturally under the age of 35, if it takes a year or more, over the age of 35, if it takes six months or longer, or anyone who is outside of that conventional partnership who is probably going to need some sort of scientific intervention to have a biological child. Nailed it.
- [05:59]
B
Yes. And I always like to add when we talk about the definition of infertility, if the person with ovaries or the person identifies as a woman doesn't have regular menstrual cycles, like, maybe they skip and they do, like, every other month or every three months, or they don't get periods, get seen right away. Don't wait until you've, you know, had a whole year go by and you've had one or two periods. Like, that's not normal. So, like, that definition of infertility would apply to people who, we presume everything is working appropriately, and that includes the menstrual cycle.
- [06:31]
A
Got it. So someone who is having a regular, probably monthly cycle, that's who that definition applies to.
- [06:37]
B
Okay.
- [06:38]
A
And for people who do experience those challenges, let's say, okay, someone's been trying to get pregnant for a year, it's not. It's not happening. Or they're over 30% trying to get pregnant for six months, it hasn't happened yet. What are some of the most common reasons why that may be occurring?
- [06:52]
B
Yep. So about 20, 25% of the time, it can be an ovary issue. So maybe not ovulating regularly, not having good quality eggs, and we can talk more about that. But that's really that ovarian aging kind of issue. About 20 to 25% of the time, it can be what we call, like, a male factor issue. So not enough sperm, not enough sperm that are moving the right way, Something in that realm about a quarter of the time, it could be something structural. Like there could be an issue with the uterus, which is what carries a pregnancy or the fallopian tubes. So that might be something like fibroids, which tend to be more common in women of color. Or an issue with fallopian tubes, which they're little structures that carry the egg from the ovary to fertilize the egg into an embryo and then carry that embryo into the uterus. So sometimes that tube can be blocked, that can cause an issue. And then about a quarter of the time, it can be something that we call unexplained infertility, which is you check everything out. We don't know what the problem is. We don't have a great way to measure it. Doesn't mean there's not a problem. Maybe it's the way the sperm and the egg meet is like, not as efficient as it could be, but we don't have a way to test for that. So you get called kind of unexplained infertility. And also within that, there might be things like endometriosis or other kind of more rare issues that contribute to infertility.
- [08:09]
A
Got it, got it. Yeah. I think of at least what I hear a lot of is a lot of people either experiencing things like endometriosis or saying, oh, PCOS made it hard for me to conceive or things of that nature. How common are those conditions? Because at least on the side of the Internet that I'm on, it seems like they're becoming increasingly common, But I don't know if that's what the actual data or true diagnoses are showing.
- [08:33]
B
Yeah, yeah, it's a little tricky because it depends on how one defines each of those conditions. So for PCOS in particular, which stands for polycystic ovary syndrome, it probably occurs in about 5 to 10% of women of reproductive age in the United States. Context is really important. So there are a few ways you can define pcos. Most commonly in the US we use the Rotterdam criteria. So you need two out of three things to be kind of off. One would be irregular menstrual cycles, one would be polycystic appearing ovaries, and one would be either laboratory signs or physical signs of having excess androgens, which are really kind of testosterone, like hormones. So that's a lot of jargon. But what I'm really trying to say is, you know, it depends on how you define pcos, what the prevalence of it is. And it might vary a little bit from country to country depending on maybe like hair distribution and how, you know, that might be categorized, just as an example. But in the US we typically say 5 to 10% of people may have polycystic ovary syndrome. And a lot of people don't recognize it and don't go and get evaluated for it. Endometriosis is probably less common, maybe somewhere 3 to 5%. But it's really hard to know because the way we technically would define endometriosis would be if you were to have a surgery and somebody looks in your abdomen and your pelvis and sees some endometriosis, which is a growth of the uterine lining outside of the uterus. So it's really defined surgically, but a lot of people don't want to get surgery and don't really need surgery to address it. So then it comes down to, do you present with symptoms that your doctor or provider would identify as, ah, that's endometriosis. And unfortunately, a lot of women or people with ovaries who have pelvic pain are often dismissed by their providers. So we're probably under diagnosing endometriosis. But on the other hand, it's very hard to really prove what's the actual prevalence without, you know, surgeries and really kind of confirming it in the general population. Yeah.
- [10:35]
A
And without that hard data, I also know some people who have been diagnosed with endometriosis after receiving surgery to confirm it. And even the process of getting the surgery and getting insurance to approve the surgery is really, really difficult. So that, I would imagine, is also a barrier for a lot of people.
- [10:51]
B
Absolutely. But for, you know, for me, what I feel like is one of the biggest barriers is, again, women are not listened to consistently when they talk about their pain. They're either told, oh, it's normal, or maybe within a community, it might be normalized. Right. Like, there is a genetic kind of predisposition to endometriosis. Like, if you have a relative with endometriosis, it might increase your risk of it. So if you're talking to your sister, your aunt, your mom, and you're like, oh, my periods are so painful, they might say, oh, well, that's normal. But they might also have endometriosis too. So there could be sort of some kind of internal social kind of pain, but then also at the medical level, and certainly I think you can see that even more if you think about, you know, you add race into the picture, other sort of underserved populations that are often dismissed.
