← That Can't Be True with Chelsea Clinton
That Can't Be True with Chelsea Clinton
Fertility, Microplastics, and IVF with Dr. Natalie Crawford
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- [00:02]
Dr. Natalie Crawford
Lemonade.
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Amazon Health AI (Advertisement Voice)
Amazon Health AI presents painful thoughts.
- [00:11]
Dr. Natalie Crawford
Why did I search the Internet for answers to my cold sore problem?
- [00:15]
Chelsea Clinton
Now I'm stuck down a rabbit hole
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Dr. Natalie Crawford
filled with images of alarmingly graphic source in various stages of ooze. I can clear my search history, but I could never unsee that.
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Amazon Health AI (Advertisement Voice)
Don't go down the rabbit hole. Amazon Health AI gets you the right care fast. Healthcare just got less painful.
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Chelsea Clinton
Welcome to that Can't Be True, a show that sorts fact from fiction, especially on issues impacting our health. I'm Chelsea Clinton. Infertility rates are rising globally. In fact, the World Health Organization estimates that one in six people are now impacted. And while we know from that there are real reasons behind this trend, from delayed childbearing to environmental exposures including microplastics, there's also a lot that we don't yet know from research and a lot of confusion and misinformation. And that's why I think conversations like this one really matter. I'm honored to be joined by fertility expert Dr. Natalie Crawford. She's a double board certified OBGYN and reproductive endocrinologist and the author of the new book, which I highly recommend, highly recommend the fertility formula, take control of your reproductive future. Her mission is to educate women and men about our health and fertility so that we're all empowered to make the right choices that are right for us. Hi.
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Dr. Natalie Crawford
Hi. How are you?
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Chelsea Clinton
I'm great. Thank you for doing this.
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Dr. Natalie Crawford
No, I'm so excited.
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Chelsea Clinton
Where do I find you today? Are you on the road?
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Dr. Natalie Crawford
I'm normally in Austin, but I'm on the road. I'm in LA right now.
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Chelsea Clinton
Oh. One of my best childhood friends lives in Austin. Went to the University of Texas and just never left. So it's a place I've been lucky enough to spend some time and see it change so much over the last 20 years.
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Dr. Natalie Crawford
Yeah, my husband is from there and went to ut and so, you know, he's always like, oh, this used to be a dirt road and now it's a highway.
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Chelsea Clinton
You're like, literally. It's not just like back in my day.
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Dr. Natalie Crawford
No, he's like, I played baseball there
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Chelsea Clinton
back in my day.
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Dr. Natalie Crawford
I think we're just old enough now where that's actually reality.
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Chelsea Clinton
Well, Natalie, Dr. Crawford, thank you so much for your time today. There's so much that I am excited to talk about. I thought that we would start with our segment that we called that Can't Be True, where we play something that has recently attracted attention and to get your reaction. So this is from A new documentary that recently came out on Netflix that certainly it seems a lot of people in my life are talking about it links infertility to microplastics. So I wanna play some clips from the trailer and get your reaction.
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Dr. Natalie Crawford
Let's do it. Microplastics are in everything now.
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Chelsea Clinton
Plastic leaches a crap ton of chemicals. Even the smallest levels of exposure can have profound effects.
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Amazon Health AI (Advertisement Voice)
Fertility worldwide is going down and it is tightly linked to chemicals that are
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Dr. Natalie Crawford
commonly used in plastic.
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Chelsea Clinton
You have been trying to get pregnant for over 10 years now, 22 months,
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Dr. Natalie Crawford
two and a half years.
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Chelsea Clinton
Say what you always call yourself. Ah. I say, you know, Julie, I'm not a human dick, though. This is a three month intervention where
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Amazon Health AI (Advertisement Voice)
we recruited six couples who have unexplained infertility. The question is, if we lower people's
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Chelsea Clinton
exposure to chemicals that are in plastic,
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Amazon Health AI (Advertisement Voice)
can we change their fertility?
- [03:56]
Chelsea Clinton
So, Dr. Crawford, clearly six couples and no control group is not statistically significant or perhaps population level relevant. But I think the documentary is clearly grappling with some of the real emergent science on not only the density and prevalence of microplastics, but kind of how those microplastics might be affecting us in a myriad of ways, including fertility. So just curious, kind of what your reaction is to what we saw in that clip and then we'll go from there.
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Dr. Natalie Crawford
Chelsea, I have lots to say about this clip.
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Chelsea Clinton
Please, I want to hear it all.
- [04:32]
Dr. Natalie Crawford
Yes. I was like, let's dive in. I got really excited when you started bringing it up. First of all, I love what this is highlighting because there is actually really robust data linking endocrine disrupting chemicals such as plastics to infertility metrics.
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Chelsea Clinton
And maybe, Dr. Crawford, maybe you can explain what endocrine disrupting means. For anyone who may not know, endocrine
- [04:54]
Dr. Natalie Crawford
disrupting chemicals are different types of toxins that can be in our world and environment, but they interfere with essentially our hormones. We want to think about our hormones as a communication system. They can interfere at different levels. Maybe it's at the brain or the thyroid or the ovaries or the testes, but they stop the normal process from happening because they act like other hormones. So it's interference on the communication radio of how our body is supposed to function. And to give clarity to this, when we think about it, we know that in couples trying to get pregnant, based on larger cohorts studies, there was a big study called the Earth Study, which is environment and reproductive health. Higher levels of having endocrine disrupting chemicals in your blood was associated with lower pregnancy rates, fewer eggs with IVF cycles, decreased implantation rates, higher rate of miscarriage, even after ivf. So we want to think about. Yes, this is a small group. This is six people. My criticism of this documentary is they say six couples with unexplained infertility acting as if endocrine disruptors are causing all unexplained infertility. Unexplained infertility means that you don't know what is going on. So normal semen analysis, you are ovulating regularly. A female has normal anatomy. But in this documentary, five of the couples actually have low sperm count. So they have male factor. That's an important clarification because sperm are extremely sensitive to. To endocrine disrupting chemicals. And unlike women, you and I are born with all the eggs we're ever going to get. Men make sperm. They make 1500 sperm a second.
