Fertility Doctor Crawford Urges Proactive Testing as Egg Reserves Drop

The Diary Of A CEO

Accelerating egg loss and rising male infertility make proactive testing at age 32 critical for those seeking multiple children.

AI-assisted summary of The Pregnancy Doctor: Pregnancy Is Halved Every Year After Age 32! If You Want 2+ Children, DO THIS! — original source. Check the original for full context.

Source published: 2024-06-03

Detailed notes

## Background Published on June 3, 2024, on the YouTube channel The Diary Of A CEO, this episode features host Stephen Bartlett interviewing double board-certified fertility doctor Dr. Natalie Crawford. According to the show notes, Dr. Crawford is the co-founder of Fora Fertility clinic and Pinnacle Conference, and the discussion focuses on actionable fertility advice, reproductive health, and family planning.

## TL;DR Dr. Natalie Crawford discusses the key factors contributing to rising global infertility, including declining sperm counts, age-related egg depletion, and lifestyle influences like sleep, diet, and environmental toxins. She breaks down the mechanics of the reproductive cycle, common conditions like PCOS and endometriosis, and the diagnostic tools available to evaluate ovarian reserve. Additionally, Dr. Crawford addresses common conception myths, explains procedures such as IVF and egg freezing, and provides practical guidance on navigating fertility preservation and medical interventions.

## Atmosphere & style The conversation carries an empathetic, candid, and deeply informative tone, balancing rigorous medical science with vulnerable personal disclosures. Dr. Crawford offers a supportive yet direct expert perspective, framing reproductive education as an empowering form of preventative health. Stephen Bartlett asks grounded questions that prompt transparent discussions about the emotional toll of pregnancy loss, relationship strains, and societal stigmas, creating a compassionate and reflective viewing experience.

## Key takeaways - [02:24](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=144s) Fertility health should be managed proactively as preventive care well before wanting children, rather than waiting until age 35 or when experiencing difficulties. - [04:31](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=271s) Global birth rates are declining rapidly, with the US average dropping to 1.3 children per woman and shifting family-building timelines significantly past age 30. - [07:47](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=467s) Male sperm counts have dropped by 50% over the last 50 years, with the rate of decline doubling in the past decade. - [30:15](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1815s) Exogenous Testosterone Replacement Therapy (TRT) shuts down pituitary signaling and halts natural sperm production, causing zero sperm count and potential permanent suppression. - [29:40](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1780s) Scrotal exposure to heat sources like hot tubs, hot baths, laptops, and frequent long-distance cycling impairs sperm production and count. - [31:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1905s) Women are born with their entire egg reserve, which rapidly declines in both quantity and chromosomal quality over time, accelerating significantly after age 37. - [42:31](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2551s) AMH and antral follicle count tests evaluate ovarian egg quantity and remaining reproductive window, but do not measure monthly spontaneous pregnancy odds. - [52:47](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3167s) 7.5 to 8 hours of sleep and stress management are vital for regulating reproductive hormones and reducing cellular inflammation that damages egg and sperm quality. - [56:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3405s) Whole-fat dairy supports normal ovulatory function better than low-fat options, while higher weekly red meat intake is associated with lower viable embryo yields in IVF. - [01:06:09](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3969s) Extreme caloric deficits or intense athletic training can trigger hypothalamic amenorrhea, shutting down ovulatory signals for years. - [01:14:50](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4490s) The fertile window spans five days before ovulation plus the day of ovulation; abstaining from sex to 'save up' sperm harms motility and increases the risk of missing this window. - [01:20:11](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4811s) Unsafe DIY sperm insemination using unwashed ejaculate poses severe risks of uterine infection and severe inflammation. - [01:24:41](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5081s) Polycystic Ovary Syndrome (PCOS) stems from an elevated egg reserve diluting FSH signals, leading to high androgen levels, insulin resistance, and irregular ovulation. - [01:33:50](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5630s) Anovulation in PCOS leads to unopposed estrogen exposure without progesterone-induced shedding, significantly increasing the risk of endometrial cancer. - [01:48:12](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6492s) Ages 32 to 33 mark a critical window to evaluate ovarian reserve and consider freezing eggs or embryos if family planning is delayed. - [01:50:25](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6625s) Preimplantation Genetic Testing (PGT-A and PGT-M) screens IVF embryos for chromosomal abnormalities and single-gene genetic disorders prior to transfer. - [01:59:13](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7153s) Birth control pills do not cause long-term infertility or preserve egg supply, but using them can mask underlying condition symptoms like PCOS or endometriosis for years.

## Detailed walkthrough Here is a detailed, faithful walkthrough of the provided transcript segment.

---

[00:00](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=0s) Intro: The Hidden Realities of Fertility and Misconceptions

Dr. Natalie Crawford introduces the overarching biological realities facing anyone trying to plan a family. She frames the female egg supply as an "egg vault": while a female is born with 1 to 2 million eggs, that number plummets to roughly 300,000 by the time she reaches her reproductive years. Waiting until age 35 to try for a baby drastically changes the odds, and by age 40, the risk of miscarriage reaches 50%. Despite these stark statistics, Dr. Crawford emphasizes that there are actionable lifestyle adjustments and preventative measures individuals can take to optimize their reproductive health.

Host Stephen Bartlett introduces Dr. Natalie Crawford, a double board-certified practicing fertility physician, co-founder of Fora Fertility clinic, and co-founder of the Pinnacle Conference. She notes a alarming shift in fertility statistics: while 1 out of 8 women used to experience infertility, that figure has now escalated to 1 out of 5. Factors driving this rise include irregular periods, surging rates of autoimmune diseases, obesity, chronic stress, and delaying pregnancy. Dr. Crawford opens up about her personal journey, sharing through tears that she experienced four pregnancy losses. The intro touches on common myths—such as whether female orgasms improve fertility chances—and highlights the core habits that truly impact the human reproductive system.

- **Egg Vault Decline:** 1–2 million eggs at birth $\rightarrow$ 300,000 during reproductive years. - **Miscarriage Rate at 40:** 50%. - **Infertility Rate Shift:** Formerly 1 in 8 women; now risen to 1 in 5 women. - **Diary of a CEO Milestone:** Stephen Bartlett announces hitting 6 million channel subscribers and launches a monthly subscriber raffle (offering a £1,000 voucher, live studio tickets, and a 10-minute 1-on-1 phone call).

---

[02:24](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=144s) You Need To Look After Your Fertility Even Before You Want Children

When asked about her identity and core mission, Dr. Crawford explains that while her daily job is helping people build their families, her larger mission was sparked eight years ago. Early in her career, she found herself constantly treating patients who were already "behind the game." These individuals lacked foundational knowledge about their own bodies, hormones, and reproductive systems. Patient after patient expressed deep regret, asking, *"I wish I'd known this earlier... why isn't this the stuff that we're taught?"* This pivotal moment drove her to educate people *before* they struggle with infertility, empowering them to make informed choices rather than letting time passively dictate their options.

Stephen notes that most people view fertility as a concern exclusive to those over 35 or approaching their 40s. Dr. Crawford refutes this mindset entirely. She points out that major medical bodies—including the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC)—define infertility as a disease (the inability to achieve pregnancy). Therefore, fertility should be treated like any other area of preventative health (such as cancer or Alzheimer's prevention). Proactive, early lifestyle decisions ensure that when someone is ready to have children, the option hasn't been unintentionally compromised.

---

[04:31](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=271s) We're Struggling More Than Ever To Have Children

Stephen raises the cultural backdrop, asking if the recent surge in fertility conversations is due to personal age bias or genuine societal shifts. Dr. Crawford outlines a complex mix of factors. On one hand, awareness is far higher today because of social media and the breakdown of silence surrounding reproductive issues. Advanced medical technology—like egg freezing and accessible IVF programs—did not exist two decades ago, meaning people can now seek evaluations and diagnoses much earlier.

On the other hand, the underlying rates of infertility are objectively climbing, independent of maternal age. While age is a major contributor—in the 1970s, only 5% of women started families after age 30, compared to 25% to 30% today as women pursue higher education and careers—it does not explain the full picture. Broader public health trends, such as rising rates of obesity, diabetes, and environmental toxin exposure, are driving an overall decline in reproductive capability across the population.

- **Maternal Age Shift (Age 30+):** 5% of women starting families after 30 in the 1970s vs. 25–30% today. - **Infertility Definition:** Formally recognized as a disease state by the WHO and CDC.

---

[07:00](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=420s) Are We Having Less Sex?

In response to Stephen's question about whether declining pregnancy rates stem from people simply having less sex, Dr. Crawford explains that frequency of intercourse is only part of the equation. While overall sexual frequency tends to decrease as couples age or marry, research highlights subtle lifestyle factors at play. For instance, studies on marijuana use reveal that individuals who consume marijuana get pregnant less frequently, despite having *more* sex on average than non-users. This demonstrates that lifestyle choices directly impair biological fertility, regardless of intercourse frequency.

Stephen shares global fertility rate statistics, noting the dramatic decline from **4.84 live births per woman in 1950** down to **2.23 in 2021**, with projections falling further to **1.59 by the year 2100**. Dr. Crawford highlights that in the United States, the current average birth rate sits at **1.3 children per woman**. This trend reflects a combination of intentional delay, lower overall family size desires, and a growing cohort of people who actively struggle with biological infertility despite starting young.

- **Global Live Births Per Woman:** 4.84 (1950) $\rightarrow$ 2.23 (2021) $\rightarrow$ Projected 1.59 (2100). - **US Birth Rate Average:** 1.3 children per woman.

---

[07:47](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=467s) Sperm Count Is Declining At Scary Risk

Dr. Crawford highlights alarming data regarding male fertility, citing a major study published recently showing that male sperm counts have dropped by **50% over the last 50 years**. Most disturbingly, the data reveals that the rate of decline over the past 10 years has **doubled** compared to the preceding 40 years. This rapid, accelerating drop points directly to modern environmental and lifestyle influences impacting male reproductive biology worldwide.

- **Sperm Count Decline:** 50% drop over 50 years. - **Acceleration:** The rate of decline doubled in the past decade compared to the previous four decades.

---

[09:40](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=580s) I Had 4 Pregnancy Losses And It's Devastating

Dr. Crawford discusses her clinical work at Fora Fertility, the Austin-based clinic she co-founded in 2020 with her partner, Dr. Amanda Skillern. Their typical patient profile is a woman over the age of 36 who has been trying to conceive for 1 to 2 years, has tracked her cycles carefully, and is seeking a personalized approach after experiencing failed attempts or unsuccessful IVF elsewhere. Beyond the medical procedures, Dr. Crawford identifies deep social isolation as the most painful aspect of infertility: watching peers move forward while feeling left behind creates profound psychological distress.

Drawing on her own past, Dr. Crawford opens up about experiencing **four pregnancy losses** before having her two children. Occurring while she was a medical resident and fellow, she admits she wasn't taking care of herself under the brutal hours of medical training. She kept her first three pregnancies entirely secret—even from close friends—believing she had to wait for the "safe zone" past the first trimester. When those pregnancies ended, she felt unable to reach out for support because she hadn't shared the news in the first place.

Her fourth loss was an ectopic pregnancy—a life-threatening condition where the embryo implants in the fallopian tube rather than the uterus. Because the tube lacks the blood supply to support a placenta, it can rupture and cause catastrophic internal bleeding. The diagnosis came while her husband was away on a bachelor trip in Las Vegas. Dr. Crawford had to be given medication to stop the pregnancy and was forced to call on friends for support during the medical crisis. That experience taught her a vital lesson: keeping struggles secret robs loved ones of the opportunity to show up. She now urges her patients to share their journeys with a trusted circle to break the cycle of isolation, guilt, and self-blame.

---

[13:36](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=816s) The Stigma Of Infertility

Stephen reflects on how friends who encounter reproductive issues often express a heavy sense that they are "broken" as human beings, carrying immense shame and silence. Dr. Crawford validates this observation, noting that infertility carries a unique social stigma driven by widespread health illiteracy and uncertainty. When an individual has envisioned parenthood as a core component of their identity since childhood, confronting the reality that it may not happen naturally creates a profound identity crisis.

Patients frequently tell her, *"I feel like I'm stuck while everybody else is moving on because I'm broken, my body is failing me."* Dr. Crawford explains that while medical science cannot guarantee a pregnancy for every single patient, establishing a fundamental understanding of how their bodies work restores agency. Her baseline standard of care is ensuring every patient understands the biological decisions being made so they can advocate for themselves with dignity, relieving the burden of hindsight regret and self-blame.

Stephen then brings up a close personal friend who recently sought fertility testing after struggling to conceive, only to discover specific issues complicating their ability to get pregnant. He reflects on the immense emotional toll and instant feeling of guilt that hits a partner in that scenario, worrying that they are holding their loved one back from their dreams.

[16:56](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1016s) The Emotional Burden and Relationship Strain of Infertility

The psychological impact of infertility often places a severe strain on intimate relationships, largely driven by feelings of personal failure and guilt. Dr. Natalie Crawford shares her own personal experience with infertility, reflecting on how her husband tried to support her, yet she still felt like the one failing in the relationship—viewing it as "a me problem" rather than an "us problem." To help couples navigate this emotional landmine, she works to reframe infertility as a shared journey, stressing that regardless of whose test results show an issue, the ultimate goal is for them as a team to achieve a pregnancy together.

Dr. Crawford illustrates this dynamics shift through the story of a former patient who had been suffering from early egg depletion. The woman carried immense guilt and self-blame for not freezing her eggs sooner or delaying her attempts to conceive. However, during an IVF cycle that yielded no viable embryos, testing revealed that her husband's sperm was actually not functioning properly—a issue that could only be detected once fertilization was attempted in the lab. Paradoxically, despite the devastating outcome of having no viable embryos, the patient reported that the discovery dramatically improved their marriage. For the first time, she no longer felt broken or isolated in her guilt, as both partners realized they shared the burden on an even playing field.

[18:49](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1129s) The Basics of Sperm Production vs. Egg Development

Understanding fertility begins with grasping the fundamental biological differences between how men produce sperm and how women store eggs. The average male produces approximately 200 to 300 million sperm per day, which breaks down to about 1,500 sperm every single second. Men possess germ cells in their testes that allow them to continuously generate brand-new sperm throughout their lives. In contrast, women are born with all the eggs they will ever have, and that finite supply steadily depletes over time. Furthermore, because eggs reside inside a woman's body her entire life, they absorb decades of environmental wear and tear, whereas a sperm's total lifespan is roughly 90 days (72 days to develop across the testicle and 18 days to travel through the ejaculatory system).

``` Sperm Lifespan & Development Pipeline (90 Days Total) ┌───────────────────────────────┬───────────────────────────────┐ │ Testicular Development │ Ejaculatory Transit │ │ (72 Days) │ (18 Days) │ └───────────────────────────────┴───────────────────────────────┘ ```

Because sperm takes three months to mature and exit the body, a man can significantly alter his lifestyle and improve his sperm parameters within a three-month window. Sperm are held in sequential "storage lockers" so that a fresh supply is available daily. However, sperm are delicate structures that degrade if left in storage for too long. Extended periods of abstinence lead to an accumulation of dead sperm and cellular debris within the ejaculate. Dr. Crawford compares this to a highway blocked by stalled cars: "If you're having very long abstinence periods in between your intercourse times, you're going to have a sample that has so much debris and dead sperm in it that it's going to make it hard for the good guys to do their job."

- **Sperm Production Rate:** 1,500 sperm per second; 200 to 300 million per day. - **Sperm Maturation Time:** 90 total days (72 days to form in the testicles, 18 days in transit). - **Optimal Ejaculation Frequency:** Every 1 to 4 days optimizes sperm quality and count. - **Abstinence Threshold:** Refraining from ejaculation for longer than 7 days severely increases dead sperm proportions and cellular debris.

[02:22:26](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8546s) Environmental Factors and Lifestyle Impacts on Fertility

Sperm counts across the globe have dropped by roughly 50% over the last 50 years, driven by a combination of medical comorbidities, lifestyle factors, and environmental exposures. Chronic health conditions like high cholesterol, diabetes, and obesity negatively impact systemic health and impair the body's ability to produce robust sperm and reproductive hormones. The brain's hypothalamic-pituitary-gonadal axis constantly monitors the body's internal state to decide if it is a safe time to reproduce. When confronted with severe stress, caloric restriction, or illness, elevated cortisol levels cause the brain to temporarily shut down the production of reproductive hormones—estrogen and progesterone in women, and testosterone in men.

Beyond metabolic health, environmental toxins present in air, food, kitchenware, and personal care products impose an additional burden on reproductive health. Living in areas with high air pollution directly correlates with reduced sperm counts and lower overall fertility rates. While certain macro-environmental factors cannot easily be changed, individuals can reduce their cumulative toxic load by altering personal habits.

- **Cigarette Smoking:** In women, it decreases egg quantity and quality while significantly raising miscarriage rates. In men, it decreases sperm count, motility, and normal morphology while increasing miscarriage risk. - **Marijuana Use:** Even if a female partner does not smoke, a male partner's marijuana use increases her risk of miscarriage due to direct DNA damage inside the sperm head. - **Vaping:** Preliminary studies indicate that vaping may be equally harmful or potentially worse than traditional cigarettes due to inhaled compounds.

[02:26:32](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8792s) Cell Phones, Radiation, and Scrotal Heat Factors

Concerns regarding cell phones and male fertility often divide into two separate categories: electromagnetic radiation and local heat emission. A long-term study evaluating cell phone usage from 2005 to 2018 noted that higher daily usage frequency was initially associated with reduced sperm production. However, this negative effect was predominantly linked to early-generation phones (2005–2010), which emitted substantially higher radiation levels than modern devices. Modern smartphones emit much less radiation, and recent data shows no significant link between cell phone location—such as carrying a phone in a front pocket versus a back pocket or leaving it on a counter—and impaired sperm parameters.

``` Key Differences: Radiation vs. Thermal Exposure ┌───────────────────────────────┬───────────────────────────────┐ │ Radiation (Cell Phones) │ Thermal (Heat Sources) │ ├───────────────────────────────┼───────────────────────────────┤ │ • Modern phones emit lower │ • Raises testicular temp │ │ radiation than older models │ • Damages sperm & Leydig cells│ │ • Pocket location shows no │ • Direct cause of lower sperm │ │ measurable impact │ counts and testosterone │ └───────────────────────────────┴───────────────────────────────┘ ```

Conversely, scrotal heat exposure remains a major, proven cause of male infertility. The testicles reside outside the abdominal cavity within the scrotum specifically to maintain a temperature lower than core body heat. For example, infants born with an undescended testicle must undergo surgical correction—typically before age one—because internal body heat destroys the cells responsible for producing sperm and testosterone. Lifestyle behaviors that elevate scrotal temperature directly suppress both sperm count and testosterone production.

- **Frequent Hot Tub or Sauna Use:** Daily exposure to high heat significantly damages sperm production. - **Hot Baths:** Taking daily hot baths lasting longer than 15 minutes is discouraged for those trying to conceive. - **Laptops on Laps:** Positioning heat-generating laptops directly over the lap creates sustained scrotal warming. - **Intense Cycling:** Extended cycling sessions (2 to 3 hours multiple times per week) combine friction, compression, and trapped heat, resulting in noticeably lower sperm counts.

[02:30:15](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=9015s) The Impact of Testosterone Replacement Therapy (TRT) on Male Fertility

A frequent point of confusion among men struggling with infertility involves the use of exogenous testosterone replacement therapy (TRT). Dr. Crawford sees couples at least once a week where the male partner was prescribed TRT by a clinic to address symptoms like fatigue or low libido while actively trying to conceive. She points out that exogenous testosterone acts as a form of male birth control.

When a man administers external testosterone, the brain detects high circulating hormone levels and assumes the testes are functioning adequately. As a result, the pituitary gland stops releasing gonadotropins, halting the signal for the testicles to produce intratesticular testosterone and sperm. This feedback loop leads to **azoospermia**—a complete absence of sperm in the ejaculate. Although the volume and appearance of the semen appear normal to the naked eye, microscopic evaluation reveals zero sperm. Furthermore, long-term TRT use carries a significant risk of permanent testicular suppression, leaving some men unable to recover natural sperm production even after discontinuing the therapy.

> "Taking testosterone yourself is telling your brain that there is testosterone present... the hormones from your brain stop being sent out and no longer tell your testicle to make any more testosterone or any more sperm."