- [11:37]
A
Yeah, yeah. There's another thing that you mentioned that I would also love to talk about, which is fibroids and how fibroids do tend to be more common for women of color, particularly black women. Has there been any research to indicate why that is and why we tend to experience them more?
- [11:53]
B
There's tons of research coming out on this. One of my mentors, Dr. Erica Marsh, has some great research in this area, as does Dr. Ayman Al Hendi. So I'm not an expert in fibroids. I certainly can treat them, but that is, you know, not my area of expertise from a biologic perspective. But, yeah, there's probably, I think, some degree of, you know, genetic predisposition also combined with environmental exposures and what exactly those are, we don't always know. But ultimately, yes, women of color do tend to get fibroids at an earlier age and may have kind of more significant, we would say, disease burden or maybe might accumulate more fibroids over time compared to white counterparts.
- [12:33]
A
That is really, really interesting, especially because I feel like fibroids are something that at least I know I learned about and heard people start talking about in recent years. But I would imagine that that's. It's not a recent problem. It's not. It's probably persisted, but we're just now beginning to learn more about it, correct?
- [12:50]
B
Yeah, yeah. I mean, there's, you know, some interesting, like, old literature. In obgyn, you could find pictures of women, I think, that used to be called, like, consumption. You know, don't quote me on this, but, you know, like in like, the, you know, 19th century, I mean, you could incredible medical pictures of, like, women with these, like, huge fibroids. And I mean, they get so big, you know, women can bleed to death, you know, from having unmanaged fibroids. And so, yes, this has been a problem probably as long as humans have had, you know, a uterus. But you're absolutely right. I think it's partially going to be social media, kind of our general kind of social comfort with talking about reproduction. All of that's really been elevated, I'd say, in the last, you know, 15, 20 years. And so any research that's been done, you know, I think is getting more widely publicized and kind of women that are having these experiences are talking about it more. So this, you know, our situational awareness of fibroids is definitely elevated, which is great, I think.
- [13:44]
A
Yeah. Cause I think it. That's what's going to hopefully lead to more solutions so that ideally future generations won't have this problem.
- [13:51]
B
Right.
- [13:52]
A
Yeah. So let's see. You had mentioned a few of the factors that can lead to fertility challenges that we've Covered. There were a few that I would love to go back to that you mentioned. 1. One being the male aspect, which I don't. I don't know if I hear people talk about a lot when it comes to fertility challenges. I feel like a lot of the assumption is that there's something wrong with the woman if a couple is having a hard time getting pregnant or staying pregnant. Can we talk more about some of the male factors?
- [14:19]
B
I would love to. Yeah. This is something that. Let's turn that up. Yes, I know this is something that always bothers me. So, you know, I think especially in, you know, unfortunately, kind of like misogynistic world. Right. Like, everything is very, like woman centered when it comes to fertility. And I mean, it makes sense to some extent. Right. Like women or people with a uterus are the ones that are carrying the pregnancy. So we're kind of the visual representation of, you know, family building. But the reality is men contribute to fertility issues almost just as frequently as women. You know, if you include kind of an overlap of like male and female factors, it's maybe even 40 to 50% of the time there's a male factor issue. But because men often either themselves feel like, well, I'm just kind of, you know, given a specimen and I'm done. Right. Like they don't feel like they're participating. And probably to some extent there's a social pressure to not be connected to fertility issues. Right. Like, you know, being fertile is a sign of virility. So, you know, I'm not a sociologist and I can't explain all of that. But at the end of the day, men do contribute a significant amount to fertility issues. And again, it's typically by either not having enough moving normal sperm, sometimes not having any sperm at all. Sometimes it can be erectile dysfunction and sexual dysfunction and the inability to ejaculate. There's a whole gamut of reasons why men may be unable to conceive.
- [15:44]
A
That is, these are important factors to consider. Then the last factor that I wanted to revisit that we touched on and I want to go deeper into, you know, mentioned egg quality. Want to talk more about what. Yeah. What egg quality means and maybe some. Some things that we can start thinking about now, even if we're not trying to conceive, to have as high quality of eggs as possible.