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Chelsea Clinton
A second.
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Dr. Natalie Crawford
I don't think I knew that a second. Wow. So they make so many sperm every single second. And the lifespan of a sperm is less than 90 days, meaning a man could make a single change right this moment and have completely different sperm counts in three months from now.
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Chelsea Clinton
Wow.
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Dr. Natalie Crawford
And so that's really is powerful. Talking about the environment, both of men and women, but specifically for men. What this documentary is highlighting and how making what might seem like a simple intervention, taking plastics out of your life, improved their sperm counts and helped many couples get pregnant.
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Chelsea Clinton
And how might women be affected?
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Dr. Natalie Crawford
Chelsea? Women are affected as well. And it's really important for them to pay attention because our eggs are inside our body our whole life. They're absorbing wear and tear. We can't rewind the clock and undo behaviors that we've done. But our eggs, an egg is the single biggest cell you have in your body. It has a lot of mitochondria. It has a lot of function besides just eggs to get pregnant. The ovary makes hormones, makes your estrogen and your progesterone. And women need their ovaries to last as long as they can to have their optimal health both now and in the future. So I think it's really important that we think about ovarian health more than just fertility metrics or getting pregnant. When it comes to plastics, they can be really disruptive. We know that these endocrine disruptors can impair how the ovary responds to the inflammation caused by them, can actually impair the egg quality faster, meaning your eggs will stop responding to the same hormones from the brain. And also you can get plastic deposits inside the ovary itself, accelerating fibrosis and loss of ovarian function. We even had a recent study come out showing you can find microplastics in the follicular fluid, the follicles, what the egg grows in.
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Chelsea Clinton
And so, Dr. Crawford, for people who, you know, are listening and are thinking like, well, what can I control for myself? Or even, like, what can I control for my children? What can people do?
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Dr. Natalie Crawford
Chelsea, we can't live in a world where we can avoid all toxins. That's unrealistic. When that's the case, I tell patients, let's start by looking at what is around us and what we encounter the most common. So this is going to be what is in your home specifically your kitchen, your food, your beauty products, the water you drink in your house. So getting rid of all plastic from the kitchens, but specifically know no plastic that we're heating up. So putting things in the dishwasher, the microwave, when plastic gets hot, that's when some of these chemicals can leach out of it a lot easier. The secret place where a lot of people are encountering this is from to go food. So maybe we order food, it comes to your house, it's in a plastic container. You want to save on not having to do dishes that night, so you just eat out of it. But it actually is a much healthier option to just take it and put it on a plate. Get rid of the plastic container immediately because it's the hot food sits in that plastic. We're just giving an exposure for those chemicals to get into the food that you're going to put directly inside your body. And then we have to look at some of our bath and beauty products. We have to pay attention to the things that have fragrance. And my big tip here is that you'll see some things will say unscented, and some will say fragrance free. And this is where we have greenwashing and marketing.
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Chelsea Clinton
Tell us more. I'm very curious about this.
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Dr. Natalie Crawford
Yes, unscented just means it doesn't have a scent, but they can be adding something to counter the scent that is in it.
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Chelsea Clinton
So they could be neutralizing whatever the natural scent.
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Dr. Natalie Crawford
Exactly. So you don't see smell it. But that doesn't mean that the toxins that cause the scent are removed, which is what it sounds like to us. Whereas fragrance free has no fragrance to it. So when you go pick out a laundry detergent, for example, and you look at the shelf, we have to be really mindful of the difference between unscented just doesn't have a scent to you. Versus fragrance free has no scents added to it at all. But isn't that misleading? So we have to be really knowledgeable consumers to do this correctly.
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Chelsea Clinton
I mean, Dr. Crawford, I feel like I just learned something, so thank you. I want to shift a bit to the a broader conversation around fertility. I mean, in the clip that we started with the Netflix documentary asserted that fertility is down by over 50% in 50 years and then seemed to make a clear not only correlation, but almost causal link to the prevalence of microplastics. And we talked about the presence of microplastics throughout our bodies. You know, also painfully, I say is apparent right. In umbilical cord blood. It really is ubiquitous. And also I do not imagine that you believe it's the only cause of declining fertility. And so I wonder if you can fact check what they said and what else you think people should know about what is affecting fertility over the last few decades, but also more recently.
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Dr. Natalie Crawford
That statistic is directly from Dr. Swan's research, but it is specifically about sperm counts. So sperm counts have dropped 52% in 50 years. And that's a real statistic and it is a scary one. But that doesn't mean that all fertility has dropped as dramatic as that. But more people are struggling to get pregnant. I have been a reproductive endocrinologist, so a fertility doctor now for 13 years. And when I first started in this field, I would sit across from people and say one out of eight couples will have infertility and now it is one out of six.
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Chelsea Clinton
That's a substantial increase.
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Dr. Natalie Crawford
It. It is. So we are absolutely seeing more people have a harder time get pregnant. And we're seeing an increased prevalence of miscarriage. We're see seeing more women diagnosed with low ovarian reserve or running out of eggs earlier.
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Chelsea Clinton
And wait, and Dr. Crawford, could you talk about that like, for people who are like, well, what does low ovarian reserve mean and what did that look like, you know, 13 years ago versus now?
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Dr. Natalie Crawford
Ovarian Reserve is how many eggs you have remaining. So if we go with this idea that you're born with all the eggs you're ever going to have, I like to imagine them as in a vault inside your ovaries. They're stored away. You can't really see them. But every month you have a group of eggs that comes out no matter what. And this happens your entire life. You actually have your peak egg count. When you are a five month old baby inside your mother's womb, you'll have six to seven million eggs. But by the Time you're born, you will have 1 to 2 million. The reason why is that when the vault is more full, it sends out more eggs every single month. So when you have more, you lose more. Now, many people think puberty is when the ovaries start working. The reality is puberty is the brain turning on and the brain starts to send out the signals that can get one of these eggs to grow and make estrogen and ovulate, and the rest of them die. All those other months, you're just losing eggs completely.
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Chelsea Clinton
And it doesn't mean that we have failed. Right. I think that so often women are like, oh, my gosh, what can I be doing? I should be doing more. How do I save them?