[02:31:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=9105s) The "Egg Vault" Concept and Female Ovarian Reserve

To illustrate how female ovarian reserve changes over time, Dr. Crawford uses the analogy of an "Egg Vault" represented by a jar of marbles. Unlike males who continually generate germ cells, a female is born with her life's entire supply of eggs. The peak number of eggs occurs before birth, after which the total count steadily declines throughout life:

``` Ovarian Reserve Depletion Over Time ┌───────────────────────────────┬───────────────────────────────┐ │ Stage of Life │ Approximate Egg Count │ ├───────────────────────────────┼───────────────────────────────┤ │ 5-Month Fetus (in utero) │ 6,000,000 – 7,000,000 │ │ Birth │ 1,000,000 – 2,000,000 │ │ Puberty Onset │ 500,000 │ │ Start of Reproductive Years │ ~300,000 │ │ Menopause │ < 1,000 │ └───────────────────────────────┴───────────────────────────────┘ ```

Despite starting with millions of eggs, a woman will only ovulate approximately 400 to 500 eggs in her entire lifetime. The remaining vast majority undergo a continuous natural degeneration process called atresia.

Each month, a cohort of eggs is recruited out of the "vault" in proportion to the total remaining reserve: when the vault is full, a larger group of eggs emerges; as the reserve thins with age, smaller groups are released. Prior to puberty, recruited cohorts simply die off due to the absence of hormonal stimulation. Once puberty begins, the pituitary gland releases **Follicle-Stimulating Hormone (FSH)** to signal these recruited eggs—which reside inside fluid-filled sacs called follicles—to grow, ultimately selecting a single dominant follicle for ovulation each cycle.

- **Lifetime Ovulation:** Only 400 to 500 total eggs are ovulated out of millions. - **Proportional Cohort Release:** The number of eggs exiting the reserve each month depends directly on how many total eggs remain inside the ovarian vault. - **Role of FSH:** Follicle-Stimulating Hormone recruits and matures a monthly cohort of follicles once puberty has begun.

[34:42](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2082s) The Biology of Follicle Selection and the Ovarian "Vault"

Dr. Natalie Crawford explains that unlike animals that deliver litters, the human uterus is designed to carry one child at a time. This constraint requires a strict biological control system. Every month, the brain releases follicle-stimulating hormone (FSH)—a rare instance where a hormone is named specifically for its function in women rather than men, though men also have FSH (which controls sperm production) and LH (which regulates testosterone). In women, FSH stimulates a single selected follicle to mature and ovulate, while the remaining recruited follicles undergo programmed cell death (atresia).

Using an analogy of a glass vault containing a woman's entire lifetime egg supply, Dr. Crawford illustrates how a cohort of eggs is released each month. At age 30, roughly 20 eggs exit the vault monthly; one ovulates, and 19 die. By age 35, that monthly recruitment drops to around 14 or 15 eggs. By age 40, only 8 to 10 emerge, and by age 44, a woman may only recruit 3 to 4 eggs per month. A sharp, accelerated decline in total egg count begins around age 37.

- **FSH & LH in Men vs. Women:** In men, FSH regulates sperm production while LH drives testosterone; in women, FSH stimulates follicle development. - **Monthly Recruitment Rates:** Age 30 (~20 eggs/month) → Age 35 (14–15 eggs/month) → Age 40 (8–10 eggs/month) → Age 44 (3–4 eggs/month). - **Steepest Decline:** Accelerated loss of ovarian reserve occurs after age 37. - **Total Egg Reserve at 37:** Down to approximately 20,000 remaining eggs from the ~500,000 present at puberty.

[37:01](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2221s) Ovarian Reserve Loss and Mechanisms of IVF Stimulation

Eventually, every woman exhausts her egg supply, resulting in ovarian failure, commonly known as menopause. While the average age of menopause is 51 or 52, primary amenorrhea or premature ovarian insufficiency can strike much earlier; Dr. Crawford notes treating patients who experienced menopause as young as 13 or in their early 20s. Accelerators that destroy eggs inside the vault include cigarette smoking, marijuana use, endometriosis, chemotherapy, and environmental toxins.

This biological reality directly dictates how fertility treatments like egg freezing and in vitro fertilization (IVF) operate. Ovarian stimulation medication cannot "reach inside" the vault to extract hidden eggs; it can only save and grow the specific cohort of eggs that naturally emerged from the vault during that specific cycle. If a patient produces 10 eggs in a given month, medications coax all 10 to grow instead of letting 9 die. If more eggs or genetically normal embryos are required, the patient must undergo multiple retrieval cycles across consecutive months.

- **Average Menopause Age:** 51 to 52 years old. - **Egg Loss Accelerators:** Smoking, marijuana, chemotherapy, endometriosis, and environmental toxic exposures. - **IVF Mechanism:** Rescues the current month's recruited cohort from atresia; it cannot force extra eggs out of the primary vault.

[39:33](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2373s) Egg Quality, Chromosomal Errors, and Miscarriage Rates

Beyond total egg count, egg *quality* represents the ultimate rate-limiting step in achieving a live birth at an older age. Because eggs sit in the body from birth, they accumulate cellular damage over decades from lifestyle choices, illness, and chronic inflammation. Dr. Crawford uses a vivid analogy to explain chromosomal degradation: *"It is like having kindergarteners stand in a line for 40 years—somebody's going to get out of line."*

When chromosomes fail to align or separate properly during division, the resulting egg carries genetic abnormalities. Most aneuploid eggs fail to fertilize, fail to implant, or end in miscarriage. Healthy habits can slow down this degradation, but age remains an inescapable factor.

``` Fertility Statistics by Age: ┌─────┬──────────────────────────┬────────────────────────────┐ │ Age │ Monthly Pregnancy Chance │ Miscarriage Risk If Pregnant│ ├─────┼──────────────────────────┼────────────────────────────┤ │ 35 │ 10% – 15% │ 25% │ │ 40 │ ~5% │ 50% │ └─────┴──────────────────────────┴────────────────────────────┘ ```

At age 40, if a woman recruits 8 eggs in a month, up to 6 of those eggs may be genetically abnormal. The body selects one egg at random to ovulate, making the statistical chance of releasing one of the few normal eggs very low in any given cycle.

- **Conception & Miscarriage Risk at 35:** ~10–15% chance of conceiving per month; 25% risk of miscarriage. - **Conception & Miscarriage Risk at 40:** ~5% chance of conceiving per month; 50% risk of miscarriage. - **Primary Barrier:** Genetic aneuploidy driven by aged cellular machinery, not just lower egg quantity.

[42:31](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2551s) Testing Ovarian Reserve: AMH vs. Antral Follicle Count

Host Stephen Bartlett expresses the deep emotional gravity of these statistics, noting that "the opposite of confronting the truth is regret." He asks about the retrospective clarity and heartbreak Dr. Crawford witnesses among patients who realization hits too late. Dr. Crawford emphasizes that understanding one's individual egg count—known as the **ovarian reserve**—is critical to preventing this regret.

Ovarian reserve is evaluated using two primary diagnostic tools: 1. **AMH (Anti-Müllerian Hormone) Blood Test:** Measures the hormone produced by small growing follicles to estimate remaining egg supply. 2. **Transvaginal Ultrasound:** Counts the actual visible eggs outside the vault in a given month (Antral Follicle Count).

Dr. Crawford clarifies a major point of confusion: your ovarian reserve testing does *not* predict your natural chance of conceiving in a single month. If two women of the same age (e.g., 30 years old) have vastly different ovarian reserves—one with high AMH and 20 eggs recruited, the other with low AMH and 5 eggs recruited—both women still ovulate only **one** egg per month. Thus, their natural monthly odds of pregnancy are identical.

However, the woman with the lower reserve has a shorter "reproductive runway" (less time before hitting menopause) and will yield fewer eggs if she ever needs IVF or egg freezing.

- **AMH Test:** Blood biomarker that correlates with the quantity of remaining eggs. - **Antral Follicle Count:** Visual count of active follicles via ultrasound. - **Natural Odds vs. Reserve:** A low AMH does *not* decrease spontaneous natural pregnancy chances per cycle, but it limits future time and IVF yield.

[45:23](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2723s) Medical Guidelines Controversy and Generational Mindsets

Dr. Crawford voices strong frustration with official guidelines from medical bodies like the American College of Obstetricians and Gynecologists (ACOG), which recommend *against* routine AMH screening for women who are not currently trying to conceive or experiencing infertility. The justification offered by these organizations is that discovering a low egg count causes "undue stress" without altering immediate natural fertility.

Dr. Crawford vehemently disagrees: *"You can't make decisions on data you don't know."* If a woman learns in her 20s or early 30s that her reserve is depleting faster than average, she can choose to freeze eggs, adjust her family planning timeline, or eliminate toxic lifestyle habits like smoking marijuana. With modern egg freezing technology delivering high survival rates and predictable success, withholding diagnostic data robs women of agency. She advocates for integrating ovarian reserve discussions into routine annual OB-GYN visits alongside birth control consultations.

- **ACOG Recommendation:** Advises against checking AMH in asymptomatic women not actively seeking pregnancy. - **Dr. Crawford's Stance:** Opposes this guideline; early knowledge gives women actionable choices (egg freezing, lifestyle modifications, timeline shifts). - **Modern Context:** Unlike previous generations who lacked cryopreservation tools, young people today actively seek personal health data to make proactive life decisions.

[49:05](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2945s) Lifestyle Toxins That Accelerate Egg Depletion

When asked how an unhealthy lifestyle impacts the ovarian vault, Dr. Crawford explains that harmful exposures operate on a dual path: they damage the cellular DNA of surviving eggs and directly kill eggs inside the vault. This accelerated destruction causes cigarette smokers, for example, to enter menopause several years earlier than non-smokers.

To preserve both egg quantity and quality, Dr. Crawford breaks down actionable daily habits into distinct risk categories:

#### Toxic Substances - **Cigarettes, Marijuana, & Hard Drugs:** Direct DNA damage and premature follicle death inside the vault. - **Alcohol:** Moderate-to-high consumption is linked to reduced egg quality. "Moderate" drinking is defined as just **4 drinks per week** (e.g., four glasses of champagne across a week or in a single evening).

#### Environmental Toxins & Endocrine Disruptors - **Plastics:** Never cook in plastic, microwave food in plastic, or put plastic food containers through the dishwasher. - **Thermal Paper Receipts:** Handling receipts (such as from grocery stores or airports) transfers bisphenols (BPA/BPS) through the skin. - **Non-Stick Cookware:** Avoid Teflon and non-stick coatings. - **Takeout Packaging:** Transfer hot takeout food out of plastic or lined cardboard containers immediately into glass containers or porcelain plates to prevent chemical leaching into the food.

- **Moderate Drinking Threshold:** Defined as 4 or more alcoholic drinks per week. - **Smokers:** Experience clinical menopause years earlier due to direct intra-vault follicular destruction. - **Heat + Plastic Risk:** Heat dramatically increases the rate at which synthetic chemicals leach into food.

[52:47](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3167s) Chronic Inflammation, Sleep, and Stress

Environmental toxicant exposures are tracked via cohort studies—following large groups over years with blood and urine sampling to observe natural fertility rates. Beyond chemical toxins, controlling chronic inflammation is essential for protecting reproductive potential. Unlike acute inflammation, which heals a localized injury, chronic inflammation leaves the body in a constant high-alert state. Elevated inflammatory markers, such as prostaglandins, directly degrade egg and sperm quality while contributing to conditions like endometriosis and autoimmune disorders.

The primary voluntary cause of systemic inflammation is insufficient sleep. During baseline sleep, cells repair cellular damage and clear daily inflammation. Prioritizing $7.5\text{ to }8$ hours of sleep per night is the most accessible, non-pharmacological step someone can take to improve reproductive hormone production and signaling.

Chronic psychological stress impacts the brain in a similar fashion. Constant elevated cortisol clouds the brain's ability to read reproductive hormonal signals, leading the body to perceive its environment as too hostile to support a pregnancy. Stress management must be individualized—whether that means yoga, therapy, acupuncture, journaling, or simply spending 20 screen-free minutes outside in the morning. Lowering cortisol allows the body to maintain proper baseline responsiveness to real, acute stressors rather than remaining under constant internal attack.

* **Cohort Studies:** Demonstrate that higher exposure to environmental chemicals significantly decreases natural pregnancy rates over time. * **Sleep Target:** $7.5\text{--}8$ hours per night is crucial for cellular repair and reproductive hormone regulation. * **Daily Stress Reset:** Dedicate 20 minutes daily without screens (phones, tablets, TV) to trigger a physical cortisol release.

---

[56:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3405s) Diet, Red Meat, and Dairy's Impact on Fertility

Diet is one of the most powerful levers for improving fertility outcomes. Processed foods, refined sugars, and processed meats (classified as Class 1 carcinogens) introduce systemic contaminants that directly impair egg and sperm quality. While observational nutrition data has inherent limitations, studies in IVF settings reveal a clear dose-dependent negative impact from red meat: individuals consuming more weekly servings of red meat yield significantly fewer viable embryos during an IVF cycle compared to those consuming fewer servings.

Rather than advocating for an unsustainable, strict vegan mandate, a practical framework involves adopting a Mediterranean-style or plant-forward omnivorous diet. Simple actionable adjustments—such as implementing "Meatless Mondays," capping fish intake at three times per week due to heavy metal toxicity (such as mercury), and substituting red meat with healthy fats like nuts, avocados, and olive oil—lower overall inflammation.

Dairy consumption presents a counterintuitive dynamic due to modern food processing. Low-fat or skim dairy is linked to higher rates of ovulatory dysfunction compared to whole-fat dairy. Steroid hormones (estrogen, progesterone, testosterone) require cholesterol as a structural baseline. Stripping fat from milk alters its natural composition and removes healthy fats necessary for hormone synthesis.

* **IVF & Red Meat:** Increased weekly red meat servings correlate with lower embryo development rates in clinical trials. * **Fish Intake:** Cap at 3 servings per week to maximize omega-3 fatty acid intake while minimizing mercury accumulation. * **Dietary Guidance:** Limit red meat to at most once per week; reserve processed foods, refined sugars, and packaged goods for rare occasions. * **Dairy Selection:** Opt for whole-fat dairy over skim or low-fat varieties to preserve intact natural fats essential for hormone production.

---

[01:01:05](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3665s) The Reproductive Cycle, Ovulation, and Implantation

To understand how exercise impacts fertility, one must examine the feedback loop between the brain and ovaries. At the start of a menstrual cycle, a cohort of eggs emerges from the ovary's "vault," each contained within a fluid-filled sac called a follicle. The brain releases follicle-stimulating hormone (FSH) to grow a single follicle. As this follicle expands over roughly two weeks, it secretes estrogen into the bloodstream. Because the brain cannot directly observe the ovaries, it relies on circulating estrogen to measure egg maturity. When estrogen reaches a specific threshold—specifically $200\text{ pg/mL}$ maintained for 50 hours—the brain triggers a surge of luteinizing hormone (LH).

This LH surge causes the follicle to rupture and release the mature egg into the fallopian tube. After ovulation, the ruptured follicle reforms into a temporary endocrine structure known as the corpus luteum. Stimulated by LH, the corpus luteum produces progesterone, which opens the implantation window in the uterine lining.

``` [ Brain / Pituitary ] / ^ FSH / \ Estrogen (Tells brain egg is mature) v \ [ Growing Follicle ] -------> [ Estrogen Secretion ] | (LH Surge) v [ Ovulation & Corpus Luteum ] ---> [ Progesterone ] ---> Opens Implantation Window ```

When sperm travels through the uterus into the fallopian tube, it fuses with the egg, injecting its DNA. The resulting single-cell zygote divides exponentially—from 2 cells to 4, 8, 16—until reaching the blastocyst stage (around 300 cells) by day 5 or 6, when it enters the uterus. If fertilization occurs and the blastocyst implants, it secretes human chorionic gonadotropin (hCG), which signals the corpus luteum to sustain continuous progesterone production until the placenta forms. If no embryo implants, the corpus luteum dies after 14 days; progesterone levels plummet, triggering menstruation.

* **Follicle Function:** Fluid-filled sac that houses the microscopic egg and produces estrogen as it matures. * **Estrogen Threshold:** $200\text{ pg/mL}$ sustained for 50 hours signals egg readiness to the brain to trigger the LH surge. * **Blastocyst Stage:** Reached at day 5 or 6 post-fertilization (~300 cells), the exact phase required for uterine implantation. * **Corpus Luteum Lifespan:** Exactly 14 days without hCG stimulation; its breakdown leads to progesterone withdrawal and period onset.

---

[01:06:09](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3969s) How Exercise and Weight Shift Ovulatory Function

Exercise affects fertility through its impact on hypothalamic signaling. The hypothalamus acts as the central control tower, monitoring energy availability and systemic hormones before authorizing reproduction.

On one extreme, intense athletic training, competitive endurance sports, or severe calorie restriction (such as in eating disorders like anorexia) cause hypothalamic amenorrhea. When energy expenditure drastically exceeds intake, the hypothalamus shuts down FSH and LH secretion, recognizing that the body cannot sustain a pregnancy. "When the brain is turned off... it takes years of being in recovery for it to turn back on." The system requires extended periods of caloric stability to resume normal gonadotropin release.

On the opposite end, excess adipose (fat) tissue generates peripheral estrogen independently of the ovaries. Because the brain assumes estrogen originates solely from growing ovarian follicles, elevated baseline estrogen tricks the hypothalamus into believing an egg is already developing. Consequently, the brain suppresses FSH output, halting follicular growth and disrupting ovulation. In both men and women, excess weight disrupts the hypothalamic axis—converting testosterone to excess estrogen in men and blunting primary signal interpretation in women.

``` +-----------------------------------+ | Hypothalamic Energy / Hormone Monitor | +-----------------------------------+ | +-----------------------+-----------------------+ | | v v [ High Strain / Low Energy ] [ Excess Adipose Tissue ] (Intense Training / Anorexia) (Peripheral Estrogen) | | v v Suppresses FSH / LH Release Tricks Brain into Low FSH | | v v [ Hypothalamic Amenorrhea ] [ Anovulation & Infertility ] ```

* **Hypothalamic Amenorrhea:** Severe calorie deficits or extreme physical output suppress FSH and LH, stopping ovulation entirely. * **Adipose-Derived Estrogen:** Fat cells convert steroids into peripheral estrogen, downregulating pituitary FSH release and stalling egg development. * **Metabolic Benefit:** Moderate exercise for individuals carrying excess weight reduces baseline peripheral estrogen, restoring the hypothalamic-pituitary-ovarian communication feedback loop.

[01:09:13](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4153s) Exercise, Muscle Mass, and the Hormonal Cycle

Dr. Natalie Crawford continues discussing the crucial role of exercise in fertility, emphasizing that weight management is vital for both men and women. For men, excess fat tissue increases the conversion of testosterone into estrogen, leading the brain to assume there is sufficient sperm and scale back testosterone production. This results in lower energy, weight gain, and a frustrating cycle where going to a Men's Health clinic leads to a prescription for testosterone replacement therapy (TRT), which ultimately drops sperm count to zero. Losing body fat through consistent movement can disrupt this cycle and restore normal reproductive signals.

When asked about exercise intensity, Dr. Crawford clarifies that regular daily movement is ideal, but extremes should be avoided. Training for a marathon while trying to conceive adds unnecessary physiological stress, whereas spending 60 minutes or less at the gym daily creates a healthy, normal level of muscle inflammation. Building muscle mass improves insulin resistance and helps the brain correctly interpret hormonal signals. Beyond physiological benefits, regular exercise helps manage stress and lower cortisol levels, making it as foundational for fertility as prioritizing sleep.

* **TRT Pitfall:** Men taking TRT for low testosterone unknowingly reduce their sperm count to zero because exogenous testosterone shuts down internal sperm production. * **Exercise Recommendation:** Moderate, consistent physical activity (up to 60 minutes daily) is ideal; avoid starting extreme endurance regimens like marathon training when trying to conceive. * **Cortisol & Insulin:** Building muscle improves insulin sensitivity and lowers cortisol, creating a more favorable endocrine environment for reproduction.

---

[01:10:58](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4258s) Defining a "Normal" Menstrual Cycle and How It Works