- [16:02]
B
Yes. This is one of my favorite topics because I feel like it's under. Under discussed. I mean, it is changing, but it's still under discussed. So women or people with ovaries are born with all the eggs that they're going to have. So at birth, that's about 1 to 2 million eggs. And then there's a pretty consistent loss of eggs over time. So even as a child, before you go through puberty, you're lo. That's fine, because, I mean, we don't need a million eggs. Right. You know, I think even people that are, you know, highly productive, maybe they might have, like, 20 kids in their reproductive lifespan. So you don't. You don't need a million eggs. You don't even need a thousand eggs. Right. So there's this constant loss. Then you get to puberty. And what happens is, on a typically monthly basis, your brain and ovaries are talking to each other to select one egg to mature to be, like, the best egg that gets ovulated or released that month. But in that process, a handful of other eggs start to mature along that process, and they're not the right one. Right. So then they die. So you're going to get, like, kind of a daily attrition of immature eggs and then a monthly attrition of more mature eggs. And so that's how we kind of lose our follicular or our egg pool over time. There is an acceleration in the loss of eggs probably in the late 30s. But ultimately, you know, most women, we think, probably still have, you know, even a thousand eggs at the time they go through menopause. And menopause typically happens around age 51 and a half in the United States. Menopause is when, no matter how hard your brain tries, it cannot stimulate the ovaries to release an egg anymore. So I think, traditionally, we think about, if I have a period and I have eggs, I must be able to get pregnant. And, like, technically. Technically, that's true, but really, the likelihood of getting pregnant goes down significantly as we get into our 30s and certainly into our 40s. And typically, the ability to. To conceive on your own ends about 10 years before you would go into menopause. So for most women, that's gonna be in the early 40s. So why. And that's egg quality. So all the cells in our body have 46 chromosomes. Chromosomes are the long strands of DNA that tell ourselves what to do. And so the issue is a mature egg should only have 23 chromosomes, and a mature sperm should have 23 chromosomes. So when they come together, 23 plus 23 is 46. Right. Great. Unfortunately, the eggs that we're born with have 46 chromosomes, and it's only at the time of ovulation so for most of us, decades later, that that egg completes a process called meiosis to separate their chromosomes evenly within the egg cell, and the egg actually divides in two. So the final egg has 23 chromosomes. This process depends on molecular machinery, some bioenergetics, and things we don't understand to make this happen. So in our 20s to early 30s, this separation process happens really well. So most eggs we release are chromosomally normal. As we get into our mid-30s and certainly into our 40s, it gets all dysregulated. It's a mess. So sometimes you release an egg, it has 22 chromosomes, or 24 or 25, anything but 23. When that egg gets fertilized, that embryo is going to be chromosomally abnormal, or aneuploid is another term for that. Those embryos typically don't implant or grow. So that's going to be experienced as more ovulatory cycles where you're not getting pregnant as you get older. So you might be going through the motions, basically, but nothing's happening. Sometimes those abnormal embryos will implant, but they won't continue to grow. And that is experienced as a miscarriage. So miscarriages go up as we get older. There are a couple chromosomal abnormalities that are compatible with life, like a Down syndrome, as an example. But children that have those chromosomal abnormalities may have developmental differences, physical differences, and sometimes a shortened lifespan. And they're pretty rare for a fetus to make it to, you know, a live birth with a chromosomal abnormality, but it does occur. So when we talk about egg quality, we're primarily talking about how many chromosomes does an egg have? And there's a pretty good model for what that quantity is, depending on your age. So starting in your mid-30s, really, it's the early 30s, but clinically it's not such a big deal. But Certainly by your mid-30s, you start to. There's a pretty, what we call, like, linear relationship between the proportion of eggs that are chromosomally normal by age, and it changes like 5% per year. So by age 40, only about maybe 40% of the embryos that you might make would be chromosomally normal. And by the time you get to 45, it's like 5%.
- [20:42]
A
So are there any things that we can do to have, like, the highest quality of eggs possible, especially if we're in our 30s and above?
- [20:50]
B
So right now, with the current technology we have, we can't reverse this process. So you have what you have, but right now the best strategy, like, if it's something that you're particularly worried about, you might want to talk with a reproductive endocrinologist like myself and think about something called egg freezing. So you can potentially freeze your eggs at an age where you're more likely to have a cohort of normal chromosomally normal eggs. That's one of the better strategies we have right now. There are certainly folks out there working on great science to kind of manipulate sometimes stem cells, to, you know, become egg cells and all sorts of stuff. So, you know, I think if we have this conversation again in 10, maybe 15 years, my answer will be different. But right now, we don't really have, you know, sort of any sort of magic pill to really meaningfully improve things. There are supplements out there that people will take, like CoQ10 sometimes or other antioxidants, and it might help a little bit. But, you know, I think if we're talking about a really meaningful difference that kind of moves the needle on the proportion of eggs that are chromosomally normal, we don't have anything really clinically available right now.
- [22:00]
A
Interesting. So lifestyle factors, like, how does that play a role? Because I. I don't know. I would imagine that maybe if someone is, like, in their late 30s, but is super healthy, would that have an impact, versus if someone's maybe in their 20s, but, like, takes terrible care of themselves, how. How would that.
- [22:18]
B
Love it. These are all the best questions you're hitting. All the things I love to talk about. Yeah. So when it comes to the chromosomal quality of the eggs, nutrition and lifestyle probably are not making a significant difference, unfortunately. But being of, like, let's say, a higher weight, you know, where you have excess kind of fat tissue that can put stress on the body and maybe increase inflammatory markers in the body. And it's possible, like, we're starting to see, maybe that could affect the eggs in certain ways and therefore the embryos. So maybe not the, like, the quantity of chromosomes that the embryo has, but perhaps how that new embryo is reading all of that genetic information. It might change a little bit depending on how healthy you are. But that's really kind of emerging data at, you know, at any point, I would always say, try to be the healthiest person that you can be. Things like smoking are certainly impactful. Actually, smoking does decrease your overall egg pool. And people who smoke consistently tend to go through menopause about at least a year earlier. So, you know, smoking impacts quantity for sure. It might impact quality a little bit, but we have to See, but something like being of a higher weight, you know, not moving around too much, those things could potentially also have an issue. I'm also interested in like microplastics and, you know, other environmental factors, endocrine disruptors. I think the data are very new, so I don't want to say anything conclusively, but I do think trying to have, you know, a healthy, colorful diet, you know, eating the rainbow, like my, my colleague, Dr. Jamie Nodal likes to say, eat the rainbow. Those strategies are certainly not going to hurt you and it's possible they could help. But again, you know, is it going to take you from being a 40 year old where, you know, 40% of your chromosomes are abnormal, to having 20% abnormal? No.