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Dr. Natalie Crawford
No, there's nothing you can do to change this. And in fact, a lot of this happens when you are a baby inside your mom.
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Chelsea Clinton
Right.
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Dr. Natalie Crawford
That's when the greatest loss happens. So you've lost majority of your eggs before you've ever had your first period. We know that when you have more eggs, more come out of the vault. We can draw blood tests and we can find out how many eggs you have available this month. It's an imperfect test. It's called amh, anti mullerian hormone, and it's made from the cells that surround each egg. So if we think about the fact that we're constantly losing all these eggs, we have a group of them, we can draw a blood test and see, well, about how many do you have right now? Could you potentially slow down the rate of loss? Maybe. We know cigarette smoking, for example, Accelera eggs. And women who smoke cigarettes, the longer they smoke them, the earlier they will go into premature menopause.
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Chelsea Clinton
Dr. Crawford, I've never heard that.
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Dr. Natalie Crawford
It's, it's so well established.
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Chelsea Clinton
Why don't people know that?
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Dr. Natalie Crawford
You know, there, there's a lot of different reasons. It's. Well, if we could go ask any, you know, fertility doctor in that one, nobody's going to debate. That's, that's so clearly established that early menopause is associated with smoking cigarettes. I think part of it, though, is that there has been stigma for a long time that, that is, you know, blaming women or blaming people and there's nothing they can do about it. And I argue the other end. Data is data.
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Chelsea Clinton
Information is information. Yeah.
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Dr. Natalie Crawford
Giving people data allows them to make informed decisions. If you sit across from me and you say, I want to have kids one day, not quite ready yet, but is there anything we can test? And I say, well, I could find out if, you know, what your egg count is and it's not perfect. It doesn't mean you can or can't get pregnant. But if it's low, we might have less time to conceive your family. We might view your future choices differently. We might consider egg freezing. We might evaluate why it's low. Do you have endometriosis or autoimmune disease? To me, that's a very important discussion to put in front of young women who are trying to take control of something that historically we've been in a position where it's like, well, just don't worry about getting pregnant until you're ready. And then if you go to your doctor, they'll say, well, just try for 12 months. And then if you don't have success, that's when we'll do testing. That's when we'll draw an amh. I'm really opposed to that. I don't think that serves us in today's day and age when women are waiting longer, infertility rates are rising. As we just said, why are we making women fail first?
- [15:24]
Chelsea Clinton
Dr. Crawford, that resonates so deeply with me. I'm curious, for anyone listening, are there other tests that you would recommend for women or men who might not be ready to start a family, but when they are, want to be fully empowered with whatever the best evidence based information is?
- [15:43]
Dr. Natalie Crawford
Absolutely. There's two other things that I think are really important. One is for women to learn to track ovulation. We live in this world of technology which is so impressive but faulty in a way. Many women track their cycles with an app and they go in and they mark their cycle day one, and the app tells them when their next period will come and it gives them a range of fertile days. Apps that are predicting when you ovulate, they're actually getting it wrong 80% of the time.
- [16:09]
Chelsea Clinton
80% of the time, wow.
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Dr. Natalie Crawford
So I've had couples have sex during when the app says fertile window, they're trying to get pregnant. And then we go and we do other testing and we find out, well, that's actually giving you a completely false narrative because it's based on a calendar method. It's assuming certain things are normal that may not be normal.
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Chelsea Clinton
Like normal for you, it might be normal for someone else, but it might not be true for you. Because it's so idiosyncratic.
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Dr. Natalie Crawford
Exactly. It's taking a population based average of how many days should happen from ovulation till the next period and applying that to you. But the reality is your body's Giving you signs. Right. Your menstrual cycle is a vital sign. Just women are not taught how to track it. In fact, most women are not taught at all how to track ovulation unless they're struggling to get pregnant. But there are little clues when it comes to your body temperature. You can measure urinary hormones, and you can actually check your cervical mucus. And these are what we call fertility awareness methods that allow you to use the clues and signs your body is giving you to know when you're ovulating. And that can be very useful data before you get pregnant. So not just saying, well, we'll just see if it happens for a year, and then we'll start tracking. But if you're sitting here saying, we want to get pregnant soon or in the future, if you're not on hormonal contraceptives, learning to track your cycle, making sure you have a regular cycle, making sure that your luteal phase, the time from ovulation to the next period is at least 11 days. Having a short luteal phase is the first sign that you're not ovulating well. So my dancers, my runners, 58% of runners, I live in Austin, so very big running community, 58% will have a short luteal phase.
- [17:43]
Chelsea Clinton
Oh, wow. I'm a big runner. I've never heard that either. I'm learning so much.
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Dr. Natalie Crawford
We just have so many facts for you today.
- [17:49]
Chelsea Clinton
So many facts for me.
- [17:50]
Dr. Natalie Crawford
So when we think about it, you know, the egg grows inside a follicle that's the house of the egg. It ruptures to allow the egg to be released.
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Chelsea Clinton
And is it because of all the running that we're disrupting that process?
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Dr. Natalie Crawford
No.
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Chelsea Clinton
No. Okay, great.
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Dr. Natalie Crawford
Follicle becomes the foundation for after you ovulate, it becomes a cyst known as the corpus luteum. And that makes progesterone. And the brain communicates to the ovary. And my favorite analogy here is to imagine they're best friends, but they don't know what's happening, so they're waiting to get certain feedback signals. Well, when you're running a lot, this can be stressful for the brain. You know, the brain is evaluating constantly if this is a good time for you to be pregnant, even if you don't want to be pregnant. That's how your brain, as a woman is made. So do you have enough calories coming in? How much energy are you expending? How stressed are you? And for many runners, we tend to run more than we're actually taking in. Calories we need, or we're also not sleeping enough. And we're really primitive beings. If we think back, you know, to when humans used to live, when would you run that much? Right.
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Chelsea Clinton
Our cortisol levels are.
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Dr. Natalie Crawford
Yeah, that wouldn't be a good, stable environment. Right. You know, are you migrating? Is there danger?
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Chelsea Clinton
I'm just training for the Boston Marathon.