The host brings up his partner's experience with long-term menstrual disruption following dietary changes and struggles with eating, noting that her period stopped for three to four years before finally returning. Dr. Crawford defines a normal, healthy period as one that is regular and predictable. While 28 days is frequently cited as the textbook standard, a normal cycle length for most individuals ranges between 24 and 35 days, measured from day one of bleeding to the day before the next period starts.

``` Cycle Phase Overview: ┌─────────────────────────┬─────────────────────────┐ │ Follicular Phase │ Luteal Phase │ │ (Variable: Day 1-14*) │ (Fixed: ~14 Days) │ ├─────────────────────────┼─────────────────────────┤ │ Bleeding & Egg Growth │ Ovulation → Progesterone│ │ Estrogen Rises & │ Corpus Luteum Forms; │ │ Stabilizes Lining │ Drops if Not Pregnant │ └─────────────────────────┴─────────────────────────┘ *Day numbers vary depending on individual cycle length (e.g., Day 21 for a 35-day cycle). ```

Dr. Crawford breaks down the physiology of the cycle step-by-step: the brain releases follicle-stimulating hormone (FSH) to mature an egg inside an ovarian follicle. As the egg grows, it releases estrogen, which stops the bleeding from the previous month and rebuilds the uterine lining. Once the egg ovulates, the remaining follicle transforms into the corpus luteum, producing progesterone for a fixed two-week luteal phase. If pregnancy does not occur, progesterone levels fall, triggering the shedding of the uterine lining (menstruation).

* **Cycle Length Variance:** A normal cycle can range anywhere from 24 to 35 days; predictability is key. * **Luteal Phase Constancy:** The luteal phase is almost always fixed at 14 days due to the lifespan of the corpus luteum. * **Main Causes of Absent Periods (Amenorrhea):** * **Pregnancy:** The most common reason for a missed period. * **Anovulation (Lack of Eggs):** Running out of eggs or premature ovarian insufficiency. * **Hypothalamic Amenorrhea / Dysfunction:** Driven by over-exercising, severe calorie restriction, high stress, or chronic illness. * **Pituitary & Thyroid Disorders:** Elevated prolactin or excess thyroid-stimulating hormone (TSH) diverting energy from FSH/LH production. * **Polycystic Ovary Syndrome (PCOS):** Miscommunication between the brain and ovaries, representing one of the leading causes of female infertility.

---

[01:14:50](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4490s) Calculating the Fertile Window and Intercourse Timing

Dr. Crawford critiques popular cycle-tracking apps for assuming everyone ovulates on day 14, emphasizing that a woman's fertile window depends entirely on her unique cycle length. The fertile window consists of the 5 days leading up to ovulation plus the day of ovulation itself. This timing aligns with reproductive biology: a shed egg lives for only 24 hours in the fallopian tube, whereas sperm can survive inside the female reproductive tract for up to 5 days (with 2 to 3 days being the average peak lifespan).

To calculate the fertile window, subtract 14 days (the fixed luteal phase) from the total cycle length: * **28-Day Cycle:** $28 - 14 = \text{Day } 14$ (Fertile window: Days 9–14). * **35-Day Cycle:** $35 - 14 = \text{Day } 21$ (Fertile window: Days 16–21).

> "Sperm can live in the female reproductive tract for 5 days... put some of that sperm from the locker there a little bit earlier, and then get some there right at the time when you're ovulating to see if you can fertilize that egg."

Dr. Crawford cautions against the widespread myth that couples should "save up" sperm by abstaining from sex until ovulation. Holding back reduces overall frequency and can actually harm sperm motility and quality. Instead, for couples with regular cycles, having intercourse every day or every other day eliminates the stress of tracking while ensuring sperm is consistently present when the egg arrives.

* **Egg Lifespan:** Approximately 24 hours after ovulation. * **Sperm Lifespan:** Up to 5 days inside the female reproductive tract (typically 2–3 days). * **Common Mistake:** Abstaining from sex to "save up" sperm, which often leads to missing the fertile window entirely.

---

[01:17:06](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4626s) Age-Based Conception Rates and the Emotional Strain on Sex

The conversation shifts to how long couples should expect to try before successfully conceiving. Age plays a defining role in monthly conception probabilities: * **Age 30:** ~20% chance of pregnancy per month (most conceive within 6 months). * **Age 35:** ~10–15% chance per month. * **Age 38:** ~5–8% chance per month. * **Age 40:** ~3–5% chance per month.

Clinical infertility is officially defined as trying for 12 months without achieving pregnancy. However, Dr. Crawford stresses that "trying" assumes regular periods and full, unassisted intercourse with internal ejaculation. If a couple has irregular cycles or experiences pain or difficulty completing intercourse, they should seek medical help immediately rather than waiting a full year.

The host observes how tracking turn sex into a scheduled "chore," creating immense tension, resentment, and performance pressure—especially as couples delay parenthood into their late 30s. Dr. Crawford acknowledges that while tracking is a useful diagnostic window into overall health, the pressure can destroy intimacy. Setting realistic expectations early or utilizing interventions like freezing embryos via IVF can alleviate timeline pressure, allowing couples to reclaim a healthy, spontaneous sex life.

---

[01:20:11](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4811s) Intrauterine Insemination (IUI) vs. At-Home "Hacks"

For couples who face scheduling barriers (such as pilots, truck drivers, or shift workers) or who struggle with sexual frequency, medical alternatives exist. Dr. Crawford describes Intrauterine Insemination (IUI), where an ejaculated sperm sample is washed, centrifuged to isolate the concentrated sperm pellets, and placed directly into the uterus via a thin catheter.

She explicitly warns against dangerous DIY attempts at home, such as inserting raw semen into the uterus using a turkey baster or syringe. Raw ejaculate contains seminal fluid designed to buffer against vaginal acidity; placing unwashed semen directly into the uterine cavity causes severe infection, cramping, and severe inflammatory reactions. She also addresses common myths like inserting tampons or menstrual cups after sex to "hold sperm in," noting these methods offer no medical benefit and can cause irritation.

---

[01:22:07](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4927s) The "Dark Web" of Unregulated Sperm Donation

Dr. Crawford highlights a growing and risky trend: individuals turning to unregulated online spaces and Facebook groups to source donor sperm rather than using established sperm banks. While sperm banks charge around $1,000 per vial (plus $1,000–$2,000 per IUI cycle) and enforce strict medical screening, genetic testing, and legal protections, informal donor arrangements lack safety regulations and legal safeguards.

To illustrate the legal perils, Dr. Crawford shares a high-profile case from Oklahoma involving a lesbian couple who sought donor sperm through a Facebook group to avoid clinic costs. They met the donor in person, and he provided sperm for free after they signed a non-formal private contract waiving his parental rights. However, the donor later changed his mind and sued for legal custody. Because the arrangement took place outside an accredited medical facility and without proper legal channels for third-party reproduction, the court awarded the sperm donor joint legal custody of the child.

* **Sperm Bank Costs:** ~$1,000 per vial, plus $1,000–$2,000 per clinical insemination cycle. * **Risks of Informal Donors:** Absence of infectious disease screening, lack of genetic testing, and severe legal exposure regarding custody and parental rights. * **Third-Party Reproduction:** Covers donor eggs, donor sperm, gestational carriers, and donor embryos, all of which require rigorous legal and medical protocols to protect parentage.

[01:24:41](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5081s) PCOS Explained

Polycystic ovary syndrome (PCOS) is a highly prevalent but heavily undiagnosed condition. While standard statistics place its prevalence around 10% to 13% of the population, up to 70% of people with PCOS remain undiagnosed, meaning the real number is significantly higher.

In essence, PCOS can be described as being born with more eggs in your "vault." Because you have a larger reserve, a greater number of eggs are sent out into the ovaries every single month. This occurs because the normal in-utero decline of eggs—from six to seven million at five months gestation down to one to two million at nine months—did not happen, likely due to something the mother did or was exposed to during pregnancy.

Because the brain does not realize there is an abnormally high number of eggs, it secretes a standard amount of follicle-stimulating hormone (FSH). This FSH, which acts like "food" or water for a plant to select and grow a single egg, gets diluted across 20 or 30 eggs instead of the typical amount. Consequently, no single egg receives a strong enough signal to grow reliably or predictably, resulting in irregular or absent menstrual cycles.

- **Prevalence:** Officially 10–13% of the population, but likely much higher since 70% of cases are undiagnosed. - **The Mechanism of FSH:** In PCOS, standard FSH levels are diluted among too many eggs, preventing any single follicle from maturing predictably. - **Ovarian Boredom:** When eggs fail to grow, the ovary stops producing estrogen and upregulates the production of testosterone instead.

[01:27:17](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5237s) Symptoms and Medical Interventions for PCOS

The excess testosterone produced by the ovaries drastically alters a woman's metabolism and body shape. It increases the risk of insulin resistance and causes weight gain to accumulate abdominally—akin to a male "beer belly"—rather than on the hips and thighs. It also causes intense androgenic symptoms like acne, facial hair growth, and male-pattern baldness, which severely impact quality of life. As weight increases, peripheral estrogen confuses the brain into sending out even less FSH, creating a vicious metabolic cycle.

To combat PCOS for those trying to conceive, doctors use ovulation induction medications like Clomid or Letrozole to signal the brain to secrete stronger pulses of FSH. To break the testosterone cycle outside of pregnancy tracking, medications like metformin or spironolactone are prescribed. Birth control pills are also frequently used because they supply estrogen and progesterone while stimulating the liver to produce sex hormone-binding globulin (SHBG). SHBG binds to free testosterone, dropping its clinical levels and clearing up acne and hair growth. Often, when women with PCOS first come off the pill, they experience a temporary window of regular ovulation before their androgen levels inevitably climb back to baseline.

- **Androgen Symptoms:** Abdominal weight gain, severe acne, hirsutism (facial hair), and male-pattern baldness. - **Ovulation Induction Medications:** Clomid and Letrozole work by forcing the brain to release more FSH. - **Testosterone Blockers:** Metformin, spironolactone, and oral contraceptives help manage insulin resistance and lower free testosterone via SHBG.

[01:29:44](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5384s) The Sensitivity of the PCOS System and Diagnosis

Managing PCOS is like managing a highly sensitive "teeter-totter of balance." Extra stressors, such as elevated cortisol or lifestyle shifts, can easily tip the hormonal system away from ovulation. While weight loss is heavily encouraged for overweight patients to help restore balance, it is a dangerous misconception that all women with PCOS are overweight; many thin individuals are born with a high egg count and suffer from the exact same condition. Furthermore, even if a person lives a perfect, stress-free, anti-inflammatory life, PCOS is a disease, and failing to ovulate regularly is not a personal failure. In many cases, medical interventions like ovulation induction, egg freezing, or IVF are fundamentally necessary to achieve pregnancy.

A formal diagnosis of PCOS requires meeting at least two out of three specific diagnostic criteria: 1. Seeing a high volume of eggs (polycystic appearance) on an ultrasound scan. 2. Demonstrating high androgen signs, either via elevated testosterone blood values or clinical symptoms like acne and excess hair growth. 3. Having irregular or completely absent periods.

[01:31:34](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5494s) Different Origins of PCOS and the Aging Factor

While the primary ideology of PCOS is genetic or epigenetic—rooted in the prenatal environment and maternal insulin resistance—individuals can also "back into" a PCOS presentation through severe obesity. Excess adipose tissue produces its own estrogen, which signals the brain to lower FSH output. Without a strong enough FSH signal, the ovaries fail to mature an egg, grow "bored," and begin producing testosterone. Because medical syndromes are defined by the cluster of symptoms a patient presents rather than a single source, these different origins yield the same clinical diagnosis.

Many women claim to have completely "healed" or cured their PCOS in their late 30s through lifestyle changes. While lifestyle improvements certainly help the ovaries respond better to hormonal signals, the reality is often related to age. Because women lose eggs every month, a woman with PCOS will eventually reach an age—such as 38—where her remaining egg count drops down to a normal range. At that point, the brain's standard FSH signal is no longer diluted, and the ovaries begin responding normally. Notably, women with PCOS still go through menopause at the same average age as everyone else because they simply lose their higher volume of eggs at a more rapid pace.

[01:33:50](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5630s) The Link Between PCOS and Endometrial Cancer

Anovulation—the irregularity or total absence of a period—is the top cause of infertility, and PCOS is its leading driver. It is vital to recognize that living without a period while not on hormonal contraception is extremely dangerous for long-term health. In a PCOS patient, the abundance of small follicles produces a low, constant stream of estrogen. While not enough to trigger ovulation, this continuous estrogen stimulation causes the lining of the uterus (the endometrium) to keep growing. Without ovulation, the body never produces progesterone, which means the uterus never receives the signal to shed its lining. This unchecked cellular growth creates a very significant risk for endometrial cancer.

- **The Cancer Risk:** Continuous estrogen stimulation without progesterone to trigger a withdrawal bleed places anovulatory PCOS patients at high risk for uterine/endometrial cancer. - **Medical Necessity of Progesterone:** Doctors must prescribe cyclic progesterone or birth control pills to force the lining to shed and clear out these cells.

Conversely, losing a period due to extreme exercise shuts down the brain's FSH signal entirely, leaving the body with dangerously low estrogen levels. Much like natural menopause, prolonged low estrogen early in life deprives the body of its primary health protector, drastically elevating the risks for heart disease, stroke, dementia, Alzheimer's, and severe bone disease like osteoporosis and hip fractures. Young women in their 20s often dismiss a missing period as a convenience, but lacking estrogen causes brain fog, fatigue, and cognitive cloudiness. Replacing estrogen in women whose ovaries aren't producing it is critical for both immediate quality of life and long-term longevity.

[01:37:02](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5822s) What Is Endometriosis & How Do You Know You Have It

Endometriosis is an inflammatory, autoimmune-like condition centered around the endometrium, which is the internal lining of the uterus that grows for pregnancy and sheds during a period. During a normal menstrual cycle, the contracting uterus squeezes, causing some endometrial cells to naturally migrate backward out through the Fallopian tubes. If a surgeon performs an appendectomy on any standard woman while she is on her period, finding menstrual blood in the abdominal cavity is completely normal.

The pathology of endometriosis occurs when the body has an abnormal, hyper-reactive response to these displaced cells. Instead of ignoring them, the immune system views them as foreign invaders and launches an aggressive "attack, attack, attack" response. Because these displaced implants are made of endometrial tissue, they remain highly responsive to estrogen, growing and swelling with every ovulatory cycle. This chronic immune response creates intense inflammation, which is the primary driver of pain.

- **Hallmark Symptoms:** Exceptionally painful periods and deep pelvic pain during intercourse (frequently noticed in positions that alter the vaginal angle, such as when the woman is on top). - **Impact on Fertility:** The chronic inflammatory environment is highly toxic to cell growth and early embryo development, leading to higher rates of infertility and miscarriage. Over time, the inflammation turns into scar tissue, which can physically obstruct and destroy the anatomy, entirely blocking the Fallopian tubes. - **Surgical Diagnosis:** Endometriosis cannot be diagnosed via a simple blood test because science has not yet identified the correct biomarkers. It remains a strictly surgical diagnosis requiring a laparoscopy, where a camera is inserted through the belly button to inflate the abdomen and physically visualize the implants.

[01:40:57](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6057s) Understanding Endometriosis and its Hidden Link to Infertility

Dr. Natalie Crawford explains that experiencing debilitating pain during menstruation—such as canceling dinner or missing school—is not normal and serves as a major red flag for endometriosis. The disease occurs when tissue similar to the lining of the uterus grows outside the womb, triggering severe, chronic inflammation. A significant hurdle in managing endometriosis is that standard medical treatments aim to stop ovulation because estrogen continuously fuels disease progression, even from a single cell. Consequently, a patient cannot actively receive disease treatment while simultaneously trying to conceive. Every natural ovulatory cycle spent trying to get pregnant causes the underlying endometriosis to progressively worsen.

``` +-----------------------------------------------------------------------+ | THE ENDOMETRIOSIS DILEMMA | | | | [Medical Treatment] ---> Suppresses Ovulation ---> No Pregnancy | | [Trying to Conceive] ---> Requires Ovulation ---> Endo Worsens | +-----------------------------------------------------------------------+ ```

While endometriosis affects roughly 10% of the general female population, its prevalence jumps to 30%–50% among patients presenting at fertility clinics. Because the condition does not disrupt the hormonal communication between the brain and ovaries, women with endometriosis often maintain perfectly regular menstrual cycles. They may suffer from painful intercourse or severe period cramps, but because their cycles appear predictable, their inability to conceive is frequently misdiagnosed as "unexplained infertility."

To overcome this inflammatory barrier, many patients turn to In Vitro Fertilization (IVF). IVF allows specialists to retrieve eggs and fertilize them in a controlled, non-inflammatory laboratory environment with optimized temperature and pH levels. Once healthy embryos are grown, clinicians can temporarily suppress the patient's endometriosis with medication, prepare the uterine lining using supplemental estrogen, and transfer the embryo back into the uterus without requiring natural ovulation.

- **Prevalence in General Population:** ~10% of all women. - **Prevalence in Fertility Clinics:** 30%–50% of women struggling with infertility. - **Impact on Menstrual Cycles:** None; periods typically remain regular because brain-ovary signalling is unaffected.

---

[01:44:13](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6253s) Ovulation Suppression and Protective Strategies

When asked whether suppressing cycles with medication for 5 to 10 years impacts long-term fertility, Dr. Crawford provides a reassuring perspective. Using combined oral contraceptive pills (which contain synthetic estrogen and progesterone) or medications like Lupron halts ovulation by tricking the brain. Because synthetic estrogen does not stimulate endometriosis tissue the way natural ovarian estrogen does, these medications effectively put a "pause button" on the progression of the disease.

Studies reveal that women who suppress their cycles via birth control for prolonged periods do not suffer from diminished fertility upon stopping. In fact, when compared to age-matched peers with untreated endometriosis who continued ovulating, those who suppressed their cycles often demonstrate higher success rates when trying to conceive later. While suppression does not cure or eradicate existing endometriosis, preventing monthly inflammatory flare-ups keeps the condition from deteriorating. Dr. Crawford emphasizes that utilizing this protective strategy requires early detection or at least a high clinical suspicion of the disease.

---

[01:45:57](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6357s) Proactive Family Planning: Endo, PCOS, and Embryo Banking

When consulting a newly diagnosed endometriosis patient, Dr. Crawford’s first step is an honest, strategic conversation about age and desired family size. Endometriosis accelerates egg loss because inflammation destroys eggs inside the ovarian reserve ("the vault"). If a 25-year-old patient desires a large family—such as four children—starting naturally at age 30 carries significant risks. The traditional, reactive approach to medicine forces couples to try naturally for a full year before offering diagnostic testing. Dr. Crawford strongly advocates dismantling this outdated model for patients with medical conditions like endometriosis or Polycystic Ovary Syndrome (PCOS).

Instead of waiting for failure, high-risk patients should run proactive diagnostics immediately, including ovarian reserve testing, checking fallopian tube patency, and analyzing partner sperm quality. For those wanting multiple children, Dr. Crawford recommends shifting from "family reaction" to true **Family Planning** via embryo banking. Individuals with PCOS make exceptional candidates for embryo banking due to their high egg counts, yielding a substantial return on investment.

``` NATURAL CONCEPTION TIMELINE (Desiring 4 Children starting at Age 30)

Age 30 Age 32-33 Age 35-36 Age 38-40 Baby #1 -----> Baby #2 -----> Baby #3 -----> Baby #4 (High risk of genetic abnormalities & loss) ```

- **Ovarian Reserve Depletion:** Inflammation from endometriosis destroys eggs at an accelerated rate. - **Proactive Diagnostic Checklist:** 1. Ovarian reserve testing (AMH / antral follicle count). 2. Fallopian tube patency evaluation (HSG test). 3. Comprehensive semen analysis. - **Natural Baseline for Large Families:** Statistically, achieving a 4-child family naturally usually requires starting before age 28.

---

[01:50:28](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6628s) Egg Freezing vs. Embryo Freezing: Survival Rates and Drop-Off Statistics

Addressing the differences between freezing unfertilized eggs versus frozen embryos, Dr. Crawford notes that the physical process for the woman is identical: roughly two weeks of daily Follicle-Stimulating Hormone (FSH) injections to stimulate a cohort of eggs, followed by a brief outpatient retrieval procedure under anesthesia. However, the cellular resilience and predictive value of frozen eggs versus embryos differ dramatically. Frozen eggs represent *potential opportunities*, whereas embryos offer concrete diagnostic data.

An unfertilized egg is a fragile single cell largely composed of fluid, making it vulnerable to damage during freezing and thawing. Modern vitrification techniques yield a ~90% thaw survival rate for eggs (up from historical rates of ~40% a decade ago). In contrast, a blastocyst embryo consists of 300 to 500 cells, allowing it to achieve a >99% thaw survival rate. Furthermore, "the proof of the pudding is seeing how the embryos grow." Even with normal-looking eggs and sperm, significant drop-offs occur at every stage of the developmental pipeline.

``` EGG-TO-EMBRYO ATTRITION PIPELINE (Example: 30-Year-Old Patient)

[ 20 Eggs Retrieved ] │ (-2 lost during thaw) ▼ [ 18 Thawed ] │ (75-80% fertilization rate) ▼ [ 14 Fertilized ] │ (50% drop-off before blastocyst stage) ▼ [ 7 Blastocysts ] │ (60-70% euploidy rate at age 30) ▼ [ 4 Euploid (Normal) Embryos ] ```

- **Egg Thaw Survival Rate:** ~90%. - **Embryo Thaw Survival Rate:** >99%. - **Expected Fertilization Rate:** 75%–80% of mature thawed eggs. - **Developmental Attrition:** ~50% of fertilized eggs fail to reach the blastocyst stage. - **Age-Based Euploidy (Genetically Normal Embryo) Rates:** - **Age 30:** 60%–70% normal. - **Age 35:** ~50% normal. - **Age 38:** ~33% normal. - **Age 40:** 20%–25% normal.

---

[01:54:05](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6845s) Live Birth Probabilities and Financial Costs

Dr. Crawford outlines the gold standard for fertility planning: aiming for **2 to 3 genetically normal (euploid) embryos per desired child**. A single euploid embryo transferred into the uterus yields roughly a 65% chance of a live birth. Transferring two euploid embryos sequentially (one at a time across separate cycles) elevates the cumulative live birth rate to 88%, while transferring three reaches a 95% cumulative success rate. This high success rate proves that the primary driver of IVF failure is usually a lack of genetically normal embryos rather than implantation failure.

When comparing costs, egg freezing typically costs roughly half as much as a full IVF cycle with embryo freezing and genetic testing. In the United States, an egg freezing cycle averages around $10,000, whereas a complete IVF cycle with preimplantation genetic testing (PGT) runs approximately $20,000. Yearly storage fees for frozen eggs or embryos range between $500 and $1,500. While egg freezing is financially advantageous for single women or patients with limited funds who need to maximize egg collection across multiple cycles, embryo freezing remains the far more reliable path to securing future family goals.

Here is a detailed, faithful walkthrough of this section of the transcript, capturing the specific facts, numbers, arguments, and conversational nuances.

---

[01:56:46](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7006s) The Stigma Surrounding IVF, Egg Freezing, and Relationship Conversations

The discussion begins with the emotional hurdles and societal stigma surrounding fertility treatments. Many individuals in their late twenties or early thirties reflexively reject options like egg freezing or IVF because of the pervasive narrative that requiring medical assistance means "you're broken" or that the process is "not natural." Movies and social media platforms like Instagram present a romanticized, effortless vision of conception—where a couple simply has sex and instantly gives birth to "little Bernie." This idealization often prevents open conversations about reproductive planning before problems arise.

The host shares a personal perspective, confessing he felt scared to bring up egg freezing with his partner because proposing, "hey babe, I think... you should freeze your eggs," feels "loaded with... a bunch of feelings." Dr. Crawford commends him for taking that step, explaining that many couples fail to align on family goals early on. When she asks new patients how many children they want or what their ideal family size looks like, she is frequently met with silence because the couple has never discussed it.

Dr. Crawford notes that stigma largely stems from fear of the unknown. She emphasizes that while some women successfully get pregnant unassisted later in life, relying on being part of that small statistical minority is a poor strategy for achieving a major life goal.

- **Overcoming Stigma:** Open dialogue normalizes fertility terms and helps reframe medical assistance as proactive planning rather than personal failure. - **The 3% Reality:** While approximately 3% of women may conceive naturally at an advanced reproductive age, Dr. Crawford calls relying on those odds "a very inefficient way to try to achieve a life goal." - **Couples Alignment:** Family planning requires both partners to be on the same page regarding desired family size and timelines before time runs out.

---

[01:58:42](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7122s) Sponsor Break: Shopify

The host transitions into a brief promotional segment for the podcast sponsor, Shopify. He contrasts how difficult it used to be to start a business with how simple modern digital tools make the process.

- **E-Commerce Growth:** The host highlights using Shopify to sell products like conversation cards with just a few clicks. - **Conversion Advantage:** He cites that Shopify's checkout system converts up to **36% better** than competing platforms. - **Special Offer:** Listeners are offered a trial period for **$1 per month** by visiting `[shopify.com/bartlett](https://shopify.com/bartlett)`.

---

[01:59:32](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7172s) Shifting Demographics and the Optimal Age to Freeze Eggs

Returning to the topic, the host references a *Time Magazine* statistic illustrating how drastically family timing has shifted: in 1970, the average American woman had her first child at **age 21**, whereas by 2022, that average had risen by six years to **age 27**. This shift is driven by modern social desires for longer career building and personal freedom in early adulthood. However, Dr. Crawford stresses that while lifestyle preferences have evolved, human biology has not. The trade-off for delaying family building shouldn't be giving up on having children, but rather being open to intervening medically to safeguard that goal.

When asked about the optimal window for egg freezing, Dr. Crawford references research indicating that **ages 32 to 33** represent the key tipping point for the average person who is not yet ready to conceive. This recommendation accounts for the statistical likelihood of when someone will start trying, rates of age-related infertility, and the steep decline in both egg quantity and egg quality after age 32.

She stresses that if a woman knows earlier in her twenties that she wants to freeze eggs, she shouldn't wait until 32; however, 32 to 33 is the critical deadline to consult a fertility specialist. Even if a woman ultimately decides against freezing her eggs, empowering herself with data—such as evaluating her ovarian reserve and understanding her individual baseline—drastically reduces the potential for future regret compared to realizing too late that the opportunity has passed.

- **Demographic Shift:** Average age at first birth in the US increased from **21 (in 1970)** to **27 (in 2022)**. - **Optimal Intervention Window:** **Ages 32–33** is identified as the crucial timeline to evaluate fertility and consider egg freezing if family building is delayed. - **Mitigating Regret:** Making an active, informed choice not to freeze eggs causes far less psychological regret later in life than remaining ignorant of one's fertility status until options are gone.