- [24:06]
A
Got it, Got it. I would love to go back to the topic of egg freezing that you mentioned, because I think it's something that people are talking about a lot more. And I'll be honest, it's something that I kind of have mixed feelings about, which may be a controversial take in this conversation.
- [24:20]
B
I love it. I want to hear.
- [24:22]
A
Yeah, because I think it is incredible that people who have ovaries, who have eggs have that option. I do think at times it can be sold as this like, I don't know, almost kind of layaway system that is oversimplified to people. And I don't think that the process risks, potential outcomes are like, as fully talked about in the conversations. It's just more of like if you're in your late 20s or your early 30s and you haven't settled down and you want to focus on your career just for your. Just freeze your eggs and then everything will be all good whenever you decide to have a baby. And I don't, I don't know if that's necessarily, if it's that simple and I think it's marketed that way. But I would love to have like a more holistic conversation.
- [25:10]
B
A hundred percent. I love it. And I agree, actually. I think, I mean, I know so many great reproductive endocrinologists around the country. So like, I don't know how my other colleagues counsel, but I do think actually the folks I talk to tend to agree with your perspective, which is it's not reductive to like, oh, you're in, you know, you turn 30, go freeze your eggs. You know, it's not like that. In fact, really, fertility is never guaranteed. So when you ask that first question, I loved it so much, you're like, well, what is fertility? Right? Like fertility is trying to get pregnant and then getting pregnant and having a live birth. I cannot look at you and say, you're gonna get pregnant or you're not gonna get pregnant. You can never guarantee fertility, and freezing eggs does not guarantee fertility. What I like to tell my patients is freezing eggs can be helpful and improve your probability of getting pregnant and having a live birth if you find that you need IVF in the future. So it's about kind of optimizing probabilities. That's how I like to talk about it with my patients. But you're right, really, I like to center it more on. I think as you blossom into adulthood, it is good to have conversations about how do you want to build your family? Do you want a family? Maybe you don't want a family, right? Like, when I was in, you know, med school, I was like, I don't want kids. They're, like, loud. They're, like, expensive. No, thank you, right? So, like, do you even want kids? If you want kids, when do you want kids? Do you want them with a partner or not? Do you want to, you know, are you okay single parenting, or do you want a co parent? How likely are you to, you know, start trying to conceive if it is important to you? Isn't the most important thing in your. In your life? Like, do you have. You always imagined being a parent? Like, these are the conversations you need to have starting, I think, in your 20s, not freeze your eggs, but as you answer those questions and you're. You know, every person's gonna change, right? The person you are at 25 is not the person you are at 30. It's not the person you are at 35. We hope that you start to get to really know who you are and can, you know, your personality and what you like and what you desire becomes more stable as you get older. But it can change, and that's okay. But I think having the conversation about what are your goals, right? If I have a patient that sits in my office at 30 and says, Gosh, Dr. Amanda, like, there's nothing more I want in life than to be a parent, nothing more, and I will be crestfallen if I can't be a parent, say, well, technically, then you should start trying now. And I said, I will never say I'm advocating for you to get pregnant now if it's not right for you, but there is no other way to know for sure. But a step down from that would be if it's very important for you, but you really don't feel like you're in a position. Position to get pregnant now. Okay, then maybe you are somebody who should consider, you know, freezing your eggs. But then you have to think about like all of the things that kind of go along with it. It's often not covered by insurance, so it's out of pocket. So then you're asking young people who are building their careers to take out, you know, thousands of dollars to freeze eggs for something that's not a guarantee. And also then, you know, they have to balance work potentially, if they're working and, or school and missing out on certain things while they're, you know, trying to freeze their eggs. So I don't think it's straightforward. I don't think it's easy. But I do think it's a conversation that needs to be had and repeated, especially as we change and we grow. Because your answers might change. And if you get to a point where it is important for you to think about having a family or you might regret it, then maybe it is worth, you know, freezing your eggs.
- [28:32]
A
That makes a lot of sense. And I think I love that example that you gave of the person who maybe said like, I want nothing more than to be a parent versus I think sometimes, at least conversations that I've heard, it's very, it's sold hard to people who are maybe on the fence. And it's like, we'll just do it because you might regret not. And I'm like, oh, I don't know about.
- [28:50]
B
I don't know.
- [28:50]
A
That's a, that's a large undertaking. I've had friends who have frozen their eggs and it's not an easy process. It's a lot mentally, it's a lot emotionally and physically and financially to do. If you're just like, well, I don't know. So yeah, that's why I like being able to ask questions about like a 360 view of all that goes into it. Can we talk more about the actual process of freezing eggs? So let's say if I'm like Dr. Amanda, I'm ready to freeze my eggs, let's say I get approved to do so, then what does the process look like?