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Dr. Natalie Crawford
I know. We just, like, have big goals. We want to achieve big goals in life. But the brain first starts to catch that and doesn't send out the signal to make enough progesterone.
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Chelsea Clinton
It's totally fascinating.
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Dr. Natalie Crawford
So that luteal phase will shorten. You'll still have a period. And if we know about that, we can start to intervene, make sure it's not, you know, your thyroid or something else going on. But we'll use runners again after we've ruled out anything else. If I have runners, you can't tell a runner not to run. Right. Like, I know that for sure. Like, my girls who are runners. If I said, just don't run because you want to be pregnant, they would walk away and never come back. But I'll say, you need to titrate your running to your luteal phase. And if it gets less than 11 days, your running is too much. You got to pull a day back. You got to shorten your mileage, add in weights.
- [19:40]
Chelsea Clinton
But this will go back to, like, information is power, right?
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Dr. Natalie Crawford
Exactly. It's like, you want to be pregnant. Like, you need to learn how to leverage your body's signs, the clues that it's giving you. It's telling you this is too stressful. So let's shift. And again, they'll make the choice that's right for them. But you can't make a decision if you don't know what's happening in your own body.
- [20:00]
Chelsea Clinton
If you don't know.
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Dr. Natalie Crawford
And then to circle back on your other question, I'm a huge believer that men should get a semen analysis. You have a partner, you want to have a child with them. Some of the hardest cases I've seen are couples who have tried for one or two or three years, and then they get a semen analysis. Because, again, we don't check until you have failed for a year and he has no sperm. There's no chance. All of those months of trying and timing intercourse, there was a 0% chance you'd get pregnant.
- [20:28]
Chelsea Clinton
That's so heartbreaking.
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Dr. Natalie Crawford
And now we're having to do pretty extreme interventions years later that would have been easier years prior. So there is a way to leverage getting that data earlier so that we can be more informed, make our decisions from a place of knowledge instead of just let's see what happens for 12 months and then if we fail then let's get an evaluation which is the current standard that I don't think serves us anymore.
- [21:02]
Chelsea Clinton
My fifth marathon is right around the corner and so most of my free time these days when I'm not working or with my kids is spent on running or thinking about running or thinking about what else I should be doing for my training in addition to running. And I really don't want to have to worry about what I'm going to wear while running or cross training. And I really have loved the Feathertech short sleeve top from Fabletics, especially as the weather gets nicer here in New York City. The VIP membership also gives you access to Fabletics scrubs for the healthcare workers in your life. Their scrubs are made with durable water repellent fabric and your first scrub set is $15 when you check out. As a new VIP member, Fabletics already has incredible deals and I'm really excited for an exclusive offer just for our listeners. You get 80% off everything when you sign up as a VIP with Fabletics. You can go to fabletics.com can't be true. Take a quick style quiz and be sure to select can't be True when prompted to unlock your 80% off. That's fabletics.com cantbetrue
- [22:13]
Julia Louis-Dreyfus
hey it's Julie Louis Dreyfus from Wiser Than Me Etc. Just popping in with a little reality check. Food waste shouldn't exist. There is no reason that our leftovers should end up in a landfill. But that's the final destination for about a third of the food we grow. Our ancestors would be confused. They use their food scraps as compost or as animal feed, or in weird soups. All the stuff we did before garbage was invented. But composting is hard work. Living with a bucket of rotten food on your counter is gross. Most food goes in the trash because it's easy. And these days we'll take any easy we can get. But now there's something easier. Drop your scraps in a mill food recycler. It looks like a kitchen bin and an iPhone had a baby. It takes nearly anything, even meat and bones. It works automatically. You can keep filling it for weeks and it never smells. When you finally empty it, you've got these nutrient rich grounds. Use them in your garden, pour them in your green bin or have mill get them to a small Farm. So the food you don't eat can help grow the food you do, just like it should be. It's why I own a mill, why I invest in mill, and why I'm still obsessed with my mill. If you want to get obsessed, too, go to mill.com wiser to get $75 off. That's mill.com. for $75 off.
- [23:49]
Chelsea Clinton
You know, before we move off this topic, I do want to ask about maternal age, because I feel like there's such a focus often on, you know, Once you're over 35, it's a geriatric pregnancy. And I remember when I was over 35 and pregnant how kind of disorienting that was.
- [24:05]
Dr. Natalie Crawford
Chelsea, the number of women I see as patients, like, immediately after their 35th birthday is alarmingly high. Right. Just to. Just to double down on this is, like, perverse in society that we think that there's a cliff that happens at age 35.
- [24:19]
Chelsea Clinton
And all of a sudden they're like, I need to go see Dr. Crawford. Like, I need more specialized help. I'm like, 35 in one month. Yeah.
- [24:25]
Dr. Natalie Crawford
So that shows a little bit of a disconnect between what's actually happening in our body and reality. So let's break down why 35 and older officially was called advanced maternal age. Because, well, before we knew what we know now, we saw that those women had higher rates of genetic abnormalities in some of their pregnancies. And so it put you on a different path for screening once you were pregnant. So if you were pregnant, you had advanced screening. You got more ultrasounds just to make sure everything was okay. What we know now, because we are able to do IVF, we can genetically test embryos, is that at age 35, most women are not anywhere near menopause. You tend to have a lot of eggs remaining, but about 50% of your eggs will be genetically normal, and about 50% of them will be abnormal.
- [25:10]
Chelsea Clinton
And what does that look like if you're 30?