---

[02:01:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7305s) A "Dummies Guide" to IVF and Genetic Screening

Dr. Crawford breaks down In Vitro Fertilization (IVF) into its core mechanics: extracting an egg and sperm, fertilizing the egg outside the body in a laboratory dish ("in vitro" meaning "in glass"), and placing the resulting embryo back into the uterus. In modern fertility medicine, doctors take a single month's cohort of eggs, grow them into embryos, perform genetic testing, and freeze them prior to transfer.

The primary form of genetic testing evaluates **aneuploidy**—checking whether an embryo has the correct number of chromosomes. Because chromosome errors increase sharply with maternal age, screening a 5- to 8-cell biopsy from the embryo ensures that only genetically normal (**euploid**) embryos are selected. Missing a chromosome leads to implantation failure or miscarriage, while extra chromosomes cause conditions like Down syndrome (Trisomy 21).

Beyond chromosome counts, IVF allows parents to eliminate specific hereditary genetic diseases from their family line. For instance, if both parents carry the recessive gene for cystic fibrosis, their child has a **25% chance** of being severely ill. Fertility specialists can construct a custom genetic probe targeted at the specific mutation on **chromosome 7** to screen the biopsied embryo cells, ensuring that only embryos without the disease-causing mutations are transferred. This technology can similarly eradicate autosomal dominant conditions like Huntington's disease or hereditary cancer syndromes.

- **Definition of IVF:** Extracting gametes, fertilizing them in a petri dish, culturing embryos, and transferring them to the uterus. - **Chromosome Screening (PGT-A):** Biopsying 5 to 8 cells from an embryo to verify proper chromosome counts (euploidy) and avoid miscarriages or chromosomal disorders. - **Targeted Single-Gene Testing (PGT-M):** Eliminating inherited conditions like cystic fibrosis (located on chromosome 7) or Huntington's disease before pregnancy occurs.

---

[02:04:18](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7458s) Single Embryo Transfer vs. Multiple Transfers and Twinning Risks

Dr. Crawford explains how clinical practices surrounding embryo transfers have evolved. In the past, before preimplantation genetic testing existed, a 40-year-old patient with four frozen embryos might have multiple embryos transferred simultaneously because doctors could not identify which single embryo was genetically normal. Today, genetic testing allows specialists to identify the single euploid embryo, making single embryo transfer (SET) the gold standard.

Dr. Crawford strongly cautions against transferring multiple embryos at once, advising: "don't make them compete for resources. Let that embryo have the full surface area of the uterus to have a really nice placenta to grow into." Transferring two embryos does not meaningfully increase the overall pregnancy rate; it primarily spikes the risk of twin pregnancies and downstream obstetric complications.

Even with a single embryo transfer, there remains a slight risk of identical twinning (where one embryo splits into two). In natural conception, identical twins occur in about **0.5%** of pregnancies. In IVF, that rate rises to approximately **2% to 3%**, likely due to physical manipulation of the embryo's outer shell (zona pellucida) during biopsy or when loaded into the transfer catheter. For a physician performing ~400 embryo transfers a year, identical twins occur regularly. Furthermore, transferring two embryos carries the hazardous risk of both splitting, potentially resulting in high-order multiples like triplets or quadruplets.

- **Single Embryo Transfer (SET):** Maximizes uterine surface area and placental development while minimizing high-risk multiple pregnancies. - **Identical Twinning Rates:** Occurs in **~0.5%** of natural conceptions versus **2%–3%** in IVF procedures. - **Annual Case Volume:** Dr. Crawford notes performing roughly **400 embryo transfers per year** in her practice.

---

[02:06:28](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7588s) Debunking Common Myths About Natural Conception

The conversation shifts to common urban legends and misconceptions surrounding natural intercourse when trying to conceive. The host mentions popular advice like women putting their legs in the air after sex or worrying that urinating afterward will "pee out all the sperm." Dr. Crawford systematically dismantles these myths with biological facts:

1. **"Saving Up" Sperm:** Couples often abstain from sex to save up sperm for the exact day of ovulation. Dr. Crawford notes there is no need to abstain; "clearing the pipes" regularly keeps sperm fresh and healthy, preventing the accumulation of dead sperm. Sperm can survive inside the female reproductive tract for up to **5 days**, so having intercourse every day, every other day, or every three days leading up to ovulation is ideal. 2. **Post-Sex Positions and Rest:** Sperm move remarkably fast, traveling from the vagina, through the cervical mucus and uterus, and into the fallopian tubes within **2 to 5 minutes**. Resting with hips propped on pillows for 30 minutes is unnecessary. 3. **Urinating After Sex:** Women cannot "pee out" sperm because the urethra and vagina are entirely separate structures. Urinating immediately after sex is strongly encouraged because it flushes bacteria and significantly reduces the risk of urinary tract infections (UTIs). 4. **Gravity and Fertilization:** Embryos fertilize and implant while women are standing, walking, and going about their daily lives—lying horizontal is not required.

- **Sperm Lifespan:** Sperm survive up to **5 days** in the female reproductive tract. - **Sperm Velocity:** Sperm reach the fallopian tubes in under **5 minutes** (entering the cervix within **2 minutes**). - **UTI Prevention:** Urinating after sex protects against urinary tract infections without losing sperm.

---

[02:08:44](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7724s) Sex Positions, Female Orgasm, and Physical Attributes

Continuing on the mechanics of conception, Dr. Crawford clarifies that there is no specific sex position that guarantees a higher chance of getting pregnant or dictates the sex of the baby (boy vs. girl). Any position that allows for full ejaculation is effective. Because sex can start to feel like a stressful "chore" when struggling with infertility, introducing variety in positions is encouraged simply to keep intimacy enjoyable.

Regarding female orgasm, Dr. Crawford confirms that studies show an orgasm *does* aid fertility. The involuntary uterine contractions associated with female orgasm act as a mechanical pump, helping to propel sperm upward toward the fallopian tubes at a faster rate.

When asked about penis size, Dr. Crawford explains that it does not impact fertility or the ability of sperm to reach the destination, as sperm naturally navigate into the cervix regardless of penetration depth. Interestingly, medical data shows that average penis size across different ethnic populations tends to correlate naturally with corresponding average vaginal lengths, but physical size variations have no bearing on conception success.

- **Positions & Gender:** No position influences pregnancy success rates or baby gender. - **Role of Female Orgasm:** Uterine contractions during orgasm physically assist in propelling sperm through the reproductive tract faster. - **Penis Size & Infertility:** Penis size has zero functional impact on fertility outcomes.

---

[02:10:33](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7833s) Is the Birth Control Pill Healthy? Re-evaluating Oral Contraceptives

The host brings up the modern debate regarding whether hormonal birth control is healthy, acknowledging that every medical intervention involves trade-offs. Dr. Crawford reframes the issue: while the birth control pill itself is not inherently "unhealthy" or toxic, its historical misuse in medicine has created significant problems for women's long-term health.

For decades, doctors frequently prescribed the pill as a blanket band-aid to mask underlying symptoms—such as irregular periods or severe pain—without diagnosing the root cause (such as PCOS or endometriosis). As a result, a generation of women who were put on the pill in their teens come off it at age 35 to try for a baby, only to find their original underlying issues immediately return, leaving them diagnosed decades late and facing time-sensitive fertility struggles.

Dr. Crawford clarifies several key facts about oral contraceptives: - **No Direct Infertility:** The birth control pill **does not** cause long-term infertility or damage the ovarian egg vault. - **Egg Loss Continues:** The pill prevents ovulation by suppressing Brain-FSH (Follicle-Stimulating Hormone) via synthetic estrogen and progesterone; however, it does not "save" eggs. Eggs continue to die off naturally each month regardless of pill use. - **Metabolic Effects:** The pill can alter certain metabolic parameters and deplete specific vitamins, meaning individual experiences vary widely—some patients love it for managing severe endometriosis pain, while others tolerate it poorly.

- **Diagnostic Delay:** The main danger of birth control is using it to mask underlying reproductive disorders (PCOS, endometriosis) without diagnosing them early. - **Vault Impact:** Birth control does not preserve or deplete the total egg supply faster; natural egg attrition occurs continuously on or off the pill.

---

Here is a detailed, faithful walkthrough covering the final part of the interview with Dr. Natalie Crawford.

---

[02:12:20](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7940s) The Real Benefits and Social Media Stigma of Birth Control

Dr. Natalie Crawford directly addresses the social media backlash surrounding oral contraceptives, cautioning against viewing birth control through a single, negative lens. While platforms are flooded with claims that the pill harms one's health, Dr. Crawford clarifies that it serves vital medical purposes beyond preventing pregnancy. For individuals suffering from severe premenstrual syndrome (PMS) or Premenstrual Dysphoric Disorder (PMDD)—which causes severe mental health fluctuations as hormones shift—having stable hormone levels can be genuinely life-changing.

Furthermore, the birth control pill actively prevents endometrial cancer risks associated with PCOS, halts the progression of endometriosis, and manages chronic pelvic pain. While the pill itself does not cause long-term health damage, the true downside is that it often leads people to delay critical family planning conversations or remain oblivious to underlying hormonal issues. To avoid being caught off guard when trying to conceive, she strongly advises coming off birth control well before you plan to become pregnant. This allows individuals to observe whether their menstrual cycles are naturally regular and spot red flags early.

- **PMDD (Premenstrual Dysphoric Disorder):** Severe hormone-driven mental health shifts that can be stabilized using oral contraceptives. - **Therapeutic Benefits:** Suppresses endometriosis progression, lowers cancer risks tied to PCOS, and manages debilitating menstrual pain. - **Family Planning Strategy:** Discontinue birth control early to track natural cycle regularity and detect hidden fertility issues before actively trying to conceive.

---

[02:13:24](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8004s) Actionable Guidance for Those Struggling with Infertility

Addressing the thousands of listeners struggling with conditions like PCOS, endometriosis, or repeated IVF embryo failures, Dr. Crawford lays out clear, proactive steps. Her core philosophy is straightforward: "You can't control everything, but you should control what you can." Patients should aggressively optimize lifestyle factors like sleep and nutrition to eliminate self-doubt. Additionally, she urges individuals deep in fertility treatments not to get stuck repeating the same unsuccessful protocols out of habit or fear.

When progress stalls, seeking a second opinion is not a betrayal of your doctor—it is a necessary step to get fresh eyes on a time-sensitive issue. Dr. Crawford notes that her own clinic actively encourages patients to seek extra input because the reproductive window is inherently brief. She strongly warns against taking a passive, reactive approach. If you already know you have a pre-existing condition like PCOS or irregular, agonizing periods that disrupt daily life, do not wait through twelve months of failed attempts before seeking expert help.

- **Proactive Care Over Waiting:** Seek testing and a game plan immediately if you have known conditions like PCOS or severe pain, rather than waiting a full year of trying. - **Second Opinions:** Encouraged as a necessary step to bring a fresh perspective when treatments fail, given the limited reproductive timeframe. - **Red Flags in Healthcare:** Inability to communicate directly with your physician, lack of clear explanations, or ignored irregular cycles are signals to seek a new provider.

---

[02:15:30](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8130s) The Life-Changing Lesson Born From Miscarriage

Answering the signature closing question of *The Diary Of A CEO*—"What is the most difficult conversation that changed your life?"—Dr. Crawford shares a deeply personal memory from her time as chief resident on the busiest labor and delivery unit in America. While managing the floor and delivering babies for other families, she realized she was actively miscarrying in the hospital bathroom. Unable to step away from her duties, she pushed through C-sections and deliveries in silence before finally seeing her own OB-GYN at the end of the shift.

Devastated by the loss, she received words from her doctor that would forever reshape her perspective on pain, fertility, and patient care: "It's really hard to understand the meaning when you're in the middle of the journey, but one day the world makes sense... it's your job to not give up hope and to stay on the path." Her doctor reassured her that she would eventually have the child she was meant to have.

Looking back tearfully at her daughter today, Dr. Crawford recognizes the truth in those words—had those earlier pregnancies resulted in birth, the specific egg that became her daughter would have been lost during pregnancy. This experience taught her that while the pain of fertility struggles makes no sense in the moment, staying on the path can lead to the children who were meant to be.

> *"It's really hard to understand the meaning when you're in the middle of the journey, but one day the world makes sense and it's your job to not give up hope and to stay on the path."*

- **The Chief Resident Experience:** Suffered a miscarriage silently mid-shift while actively delivering other patients' infants and performing C-sections. - **Biological Reality:** Ovulation pauses during pregnancy, meaning different eggs in the "vault" are recruited later—making specific children unique to the timing of past losses. - **Doctor-Patient Paradigm:** Translating personal grief into deep empathy, allowing her to hold space for her patients' heartbreak without sugarcoating reality.

---

[02:18:15](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8295s) Navigating Heartbreak, Hard Truths, and Loss in Medicine

Dr. Crawford reflects on the emotional toll of practicing medicine in the fertility space, admitting that she carries her patients' heartbreaks home with her every day. She refuses to distance herself emotionally, choosing instead to grieve with her patients and offer unflinching, honest truth. Sometimes that truth requires telling couples that conceiving a genetically linked child is no longer possible. In those moments, her role shifts to guiding families toward alternative pathways such as donor eggs, donor sperm, donor embryos, or adoption—reframing the dream from achieving a specific genetic link to simply welcoming a child into a loving home.

When host Stephen Bartlett asks about her hardest day at work, Dr. Crawford recalls the agonizing losses experienced during her obstetrics training—fetal deaths, stillbirths, and the lingering sound of grieving parents' screams. She emphasizes that pregnancy is far from "health neutral" and carries real risks that must be understood. Despite the intense pain, she considers her role both the hardest and best job in the world, grateful to light the path for prospective parents navigating the dark uncertainties of family building.

- **Alternative Family Building:** Pivoting to donor gametes or embryos when genetic plans are no longer viable. - **Obstetric Realities:** Pregnancy carries inherent physical and medical complications that require realistic understanding rather than romanticized assumptions. - **Closing Gratitude:** Stephen Bartlett thanks Dr. Crawford for making high-level fertility expertise accessible to millions, while Dr. Crawford thanks him for breaking the social stigma surrounding reproductive health.

## Notable quotes > [18:49](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1129s) If you're having very long abstinence periods in between your intercourse times, you're going to have a sample that has so much debris and dead sperm in it that it's going to make it hard for the good guys to do their job. — Dr. Natalie Crawford

> [02:20:15](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8415s) Taking testosterone yourself is telling your brain that there is testosterone present... the hormones from your brain stop being sent out and no longer tell your testicle to make any more testosterone or any more sperm. — Dr. Natalie Crawford

> [39:33](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2373s) It is like having kindergarteners stand in a line for 40 years—somebody's going to get out of line. — Dr. Natalie Crawford

> [42:31](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2551s) the opposite of confronting the truth is regret. — Stephen Bartlett

> [45:23](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2723s) You can't make decisions on data you don't know. — Dr. Natalie Crawford

> [01:06:09](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3969s) When the brain is turned off... it takes years of being in recovery for it to turn back on. — Dr. Natalie Crawford

> [01:14:50](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4490s) Sperm can live in the female reproductive tract for 5 days... put some of that sperm from the locker there a little bit earlier, and then get some there right at the time when you're ovulating to see if you can fertilize that egg. — Dr. Natalie Crawford

> [01:46:13](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6373s) a very inefficient way to try to achieve a life goal — Dr. Natalie Crawford

> [01:52:58](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6778s) don't make them compete for resources. Let that embryo have the full surface area of the uterus to have a really nice placenta to grow into. — Dr. Natalie Crawford

> [02:02:04](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7324s) You can't control everything, but you should control what you can. — Dr. Natalie Crawford

> [02:04:10](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7450s) It's really hard to understand the meaning when you're in the middle of the journey, but one day the world makes sense... it's your job to not give up hope and to stay on the path. — Dr. Natalie Crawford's OB-GYN

## Mentioned Dr. Natalie Crawford, Stephen Bartlett, The Diary Of A CEO, Fora Fertility, Pinnacle Conference, World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), American College of Obstetricians and Gynecologists (ACOG), Dr. Amanda Skillern, Shopify, Clomid, Letrozole, Metformin, Spironolactone, Testosterone Replacement Therapy (TRT), PCOS, IUI, IVF, Time Magazine, Lupron, Endometriosis, PMDD, PGT-A, PGT-M

[Source](https://www.youtube.com/watch?v=w8h4qksd6Yw)

中文简报

卵巢储备下降，生育专家 Crawford 呼吁及早主动检测卵子流失加速与男性不育率上升，使32岁时的主动检测对计划生育多个孩子的群体而言至关重要。 Dr. Natalie Crawford 探讨了导致全球不孕不育率上升的关键因素，包括精子数量下降、随年龄增长的卵子消耗，以及睡眠、饮食和环境毒素等生活方式的影响。她深入剖析了生殖周期的机制、多囊卵巢综合征（PCOS）和子宫内膜异位症等常见病症，以及评估卵巢储备的诊断工具。此外，Crawford 医生还澄清了常见的受孕误区，解释了体外受精（IVF）和冻卵等流程，并为应对生育力保存及医疗干预提供了切实指导。生育健康应当作为前置预防性医疗及早管理；数据显示全球生育率正在大幅下滑，过去50年间男性精子数量减少了50%，且近10年的下降速率加快了一倍。 (7:47) 外源性睾酮替代疗法（TRT）会阻断脑下垂体信号并抑制自身精子生成，甚至导致无精子症；同时，笔记本电脑置于膝上、频繁泡热水澡等阴囊局部高温暴露也会严重破坏精子生成。 (30:15) 女性一生中的卵子储备不可逆地持续衰减并在37岁后急剧加速，由于细胞老化导致的染色体异常比例增加，40岁女性怀孕后的流产风险高达50%。 (39:33) 抗苗勒管激素（AMH）和超声窦卵泡计数用于评估卵巢卵子库存及绝经倒计时，但并不会降低单个月经周期内的自然受孕概率。 (42:31)

Reading summary

Fertility physician Dr. Natalie Crawford argues that modern family planning faces steep biological, lifestyle, and environmental obstacles, making the traditional reactive approach to reproductive health outdated. She contends that early diagnostic screening, cycle awareness, and proactive interventions such as embryo banking are necessary to prevent age-related regret and manage widespread underdiagnosed conditions. The Biology of Ovarian Reserve Depletion (34:42) Dr. Crawford conceptualizes female fertility as an "egg vault" that constantly diminishes over time, dropping from 1 to 2 million eggs at birth to roughly 300,000 by reproductive maturity, with an accelerated loss beginning around age 37. Each cycle, a cohort of follicles leaves the vault; this monthly recruitment declines from approximately 20 eggs at age 30 to 14–15 at age 35, 8–10 at age 40, and 3–4 by age 44. Consequently, natural monthly conception rates fall from roughly 20% at age 30 to 10–15% at age 35, and down to 3–5% by age 40, at which point the miscarriage rate reaches 50%. Addressing diagnostic evaluations, Dr. Crawford criticizes guidelines from organizations like the American College of Obstetricians and Gynecologists (ACOG) that discourage routine anti-Müllerian hormone (AMH) screening for asymptomatic women. She clarifies that while AMH does not predict natural monthly conception probability—because only one egg ovulates regardless of total reserve—it directly reflects a woman's reproductive runway and the number of eggs obtainable through IVF or cryopreservation, offering vital information for proactive decision-making. Managing Anovulation, PCOS, and Endometriosis (84:41) Anovulation is the primary driver of infertility, frequently caused by Polycystic Ovary Syndrome (PCOS), a condition characterized by a larger baseline egg reserve. In PCOS, standard pituitary secretions of follicle-stimulating hormone (FSH) become diluted across 20 to 30 follicles, preventing any single egg from receiving adequate stimulation to mature and ovulate. This creates a state of continuous low-level estrogen without the progesterone produced after ovulation, leaving the endometrial lining unshed and placing anovulatory PCOS patients at an elevated risk for endometrial cancer unless managed with cyclic progesterone or oral contraceptives. In contrast, endometriosis involves an aggressive inflammatory autoimmune response to displaced endometrial tissue that naturally backflows into the pelvis during menstruation. This chronic inflammation damages eggs within the ovarian reserve and degrades embryo development. Dr. Crawford notes that suppressing ovulatory cycles with oral contraceptives or medications like Lupron pauses the progression of endometriosis and prevents recurring inflammatory flares, preserving subsequent fertility without causing long-term ovarian harm. Environmental Disruptors, Heat, and Male Fertility (142:26) Reproductive decline is not solely a maternal age issue; global sperm counts have declined by roughly 50% over the last half-century due to lifestyle and environmental pressures. Chronic inflammation, elevated cortisol from sleep restriction, and chemical toxicants alter the hypothalamic-pituitary-gonadal axis in both sexes. Dr. Crawford advises minimizing daily toxicant exposures, specifically noting that cigarette smoking accelerates egg loss inside the vault, while handling bisphenol-coated thermal paper receipts, using non-stick cookware, and heating food in plastic containers leach endocrine-disrupting chemicals into the body. Regarding male fertility, Dr. Crawford differentiates between mobile phone radiation—which current data shows has minimal impact with modern smartphones—and scrotal heat exposure, which directly destroys sperm and testicular Leydig cells. She warns against the widespread clinical misuse of testosterone replacement therapy (TRT) for men trying to conceive; exogenous testosterone triggers negative feedback on the brain, shutting off gonadotropin signals to the testes and inducing azoospermia (a complete absence of sperm in the ejaculate), which carries a risk of permanent suppression. Proactive Family Planning and Assisted Reproduction (105:57) For individuals with underlying conditions or those planning to have multiple children, Dr. Crawford recommends shifting from passive waiting to proactive embryo banking. Clinical data indicates that establishing two to three genetically normal (euploid) embryos per desired child provides optimal security: a single euploid transfer yields a 65% live birth probability, rising cumulatively to 88% across two sequential transfers and 95% across three. She advises single embryo transfers to maximize uterine surface area and minimize obstetric risks, noting that IVF already carries an elevated identical twinning rate of 2% to 3% compared to 0.5% in natural conception. Finally, Dr. Crawford dispels several persistent conception myths. Because sperm can survive in the female reproductive tract for up to 5 days and reach the fallopian tubes within 2 to 5 minutes of ejaculation, practices such as elevating legs post-intercourse or abstaining to "save up" sperm are medically unnecessary and can compromise sperm motility. Dr. Crawford emphasizes that while assisted reproductive technologies provide reliable alternatives, they rely strictly on the existing monthly cohort of eggs and cannot reverse total ovarian reserve exhaustion. She argues that replacing cultural stigma with early reproductive literacy and open relationship communication is the most effective approach to preventing involuntary childlessness.