- [29:23]
B
Yeah. So going back to what I said earlier, every month, ideally, your body is choosing a cohort of eggs to mature a little bit further and typically you pick one and the rest of those eggs go away. So all egg freezing does, and actually it's really similar for IVF is try to rescue those eggs that were going to die that month anyway. And we can't change what amount that is. Some women, you know, for month to month, they've got a pool of 20 some, it's a pool of five some, it's a pool of 10. That's just the variety in life. Okay. But you're going to have what you're going to have. And the goal is to try to get those eggs to grow, to mature. And so we do that with injectable medications. And you would take them usually two to three medications every day for about 10 to 12 days.
- [30:06]
A
What is in the medication?
- [30:08]
B
So they're the medications that are meant to mimic the hormones that your brain makes to recruit, like that one mature egg. Okay. So one is something that mimics fsh, or follicle stimulating hormone. The other one is lh, or luteinizing hormone. It's not actually luteinizing hormone anymore, but that's a technical aside, but it's meant to kind of mimic that hormone. And so together they're really trying to grow that cohort of follicles. The third medication that people often use is to prevent you from ovulating, because once you ovulate, if you ovulate, you're losing the egg, then we can't get it.
- [30:38]
A
Yeah. So, okay, interesting. And do people sometimes experience any side effects of these medications? How do people feel when they're on it?
- [30:48]
B
So you might, depending on how many eggs are kind of maturing in that process. And we really say follicles because they're eggs inside of a shell of cells, and that that structure is called a follicle.
- [30:57]
A
Right.
- [30:57]
B
So depending on how many follicles are responding and growing, you might start to get bloated, you might get a little. You might get like an injection site reaction. You might get some burning, some bruising, maybe some mood changes. Everybody's different. It's very hard to say. Yeah, actually, like, as your estrogen levels go up, that probably is good for your mood, but everybody's different. And what I like to say is, like, listen, you're here thinking about life, right? Like, you are putting your time and your energy on the line because you think you to be a parent in the future, that's such a big deal. Or for my infertility patients, they really want to be a parent, right? And this is the thing. This is like the last thing they can really do to have a biologically related child. And so it's a big deal. So just that alone sets the table for being pretty emotional, Right? And there's good data emerging that, like, stress levels and depression and anxiety can be very high. Certainly people with infertility but also for people that are freezing their eggs. And so, yes, there can be a lot of emotion involved. Whether it's the side effects of the medication, I think is really hard to tease out. But ultimately, you take the medications for about 10 to 12 days. And then in that process, you're usually going to your doctor's office getting a pelvic ultrasound. So that's going to be an ultrasound where there's an ultrasound probe that goes into the vagina. I like to mention that because it might sound pretty easy if I just say ultrasound, but it's a pretty, you know, invasive ultrasound, and they get their blood drawn. And this is usually about maybe six times in 10 to 12 days. So it's pretty frequent, typically in the mornings. And then when your follicles are nice and big, about 2cm in size or almost there, you'll take a final medication called the trigger shot to make the eggs ready to be released. Then you go to your doctor's office. Really, it's a procedure office. About 36 hours later, in many clinics around the country, you'll go to sleep. Sometimes you'll get conscious sedation. And while you're asleep, then an ultrasound is placed in the vagina. A needle is placed through the back of the vagina to the ovary, so it goes into your pelvis. And then those, like, follicles are aspirated. We suck up the fluid, and hopefully the egg comes with it. Then an embryologist in the next room will look at the fluid, find the eggs, and prepare them to be frozen.
- [33:06]
A
Got it?
- [33:06]
B
That takes like, 20 minutes. You wake up, eat some crackers, you go home. Most people technically can go back to work the next day. I say technically because it's not like there's any real incisions. You're not trying to heal in that regard, but you might be pretty bloated. You might not feel great, you might be sore. So it's not going to be like a walk in the park going back to work. And then for a small subset of women, they might experience something called ovarian hyperstimulation syndrome, or ohss, where you get really bloated. So bloated, you get nauseated, you might not want to eat or drink anything. You get dehydrated, it's hard to breathe. That's a smaller subgroup of people that really robustly respond. But that can also, you know, take. Make the recovery process take a little bit longer.
- [33:47]
A
Okay, got it. So then once the eggs are retrieved, are they, like, observed or tested for viability before they're frozen or are they just frozen immediately?
- [33:57]
B
All we can do is check to see if the eggs mature or not. And mature just means that it go through the final step of separating out those chromosomes so that hopefully the egg that's left has 23 chromosomes. But the really important part is we can't see how many chromosomes the egg has. We can only see that did the cell finish that process and become mature. That becomes very important because you freeze these eggs, you have no idea whether or not they're gonna lead to a live birth.
- [34:25]
A
Yeah. So do you not know until it's time to try and fertilize it and plant it embryo?
- [34:32]
B
So we go by age as the best proxy for like the likelihood that eggs are gonna lead to a live birth. So under the age of 35, about 70% of eggs will lead to a live birth. And then as I was mentioning earlier, it starts to decline about 5% per year after around age 35. So, you know, I think if I have a 40 year old who comes into my office and wants to freeze their eggs, they're probably going to need a lot more eggs frozen, potentially many more rounds of it than somebody who comes into my office at 30, when the majority of their eggs are normal. And they also tend to have a higher quantity of eggs from month to month.