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Dr. Natalie Crawford
If you're 30, we're closer to having about 65 to 70% normal. But if you are 37, it's like 40% normal. So it's not a huge drop, but it accelerates. 38 and older starts to accelerate much faster. So every year, kind of once you hit 38 and on, I tell patients that the time between 38 to 42, we see a huge drop every year. So these are our really fast action years. Those become really concerning. Not necessarily if you're 35 and ready to get pregnant with your first baby, but if you sit across from me and you say, I really wanna have three kids, we have to mentally do the math and know those later kits might become harder. There's a couple reasons why, right? This genetic abnormality. The analogy I like to use is, you know, our chromosomes are actually lined up inside our eggs. They're held in perfect position by these little meiotic spindles, which are proteins. And they stay this way until we ovulate. So the simplest way to think about is when you ovulate at 30, they've only been hanging out 30 years. But when you ovulate at 40, now there's 10 extra years. They've been asked to stay in perfect position. And I would say it's like kindergarteners. The longer I ask them to wait in alphabetical order, the higher likelihood somebody's gonna get out of place. It's kind of what's happening in our ovary. The other thing that happens is that these little spindles are proteins. And proteins break down over time, but also from inflammation. When we get less healthy, our metabolic health is not as good. We accelerate the rate of genetic abnormalities and the rate of these breakdown of these proteins. And of course, as a population, people tend to get more metabolically unhealthy as they progress from age 30 to 42. And, you know, as somebody who's already been through all those years, like, we know, like, I have more back pain and knee pain, like, we feel the impact of getting older on other parts of our bodies, but the same thing is happening inside our eggs.
- [27:02]
Chelsea Clinton
And, and what about for a man's age? How does that play into this equation?
- [27:07]
Dr. Natalie Crawford
Unfortunately, they, they are preserved a little bit longer than we see for women. But, but we do have advanced paternal age as well. And there are some specific situations that happen. We have to acknowledge that 50% of all infertility is due to male factor, right? So 50% are male factors, 50% are female factors. Of course, there's a group of people who have some of both the DNA inside the head of the sperm. Sperm are highly sensitive. It's why men make so many of them. They get damaged along the way. But that DNA does start to break down as men get older, specifically. So men who are 50 and older, in addition to starting to see poorer sperm parameters, like a lower sperm count, we tend to see specific genetic diseases that start to happen as well. So we see an increase in new onset autosomal dominant mutations, like dwarfism, as an example, where the sperm has changed. And then we also see some behavioral diseases as well, such as higher rate of autism, higher rate of schizophrenia. It's one of those things, though, that that's just statistically a higher risk that we like to make people aware of. Certainly if you are purposefully waiting and your partner's going to get older, freezing sperm or making embryos at an earlier age and saving the embryos can be a step to try to limit some of those risks. But it's partly just due to the same concept is that our body doesn't package and hold our DNA as well as we get older.
- [28:29]
Chelsea Clinton
I do want to talk about ivf, but before we do, I want to ricochet to the younger side of the equation because one of the things that I know you've been really focused on are all of the misconceptions that often Gen Z and even younger people have about fertility. And even a recent study found rather substantial, shall we say, gaps in fertility knowledge among people in their teens and kind of early to mid 20s. I wonder if you can reflect on what has surprised you and what do we need to do better to ensure that I mean everyone, but in this conversation specifically younger people know the facts about fertility so they can make the right choices for themselves throughout their lives.
- [29:13]
Dr. Natalie Crawford
It's such a good question. Even though I see this day to day, I see women sit across from me and say, gosh, had I known that, maybe I would have done something different or I wish I'd had this knowledge. The recent study was published showing that of gen Z, that 74% of them said that they wanted children, but about 60% said they didn't feel like they knew information about their reproductive health. And almost 70% said they were concerned about their future fertility. So it speaks to when do you learn these things because you know know how to track your menstrual cycle, that it's a vital sign that you shouldn't bleed through your clothes, you shouldn't be in such bad pain from your period that you would cancel something fun with your friends. You should know when your period's coming. I mean, even basic facts. I posted a Instagram video this week saying that your ovary and your fallopian tube are not connected right? Your ovary is connected to your pelvic sidewall and your fallopian tube's connected to your uterus. I did know that you knew this one. So even if you lose one tube, the other tube can swoop around and get an egg from the opposite side because tubes move. But the amount of women in the comments saying they've never heard this before just basic anatomy about our bodies that we're not ever taught.
- [30:21]
Chelsea Clinton
And so Dr. Kravit, do you think that is also just then bluntly, like a failure of education? I mean, I remember as a public school kid in Little Rock, Arkansas in seventh grade, I had totally age appropriate, also evidence based, but very basic like reproductive and sexual health education. And, and I think that unfortunately is not the norm in much of the country any longer now, 30 years later. But I don't think I would have ever been exposed to that level of information even in the early 90s. And yet I think we should teach people, especially if collectively, as I know many policymakers and advocates are, about our decline in fertility to population level. We should be informing, equipping and then ultimately hopefully empowering young people with all of the available information at age appropriate levels so that they can make the right choices for themselves over time.
- [31:20]
Dr. Natalie Crawford
Chelsea? Absolutely. I mean, I grew up in South Georgia and a public school kid and I didn't learn. I mean it was abstinence only curriculum, right? There was definitely very little that was true. Body facts and we think about science and I was a science kid, obviously, like why are we dissecting frogs that we don't even understand basic true human biology, right? These type of facts about our body and our health. And to your point, we have policymakers now who are making serious public health decisions without a fundamental base of knowledge of how the human body works. So there's a disconnect between who's even making decisions that impacts people, the knowledge that they have, the knowledge the general public has. I think it's why I spent so long trying to put out, you know, free health education. And there's a lot of really great physicians who are doing that in the same breath. There's a lot of people putting out misinformation. I mean, there's something going viral right now here. We'll just clear it up without naming who it is. There's a very popular creator in the health space who has no health training and he is saying the top cause of miscarriage is getting your blood drawn when you're pregnant, which is completely false. Completely obviously completely false and has 5 million followers on Instagram alone. And so you see, that's, that's not just like bad information, that's harmful information. Harmful, because if harmful information, declining blood draws in pregnancy like that, completely, we lose our ability to safely manage a pregnancy, to help diagnose and treat and keep you and baby safe. And so we live in a world where misinformation can Be truly harming.
- [32:51]
Chelsea Clinton
It's really scary.
- [32:52]
Dr. Natalie Crawford
It is scary. So I. I think we have to, I mean, do better on a. On a personal level, like when we can, like how we educate our children, how we discuss health. I mean, like, even with my daughter and her friends, she's 11. We talk about our bodies a lot, make it very open, even with. With my son knows a lot about female health. Because trying to elevate that to be normal conversation because this is how bodies function is. Is part of this. But often, I mean, I see moms come to me in my friend group who are saying, my daughter's about to go through puberty, but I don't really even know enough to help her. Right. Because of this education gap. So I do think it's a failure of education. I don't have the perfect answer except trying to find, you know, trusted health sources. It's, you know, part of what I'm out here trying to do, too. It's part of, you know, one thing you're trying to do is help elevate these conversations. We gotta have that fundamental knowledge of what's normal to then advocate when things are not.