精炼阅读摘要

双重认证生育专科医生Natalie Crawford指出，全球生育能力正受到晚育趋势、环境毒素与代谢疾病的多重侵蚀；鉴于女性卵巢储备具有不可逆衰减且非整倍体率随年龄剧增的刚性生理规律，有意组建多子女家庭者需尽早从“被动等待”转向以储备评估和胚胎冷冻为核心的主动规划。宏观生育率下降与卵巢储备生物学极限 (34:42) 全球人口统计显示，全球活产率已从1950年的每名女性4.84人降至2021年的2.23人，预测到2100年将降至1.59人，而美国目前平均出生率仅为1.3人；临床上遭遇不孕症的女性比例已从早期的八分之一上升至五分之一。Crawford医生阐释，人类子宫在进化上适配单胎妊娠，受到严格的下丘脑-垂体-卵巢轴调控。女性卵子储备如同一个封闭且持续消耗的“保险库”：出生时拥有100万至200万颗卵子，进入育龄期降至约30万颗。30岁时每月约募集20颗卵泡并自然闭锁凋亡其余19颗；35岁降至14至15颗；40岁降至8至10颗；44岁仅剩3至4颗，且在37岁左右损耗显著加剧。年龄的增长直接制约自然受孕率与妊娠安全性。单月自然受孕概率从30岁的约20%持续递减至35岁的10%至15%、38岁的5%至8%，到40岁时仅为3%至5%，且40岁孕妇的流产风险高达50%。Crawford强调，这一断崖式下跌的主因并非子宫着床功能衰退，而是残存卵子减数分裂异常导致的胚胎染色体非整倍体率上升。绝经平均年龄约为51至52岁，但吸烟、卵巢子宫内膜异位症及环境毒素会显著加速库内卵子耗竭。卵巢储备评估争议与主动胚胎规划策略 (42:31) 临床主要通过抗苗勒氏管激素（AMH）血液检测与阴道超声窦卵泡计数（AFC）测定卵巢储备。针对美国妇产科医师学会（ACOG）建议无症状非备孕女性无需筛查AMH的指南（其理由为避免引发不必要焦虑且AMH不预测单月自然受孕率），Crawford持坚决反对态度。她指出，同龄女性无论AMH高低，单月均仅排卵一颗，自然受孕率相同；但低AMH预示着绝经前的时间跑道显著缩短，且在IVF促排卵中可挽救的卵子配额更少。剥夺女性对自身生殖数据的知情权，将使其丧失提前冷冻或调整家庭计划的主动权。针对渴望生育两名及以上子女的群体，Crawford主张颠覆“尝试一年失败方能就医”的传统滞后模式，转向以胚胎冷冻为核心的主动规划。临床推荐标准为每计划生育一名健康婴儿，应储备2至3个经植入前遗传学筛查（PGT）正常的整倍体胚胎：单整倍体胚胎单次移植活产率约为65%，累积移植两枚升至88%，三枚可达95%，单胚胎移植亦可规避双胎妊娠的高并发症风险。在美国，单次冻卵周期均价约10,000美元，而包含遗传学检测的完整IVF周期均价约20,000美元，冷冻胚胎比单纯冻卵具有更明确的活产可预测性。多囊、内异症病理及避孕药的双重效应 (84:41) 无排卵是不孕症的首要诱因，其中多囊卵巢综合征（PCOS）在人群中官方患病率为10%至13%，但因70%未确诊，实际比例远高于此。PCOS本质为先天卵巢储备过高，导致脑垂体分泌的标准FSH浓度被数十个卵泡稀释，无法促成单一优势卵泡排卵，未发育的卵巢进而异常分泌过量睾酮。持续无排卵使子宫内膜长期暴露于单一雌激素刺激而缺乏孕激素拮抗，显著推高子宫内膜癌发病风险。与之相对，子宫内膜异位症是机体对逆流经血内膜碎片产生的慢性自体免疫样炎性攻击，其局部长期高炎环境不仅破坏输卵管与胚胎着床，更会直接毒害并加速消耗卵巢内的储备卵子。 Crawford破除了社交媒体对复方口服避孕药的污名化，指出避孕药本身既不损害卵巢“保险库”，亦不导致长远不孕，但同样无法“封存”或节省卵子。以往医疗实践的缺陷在于将其作为遮掩月经紊乱和严重痛经的通用“创可贴”，导致诸多女性在30多岁停药备孕时才发现底层病灶已延误诊治数十年。从治疗价值而言，避孕药能通过外源孕激素强行保护内膜脱落以预防内膜癌，并通过抑制自发排卵为内异症按下“暂停键”，同时可有效稳定经前期烦躁障碍（PMDD）患者的情绪波动。男性生精隐患、环境毒素与受孕误区辨析 (142:26) 全球男性精子数量在过去50年间滑坡约50%，除高血脂、糖尿病和肥胖导致外周睾酮向雌激素转化外，外源性睾酮替代疗法（TRT）构成了严重的医源性生精抑制。外源睾酮会通过负反馈使大脑误判睾丸机能正常，彻底切断促性腺激素信号，诱发精液无精子症，长期使用更存在不可逆损伤风险。物理暴露方面，阴囊长时间处于高温环境会直接破坏精子与间质细胞；但长期数据表明，现代智能手机辐射与放置口袋并无显著精液参数损伤。此外，吸烟、接触含双酚类的热敏纸收据、加热塑料器皿及特氟龙涂层释放的内分泌干扰物均会加剧配子DNA损伤。在自然受孕实践中，诸多民间偏方缺乏生理学依据：精子射精后2至5分钟内即可穿透宫颈黏液抵达输卵管并存活长达5天，房事后垫高臀部无法提升受孕率，而事后排尿不仅不会冲走精子，更能有效冲刷尿道以预防泌尿道感染。此外，刻意长期禁欲“储存精子”会导致死精积聚与活力下降；夫妻在排卵日前5天至排卵日当天的受孕窗口期内，维持每1至2天的规律同房才是提高受孕概率的最有效生理策略。 Crawford医生总结强调，生殖医学的核心在于破除因健康知识匮乏带来的耻感，使个体在面对生理衰老与疾病现实时拥有自主权；即便基因层面的受孕途径中断，借助供卵、供精或领养同样能实现家庭构想。然而，辅助生殖的高昂经济门槛以及官方筛查指南在预防性AMH检测上的保守立场，依然制约着早期诊断的普及，如何在避免大众焦虑与防止生育遗憾之间建立普惠性筛查机制仍是尚存争议的公共卫生课题。