- [35:03]
A
Yeah, yeah. So that's really interesting that someone could potentially go through that process and have eggs retrieved that couldn't necessarily lead to a successful pregnancy.
- [35:15]
B
And not that I want to be a Debbie Downer, but I do try to hammer that home with patients. Right. Like if you're making this decision, you're taking money out of your pocket, you're taking out this time, and you're 37 and I see that you have like maybe five follicles per month and each egg has about a 5 to 8% chance of leading to a live birth. Maybe 5% chance. Even one round may not lead to, you know, a sufficient number of eggs for even one life birth. What if you want two kids? Right. So yeah, there's, there's definitely still a lot of ambiguity in the process. And so I think finding a good team, a good doctor, a good clinic that you're comfortable with where you can ask all those questions and really reason through, like what's the best fit for you? It may not be, you know, freezing your eggs.
- [35:57]
A
Yeah. So what if, what if it isn't the best fit for somebody, then what?
- [36:01]
B
Yeah, I think it's just, it's good to really be honest with yourself about what do you see for yourself in the future? I don't think kids are obligatory. I mean, I have three.
- [36:11]
A
I love them.
- [36:12]
B
They're amazing. Right. But they're a lot. They're hard work, and it's not for everyone. And so I think if you're somebody who's like, really at peace with, you know what? It happens, great. If it doesn't happen, I'm totally fine.
- [36:22]
A
Yeah.
- [36:22]
B
Okay, great. And also, you know, this whole conversation, you know, has a presumption of, you know, somebody desiring biologically related kids. But there's so many other ways to build a family. Yeah. You know, you certainly can foster, you can adopt, you can have a social family, you can be, you know, an auntie, all that great stuff. So you don't have to build kit, you know, build a family with genetically related kids. But I do think it is very important to be thoughtful and intentional about what you want. Don't just say what your friends say, because your friends say they don't like kids. And you don't like kids either. No, if you want kids, that's okay. Go for it. And if you don't, that's okay. But what I don't like is when I have my, like, 43, 40 year old patient come into my office talking about wanting to freeze their eggs, and they have no context or understanding of ovarian aging. And now they're coming to me at a point where their likelihood of having a biologically related child is so low. It breaks my heart, because then these are people who really do want to have kids. And it's like, gosh, I really wish you'd heard about this 10 years ago, you know? Cause it's. There's very little I can do at that point. You know, when somebody gets to their mid-40s.
- [37:30]
A
Yeah. That's why conversations like this are really important. So that people can just have information and then decide what best to do with it.
- [37:38]
B
Right.
- [37:39]
A
Yeah. Right. I also want to talk about our political climate because it's very challenging, for lack of a better word. But one of the things that is kind of up in the air right now is reproductive health. Obviously, we saw with the overturn of Roe v. Wade a few years ago that that has set off kind of a domino effect with us not really knowing what's next for women's health and kind of what we will have access to or not in the future. I'm curious how this could potentially impact fertility treatments. Either accessibility, if someone has maybe gone through ivf, or who maybe has embryos already. What that could mean for those people. I'm just really curious what the broader effects of the climate we're in could be for fertility support.
- [38:28]
B
Ultimately, I'm not a politician, so I don't know. Right. So I just wanna be super clear about that. That, like, kind of anything I say is gonna be just kind of positine based on what we've seen in the past. But who knows what the future holds? I feel like, especially nowadays, every. Every morning, I wake up at very different political event.
- [38:46]
A
Yeah.
- [38:47]
B
But with that said, so some of the things that we really worry about when it comes specifically to fertility care would be really, how is an embryo viewed? And really, like, at first, it's a fertilized egg. We call it a zygote, then it's an embryo, and that kind of technicality matters, and then it doesn't really matter. Right. Unfortunately, one of the clinics in Alabama, there was somebody who was allowed into the. Who came into the IVF lab where the cryo storage area was, and they were not supposed to be there. And unfortunately, they dropped embryos, and those embryos were lost, which is devastating. I want to be super clear that that is really just so awful for.
- [39:26]
A
Especially for those families.