- [33:44]
Chelsea Clinton
I do want to talk about IVF because, you know, IVF now accounts for, you know, 2.6% of live births in the United States, or roughly 95,000 babies every year. I know that it's even more a part of kind of conversations that are broader in scope than those percentages or numbers reflect. What do you wish that more people knew about ivf? What are the myths to continue on that front around IVF that you'd like to debunk? And how have the conversations changed over the last 13 years?
- [34:18]
Dr. Natalie Crawford
Brilliant question. 17 million babies have been born in this world because of ivf. Like, total. It's crazy, right? It's incredible.
- [34:27]
Chelsea Clinton
It's amazing.
- [34:28]
Dr. Natalie Crawford
It's amazing, amazing science. There's a few things that I think are really important for people to know because the field has changed incredibly, but it's definitely still an evolving science. First, simple fact is the number one reason I have women telling me they don't want to freeze their eggs or do IVF is they don't want to run out of eggs earlier. If we go back to the very beginning talking about ovarian reserve, you have your eggs in the vault. You have a group come out every month. If we're going to freeze your eggs or do ivf, I can only get the group outside the vault to grow. That's what I'm trying to do. I can't Tap into the vault. So if you're going to freeze your eggs, you're not accelerating your rate of egg loss by any means. We're just saying for this one month in time, instead of ovulating one and having 19 die, we're going to take medication. FSH, same hormone. The brain sends out just higher doses than your body would ever let you normally have because your body doesn't want you to have 20 babies at one time. But we're going to take some shots of FSH to override the normal brain ovary communication and try to get all 20 of those eggs to grow, take them out of your body. The next month, your ovary will send out another group of around 20 if you were an average 30 year old. So IVF egg freezing doesn't change, ovarian reserve doesn't change the rate of loss of eggs. And I think that's an important thing to distinguish because women are quite afraid of that they're going to have infertility later or they're going to run out of eggs. The other thing to know is it's not perfect. I probably will have a lot of women who are older, maybe over age 40, come to me and say, oh, I was chasing these big career dreams, but I figured I could just do IVF when the time came. IVF does get harder as you get older for most people because you have fewer eggs, therefore fewer to get every month, and more of them will be genetically abnormal, like we talked about earlier. So if we use the simple math, a 30 year old would have on average 20 eggs outside the vault. We said 65 to 70% will be genetically normal. An average 40 year old would have eight eggs outside the vault and only about 25% of them will be genetically normal.
- [36:28]
Chelsea Clinton
And, and Dr. Crawford, what if someone froze their eggs at 30 and then at 40 is like, I'm ready to get pregnant.
- [36:34]
Dr. Natalie Crawford
That's great. That, that's one of the single greatest advantages you can give yourself because we stay with our 30 year old rates when we go thaw those eggs, which that technology has significantly improved in the past 10 years. Egg freezing, which is, you know, it's quite incredible to freeze a single cell, which is what an egg is.
- [36:52]
Chelsea Clinton
Well, and I'm asking selfishly, admittedly, because I feel like I now say to younger women, if you can afford to do this, I hope that you will so that you have greater optionality later in life.
- [37:02]
Dr. Natalie Crawford
Absolutely. I think it's one of the best advantages an employer can give to its employees if they want to Be competitive in a market because taking that pressure off, that biologic, clean pressure off. I have also had young women say they were able to explore relationships fuller. Not feeling like this has got to be the one because I want to have children because they had eggs in storage. It's not an insurance policy, it's not a guarantee, but it is an investment. And I always liken it to like investing in the stock market. Like ROI will be determined later based on things we don't know yet. But is it generally smart to invest your money? Yes. It's just, it's an investment in you.
- [37:39]
Chelsea Clinton
That makes a lot of sense to me. You mentioned how much the science has changed. I feel like, you know, every week I see a different either company or doctor or claim, maybe not tethered to a company or a doctor about kind of what is now possible in IVF testing. You can test for height, you can test for iq, you can test for eye color, you can test for athleticism. Is any of that true? And what do you want people to know about all of these claims?
- [38:09]
Dr. Natalie Crawford
Hot Topic. Let's talk about the difference in what's like proven and promised and what people are trying to sell you when we do ivf. What's proven is something called pre implantation genetic testing, which is the idea that the embryo at the stage of implantation is called a blastocyst. It's like 300 to 500 cells. I tell my patients to imagine it like a soccer ball or the middle of. It's mostly hollow and everything that we see is actually what becomes the placenta. We can take five to eight of those cells. We can then kind of take the air out of the soccer ball, collapse it and freeze it. And I can send those five to eight cells off to test certain genetics before we put the embryo inside your body.
- [38:50]
Chelsea Clinton
And you recommend doing this, especially if
- [38:52]
Dr. Natalie Crawford
you're over age 35 or you carry a genetic disease. What you asked about in this question was something called pgtp, which is for polygenetic diseases. And this is not proven science. All these are companies that are charging a ton of money, usually upwards of about $50,000 for you to send these samples to them. And they are using an AI created algorithm to look through database of adult blood samples and traits and trying to link random genetic tags to things that by definition are caused by multiple genes. Things like type 1 diabetes or autism, or height or hair color or athleticism. It's using pretty much Caucasian white data from adults, trying to look at five to eight cells from an embryo. It is experimental at best, yet it's rolled out to consumers directly. It is not something that we offer, you know, in our clinic. I think it's something that many fertility doctors are not offering. We have to acknowledge, though, that all scientific advancements will always be slightly controversial. Right. And so how this gets rolled out eventually, if it could be proven, could be incredible, right? Imagine if we could eliminate type 1 diabetes, which can be, you know, deadly if you don't have access to insulin. It's an extremely hard disease to manage. So the idea of being able to identify certain diseases that are polygenetic in nature could be incredibly powerful. But of course, there's going to be people who start talking about, you know, genetically modified super babies who are the right height or athleticism or have the right eye color, and it starts to get into such an ethically gray line. What I want somebody to know hearing this right now is this is not by any means proven science. It's completely experimental out of dairy, high dollar point. Not something I would recommend doing.