Detailed notes — zh

## Background 本期内容由主持人斯蒂芬·巴特利特（Stephen Bartlett）于 2024 年 6 月 3 日发布在 YouTube 频道《The Diary Of A CEO》上。节目邀请了拥有双重执业认证的生殖内分泌专家、Fora Fertility 诊所联合创始人纳塔莉·克劳福德博士（Dr. Natalie Crawford），围绕现代人生育力危机展开深度对谈，内容涵盖 32 岁后生育率骤降的生理机制、精卵衰竭规律、辅助生殖技术真相以及家庭规划建议。 ## TL;DR 克劳福德博士指出全球不孕率正在急剧上升，女性卵巢内的卵子储备随年龄增长不可逆地减少且染色体异常率在 35 岁后急剧飙升，而男性精子数量在过去 50 年内也腰斩了 50%。针对现代人推迟生育的现状，她系统拆解了睾酮替代疗法（TRT）、环境毒素、睡眠不足与慢性压力等生活方式对生殖轴的毒害，并详细阐释了多囊卵巢综合征（PCOS）和子宫内膜异位症的发病机制。克劳福德博士强烈主张生殖健康应从“被动治疗”转向“前瞻预防”，若在 32 至 33 岁前仍未准备好组建家庭，应主动进行卵巢储备评估，并理性看待冻卵与试管婴儿（IVF）的概率漏斗与真实成本。她呼吁大众打破不孕不育的社会病耻感，在残酷的生理时钟面前用科学知识掌握自主生育抉择权。 ## Atmosphere & style 整场对话呈现出一种兼具严谨医学洞见与深切人文关怀的底色。克劳福德医生既以清晰的逻辑拆解复杂的激素反馈与染色体机制，又毫无保留地袒露自己亲历四次流产、在产房忍痛接生别人婴儿的心碎过往，数度眼泛泪光；主持人斯蒂芬则以真诚、敏锐且充满共情的视角不断追问，打破了传统的访谈界限。在冷静客观的数据揭示与温厚真挚的情感流动相互交织中，听众不仅能深刻体会到面对生理局限时的敬畏与紧迫感，更能从中汲取到走出孤立无援、勇敢直面生命的坚韧力量。 ## Bulletin - [04:31](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=271s) 全球不孕不育发生率持续恶化，初次备孕群体的不孕率已从以往的 1/8 升至 1/5，而全球男性精子数量在过去 50 年暴跌 50%，且近 10 年衰退速度翻倍。 - [31:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1905s) 女性卵子储备在出生时已固定且不可再生，37 岁后库存急剧下滑至约 2 万颗，40 岁时月均自然受孕率仅剩约 5%，且妊娠流产率高达 50%。 - [30:15](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1815s) 睾酮替代疗法（TRT）本质上是一种强效男性避孕药，外源性睾酮会通过负反馈完全阻断大脑信号，诱发无精子症，且存在永久不可逆致不育的风险。 - [01:33:50](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5630s) 多囊卵巢综合征（PCOS）和长期闭经患者若长期缺乏孕激素对抗，子宫内膜持续异常增生将面临极高的子宫内膜癌风险，闭经绝非生理常态。 - [01:59:46](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7186s) 若到了 32 至 33 岁仍未准备好组建家庭，是考虑冻卵干预的最佳时间窗口；单次移植染色体正常的整倍体胚胎活产率约为 65%，每计划生育一个孩子建议储备 2 至 3 颗整倍体胚胎。 ## Key takeaways - [02:20](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=140s) 生殖健康管理亟需从“确诊后的被动救济”转向“全生命周期的前置预防”，生育能力应当像心血管疾病或癌症一样提前进行主动监测与规划。 - [18:49](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1129s) 男女生殖细胞存在根本生物学差异：女性终身卵子不可再生且终身累积外界损耗；男性睾丸依赖生殖干细胞每秒制造约 1500 个精子，更迭周期仅为 90 天，生活方式干预可在 3 个月内迅速显现效果。 - [20:35](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1235s) 排精间隔过长不仅不能“积攒优质精子”，反而会导致大量死精在生殖道内堆积阻碍通路，男性最佳排精频率应维持在每天一次到每三至四天一次之间。 - [26:32](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1592s) 环境高温对睾丸杀伤力巨大，蒸桑拿、泡热水澡、膝上放置笔记本电脑以及长时间户外紧身骑行都会显著压制精子生成。 - [43:37](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2617s) 抗缪勒管激素（AMH）和窦卵泡计数反映卵巢库存总量及试管促排上限，但单月自然受孕质量与染色体正常率完全取决于女性年龄，而非储备数量。 - [54:07](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3247s) 充足睡眠（7.5 至 8 小时）是扑灭慢性炎症、维护生殖内分泌轴最廉价有效的手段；每天 20 分钟完全远离屏幕的独处能有效释放皮质醇并解除大脑对生殖系统的抑制。 - [59:11](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3551s) 全脂乳制品比脱脂乳制品更有助于维持规律排卵，因为类固醇激素合成高度依赖天然健康脂肪，而脱脂奶属于失去天然脂肪酸的高度加工食品。 - [01:07:54](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4074s) 体脂过高或过低都会破坏排卵机制：极低能量摄入与过度训练会触发下丘脑性闭经；而肥胖会使脂肪细胞过量合成雌激素，误导大脑降低促性腺激素指令，同时重创男性内源性睾酮与精子计数。 - [01:14:48](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4488s) 健康的月经周期核心指标在于“规律与可预测性”，易孕窗口恒定为排卵日前 5 天加上排卵当天，盲目禁欲等待排卵日不如在整个周期内保持每周 2 至 3 次规律同房。 - [01:21:21](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4881s) 未经实验室无菌洗涤与离心处理的原始精液绝不能直接注入子宫腔；通过社交网络寻找地下捐精者存在巨大的传染病暴露与日后监护权纠纷等法律灾难。 - [01:24:48](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5088s) 多囊卵巢综合征（PCOS）由于初始卵泡基数过大摊派稀释了垂体 FSH 信号，导致无法形成优势卵泡，停滞的卵巢代偿性大量分泌雄激素，诱发胰岛素抵抗和向心性肥胖。 - [01:37:02](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5822s) 子宫内膜异位症是引发重度痛经、深部性交痛和不明原因不孕的慢性炎症性疾病，金标准确诊必须依赖腹腔镜手术，而 IVF 结合药物降调能有效绕过腹腔内的炎性毒性环境。 - [01:50:20](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6620s) 冻卵不是百分之百受孕的保险单，而是面临逐级递减的概率漏斗（解冻损耗、受精损耗、囊胚阻滞及染色体非整倍体率），胚胎抗逆性与复苏存活率远高于单细胞的未受精卵。 - [02:03:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7425s) 现代试管婴儿技术已全面转向单胚胎移植（SET），通过 PGT 基因筛查筛选染色体正常胚胎，既能杜绝多胎高危妊娠风险，又能阻断严重的家族单基因遗传病。 - [02:06:28](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7588s) 同房后抬腿倒立、垫枕头或刻意憋尿没有任何受精学意义，精子在 2 分钟内即穿透宫颈黏液并在 5 分钟内到达输卵管，事后及时排尿反而能有效预防尿路感染。 - [02:10:33](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7833s) 口服短效避孕药在遏制子宫内膜异位症恶化及预防 PCOS 诱发内膜癌方面具有极高临床价值，但长期服药容易掩盖真实的月经失调病因，建议备孕前尽早停药观察评估。 - [02:18:36](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8316s) 面对不孕治疗不应盲目重复失败方案，寻求第二诊疗意见至关重要；当常规自体生育路径彻底受阻时，适时退后一步转向供卵、供精或胚胎收养能帮助家庭重新实现拥抱新生命的核心目标。 ## Detailed walkthrough ### [00:00](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=0s) 孕育倒计时与被忽视的生育真相女性体内的卵子储备犹如一座随时间不断消耗的“卵子银行”：出生时大约拥有 100 万至 200 万颗卵子，进入育龄期时锐减至约 30 万颗，若拖延到 35 岁以后，自然受孕的几率将急剧下滑，到了 40 岁流产率更是高达 50%。生殖医学专家 Natalie Crawford 博士指出，不孕不育率正在以惊人的速度攀升，以往每 8 位女性中会有 1 人遭遇不孕，如今这一比例在初次备孕群体中已恶化至每 5 人中就有 1 人。更令人心碎的是，即使是顶尖的生殖专科医生也难逃生育创伤的打击，Crawford 博士在节目开头动情地透露自己曾经历过 4 次流产，“我现在都忍不住想哭”。面对日益严峻的生育困境，公众却充斥着大量关于如何受孕的误区与盲区，例如女性高潮是否能提高受孕率，以及人们日常最容易忽视却对生殖系统造成最大破坏的生活习惯。在正式切入专业对话前，主持人 Stephen Bartlett 宣布频道《The Diary Of A CEO》订阅者突破 600 万，并特别推出回馈抽奖活动，随机抽取三位订阅者分别赠送 1,000 英镑代金券、节目录制现场后台探班门票以及与主持人本人进行 10 分钟深度通话的机会。 - **卵子储备演变**：出生时拥有 100 万至 200 万颗卵子，育龄期初始降至约 30 万颗。 - **高龄妊娠风险**：40 岁女性妊娠流产率高达 50%。 - **不孕发生率攀升**：从过去的 1/8 上升至目前的 1/5。 --- ### [02:20](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=140s) 医生 Natalie Crawford 的使命：从被动补救到预防医学 Natalie Crawford 博士拥有妇产科与生殖内分泌/不孕症的双重执业认证。她回顾自己早期职业生涯时发现，大多数患者走进生殖诊所时已经处于“全盘落后”的被动境地。他们对自己的荷尔蒙、月经周期和生殖系统运作机制极度匮乏基本认知。几乎每一位就诊者都会痛苦地感叹：“为什么以前从来没有人教过我这些？如果我能早点知道，我当年一定会做出完全不同的人生抉择。”这种普遍的认知缺位促使她在八年前下定决心，必须在人们陷入不孕困局之前提早介入普及教育，让大众掌握主动权，而不是任由岁月流逝代替自己做出无法挽回的决定。世卫组织（WHO）和美国疾病控制与预防中心（CDC）均已将不孕不育正式定义为一种“疾病”。Crawford 博士强调，人们对待生育应当像对待癌症或阿尔茨海默病预防一样，树立“预防性健康管理”的意识。很多人误以为只有年过 35 岁或临近 40 岁时才需要操心生育问题，但事实上，年轻时做出的每一个日常生活选择与生活方式，都在潜移默化地决定未来能否顺利组建家庭。 ```mermaid flowchart TD accTitle: 生育健康管理范式转变 accDescr: 展示从传统的被动应对不孕不育转变为主动预防性健康管理的逻辑路径。 subgraph Traditional["传统被动救济模式"] A["缺乏生殖生理通识"] --> B["推迟到35岁以上才关注"] B --> C["被动确诊不孕不育疾病"] C --> D["耗费巨大成本接受补救性治疗"] end subgraph Preventive["现代前置预防模式"] E["早期生殖健康普及"] --> F["全生命周期生活方式干预"] F --> G["主动评估卵巢与精子储备"] G --> H["自主规划受孕与家庭时间线"] end ``` --- ### [04:31](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=271s) 全球不孕不育率激增与背后的宏观社会变迁对于近年来生育话题讨论度暴增的社会背景，Crawford 博士认为这是多重因素叠加的结果。一方面，现代社交媒体让人们更愿意公开分享原本难以启齿的生育挫折，且辅助生殖技术（如冻卵、试管婴儿技术 IVF）的可及性大幅提高，促使更多人能尽早筛查与确诊；但另一方面，不孕不育率的真实上升是不争的事实。即使排除年龄偏差，数据依然显示出恶化态势：在 20 世纪 70 年代，仅有 5% 的人选择在 30 岁之后生育第一胎，而如今这一比例已激增至 25% 到 30%。女性在教育与职场上的赋权虽带来了发展机遇，但也推迟了生育年龄窗口。随着生育年龄后延，生殖器官疾病的发展窗口被拉长，同时现代社会整体健康状态的恶化也雪上加霜。肥胖、糖尿病等代谢性疾病的爆发式增长，加上日常生活中前所未见的各类环境毒素暴露、自身免疫性疾病与慢性压力，共同构成了现代人生殖能力滑坡的催化剂。 - **初育年龄结构变化**：30 岁以上初次生育人群比例从 1970 年代的 5% 激增至如今的 25%-30%。 - **初育不孕率**：目前在美国，首次尝试受孕的女性中不孕比例已攀升至 20%（1/5）。 - **复合致病因素**：包括高龄推迟、代谢异常（肥胖/糖尿病）、慢性压力综合征及环境内分泌干扰物。 --- ### [07:00](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=420s) 性行为频率、大麻迷思与断崖式下跌的精子危机针对现代人是否因为性生活减少而导致生育率下降的疑问，Crawford 博士指出，尽管随着年龄增长与步入婚姻，性行为频率确实呈现下降趋势，但生理层面的受孕能力削弱才是核心症结。她引用了一项关于吸食大麻的研究为例：大麻吸食者群体的性生活频率往往高于非吸食者，然而其受孕成功率却显著更低。这一对比强有力地证明，受孕失败绝非单纯的“时机不对”或“同房太少”，而是各种被社会广泛接纳的生活习惯在分子层面严重干扰了生育机能。 ```mermaid flowchart LR accTitle: 精子数量历史跌幅对比 accDescr: 对比过去四十年与最近十年的男性精子数量下降速率。 subgraph Historical["过去50年总体趋势"] A["50年内精子总数跌幅达 50%"] end subgraph Acceleration["近十年断崖式加速"] B["前40年温和递减"] --> C["近10年以2倍加速度暴跌"] end ``` 宏观数据更为触目惊心：全球总和生育率已从 1950 年的每位女性生育 4.84 个活产婴儿，锐减至 2021 年的 2.23 个，预计到 2100 年将跌至 1.59 个；而在美国，平均每位女性的生育数已仅剩 1.3 个。更令人警惕的是男性精子质量的崩塌——研究显示全球男性精子数量在过去 50 年间缩减了整整 50%，且最近 10 年的下降速率竟然是此前 40 年平均速率的两倍。这种短期内的断崖式下滑表明，外部生存环境与现代生活毒素正在对男性生殖力发起毁灭性的冲击。 - **全球生育率骤降**：1950 年每位女性平均生育 4.84 个子女，2021 年降至 2.23 个，预测 2100 年跌破代际更替线至 1.59 个；美国目前仅约 1.3 个。 - **精子数量腰斩**：过去 50 年全球男性精子总量下降 50%。 - **精子恶化加速度**：近 10 年精子浓度与数量的衰退速度是此前 40 年均速的整整 2 倍。 --- ### [09:13](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=553s) 创办 Fora Fertility 诊所与个性化生殖医学面对日趋复杂的生殖系统障碍，Natalie Crawford 博士于 2020 年与搭档 Amanda Skillern 博士在德克萨斯州奥斯汀共同创立了 Fora Fertility 诊所。两位医生在长期临床实践中深感传统生殖流水线式医疗的局限性，决心打破千篇一律的机械诊疗框架，提供深度的“个性化定制医疗”（personalized care）。由于这种专注个体异质性的定位，该诊所接诊的最主要患者类型，便是在其他生殖医疗机构多次尝试受孕并遭遇失败的疑难病例。这些患者带着挫败感与未解的疑问辗转来到这里，寻求针对自身激素特征、生活环境及隐匿病因的全面重估与精准干预。 ### [09:57](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=597s) 不育背后的孤岛效应：典型患者画像与同伴落差在生殖门诊中，最典型的求诊患者往往在36岁以上，通常已经自主备孕一到两年。她们认真学习了月经周期，细致记录排卵期，基础医学检查也大致正常，最终走向试管婴儿（IVF），却未能在预期的周期内得到渴望的结果。克劳福德医生指出，对这些家庭而言，身体上的折磨往往还不是最痛苦的，真正摧毁一个人内心的是强烈的孤立感。在原本步调一致的社交圈和同龄人中，身边的朋友纷纷结婚生子、顺利组建家庭，唯独自己被远远抛在了后面。这种“被同龄群体抛弃”的孤独与心理压力，其残酷程度甚至远超许多其他严重的内科诊断。 - **典型就诊患者画像**：通常年龄超过36岁，尝试自然受孕1至2年无果；对排卵周期了如指掌；基础生育评估无明显异常；接受IVF治疗但初期效果未达预期。 - **核心心理负担**：同龄人相继生育造成的社交隔离感，使患者陷入深刻的自我怀疑与情感孤岛。 --- ### [10:38](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=638s) 克劳福德医生的四次流产经历：独自承受与宫外孕危机克劳福德医生坦言，自己之所以对这种孤立感刻骨铭心，是因为在拥有如今的两个孩子之前，她曾亲历过四次痛苦的流产。当时她正处于住院医师和专科培训期（fellowship），高强度、昼夜颠倒的医生培训让她根本无暇照顾自己的身体。在前三次怀孕时，除了丈夫，她没有向任何亲友吐露过半句，因为当时社会风气普遍讳疾忌医，且大众有一种“必须熬过前12周（早孕期）进入安全区才能公开”的思维定势。结果，当流产发生时，她陷入了更可怕的困境：由于一开始没有向外界打开心扉、建立信任，事后便更难向他人开口求助并承认自己失去了孩子，只能在完全无声的角落里默默承受创伤。真正的转折点发生在她的第四次怀孕。那是一次宫外孕（输卵管妊娠），胚胎着床在输卵管而非子宫内。由于输卵管缺乏滋养胎盘的充沛血供，胚胎无法存活，且极易导致输卵管破裂大出血，属于危及生命的妇科急症。当时她的丈夫正远在拉斯维加斯参加单身派对（bachelor party），突发险情的克劳福德医生必须立即接受药物注射阻止胚胎生长，同时面临着随时破裂手术的极高风险。这一突发危机迫使她打破沉默，向身边的朋友求救，请朋友陪伴自己去医院。出乎她意料的是，当她选择敞开心扉后，朋友们给予了排山倒海般的温暖与支持。这段经历让她猛然醒悟：保守秘密反而是自己犯下的最大错误。她常常告诫患者，虽然不需要在社交网络上向全世界公开怀孕，但必须给那些真正在乎你的亲朋好友一个“为你挺身而出”的机会。特别是对于那些习惯制定目标、掌控人生的成功人士来说，面对生育失败时往往会产生巨大的羞耻与自责，仿佛是自己的身体背叛了自己，如果将这份负罪感深埋心底，只会将人彻底压垮。 ```mermaid flowchart TD accTitle: 面对生育困境时的应对模式对比 accDescr: 对比传统封闭隐瞒模式导致的孤立与自我怀疑，以及主动寻求社会支持所带来的减压与情感共担。 subgraph ClosedMode ["封闭隐瞒模式（恶性循环）"] A["坚守“满3个月安全期”教条"] --> B["完全对外界隐瞒孕情"] B --> C["遭遇突发流产/并发症"] C --> D["羞于开口求助，独自承受创伤"] D --> E["陷入严重自我怀疑与羞耻感"] end subgraph OpenMode ["建立支持网络（良性应对）"] F["向核心信任圈倾诉备孕/受挫现实"] --> G["赋予身边人挺身支持的机会"] G --> H["分担疾病负担与心理压力"] H --> I["走出孤岛，重构情感韧性"] end ``` --- ### [13:36](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=816s) 无法生育带来的耻辱感与自我身份认同的坍塌不孕不育在当今社会依然背负着沉重的污名化烙印，伴随着大量的错误信息与认知盲区，让人们羞于启齿。斯蒂芬·巴特利特补充道，他身边的许多朋友在查出性生殖系统存在问题时，往往会产生一种近乎窒息的情绪——觉得自己的身体“坏掉了”（broken），觉得自己作为一个完整的人出现了功能缺陷。这种自卑和残缺感让无数人在沉默中饱受折磨。克劳福德医生深有同感地指出，这种情绪实质上是一场深刻的“存在主义身份危机”。许多人从小就对未来建立了一套确定性的构想，设定了三十岁后成家立业、生儿育女的人生蓝图。当突然面对可能永远无法拥有孩子、或者必须借助复杂医学干预才能受孕的现实时，原本稳固的自我认同瞬间土崩瓦解。坐进诊室的患者最常倾诉的一句话就是：“我觉得自己不再是自己了，别人都在往前走，唯独我因为身体的残缺被困在原地。”对此，克劳福德医生的底线原则是：即便医疗手段无法保证让每一个求诊者都百分之百怀上孩子，但她必须让患者彻底弄明白自己身体的运行机制。“了解真相、掌握知识”能让患者在未来回首往事时不留遗憾，明白自己已竭尽全力，并拥有为自己的治疗方案积极发声（advocate）的能力。 --- ### [16:15](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=975s) 伴侣关系中的愧疚与责备：生育是团队作战而非个人缺陷生育困难对伴侣关系的杀伤力极其隐蔽而剧烈。当夫妻双方步入适孕年龄，一旦检查结果显示其中一方存在生理障碍，负责提供“有缺陷”那一组生殖细胞的人往往会被无休止的负罪感吞噬，甚至产生“对方一定会离开我，因为我无法给予对方想要的孩子”这种极端而又真实的恐慌。克劳福德医生回顾自己的流产经历时谈到，虽然丈夫全心全意给予支持，但她潜意识里总觉得是自己“没有发挥出最佳状态”，错误全在自己身上。正因如此，克劳福德医生在临床中极力重塑患者的思维认知：“生育问题不是某一个人的问题，你们是一个不可分割的团队，我们要解决的是‘让我们怀孕’，而不是‘谁耽误了谁’。”她分享了一则真实的临床案例： - 一位女患者因卵巢功能早衰、卵子储备提前告罄而进行试管治疗。长久以来，这位女性背负了巨大的内疚，日夜自责于自己为什么没有早点冻卵、为什么拖延了生育时间。 - 然而在实验室受精培养阶段，医生发现胚胎完全无法发育，进一步检测才证实，男方的精子功能同样存在严重缺陷。 - 尽管那个治疗周期一枚胚胎都没能养成，结果令人心碎，但这名女患者在复诊时却表示，这反而拯救了他们的婚姻。因为第一次，夫妻双方回到了平等的起点，双方共同承担着困境的因由，卸下了女方长期以来独自背负的耻辱与枷锁。 --- ### [18:49](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1129s) 精子与卵子的生物学悬殊：终身储备与90天的再生周期谈及生殖生理机制的核心差异，克劳福德医生以精子与卵子的生成逻辑作为认知的基石。当她询问斯蒂芬是否知道男性每天乃至每秒能产生多少精子时，斯蒂芬自嘲自己对生殖医学完全是个“麻瓜”（muggle）和小白。克劳福德医生给出的数据令人震撼：一名健康成年男性每天可以产生 **2亿至3亿** 个精子，相当于**每秒钟就有约1500个精子**在睾丸中被制造出来。男性睾丸中拥有源源不断的生殖干细胞（germ cells），能够在整个人生阶段持续、高速地生产全新的精子。相比之下，女性的卵子系统则遵循着一套截然相反、异常严酷的生物学法则： - **女性卵子的不可再生性**：女性一生中所拥有的全部卵子早在出生时就已完全固定，数量随年龄增长不可逆地持续衰减，没有任何生殖干细胞可以补充新生卵子。 - **环境损耗的终身累积**：卵子常年封存在女性体内，伴随个体经历几十年的岁月，完整承受着宿主一生所经历的一切物理损伤、毒素暴露和代谢损耗。 - **精子的更迭周期为90天**：精子的全生命周期仅约3个月——在睾丸中发育成熟需要约 **72天**，随后需要大约 **18天** 通过附睾和射精系统完成转运并具备排出条件。这构成了男女生育能力改善上的本质分水岭：男性只要彻底改变生活方式、改善营养与环境暴露，只需短短三个月就能显著更新并提升其精液质量与精子计数。斯蒂芬惊讶地承认，自己过去一直天真地以为“今天身体生成的精子，在今天射精时就会被排出来”，完全没有意识到体内存在长达18天的射精管道转运与成熟延迟。 ### [20:35](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1235s) 精子的“储物柜”储备与排精频率的平衡艺术男性体内的精子并不是现用现造的，每次射出的精子其实早在两三个月前就已经生成，并像存放在一排排“储物柜”里一样按顺序排好，以备每天随时调用。Natalie Crawford 医生打了个生动的比方：假设每个储物柜里都存放着大约 2 亿颗精子，如果你每天射精一次，每次就会排出约 2 亿颗；如果积攒两天再排，数量会上升到 4 亿；禁欲三天，可能就会达到 6 亿。然而，数量的增加并不直接等同于生育能力的提升，因为精子非常脆弱娇气，在体内极易衰亡。如果男性为了“攒大招”而长时间禁欲，储物柜里就会堆积大量死亡的死精子，从而反过来严重破坏优质健康精子的游动与功能。Crawford 医生将这种现象比喻为一条车流滚滚的高速公路：死掉的精子就像是一辆辆直接抛锚在整条高速路中央的坏车。即便精子总计数在正常范围内，但如果排精间隔过长，精液样本中就会充斥着大量细胞碎片与死精，优质精子根本寸步难行，无法完成穿透受精的使命。因此，为了最大化提高精子的受精潜力，男性必须保持规律的排精以更新储备。究竟多久排一次最好？Crawford 医生指出，最佳的平衡点介于**每天一次到每三至四天一次之间**，具体方式完全由个人偏好决定。一旦禁欲时间超过 7 天，精液中的细胞杂质碎片以及死精所占的比例就会急剧飙升。 --- ### [22:26](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1346s) 过去半个世纪精子量腰斩：生活方式、压力与“大脑-性腺轴” 针对过去 50 年间男性平均精子数量暴跌 50% 这一骇人现状，Crawford 医生指出，这并非单一原因所致，而是现代世界中各种可变与不可变因素交织在一起的综合恶果。除了普遍的亚健康、肥胖、高胆固醇和糖尿病等代谢合并症直接压制精子生成外，更深层的核心在于大脑与性腺（睾丸或卵巢）之间的神经内分泌反馈轴。