- [39:27]
B
Exactly. But the question was, you know, was it a wrongful death? Which is now we're getting into an area that, like, I'm not a lawyer, so, like, the technicalities of this are, you know, fuzzy to me. But the question was, was it a wrongful death? Well, you know, that really applies to humans, like living human people. Right. And the decision that was made in the Alabama Supreme Court was that, yes, you know, it could be applied to these embryos. Now, if embryos are, you know, given the rights of, you know, humans, like, full. Like people that were born and living, it really changes the game and how we practice medicine. At the bare minimum, you know, what do you do with the frozen embryos? Because we often will freeze embryos if we're not ready to transfer them. You know, what do we do with them? Can we ever thaw them? Can they ever be discarded? And then really, how do we practice, you know, ivf? So right now, we talked about kind of stimulating the ovaries to get as many eggs as we can in a particular cycle because it's efficient. Because if any individual egg has a 5 to 8% chance of leading to a life birth, I don't want to pick one egg per month, fertilize one egg at a time. That person, especially if they're in their late 30s or early 40s, they may not get pregnant that way, and they may never become a parent. But if we start having to kind of navigate what is often called, like, embryo personhood, it can make the practice of fertility care in the US very challenging and potentially and accessible. More broadly speaking, you know, I'm an ob gyn, and I don't just manage people with infertility, but hopefully my patients get pregnant. And when they do, unfortunately, sometimes they can lead to a miscarriage or a pregnancy in the fallopian tube, which we call an ectopic pregnancy. And so I'm still an obgyn. And, you know, I am also, you know, still very much kind of aware of and involved in, you know, like, let's say you mentioned the Dobbs decision a few years ago, which also can have broad effects on fertility care, too, because if a person gets pregnant and then has, you know, a pregnancy that is not going well, that results in a miscarriage or a very abnormal pregnancy, their options for what to do about that safely now vary quite significantly depending on where they live or where they happen to reside. When it happens right now, my patients even have to think about, like, well, where do I go for a vacation or if I want to go visit family at the holidays, and how far along am I when I go do that? Things we never had to really think about just five years ago.
- [41:58]
A
Yeah. Just makes a lot of it something that's already so complex, even more complex and challenging.
- [42:04]
B
Exactly. And it really breaks my heart for my patients. Like, I love my patients so much and, like, thinking about all the things that. It's just like another pile on, you know, for people that have already suffered so much and now they're scared, they're worried, am I even going to be able to be. Be a parent if I can, can I do it safely in this state or that state? Do I have to move my embryos? Like all these other things? They're thinking about so much already. This is just another layer. But, you know, I feel really fortunate to be in Illinois. So Senator Duckworth is one of my senators, Senator Duckworth and Senator Durbin. And actually, I got to go to the State of the Union last year as Senator Duckworth's guest because she's incredibly passionate about access to fertility care. And so I would just really encourage all of your viewers and listeners, like, talk to your Congress people, let them know if this is something that really resonates with you and speaks to you, something that you could foresee being an issue in the future, or if you have empathy for other people that might have this issue, speak up about it, because the conversation is happening now.
- [43:06]
A
Absolutely, yeah. It's a big part of why I wanted to ask that question, so that people are as aware as possible. Because these are things that impact all of us. I would also love to talk a bit about fertility education, which, I mean, I think so far in this episode, our listeners have, have gotten a lot of education, hopefully about fertility and infertility that they may not have understood before. But there is a really large gap, especially I think, in our community and other communities where just information around fertility infertility. There is a really big gap there. And a lot of the work that you do is also in filling that gap, making sure that fertility education is done at the community level. Can we talk more about that?
- [43:47]
B
Yes. I'm so passionate about this. So, like, when I went into rei, that's the name, the long name for the field, reproductive endocrinology and infertility, I was thinking, I was like, you know, I'm so curious about puberty and what's happening in the brain and neuroendocrinology and all this. And then when I started practicing, I would have patients in my office who really didn't even understand how babies are made. Like, basic, basic, basic stuff. And again, you know, I would have patients that come in in their mid-40s asking to freeze their eggs. I. I just found that instead of kind of digging into some very, like, nerdy, esoteric thing, I was sitting down really explaining things to people that should have been explained to them in high school, period. And it was very sad because education is something I think that is so valuable and just if you're weaponized, if you're protected with education, you can make decisions about your life. Right. And I think ignorance just leads to suffering, in my opinion. And so I've just become very passionate about education. Cause it just really, it's an easy way for people to be advocates for themselves. And so, yeah, so I have a project I've been working on with Reverend Stacey Dunn, Edward Stunn from Fertility for Colored Girls and Guys. And so she got a grant about, gosh, three or four years ago now at this point from the American Society of Reproductive Medicine to develop a set of seminars around the country where we would basically have a series. It was free and talk about fertility and infertility. And it was free and it was open to anybody. And outreach was through, you know, typically black centered churches and historically black fraternities and sororities and just really community networks and what we saw is that we actually surveyed patients, Patients, participants before these events and asked them basic questions about infertility and then asked them again afterwards. And there was a significant improvement in knowledge after these. These seminars. And there's a pretty good amount of literature out there on kind of disparities in education around fertility. By race, I mean, all of us as a community, regardless of race or ethnicity, our education around fertility and family building is pretty poor. But, yes, there's kind of an additional disparity based on race. And I think some of that has to do with, number one, we don't maybe talk about it as much. There can be social stigma there that, you know, can differ by community. And also there's this kind of. This myth that people of color are hyper fertile, particularly black people. Given our history with slavery, there's this misconception that black people are just. It's easy to get pregnant and we, like, have babies all the time. And that's absolutely not true. And in fact, black people tend to have higher rates of infertility than their white counterparts. So I think having the social stigma and kind of misinformation really can do significant harm. And it winds up that people might be experiencing infertility not even knowing they have it and not talking to anybody about it until, like, several years later. I can't tell you how many patients I've had in my office who've told me they've been trying for 10 years.
- [46:50]
A
My goodness.
- [46:51]
B
And I'm like, nobody told you?
- [46:53]
A
Yeah.