- [40:42]
Chelsea Clinton
I do want to, Dr. Crawford, talk about cost because you mentioned in various parts of our conversation how much various tests can cost, those with real strong scientific evidence behind them and those with anemic or no scientific evidence behind them. Like what do you think people should expect as the average cost for iv, whether kind of one cycle or to try to get to kind of the 95% rate that you mentioned over three cycles. And what options do people have to try to ameliorate or defray some of those costs through insurance or otherwise?
- [41:18]
Dr. Natalie Crawford
This is really tough. IVF is extremely expensive. Let's say that IVF is roughly 20 to $25,000, depending on medications you need. And some other things which we have seen a drop in some drug costs which has been great rate, and then an embryo transfer is about $5,000. So the 30 year old who might be able to make five genetically normal embryos to grow their whole family will spend much less money than somebody who's 40 and maybe wants a couple kids. They're going to have to do numerous IVF cycles, getting numerous months of eggs. If we say the average at age 40 would be to get one embryo per each cycle that could be usable for a transfer. So it is something that's extremely expensive. It is easier the younger you are when you do it. As far as cost effectiveness, you'll have to spend less money to get the same outcome. But we are seeing, luckily, bipartisan push to at least try to help people have families. If we're going to have a slightly political conversation. We have to say one of the biggest threats to IVF that exists is going to be, you know, access to reproductive rights because of personhood amendments put in a lot of abortion bills, cells. The idea there is if life begins at fertilization and we're talking about ivf, it severely impacts the ability to do genetic testing of embryos, to freeze embryos, and would roll IVF technology back by about 20 years. So I think it's really important that we think about how, you know, in science, words have meaning. And again, many politicians don't fully understand that. It's not necessarily their fault they didn't have the foundational knowledge. But it's why we have to be really careful using broad generalizations to understand how something could maybe sound good theoretically. But in reality, if we say something happens at fertilization, that's a really clearly defined time point that impacts how we help people have families.
- [43:27]
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- [43:58]
Chelsea Clinton
One of the moments of enormous pain that I know that you talk about in your book is miscarriage. And I acknowledge that until my first beloved friend suffered a miscarriage, I had no idea how common a miscarriage is as a form of loss and grief. And I'm so sorry that you navigated this and imagine you're still navigating it it and wonder what you want people to know about how painfully common miscarriages are and how we can best support each other through those moments too.
- [44:33]
Dr. Natalie Crawford
Oh, such a beautiful question. Also, you know, one out of four pregnancies will end in a pregnancy loss and that rate does get higher as we get older. One of my most traumatic pregnancy losses happened back when I was in training and I was working and nobody knew I was pregnant. It also was never the culture to not be at work for something personal. I think as we have grown into the generation that our bosses it's really important that we treat the people who we work with a lot differently and we make space for something that is so traumatic and personal that we, you know, give people an environment where they can share but also have time to recover because that grief is really hard. It doesn't feel as tangible. Sometimes it's harder to share with people, especially if they didn't know you were pregnant. But I think it's really important to acknowledge it, that it is common. You know, you didn't cause your miscarriage.
- [45:27]
Chelsea Clinton
It's so important.
- [45:27]
Dr. Natalie Crawford
It's not your fault, you did not cause it. It's so important to know that, I mean, I went through it, right? Four pregnancy losses and you know, the things in my brain that went through and how I blamed my body and had all this guilt and shame and all the feelings that come with it. The best thing you can do is just, is try to educate yourself because you're, you're going to want to advocate for yourself. We are all patients in a healthcare system that is, is not patient centric. That is the reality of American healthcare right now. So trying to say what can we learn? What questions can we ask, what testing can we advocate for? That's really kind of a more goal oriented nature that can help you versus being just a cog in the wheel. You know, Chelsea, I had two pregnancy losses and went to my own doctor and was told, well, we don't do an evaluation until you've lost a third. So just keep trying. I'm sure it's bad luck and what. Right. And I was a physician and I,
- [46:20]
Chelsea Clinton
you know, I was, I am aghast at that and horrified for you and really offended and angry on your behalf.
- [46:25]
Dr. Natalie Crawford
Yeah, well, it's so interesting, you know, so it just shows you once you're the patient, you view the whole world different too. Because I'm sure, I mean, I had said that to patients too. I'm sure I was in training and I sat there, I was like, that is, that's the worst thing you could have said to me. I mean, I felt it in my core, right. I had questions, I felt like something was wrong and to be told, you know, same, same kind of thing and failed bad enough. Like once you lose another, then we'll work it up. And I will say now as a field, we've pushed back and we consider two pregnancy losses. We do a full evaluation. So we have to bring women up where we feel confident saying like, this is not normal and I need help. And I think that's really what we're trying to do here.
- [47:07]
Chelsea Clinton
Natalie, we've talked already about a number of myths and misconceptions. I'm still stuck and probably will be for quite some time on the social media phenomenon of having your blood drawn while you're pregnant could cause a miscarriage. I wonder before we move into our final segment where I'll toss out some things that we've heard recently, or maybe even some longstanding beliefs and get your assessment as to whether they're fact or fiction, if there are any other kind of misconceptions, harmful disinformation that you have seen percolating recently on social media or that you've heard for many years in a clinical setting that you want to address here.
- [47:48]
Dr. Natalie Crawford
The most common one that I'm seeing right now is that cannabis use is a healthier behavior option than, you know, alcohol, smoking, et cetera. When it comes to fertility specifically, you know, cannabis use is if a male uses cannabis, in addition to having lower sperm counts, lower testosterone levels, his female partner has a higher rate of having a pregnancy loss. We see more placental problems. So we see a direct correlation even if the female's not exposed to it directly. So we know if women use cannabis, they're getting fewer eggs with ivf, have lower pregnancy rates, even if they are intending to stop before they're pregnant. So this idea that, like, maybe it's a healthier choice because it's not alcohol, I'm glad to see less people drinking alcohol, but that doesn't mean that, that, you know, using marijuana is the safer, better choice. Maybe it's also just where I live and where I practice, it's probably like one of the single greatest choices that people are actively making, not understanding the impact it has on their reproductive health and trying to get pregnant.