大脑无时无刻不在严密监控着全身体内环境与外界信号，以此判断当前机体是否处于繁衍后代的安全时机。在远古时代，当遭遇野兽袭击、大饥荒或瘟疫蔓延时，生存压力会促使肾上腺大量分泌皮质醇，或者卡路里摄入骤降，大脑就会判定当前生存环境极其恶劣，必须关闭制造生殖激素的系统，以保全母体或父体自身的存活。现代生活中的慢性压力、全身慢性炎症、自身免疫性疾病及超重，都在向大脑持续发送这种负面危机信号，促使大脑抑制向性腺发送促性腺激素指令，进而扼杀精子与睾酮的合成。 ```mermaid flowchart TD accTitle: 现代压力与环境毒素抑制生殖内分泌轴流程图 accDescr: 展示外界慢性压力与毒素如何通过大脑皮质醇反应抑制下丘脑-垂体-性腺轴，进而导致精子与睾酮生成骤降。 subgraph Brain["大脑与下丘脑调控"] Stress["慢性压力 / 疾病 / 代谢异常"] --> Adrenal["肾上腺大量分泌皮质醇"] Adrenal --> BrainDecision{"大脑评估繁殖环境\n'现在适合要孩子吗？'"} end subgraph Gonad["性腺（睾丸）响应"] BrainDecision -- "环境恶劣：发出关闭信号" --> ShutDown["抑制促性腺激素释放"] ShutDown --> Drop["睾酮与精子产量暴跌"] end ``` 此外，环境中无处不在的微塑料、空气污染、重金属和劣质厨具毒素，同样在无形中削弱着生育能力。尽管身处重污染地区等地理居住环境很难凭一己之力改变，但这恰恰意味着处于这种逆境中的人群，更需要主动消除那些可控的额外生活负担。 --- ### [25:24](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1524s) 尼古丁、大麻与电子烟对生殖细胞的致命打击谈及吸烟对生育的危害，Crawford 医生发出了极其严肃的警示，称香烟与大麻在备孕期是绝对不可触碰的禁忌（"Absolute no-no"）。传统卷烟对女性而言，会直接消耗卵巢储备、摧毁卵子质量，并显著拉高流产几率；对男性而言，则会造成精子密度下降、活力衰退、畸形率暴增，同时也是流产发生的重要诱因。更常被大众轻视的是大麻的危害。临床中常见的一种误区是：只要伴侣不吸大麻、且吸食时不在伴侣身边，就不会有影响。然而 Crawford 医生明确警告，男性吸食大麻本身就会直接导致伴侣的流产率激增。其核心机理在于大麻会破坏精子头部包裹的遗传物质，诱发不可逆的 DNA 碎片化损伤。换言之，男性射出的是表面看似能游动、实则内部基因链断裂的“劣质精子”。至于流行于年轻群体中的电子烟（Vaping），尽管目前尚缺乏长期的跟踪数据，但现有的所有初步医学研究均显示其危害极高，甚至因吸入物质成分复杂，其对生殖系统的毒害潜力可能比传统香烟有过之而无不及。 --- ### [26:32](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1592s) 手机与电脑：辐射真相与被忽视的阴囊“热效应” 关于日常科技产品是否会杀精的疑惑，Crawford 医生拆解了一项跨越 2005 年至 2018 年的大型回顾性研究。数据表明，早期手机（2005 年至 2010 年间）由于电磁辐射相对较高，使用频率确实与精子数量下降呈正相关；但对于现代智能手机而言，由于辐射发射强度已被大幅削减，加上当代人每天翻看手机早已远超数十次，手机使用频次乃至放置位置（无论是揣在前袋、后兜还是放在桌上）对精子参数均未表现出统计学差异。真正对睾丸构成巨大致命威胁的，从来都不是微弱的电磁辐射，而是实打实的物理高温： - **睾丸外置的生理学意义**：睾丸之所以悬挂在体外的阴囊中，本质上就是为了维持比机体核心温度低几度的低温环境。如果男婴出生时患有“隐睾症”（即睾丸未能下降至阴囊而滞留在腹腔内），必须在一岁前通过手术矫正，否则腹腔内的高温会在极短时间内彻底破坏生精细胞与间质细胞，导致永久丧失造精和分泌睾酮的能力。 - **睾酮与精子的同步生成**：睾酮与精子是在同一生理微环境中协同合成的，任何破坏睾丸温度的因素都会对其造成双重打击。 - **高危升温场景**： - 每天蒸桑拿或泡热水澡（在热水中浸泡超过 15 分钟且频率过高，必须予以削减）。 - 将发热的笔记本电脑直接放在大腿膝盖上办公。 - 长时间把发烫的手机或电子设备紧挨着阴囊放置。 - 狂热的户外公路骑行：Crawford 医生在得州奥斯汀的诊所中经常遇到热爱自行车运动的男性患者，他们每周多次进行单次长达 2 至 3 小时的骑行，紧身骑行裤和持续挤压摩擦将高热死死锁在阴囊区域，往往导致精子计数断崖式暴跌。 --- ### [30:15](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1815s) TRT 睾酮替代疗法：伪装成保健品的“男性避孕药” 针对近年来在男性抗衰与健身领域风靡的睾酮替代疗法（TRT），Crawford 医生揭示了一个触目惊心的临床现实：在她的生殖诊所中，几乎**每周都会接诊至少一对**备孕受阻的夫妻，原因无一例外是男方此前因为性欲减退或日常疲劳，前往所谓的“男性健康门诊”或荷尔蒙诊所，直接接受了 TRT 外源性睾酮注射。 Crawford 医生直言，对外源性睾酮的滥用本质上就是一种强效的“男性避孕药”。其背后的生理反馈机制极为直接：在健康人体内，睾酮与精子是同步在睾丸内部自发生成的；而当男性从外部摄入大量睾酮时，血液中的高浓度睾酮会欺骗大脑中枢，使大脑误以为体内的雄激素已经极其充沛、完全不需要再生工。结果，大脑便会彻底切断向睾丸发送促性腺激素信号，直接导致自身睾丸的生精机制全面“关停”，最终造成精子数量断崖式归零。 ### [31:14](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1874s) TRT 对精子生成的破坏与不可逆风险对于男性而言，睾酮替代疗法（TRT）的使用会对生育能力造成毁灭性打击。外源性补充睾酮会通过负反馈抑制大脑信号，导致大脑不再向睾丸发出产生睾酮或制造精子的指令。结果就是，长期使用 TRT 会导致男性患上无精子症（Azoospermia）——即射出的精液中完全检测不到精子。男性的精液外观和量可能与以往毫无二致，但在显微镜下观察时却空空如也。最可怕的是，这种损伤有时是不可逆的；使用 TRT 的时间越长，精子彻底无法恢复的概率就越高，甚至变成永久性不育。 --- ### [31:47](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=1907s) 卵子“保险库”隐喻：女性一生卵子数量的急剧缩减为了解释女性体内的卵子库存变化，主持人拿出一个装满弹珠的玻璃罐，邀请 Natalie Crawford 医生一同做视觉化演示。两人先是幽默地打赌猜弹珠数量，主持人猜 200 颗，并在数弹珠的玩笑互动中让 Crawford 猜了 140 颗。Crawford 医生借此引出核心隐喻——女性的卵巢就像一个装有卵子的“保险库（The Vault）”。 ```mermaid flowchart TD accTitle: 女性卵子数量随年龄骤降过程 accDescr: 展示从胎儿期到绝经期女性卵子总数的急剧减少趋势 A["胎儿期（5个月大） 600万至700万颗"] --> B["出生时 100万至200万颗"] B --> C["青春期开始 约50万颗"] C --> D["育龄期开始 约30万颗"] D --> E["37岁左右 锐减至约2万颗"] E --> F["绝经期 少于1000颗"] ``` 与男性睾丸每天源源不断制造全新精子截然不同，女性从出生前就已经拥有了一生中所有的卵子： - **胎儿期（5个月大）**：在母亲子宫内时卵子数量达到顶峰，拥有约 **600万至700万** 颗卵子； - **出生时**：降至 **100万至200万** 颗； - **青春期开启**：剩余约 **50万** 颗； - **育龄期初期**：库存约剩下 **30万** 颗； - **绝经期**：卵子数最终少于 **1000** 颗。令人震惊的是，尽管卵子基数庞大，女性一生中实际排出的成熟卵子仅有 **400至500** 颗。其余绝大部分卵子都在漫长的岁月里自然凋亡消耗掉了。 --- ### [33:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2025s) 比例淘汰机制与促卵泡激素（FSH）的选择卵子从保险库中释放的过程遵循着严格的“比例淘汰机制”。每月涌出保险库的卵子数量与库内存量成正比：当保险库储量充盈时，单月释出的卵子较多；储量变少时，释出的数量也随之减少。在青春期之前，每月释放出来的这批卵子都会默默凋亡。进入青春期后，大脑垂体开始分泌促卵泡激素（FSH）。有趣的是，FSH 是医学界少数完全以其在女性体内的功能来命名的激素之一（尽管男性体内也存在 FSH 和 LH，分别负责精子生成与睾酮合成）。每个卵子都生长在一个微小的卵泡中。人类子宫的进化设定通常只允许单胎妊娠，因此人体进化出了一种保护机制：大脑释放的 FSH 在正常生理状态下只足够刺激这批卵子中的**单一一颗**优势卵泡成熟并排出，而其余随同离开保险库的卵子则全部闭锁死亡。更残酷的是，被挑中排出的那一颗完全是随机的，并不代表它在基因层面上更健康或更优质。 - **30岁时**：每月大约有 20 颗卵子离开保险库，1 颗排卵，19 颗闭锁凋亡； - **35岁时**：每月释出约 14 至 15 颗； - **40岁时**：每月仅释出 8 至 10 颗； - **44岁时**：每月仅能释出 3 至 4 颗； - **37岁转折点**：37 岁之后卵子库存加速下滑，库内仅存约 2 万颗，单月释出量断崖式减少。绝经意味着卵巢功能的衰竭。虽然全球女性平均绝经年龄为 51 至 52 岁，但在临床上，Crawford 医生甚至见过 13 岁就出现原发性闭经、天生卵巢无法产生卵泡的极端罕见病例，也见过二十多岁就提前耗尽卵子的年轻女性。此外，吸烟、吸食大麻、子宫内膜异位症、化疗药物以及环境毒素都会侵入保险库，加速卵子储备的耗竭。 --- ### [38:00](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2280s) 冻卵与试管婴儿（IVF）的真相：无法透支库存针对冻卵和试管婴儿（IVF），Crawford 医生澄清了一个普遍的误区：医生**无法打开保险库强行提取深层卵子**，IVF 的促排卵仅能作用于“当月已经被保险库释放出来的卵泡”。在常规自发排卵中，身体只分配足够的激素让 1 颗成熟，其余 9 颗（以单月 10 颗为例）只能凋亡。而在促排卵周期中，医生通过外源性注射高剂量激素，强行挽救当月原本会死掉的所有卵泡，促使它们全部同步长大并取走。因此，许多患者取卵数量差异巨大（有的取 6 颗，有的取 24 颗），或者需要进行多轮取卵周期才能凑够数量制造出正常胚胎，其根本原因完全受制于该女性当月保险库自然释出的卵子基数。 --- ### [39:33](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2373s) 卵子质量与染色体老化：“排队40年的幼儿园小孩” 除了卵子总数的急剧减少，年龄带来的另一个致命打击是**卵子质量的劣化**。沉积在保险库底部的卵子伴随女性经历了数十年的生活风霜：慢性炎症、不良饮食、吸烟、疾病以及各类细胞氧化损伤。卵子需要将内部的染色体维持在极度精准的排列位置以等待受精，Crawford 医生在此打了一个生动的比方： > “这就像让一群幼儿园小朋友整整齐齐地排成一队站立 40 年——总会有人忍不住乱跑出列的。” 当染色体排列错位，非整倍体等遗传学异常的发生率便会飙升。带有染色体异常的卵子绝大多数无法成功受精、无法着床，或者最终以流产告终。 - **流产率对比**： - **35岁**：获得阳性验孕结果后，自然流产率约为 **25%**； - **40岁**：验孕呈阳性后的流产率急剧飙升至 **50%**。 - **单月受孕概率对比**： - **35岁**：健康夫妻备孕，每月的自然受孕率仅有约 **10% 至 15%**； - **40岁**：单月自然受孕率直接暴跌至仅剩约 **5%**。这意味着，即使一位 40 岁的女性生活方式极为自律健康，仅仅是卵子随时间流逝而经历的自然老化，就会让胚胎畸变与受孕失败成为巨大的生理瓶颈。虽然日常健康抉择有助于减缓衰退，但时间的物理流逝依然是对女性生育能力最严酷的考验。 ### [42:01](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2521s) 卵子异常率与推迟生育的代价在女性 40 岁时，体内约 50% 甚至更高比例的卵子在遗传学上是异常的。每个月身体会从卵巢“保险库”中释放出一小批候选卵子（例如 8 颗，其中可能 6 颗异常、仅 2 颗正常）。在自然排卵时，身体随机选中正常卵子的概率极低，大多数月份排出的卵子根本不具备发育成活产婴儿的潜力。听到这里，Stephen 忍不住惊呼：“天呐，我感觉我真得抓紧时间了。” Dr. Natalie Crawford 指出，普及这些知识并不是为了恐吓大众，而是因为现实中极少有人坦诚地谈论生育衰退的客观规律。直面真相的反面往往就是痛苦的“后悔”。在门诊中，她频繁目睹许多人在得知真相后陷入无尽的自责与“后见之明”——尤其是那些习惯掌控一切、却仅仅因为缺乏数据而错失时机的精英人群。许多伴侣在一起多年，原本完全可以更早要孩子，却因误以为生育能力可以无限期等待，最终走入无力回天的困境。 --- ### [43:37](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2617s) 卵巢储备评估：AMH 与每月受孕概率的迷思评估女性卵巢中还剩多少卵子（即卵巢储备，Ovarian Reserve）主要依赖两种方式：一是通过血液检测抗缪勒管激素（AMH），二是通过超声检查评估当月窦卵泡数量（Antral Follicle Count）。然而，临床上存在一个广泛的认知误区：卵巢储备的多少并不直接决定某一个自然月经周期的单次受孕几率。 Dr. Crawford 用形象的比喻解释道：假设两位同龄女性，一位卵巢储备高、一位卵巢储备低，她们每个月派出的候选卵子数量虽然不同，但身体最终都只挑选并排出一颗卵子。因为年龄相同，那颗排出的卵子在基因层面的正常概率也是完全相同的，所以她们在任何单个自然周期内的怀孕几率没有任何区别。卵子数量少并不意味着每个月单次受孕几率更低；决定单次受孕质量的是年龄，而非总数。然而，卵子总数决定了生育的“时间窗口”以及试管婴儿（IVF）促排卵时能获取的卵子上限。 ```mermaid flowchart TD accTitle: 卵巢储备与单月受孕概率对比图 accDescr: 对比高卵巢储备与低卵巢储备在单月排卵概率与长期IVF机会上的差异 subgraph Monthly["单月自然受孕机制 (同龄女性)"] A1["高卵巢储备 (高 AMH)"] --> B1["候选卵泡群较大"] A2["低卵巢储备 (低 AMH)"] --> B2["候选卵泡群较小"] B1 --> C1["排卵数量：1 颗"] B2 --> C2["排卵数量：1 颗"] C1 --> D["单月自然受孕几率完全相同\n(受孕质量由年龄决定)"] C2 --> D end subgraph LongTerm["长期家庭规划与 IVF 影响"] A2 -.-> E1["生育时间窗口严重缩短"] A2 -.-> E2["IVF 单次促排获卵数较少"] A1 -.-> F1["拥有更充裕的时间试错与规划"] A1 -.-> F2["IVF / 冻卵单周期成功率更高"] end ``` - **AMH（抗缪勒管激素）**：反映卵巢内原始卵泡库存量的血清学指标。 - **超声窦卵泡计数**：直观观察单月从卵巢“保险库”出来参与竞争的卵泡数量。 - **单月受孕率 vs. 长期机会**：同龄女性自然周期单月受孕率相同，但低卵巢储备者经不起岁月拖延，IVF 促排卵反应也较弱。 --- ### [45:23](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2723s) 为什么妇产科指南反对常规筛查？Dr. Crawford 的反驳美国妇产科医师学会（ACOG）等主流学术组织建议：对于没有备孕需求且没有不孕史的女性，不推荐常规筛查 AMH。官方的理由是，既然 AMH 不能预测近期的自然受孕概率，检查出低储备只会给年轻女性带来不必要的恐慌和焦虑。Dr. Crawford 对这一观点表示强烈反对：“没有数据，你根本无法做出明智的人生决定。” 她认为，如果女性能及早获知自己的卵巢正在以快于常人的速度耗竭，她们很可能会改变人生轨迹：例如选择提前冻卵、将怀孕计划提前，或是主动戒除吸大麻、熬夜等损伤卵子的高危行为。如果不去检测，女性就被剥夺了知情权，最终只能在几年后库存耗尽时悔恨不已。妇产科医生在为女性开避孕药或讨论避孕措施时，本就应该同步评估卵巢储备：“你现在不想生，那我们是否该确认一下你的生育时钟还能维持多久？” - **学术界传统观点**：避免“健康无症状”女性因低 AMH 产生不必要的心理压力与焦虑。 - **Dr. Crawford 的临床主张**：知情权即选择权。在卵巢功能尚存时干预，远好过卵巢衰竭后的无可挽回。 - **现代技术的加持**：与上一代人不同，现代医学已拥有成熟、高复苏率的玻璃化冷冻卵子技术，提前得知数据具备切实的临床应对手段。 --- ### [49:06](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2946s) 生活方式对卵巢“保险库”的直接破坏：毒素与塑料不良生活习惯不仅会损害排出的卵子质量，还会直接潜入卵巢“保险库”，杀死休眠中的原始卵泡，导致卵子库存不可逆地缩水。以吸烟为例，香烟中的有毒物质会穿透卵巢屏障，直接导致卵泡细胞大量凋亡并损伤 DNA，因而吸烟女性的更年期平均比不吸烟者提前数年到来。当 Stephen 询问如何将卵巢储备保养到“满分”时，Dr. Crawford 给出了具体的避毒指南： 1. **远离毒性嗜好品**：彻底戒除香烟、大麻和可卡因；严格限制酒精摄入。医学上通常将每周饮酒 4 杯（例如一顿晚餐喝下 4 杯香槟）定义为中度饮酒，而中度至重度饮酒与卵子质量显著下降直接相关。 2. **阻断环境内分泌干扰物**： - **严禁塑料加热**：绝不使用塑料容器盛装热食，绝不能将塑料盒放进微波炉或洗碗机。 - **摒弃特氟龙不粘锅**：避免高温下涂层释放的全氟化合物。 - **远离热敏纸收据**：超市小票、机场登机牌等热敏纸表面含有高浓度双酚 A（BPA），经皮肤接触即可被机体吸收。 - **外卖热食及时转移**：热外卖送达后，即便食物本身很健康，在塑料或涂层纸盒中长时间保温也会加速化学毒素析出，应立即转移到玻璃器皿或陶瓷餐盘中食用。 ### [52:44](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3164s) 环境毒素与体内慢性炎症对生育能力的破坏环境化学毒物对生育能力的影响已不再停留在动物实验阶段。流行病学研究与大型队列追踪研究（对人群进行长年追踪并定期检测血液和尿液中的化学物质浓度）证实，在不进行任何外力干预的自然受孕尝试中，接触已知有毒化学物质越多的个体，受孕难度显著增加。除了避开环境毒素，保护“卵子宝库”（The Egg Vault）最关键的内部机制是降低体内炎症。人体内的炎症主要分为两类： - **急性炎症（Acute Inflammation）**：如手臂划伤后局部的红肿与愈合反应，这是正常的生理自愈过程。 - **慢性炎症（Chronic Inflammation）**：身体长期耗费能量处于对抗炎性状态的应激中。体内持续飙升的前列腺素（Prostaglandins）等炎性标志物，对卵子和精子的质量具有直接的毒性作用。子宫内膜异位症（Endometriosis）及各类自身免疫性疾病便是慢性炎症的典型代表。 --- ### [54:07](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3247s) 睡眠：调节生殖激素系统最简单、最根本的良药当被问及人们在日常生活中最常通过何种方式主动增加自身炎症时，娜塔莉·克劳福德医生（Dr. Natalie Crawford）毫不犹豫地指出：首要原因就是**睡眠不足**。 ```mermaid flowchart TD accTitle: 睡眠不足对生殖系统影响机制 accDescr: 展示缺乏睡眠如何通过积累炎症和干扰修复进而损害生殖激素系统 subgraph S1["日常状态"] A["日间暴露与代谢压力"] --> B["产生正常生理性损伤"] end subgraph S2["修复受阻"] B -.->|"缺乏 7.5 至 8 小时睡眠"| C["细胞无法修复损伤"] C --> D["慢性炎症指标攀升"] end subgraph S3["生殖危害"] D --> E["干扰大脑生殖内分泌信号"] D --> F["直接损伤精卵品质与卵子宝库"] end ``` 睡眠是人体自我修复与细胞修复损伤的黄金窗口，每晚必须保证 **7.5 至 8 小时** 的高质量睡眠。克劳福德医生直言，缺乏充足睡眠是现代人破坏自身生殖激素系统最普遍的行为。这并不需要服用昂贵药物，也不需要做出反人性的巨大生活妥协，仅仅是“给予身体从日常炎症中自我治愈所需的时间”。按时睡饱觉，是改善激素合成与信号传导最廉价也最有效的手段。 --- ### [55:07](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3307s) 压力如何蒙蔽大脑判断，以及每天20分钟的“皮质醇释放法” 压力对大脑的干扰机制与慢性炎症类似。虽然古代人类经历的是面对猛兽袭击等急性压力，但现代人每天都在承受无休止的生活与精神压力。每个人的压力耐受与应对方式千差万别，并没有放之四海而皆准的解法（如强制规定练瑜伽、针灸或做心理咨询）。关键在于认识到底层生理机制： 1. **皮质醇的信号遮蔽效应**：当人体处于长期高压状态时，体内皮质醇（Cortisol）持续大量分泌，会直接“遮蔽”大脑对生殖信号的解读与判断。 2. **大脑的生存优先策略**：大脑接收到高压信号后，会误判当前处于极度恶劣、不适宜孕育后代的环境，从而下调甚至抑制生殖激素的分泌。克劳福德医生建议每个人每天必须留出专属的 **20 分钟**：彻底远离手机、iPad、电脑和电视等一切电子屏幕，让自己沉浸在一个能感受到“皮质醇下降、压力完全释放”的宁静环境中。她分享自己的习惯是在清晨端一杯咖啡坐在后廊听鸟鸣；而对于其他人，散步、写日记、正念冥想或心理咨询同样有效。只有让身体体验到从紧绷中解脱出来的释怀感，免疫与内分泌系统才能在应对突发危机时正常运转，而不是日复一日承受系统性损耗。 --- ### [56:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3405s) 保护精卵质量的饮食法：红肉限量与“无肉星期一” 饮食是调节生育力最可控的一环。加工食品、精制糖以及加工肉类（已被世界卫生组织列为 1 类致癌物）充斥着人造添加剂与污染物，大量摄入精制糖和加工肉制品与受孕率下降直接相关，其核心病理在于直接破坏精子与卵子的内在质量。针对红肉（Red Meat）对生育的影响，克劳福德医生梳理了关键营养学事实： - **IVF 临床数据**：体外受精（IVF）临床研究显示，女性每周摄入红肉的份数越多，促排卵周期中成功发育形成的优质胚胎数量就越少。红肉过量同样会损伤男性的精子生成。 - **重在总量控制**：吃一份红肉本身并不会致病，核心是“凡事有度，过犹不及”（Everything in moderation, nothing in excess）。 - **抗炎优质饮食结构**：最有利于生育的饮食模式应富含大量新鲜蔬菜与水果。蔬果富含膳食纤维与抗氧化剂，能维护肠道菌群健康并显著扑灭体内炎症。 - **可操作的落地建议**： - **实行“无肉星期一”（Meatless Monday）**：每周至少挑一天完全不吃肉，促使自己摄入更多优质植物蛋白与蔬果。 - **鱼类替代**：鱼肉是极佳的蛋白质来源，富含优质 Omega-3 脂肪酸。但为规避重金属汞蓄积风险，建议**每周摄入不超过 3 次**。 - **荤素分配**：杂食者在其余日子里，建议将肉类摄入控制在**每天一份**；若偏好红肉，每周仅安排在其中一餐，避免一周多次大量食用。 --- ### [59:11](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3551s) 全脂乳制品与脱脂乳制品的生育力之谜克劳福德医生指出了现代流行饮食中长久以来的一个健康误区——盲目崇拜“低脂”或“脱脂”食品。从生殖内分泌学来看，健康的脂肪至关重要，因为雌激素（Estrogen）、孕酮（Progesterone）以及睾酮（Testosterone）全都是类固醇激素（Steroid Hormones），它们的合成高度依赖胆固醇作为原料。坚果、牛油果和优质油脂都是绝佳的健康脂肪来源。在乳制品选择上，研究数据显示：**全脂乳制品（Whole-fat Dairy）比脱脂乳制品（Skim Dairy）更有助于促进正常排卵与提升生育力**。其原因在于： - **深度加工的隐患**：脱脂奶属于高度加工食品。生产厂家在抽离牛奶天然脂肪的同时，为了维持其像牛奶一样的外观与质感，必须额外添加各类添加剂（“减去脂肪，再加上别的东西”）。 - **保留营养价值**：牛奶对生殖健康最核心的益处本就是其天然的健康脂肪酸，将脂肪完全剥离后，这一正面效应便荡然无存。因此，克劳福德医生建议备孕人群如果摄入乳制品，务必选择适量的全脂版本，彻底摒弃低脂和脱脂乳品；日常尽量远离包装膨化食品与精制碳水等“完全虚假的深加工垃圾”，将它们视作极少数特殊场合的消遣，而非一日三餐的常态。 --- ### [01:01:05](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3665s) 运动对生殖周期的双向影响与卵泡生长机制过度剧烈运动往往导致部分女性月经失调甚至完全闭经，而适度运动却被证实能促进生育。为了讲清这一矛盾，克劳福德医生现场拿出一颗弹珠形象地比喻“卵泡”，详细拆解卵巢与大脑之间精密的“无盲盒通信机制”： | 阶段 | 卵巢内的生理事件 | 大脑（垂体）与卵巢的信号交互 | |:--- |:--- |:--- | | **募集与启动** | 每个周期开始时，一批休眠卵子从“宝库”中被唤醒，各自包裹在独立的卵泡内。 | 垂体分泌促卵泡生成素（FSH），像施肥一样刺激其中一个优势卵泡生长。 | | **卵泡发育（约2周）** | 优势卵泡在约两周时间内不断吸收营养长大，卵泡壁颗粒细胞开始大量合成并分泌雌激素。 | 大脑无法肉眼观察卵巢，就像“不上 Instagram 的闺蜜，除非你发动态否则对你的生活一无所知”，大脑完全靠血液中的**雌激素浓度**来感知卵泡的成熟进度。 | | **成熟与排卵** | 雌激素飙升至峰值阈值，成熟卵泡囊壁逐渐膨胀至破裂，将内部微小的卵子排入输卵管。 | 大脑感知到极高浓度的雌激素信号，确认卵子已完全成熟，随即触发黄体生成素峰值启动排卵。 | - **卵泡（Follicle）的微观结构**：肉眼可见的卵泡本质上是一个充满液体的囊泡结构，就像一颗包裹着微小晶莹水珠的胶囊，而肉眼不可见的卵子就静静浸润在其内部微环境中发育。 ### [01:02:44](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3764s) 卵泡发育、受精与黄体形成：精密的着床倒计时 Dr. Natalie Crawford 用弹珠作比喻来拆解卵泡的结构：卵泡本质上是一个充满液体的小囊泡，卵子就安然储存在其中。随着卵子逐渐成熟，卵泡会不断膨胀变大，并分泌出越来越多的雌激素（Estrogen）。