- [46:54]
B
Like, that didn't seem weird. Like, it breaks my heart. So, yeah, so education is super important to me. I just think it's such an easy way to change people's lives.
- [47:03]
A
Yeah, yeah. Super important work. And I believe I read that there's a documentary that's going to be in the works as well.
- [47:11]
B
Yeah. So Fertility for Color Girls got a second grant from ASRM to develop a documentary about the experience of black people with infertility because Reverend Citizen Stacey Edwards Dunn, she herself had infertility. And really kind of it changed her experience and this whole process. And so she's become such a champion about this. So it's in the works. Stay tuned. But hopefully it should be out by the end of the year.
- [47:35]
A
Okay, very cool. We'll definitely keep an eye out for that and share it once it's out. Yeah, really, really cool. So I would love to just talk a little bit more about, you know, if our listeners are interested in either working with you, if they're in Illinois, or working with ccrm. Which also helps, helps folks across the country what that process looks like and how they can get more help.
- [47:57]
B
Yeah, so I have a clinic that's opening, CCRM Fertility of Chicago. It's going to be opening in hopefully May of this year. Brand new, state of the art IVF lab, all the bells and whistles. So I should be able to see folks in the Chicagoland area or, you know, if you live further, but you want to come in, you're totally welcome. But yeah, but. So CCRM is really a network of experts, excellent fertility clinics around the country. And so whichever one is closest to you, you can check out. But yeah, I think if you're having questions, if you're wondering, I think the most important first step is just talk to someone. If you are a person with uterus and ovaries, talk to your OB gyn. You know, you might not feel like you're ready to talk to an rei. Talk to your OB gyn, say, hey, I heard this podcast. I'm thinking about this and you know, what do you think? And, but make sure you feel like you're getting an answer that you understand. And also I would say when you talk to this provider, say, hey, I want to talk with you about fertility and family building. Is that something you're comfortable with? Because some people can be a great, great doctors, but this might not be their wheelhouse. They might be an excellent surgeon. They can take out fibroids with their eyes closed. Don't do that. But maybe they could. But maybe they just don't think about fertility. So I do think it is good to kind of get a sense of like, okay, if I'm going to ask you these questions, are you going to give me a really thoughtful answer? But then if you feel like yes, then ask. And if you're not getting your questions answered, then keep, keep looking or jump ship, go right to an REI and just kind of get the information from a direct source.
- [49:26]
A
Yeah, I think that's a really good tip. Which sounds simple but really isn't. I think we all just assume like, oh, this person is a doctor, they can help me with everything. And no, that's what specialties are for. And just because a doctor may specialize in one thing or be really great about one thing, doesn't mean that they can necessarily help or be the most informed in another area.
- [49:47]
B
Correct? Yeah, that's absolutely correct. Yeah, like there's like another subspecialty in OB GYN called like urogynecology. So like, if you have like incontinence or Other, like, pelvic floor issues. They're fantastic. I've done those surgeries before, but if a patient walked into my office now and asked me about, like, you know, pelvic floor dysfunction and can I do their surgery? Absolutely not. Absolutely not. Right? It's not my expertise. You know, I didn't, you know, spend extra years thinking about it, but I'm still a good doctor, I hope, but that's just not what I do. So. Yeah. So I think, you know, you're right. People don't always realize that different doctors specialize in different areas. And even a general OBGYN just might have things that they really love to treat. Maybe they're really great with pap smears and the most recent, you know, guidelines, but they may not think about fertility. Because what I also don't want to see is, and I have seen this, sometimes patients will maybe have irregular periods. They'll talk to their doctor about it, and their doctor will just put them on birth control pills. That's not the answer. The answer is make sure they don't have polycystic ovary syndrome or some other underlying condition. Why are your periods so irregular? Get that answer before you put them on birth control pills. Birth control pills can still be good. That's actually a very good treatment for pcos, but you don't want to jump to that without really exploring the why. And I think a lot of times as patients, because I'm a patient too, we miss out on that why. And so you have to advocate for yourself and make sure you understand it and make sure your provider gives you the time to make sure you really understand what's going on with your body.
- [51:18]
A
Absolutely. So important. Dr. Amanda, thank you so much for joining me. I will also make sure that I put in the show notes more information about your upcoming clinic as well as CCRM so that our audience knows where to find you.
- [51:31]
B
Thank you. Great. I love it.
- [51:33]
A
It's so helpful.
- [51:34]
B
Love talking about fertility.
- [51:36]
A
Awesome. Well, thank you so much for all of your insights today. This was super helpful and I really enjoyed it.
- [51:40]
B
Thank you.
- [51:41]
A
And thank you so much for tuning into this week's episode. Like I said, I will make sure that all of our information is linked in the show. Notes that you can learn more about CCRM so that you can learn more about your reproductive health. If you enjoyed this episode, please make sure that you're subscribed to the show, wherever you listen or wherever you watch. And also if you enjoyed this episode, leave us a five star review. Because we're five star girlies trying to offer a five star experience. Thank you so much for tuning in and I will see you next week.
- [52:32]
B
Please note that this episode may contain paid endorsements and advertisements for products and services. Individuals on the show may have a direct or indirect financial interest in products or services referred to in this episode.