- [48:53]
Chelsea Clinton
I've learned so much in our just final segment. Dr. Crawford, I'm going to throw out some things we haven't talked about yet, but feel free, of course, to add anything else that we should be talking about. All right, so here. Fact or fiction? Please say fact, fiction, or. We like nuance. Here. You can add. You can add nuance.
- [49:11]
Dr. Natalie Crawford
Okay.
- [49:12]
Chelsea Clinton
Sperm can live in the female reproductive tract for up to five days. Fact or fiction?
- [49:17]
Dr. Natalie Crawford
They can. That is a fact. The majority of them will survive those first 24 to 48 hours, but that is why the fertile window is defined as the five days before and the day of ovulation. The egg, however, only lives for 24 hours.
- [49:32]
Chelsea Clinton
IUDs and other forms of hormonal birth control can cause infertility. Fact or fiction?
- [49:39]
Dr. Natalie Crawford
Infertility is defined as not getting pregnant at one year. All forms of contraception have not been shown to have a greater rate of infertility, meaning by one year, we don't see a difference in who's gotten pregnant, who hasn't. The nuance, the birth control pill, what most people are Thinking about when they think about hormonal contraception has a Half Life. At 28 hours, it's out of your body very fast. The next month you should resume ovulating, be perfectly fine. If you didn't, something could be underlying wrong. Nothing to do with the birth control. You should get that evaluated. The progesterone IUD often works by the local progesterone. Causes a thinning of the endometrial lining, and it can take a while for that to grow back. And we do see a change to the receptivity of the uterus or the ability to implant a pregnancy for about six months. By one year, again, the same amount of people are pregnant. But that's why I Recommend Getting an IUD removed about 6 months before you want to start trying to get pregnant.
- [50:34]
Chelsea Clinton
You should take methylated folate rather than folic acid because it's easier for people to digest. Fact or fiction?
- [50:40]
Dr. Natalie Crawford
Fiction. Okay, Chelsea, you want to get into it?
- [50:44]
Chelsea Clinton
I mean, Dr. Crawford, you're here.
- [50:46]
Dr. Natalie Crawford
So folic acid is important for cell division. It's extremely important for what we call neural tube development of the baby. Actually, when the baby is dividing, the. The spinal cord in the brain are some of the first cells to start to differentiate, even before you get that first positive pregnancy test. And a landmark study, folic acid supplementation and its folic acid form of at least 400 micrograms a day was the level that prevented neural tube defects. And that is the medical recommendation to be taking if you want to conceive. Many prenatals now have methylated folate in them instead because it's a downstream metabolite. And there's concern that some people might. Might have higher blood levels if they take methylated folate versus folic acid. The big thing here, I always want to say, is that what may be true for you is not always true for the baby. Just because there's studies showing that blood levels taking methylated folate are the same or higher does not mean that methylated folate is stable enough or crosses the placenta and a high enough dose to prevent a neural tube defect. So if you love a prenatal that has a methylated folate in it, it's also perfectly fine to take an additional 400 micrograms of folic acid as an
- [51:54]
Chelsea Clinton
additional t. Such helpful advice. One thing I have to ask, because I feel like I see this online sometimes, are all sorts of recommendations around, like the best position to use to get pregnant or the optimal temperature in which you should be having sex to get pregnant or the time of day. Is any of that true or is it all fiction?
- [52:16]
Dr. Natalie Crawford
All of that is fiction. It doesn't matter what position, if you put your legs up, if you go to the bathroom afterward, the time of day, the temperature outside, the temperature in the room, room. As long as ejaculation is occurring, you have the same odds of conceiving. The one nuance I'll add here is that if you don't need lubricant, you should not use it. There are some lubricants marketed like help you get pregnant and fertility safe lubricants do exist, but they are just better than non fertility safe or spermicidal lubricants. None of them improve your odds of conceiving. It's all an additional barrier for sperm to get through. And the fun fact that most people don't know is saliva is actually the most toxic thing you can use for sperm. So if you are lubricating with saliva, that is actually very toxic to sperm.
- [53:05]
Chelsea Clinton
Oh wow. Anything we didn't touch on anything else that we should cover?
- [53:10]
Dr. Natalie Crawford
Chelsea? I think we've covered everything.
- [53:12]
Chelsea Clinton
I mean we've had an awesome conversation. I've learned so much. Natalie, thank you so much. Dr. Crawford, thank you so much for your time and your work and like trying to educate us as a public and taking care of your patients. And I'm going to send all my friends, Austin, to come and see you if they need your help. So really just thank you for everything.
- [53:29]
Dr. Natalie Crawford
Thank you so much. I appreciate it.
- [53:33]
Chelsea Clinton
You can follow Dr. Natalie Crawford Atalie Crawfordmd on Instagram and TikTok again. Her new book is called the fertility formula Take control of your reproductive future. Thanks for listening. Talk to you next week. That can't be True is a production of Limonada Media and the Clinton Foundation. The show is produced by Katherine Barnes Mix and sound design by Johnny Vince Evans. Kristin Lepore is senior director of new content and Jackie Danziger is VP of narrative and production. Maggie Kral Shore is our managing director of partnerships. Executive producers are Jessica Cordova Kramer, Stephanie Whittles Wax and me, Chelsea Clinton. Special thanks to Erica Goodmanson, Sara Horowitz, Francesca Ernst Kahn, Caroline Lewis Sage Svalter, Barry Lurie Westerberg, Emily Young and the entire team at the Clinton Foundation. You can help others find our show by leaving us a rating and writing a review. And if you can think of someone who might benefit from today's episode, please go ahead and share it with them. There's more of that Can't Be true with Lemonada Premium subscribers get exclusive access to bonus content when you subscribe on Apple Podcasts. You can also listen ad free on Amazon Music with your prime membership.