大脑对雌激素水平的监测极其精密——必须达到特定阈值（例如约 200 pg/mL 且持续约 50 小时），大脑才会确信已经有一颗发育成熟的卵子准备就绪。随后，脑下垂体便会倾泻出峰值促黄体生成素（LH）。LH 会促使卵泡壁破裂，卵子随之释放并被输卵管伞端吸入，踏上受孕之旅。然而，卵泡的使命在排卵后并没有终结。失去卵子后，残留在卵巢内的卵泡会重组演变成一个被称为“黄体”（Corpus Luteum）的囊肿状结构。在大脑 LH 的持续指令下，黄体开始全速分泌孕酮（Progesterone，黄体酮）。孕酮的作用至关重要，它就像一把钥匙，专门负责开启和关闭子宫内膜的“着床窗”（Implantation Window）。如果没有充足且适时的孕酮，即使胚胎质量再好，也无法在子宫内膜着床扎根。受精过程同样奇妙。精子游过宫颈与子宫，在输卵管与在此“静候佳音”的卵子相遇。精子的头部如小蝌蚪般撞击卵子表面，触发微小的膜融合反应，将其 DNA 注入卵子。单细胞的精子与卵子融合为受精卵，随即开始指数级的细胞分裂：从 2 细胞、4 细胞、8 细胞一路分裂到第 5 或第 6 天，发育成为一个包含约 300 个细胞的囊胚（Blastocyst）。此时，它才真正具备了游入子宫并着床的能力。 ```mermaid flowchart TD accTitle: 排卵至早期妊娠维持流程图 accDescr: 展示从卵泡成熟、排卵、受精分裂到黄体支持及着床反馈的完整荷尔蒙与生理路径 subgraph FolliclePhase ["卵泡发育与排卵"] A["卵泡增长 / 分泌雌激素"] --> B["雌激素达到阈值 200 pg/mL"] B --> C["大脑释放 LH 峰"] C --> D["卵子排出进入输卵管"] end subgraph LutealPhase ["受精与黄体形成"] D --> E["精卵在输卵管结合受精"] E --> F["第 5-6 天形成囊胚 (约 300 细胞)"] C --> G["空卵泡重组成黄体"] G --> H["黄体分泌孕酮 / 打开着床窗"] end subgraph OutcomePhase ["着床窗结局"] F & H --> I{"是否成功着床？"} I -- 是 --> J["胚胎产生 hCG 维持黄体"] I -- 否 --> K["2 周后黄体凋亡 / 内膜脱落月经来潮"] end ``` --- ### [01:05:08](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3908s) 孕酮与着床之谜：为什么月经会按时降临？ Dr. Crawford 指出，人体的生育设计具有极高的筛选淘汰率：绝大多数卵子根本无法成功受精，或者无法正常分裂发育，甚至无法顺利抵达子宫。更为严苛的是时间窗口——即使胚胎到达子宫，如果宫腔内的孕酮水平没有调配得恰到好处，着床依然无法完成。这正是现代许多激素类避孕药的作用机制原理。黄体在排卵后按部就班地分泌孕酮，精准设定着床窗的开启与关闭时间；如果胚胎未能如期抵达、耽搁过久，着床窗口就会无情关闭。正常情况下，黄体的固有生存寿命仅有两周： - **未怀孕状态**：如果本月没有胚胎着床，黄体在两周后便会衰老坏死，体内孕酮水平随之发生断崖式下跌。这一骤降向子宫内膜发出了明确信号：“本月未能受孕，推倒重来”，于是内膜剥落形成月经，身体开始为下一批卵泡的动员做准备。 - **成功受孕状态**：一旦胚胎在子宫内成功着床，囊胚就会开始分泌人绒毛膜促性腺激素（hCG，即验孕棒检测的指标）。hCG 会强行给黄体“续命”，督促其持续供应高水平孕酮，从而维持子宫内膜的稳定性并保护早期妊娠，直至后续胎盘发育成熟接管激素分泌。 --- ### [01:06:09](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=3969s) 过度运动与能量危机：下丘脑空中管制台的停摆理解了这套激素反馈回路，就能看清极端运动与压力如何摧毁月经周期。Dr. Natalie Crawford 将大脑中掌管 FSH 与 LH 释放的司令部——下丘脑（Hypothalamus），比作“机场的空中交通管制塔台”。它负责严密监控身体输入的每一项能量与压力指标，并指挥后续航班调度。当一名女性进行超负荷的高强度训练（如备战奥运会的精英运动员）或陷入厌食症等饮食失调状态时，下丘脑通过精密核算发现：摄入的卡路里与消耗的能量严重失衡，当前机体根本无法承担孕育另一个新生命的能量重负。于是，塔台会果断拉下紧急制动阀，彻底停止分泌 FSH 和 LH，导致卵巢不排卵、月经完全消失。这就是“下丘脑性闭经”（Hypothalamic Amenorrhea）。 Dr. Crawford 发出沉重警示：**当大脑主动选择“关闭”这套生殖系统后，哪怕患者脱离极端训练或进入饮食康复期，往往也需要数年时间才能让下丘脑重新启动**。大脑必须在极度安全、能量充裕的环境中被“说服”数年之久，才会重新相信身体已恢复到能够安全繁衍的状态。 --- ### [01:07:54](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4074s) 脂肪细胞的激素陷阱：肥胖如何同时阻碍男女生育力生育轴不仅惧怕能量匮乏，同样会因能量严重过剩而陷入瘫痪，其中的核心元凶就是脂肪组织。脂肪细胞具有将其他激素转化为雌激素的能力。大脑本身非常单纯，它默认“体内的雌激素全都是成熟卵泡分泌出来的”： - **女性超重与排卵停滞**：当女性超重或肥胖时，多余的脂肪细胞持续释放雌激素。大脑监测到基线雌激素偏高，误以为已经有一颗卵泡在健康生长，为了避免多胎风险，大脑会主动降低促性腺激素的输出。结果，卵巢因为得不到足够的启动信号，反而没有卵子能真正发育成熟，排卵机制被锁死，导致月经失调或闭经。因此，超重女性通过运动减重能显著降低基线雌激素，让大脑重新“看清”卵巢的真实信号。 - **男性肥胖与 TRT 致命陷阱**：男性体内的雄激素与雌激素处于相同的转化通路上。男性肥胖时，多余脂肪会将睾酮转化为雌激素。大脑感知到雌激素升高，产生错觉：“Steven 最近长胖了，雌激素挺充沛，精子产量应该完全够用”，因而削减向睾丸发送的指令，导致内源性睾酮和精子生成量双双暴跌。患者随之陷入疲劳、缺乏精力的恶性循环；当他们前往某些不专业的男科诊所抽血时，医生往往只看到睾酮偏低，直接开具外源性睾酮替代疗法（TRT）——外源睾酮进一步完全阻断大脑分泌信号，最终彻底击溃精子生产线，导致精子计数清零。对于普通人群，Dr. Crawford 强调“最好的运动就是你能坚持下去的运动”。备孕期不应盲目挑战身体极限去跑马拉松，但每天进行 60 分钟以内的主动锻炼极其有益：肌肉轻微的生理性炎症不仅能提高胰岛素敏感性，还能帮助消耗过多体脂、平衡皮质醇并有效释放压力。 --- ### [01:10:58](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4258s) 什么是正常月经周期？可预测性是第一指标 Steven 谈及自己的伴侣曾公开分享过的一段亲身经历：伴侣因饮食习惯改变与进食困难，经历了长达三到四年的闭经，经过漫长的调理后月经才终于恢复。Steven 由此发问：究竟怎样的月经周期才算得上“正常与健康”？ Dr. Crawford 强调，医学上界定健康月经的核心特征在于**“规律与可预测性”（Regular and Predictable）**。如果一位女性打开日历，能够以两三天之内的误差准确预测下一次月经何时降临，通常就意味着其排卵系统在稳定运作。 - **周期的计算标准**：月经周期的“第一天”（Day 1）是从出血开始的第一天算起，一直计算到下一次月经来潮前一天的总天数。 - **个体差异与误区**：大众文化和教科书里常常将“28 天”奉为铁律，但实际上每个健康女性的周期天数都存在个体差异，不一定每个人都必须严丝合缝地吻合 28 天。只要周期长短稳定、可规律预测，就是机体激素稳态的重要体现。 ### [01:12:05](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4325s) 月经周期的生理机制与不规律的原因月经周期并非每个人都恰好是 28 天，普通女性的正常周期通常在 24 到 35 天之间波动。从生理本质来看，月经周期的运转始于卵巢内的一批基础卵泡被募集。大脑垂体释放促卵泡生成素（FSH），促使其中一个优势卵泡发育成熟并排卵。排卵后，卵泡转变为黄体（Corpus luteum）并开始分泌孕酮（黄体酮），使身体进入月经周期的后半段——黄体期。黄体的存活寿命极其固定，恒定为 14 天（两周）。如果没有成功受孕，黄体退化、孕酮骤降，子宫内膜失去激素支持而脱落，形成月经出血。与此同时，在经期出血期间，卵巢已经马不停蹄地启动了下一个周期的卵泡发育；随着新卵泡分泌出足够的雌激素，子宫内膜重新修复、稳定并止血。正常情况下，如果排除外界干预，月经没有如期而至通常只有两个原因：要么是怀孕了，要么是没有排卵。排卵需要孕酮随后的下降作为撤退性出血的信号，如果排卵根本没有发生，生理闭环就会被打断。导致不排卵或月经失调的病理机制主要包括四大类： 1. **卵巢储备耗尽**：体内已经没有可供排卵的卵子。 2. **下丘脑闭经或功能障碍（Hypothalamic Amenorrhea / Dysfunction）**：过度运动、严苛的热量限制、慢性疾病或沉重的精神压力，导致大脑停止向卵巢发出启动指令。 3. **垂体与甲状腺轴失衡（如高催乳素血症、甲状腺疾病）**：促甲状腺激素（TSH）或催乳素（Prolactin）分泌异常时，垂体会将能量分流，导致 FSH 和黄体生成素（LH）释放受阻。 4. **多囊卵巢综合征（PCOS）**：女性不孕和月经紊乱最常见的诱因之一，本质是大脑与卵巢之间出现了严重的激素信号沟通紊乱。 ```mermaid flowchart TD accTitle: 月经周期的激素与生理调节循环 accDescr: 展示从下丘脑垂体激素信号触发卵泡发育，到排卵、黄体形成，以及未受孕时子宫内膜脱落流血并启动下一轮周期的全流程。 subgraph Follicular["前半周期：卵泡期"] A["垂体释放促卵泡生成素 (FSH)"] --> B["优势卵泡生长发育并排卵"] B --> C["卵泡分泌雌激素 (修复并增厚子宫内膜)"] end subgraph Luteal["后半周期：黄体期 (恒定14天)"] B --> D["黄体形成并分泌孕酮"] end subgraph Outcome["周期结局判定"] D --> E{"是否成功受孕？"} E -- "未受孕" --> F["黄体萎缩退化 孕酮水平骤降"] E -- "受孕" --> G["维持妊娠与闭经"] F --> H["子宫内膜脱落 (月经来潮)"] H -.->|"启动下一轮卵泡募集"| A end ``` --- ### [01:14:48](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4488s) 排卵易孕期计算与同房频率的误区不同女性的生理周期长度各不相同，因此排卵日和易孕期（Fertile window）差异极大，单纯依赖通用的周期追踪 App 往往会造成严重的排卵误判。易孕期严格定义为**排卵前的 5 天加上排卵当天**：卵子排出后在输卵管中的存活受精寿命仅有 24 小时，而精子在女性生殖道内最长可存活 5 天。因此，精子需要提前进入输卵管“蹲点待命”，并在排卵当天相遇才能成功受精。由于黄体期恒定为 14 天，易孕期的精确计算必须采用**倒推法**，即用总周期天数减去 14 天： - **28 天周期**：$28 - 14 = 14$，排卵发生在第 14 天，最易受孕的窗口是月经周期的第 9 至 14 天。 - **35 天周期**：$35 - 14 = 21$，排卵发生在第 21 天，易孕窗口则是第 16 至 21 天。面对复杂的周期测算，许多备孕夫妇会陷入一个严重的认知误区：为了在排卵日“集中火力”，故意在备孕期间长时间禁欲“攒精子”。这反而是临床上最常见的错误做法。更科学的策略是，只要月经规律，无需过度精神内耗去卡点测算，直接在整个周期内保持**每天或隔天一次**的高频性生活，确保存活的精子始终充盈在输卵管内。 --- ### [01:17:02](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4622s) 年龄阶梯下的受孕几率与“备孕工作化”的心理压力临床医学对不孕症（Infertility）的定义是：在未采取避孕措施、能完成正常射精且月经规律的前提下，规律尝试备孕满 1 年未孕。不同年龄段的自然受孕几率存在断崖式变化： - **30 岁左右**：每个月的自然受孕几率约为 20%，大多数健康的夫妻会在 6 个月内自然怀孕。 - **35 岁**：每月自然受孕几率降至 10% 到 15%。 - **38 岁**：每月几率仅剩 5% 到 8%。 - **40 岁**：每月自然受孕几率已暴跌至 3% 到 5%。随着现代人婚育年龄大幅推迟，“生孩子”在夫妻生活中逐渐从一件充满爱意与欢愉的事情，退化成一种充满考核意味的“家务苦差”（Chore）。许多女性因为年龄紧迫感和卵子不可逆的衰减，时刻紧盯体温计和排卵试纸；一旦丈夫在易孕窗口出差或状态不佳，便会引发争吵与巨大焦虑。这种巨大的心理压力与高压情绪恰恰是性欲的死敌。临床医生对此建议，建立现实的预期至关重要：如果 37 岁才开始备孕却希望生 4 个孩子，不借助 IVF（试管婴儿）等辅助生殖技术提前冷冻胚胎几乎无法实现。提早进行医学干预不仅是为了生育保障，更是为了把夫妻从压抑的“按表做爱”中解救出来，让性生活回归其本身的亲密与乐趣。 - 若无法顺利完成体内射精，或女方月经长期极不规律，绝对不要苦等 1 年才就医，应当立即前往生殖中心做专业评估。 - 精子在体内最黄金的存活期通常为 2 至 3 天（极少数强健者可达 5 天），每周保持 2 至 3 次规律同房即可覆盖大部分受孕机会。 --- ### [01:20:11](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4811s) 缺乏性生活的困境与宫腔内人工授精（IUI）的介入在现代高压社会中，许多夫妻面临着“无性化”（Sexlessness）的困局。除了因为日程繁忙、压力过载或单纯对性生活失去兴趣外，还有部分群体受限于特殊职业——例如长途卡车司机、经常跨时区飞行的机长与空乘，彼此的物理分离导致他们几乎不可能恰好在女方的排卵窗口期同房。针对这部分无法通过自然同房实现精卵结合的群体，生殖医学提供了相对温和的辅助方案——**宫腔内人工授精（IUI，Intrauterine Insemination）**。该技术跳过了阴道性交的环节，由男方提供手淫排出的精液样本，经过实验室洗涤、分离和高浓度优化处理后，通过细导管直接注入女方的子宫腔内。男方不能在家里随意将精液收集并用吸管自行注射，因为射出的原始精液主要由前列腺液和精囊液构成，其碱性液体是为了中和阴道的酸性环境并保护精子；若未经无菌处理和生化洗涤直接将原始精液强行推入子宫，会引发强烈的子宫剧烈痉挛甚至严重感染。 ### [01:21:21](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=4881s) 民间受孕偏方与精子黑市的法律隐患在临床辅助生殖中，未经处理的精液绝不能直接注入子宫腔。精液中的大部分成分本来就不会进入子宫，如果直接将整份样本注入子宫，会引发强烈的炎症甚至严重感染。正规诊所必须对样本进行洗涤、离心分离（centrifugation），提取纯净的精子沉淀物后再注入子宫，从而完全避开射精液中的保护性成分。然而，许多求子心切的夫妇在私下尝试各种匪夷所思的手段：有人在同房后塞入卫生棉条或子宫帽，试图“兜住精子”防止流出；还有人自行购买移液管甚至家用烤火鸡滴管（turkey baster），抽取精子注入阴道。更令人震惊的乱象发生在捐精领域。许多人并不知道，在社交媒体群组（如 Facebook 群组）中存在着一个庞大的“精子捐赠黑市”。正规精子库不仅会对精液进行传染病筛查和全面健康测试，限制使用次数，更重要的是能在法律层面上彻底厘清并保障抚养权。而在网络地下渠道中，人们往往通过私聊联络，直接在沃尔玛停车场的车里碰头，捐精者以“出于善心”为由递上一管未经检测的精子。这种私下交易潜藏着巨大的法律灾难。Dr. Natalie Crawford 分享了发生在俄克拉荷马州的一个真实判例：一对女同性恋伴侣因承担不起诊所的高昂费用，通过 Facebook 群组找到了一位自愿捐精者。双方虽然签署了放弃抚养权的协议文件并成功受孕产子，但这位捐赠者随后反悔并向法院提起诉讼争夺监护权。最终法院裁定协议无效，判决该捐赠者胜诉并与这对伴侣共同拥有孩子的监护权。这正是因为双方没有通过正规医疗和法律程序，缺乏合法的金钱服务交换界定。在涉及第三方生殖（供卵、供精、代孕、供胚）时，保护父母的法定抚养权益是生殖医生首要考虑的核心底线。 - **正规捐精与治疗的成本核算**：从精子库购买一管合格冷冻精子约需 $1,000 美元；在诊所进行一次子宫内人工授精（IUI）周期的操作费用通常在 $1,000 至 $2,000 美元之间。 - **单周期累积成本与成功率**：每个周期的总花费大约在 $2,000 到 $3,000 美元。若女性年龄达到 35 岁，单周期的成功率仅约为 10% 到 15%，通常需要尝试多个周期才能受孕。 --- ### [01:24:48](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5088s) 多囊卵巢综合征（PCOS）的发病机理与激素失衡恶性循环主持人谈到身边的挚友长期饱受多囊卵巢综合征（PCOS）折磨，并指出该病可能影响多达 20% 的人群。Dr. Natalie Crawford 解释道，官方统计的患病率通常在 10% 到 13% 左右，但令人担忧的是，高达 70% 的 PCOS 患者处于未被确诊的状态，因此实际患病人数远高于现有数据。为了通俗解释 PCOS 的本质，Dr. Crawford 将其形象地描述为“出生时卵子金库里自带了过多的卵子”。女性在胎儿期 5 个月时拥有大约 600 万到 700 万枚卵子，正常情况下到足月出生时会自然凋亡递减到 100 万至 200 万枚。而 PCOS 患者很可能因母亲妊娠期间的某些行为或环境暴露，导致正常的细胞凋亡减少，从而带着远超常人的卵子储备出生。由于每月募集出库的卵子数量与储备库总量成正比，PCOS 患者每个月会派出多达二三十个卵泡。然而，大脑并不知道卵子基数变大了，垂体分泌的卵泡刺激素（FSH）总量依然维持在正常标准。“FSH 就像挑选并浇灌单颗卵子的养分”，当这份固定的养分被摊派给 20 到 30 个卵泡争夺时，没有任何一颗卵泡能获得足够强烈的信号成长为优势卵泡并规律排卵。当卵泡无法正常生长时，卵巢就无法按时分泌雌激素。Dr. Crawford 强调：“所有人都以为卵巢的主要功能是产生卵子，但它真正的挚爱其实是制造激素。”当小卵泡停滞、卵巢“感到无聊”时，其体内合成雄激素（睾酮）的通路就会被异常上调。过量的雄激素在女性体内引发胰岛素抵抗，导致脂肪在腹部堆积——呈现出类似男性“啤酒肚”的形态，而非传统的女性臀部和大腿脂肪。同时伴随痤疮、多毛症（面部毛发生长）甚至雄激素源性脱发等严重影响生活质量的体征。随着腹部脂肪增加，外周转化的异常雌激素反过来扰乱大脑反馈，进一步下调垂体释放 FSH，形成顽固的恶性内分泌循环。 ```mermaid flowchart TD accTitle: PCOS 激素失衡恶性循环图 accDescr: 展示从卵子基数过大到雄激素升高、胰岛素抵抗以及下调 FSH 的内分泌恶性循环流程。 subgraph OvarianVault["卵巢储备与募集"] A["出生携带卵子总量超标"] --> B["每月募集卵泡过多 (20-30个)"] end subgraph PituitaryFSH["垂体激素信号"] C["大脑分泌常规剂量 FSH"] --> D["FSH 信号被稀释，卵泡无法优势化"] end subgraph HormoneShift["激素分泌异常"] D --> E["无优势卵泡，雌激素合成受阻"] E --> F["卵巢合成通路代偿性转向产生睾酮"] end subgraph MetabolicImpact["代谢紊乱与负反馈"] F --> G["胰岛素抵抗、腹部脂肪积聚、痤疮与多毛"] G --> H["脂肪代谢扰乱大脑反馈，进一步压制 FSH"] H -.-> D end B --> D ``` --- ### [01:28:06](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5286s) PCOS 的药物干预策略与生理脆弱性面对 PCOS 带来的无排卵与内分泌紊乱，临床治疗的核心是打破雄激素与胰岛素抵抗的连锁反应。对于有即时生育需求的患者，首选方案是“诱发排卵”（ovulation induction）。通过使用克罗米芬（Clomid）或来曲唑（Letrozole）等药物，迫使大脑垂体释放更强烈的 FSH 脉冲信号，从而在众多卵泡中强行催熟一颗并诱导排卵。对于暂无生育计划的患者，关键在于切断过量雄激素的生产。常用方案包括改善胰岛素敏感性的二甲双胍（Metformin），以及直接阻断雄激素合成的螺内酯（Spironolactone）。口服复方避孕药在 PCOS 管理中扮演着重要角色：它不仅能外源性补充规律的雌孕激素，更重要的是能刺激肝脏合成性激素结合球蛋白（SHBG）。SHBG 像海绵一样大量结合血液中游离的睾酮，显著降低游离雄激素水平，从而缓解痤疮和体毛等雄化体征。临床上常观察到一个有趣现象：许多 PCOS 患者在刚停用避孕药的初期往往能规律排卵，但随着时间推移，体内的雄激素水平逐渐回升至基础高位，排卵又会再度受阻。 Dr. Crawford 特别向患者强调，PCOS 的内分泌系统就像一个“极其敏感的跷跷板”（teeter-totter of balance）。任何额外的外界压力激增皮质醇，或者体重的明显波动，都极易打破脆弱的激素平衡而导致排卵彻底停止。尽管控制体重对伴有肥胖的患者非常重要，但临床上也存在大量体型消瘦的“瘦型多囊”（lean PCOS）患者，她们同样面临卵泡过多、信号稀释和无排卵的困扰。Dr. Crawford 郑重呼吁，患者不应为此产生自责与负罪感： > “即便你过着最健康的生活、远离一切炎症和压力，你依然可能患上 PCOS，这是一种真正的疾病。在育龄期无法规律排卵不是你的失败，也绝不是你的过错。” 对于那些因病理机制无法自然受孕的患者，医学干预——包括促排卵药物、冷冻卵子和体外受精（IVF）——能够提供切实有效的解决方案。 ### [01:30:58](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5458s) 多囊卵巢综合征（PCOS）的诊断标准与成因机制 Natalie Crawford 医生详细解释了如何诊断多囊卵巢综合征（PCOS）。诊断通常依据“鹿特丹标准”（三项中满足两项即可确诊）： 1. **超声检查下卵巢内存在大量卵泡**（卵巢呈多囊样改变）； 2. **雄激素过高的体征或实验室指标**（如血液化验睾酮水平高于正常女性，或临床表现为痤疮、多毛等）； 3. **月经不规律或完全闭经**。这意味着，只要一名女性存在月经不规律且常年长痤疮，即便没有立刻做超声，也已经符合了 PCOS 的临床诊断标准。关于 PCOS 的成因，Crawford 医生指出这很大程度上与**遗传**和**表观遗传**有关。当胎儿在母亲子宫内发育时，母体的宫内环境（例如母体存在胰岛素抵抗或不良代谢暴露）就会深刻影响胎儿卵巢未来的功能模式，使女性出生后患 PCOS 的风险显著增加。此外，还有一种“由肥胖诱发”的 PCOS 表现形式：严重肥胖会导致脂肪组织过量转化产生雌激素，大脑垂体感知到持续的雌激素后便减少促卵泡生成素（FSH）的分泌；由于缺乏足够强烈的启动信号，卵巢无法正常排卵，卵泡处于停滞状态并开始分泌睾酮。这种机制与先天“卵子储备库（Egg Vault）中存量极大”的典型 PCOS 有所不同。因此，作为一种由多种症状构成的“综合征”，PCOS 往往具有不同的底层病理来源。 ```mermaid flowchart TD accTitle: PCOS 诊断与分型逻辑 accDescr: 展示鹿特丹诊断标准的三选二原则，以及先天遗传和肥胖诱发的不同成因路径。 subgraph Criteria["鹿特丹诊断标准（满足 2 项即可）"] C1["超声显示大量卵泡"] C2["高雄激素（指标升高/痤疮/多毛）"] C3["月经不规律或闭经"] end subgraph Origins["底层病理机制"] O1["遗传与表观遗传 （宫内环境、母体胰岛素抵抗）"] --> Mech1["先天卵子储备库巨大 大量小卵泡分泌微量雌激素"] O2["严重肥胖与代谢障碍"] --> Mech2["脂肪转化雌激素 -> 抑制FSH 卵巢缺乏排卵信号而分泌睾酮"] end Criteria --> Diagnosed["确诊 PCOS"] Mech1 --> Diagnosed Mech2 --> Diagnosed ``` ### [01:32:54](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5574s) PCOS 能够被完全治愈吗？年龄与卵子消耗的自然转机当主持人询问 PCOS 是否能完全治愈时，Crawford 医生给出了一个耐人寻味的答案：“对于某些人来说，是的，但我常对声称‘治愈了 PCOS’的患者说：其实你只是到了 38 岁。”女性每个月都在不可逆地消耗卵子，PCOS 患者虽然出生时储备的卵子总量远多于常人，但她们绝经的年龄却与普通女性完全相同。这说明 PCOS 女性卵子耗损的速度实际上比常人更快。随着年龄增长，当卵巢储备库中每个周期被唤醒的卵子数量下降到一个“大脑垂体能够有效调控的合理区间”时，卵泡对激素信号的响应重新恢复，排卵与月经周期便自然规律起来。Crawford 医生强调，虽然健康的生活方式干预（如改善饮食、减重、提高胰岛素敏感性）对卵巢功能的改善至关重要，但很多时候周期的恢复是生活方式改善与年龄增长导致卵子基数下降共同作用的结果。 - **卵子基数动态**：PCOS 患者拥有比普通人多得多的卵子储备，但绝经年龄并无延迟，卵子是以更快的速率被自然凋亡和消耗。 - **排卵障碍（Anovulation）**：PCOS 患者面临的核心生育障碍是不排卵，这是导致女性不孕最主要的原因之一。 ### [01:33:50](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5630s) 闭经的严重健康代价：子宫内膜癌与早衰风险的两极 Crawford 医生极其严肃地强调了一个健康红线：“**在没有服用避孕药等外源激素的情况下，不来月经绝对是不正常的，且对全身健康危害极大。**”她将闭经的危害分为截然不同的“两极”： 1. **PCOS 导致的闭经（高/持续雌激素，无孕激素对抗）**：卵巢内数以百计的小卵泡每天都在分泌少量的雌激素。虽然单日浓度不高，但日复一日持续刺激子宫内膜不断增厚。由于没有发生排卵，黄体无法形成，体内便**完全没有孕激素（Progesterone）**来发出剥脱出血的信号。失去孕激素保护的子宫内膜细胞持续异常增生，演变成**子宫内膜癌（Endometrial Cancer）**的风险极高。这也是为什么妇科医生会坚决要求 PCOS 闭经患者定期服用孕激素或口服短效避孕药，强行制造撤退性出血以防癌变。 2. **过度运动或下丘脑性闭经（低雌激素状态）**：当女性因为过度节食、剧烈运动长达 3-4 年不来月经时，大脑会彻底关闭下丘脑-垂体信号（无 FSH），卵巢完全处于休眠状态，**体内几乎测不到雌激素**。过早缺乏雌激素会使年轻女性提前暴露在绝经期后的健康灾难中：骨密度急剧下降、早发严重骨质疏松与髋关节骨折风险，同时心血管疾病、中风、认知障碍及阿尔茨海默病（Alzheimer's）的风险大幅飙升。许多二十多岁的年轻女孩误以为“每个月不流血反而更省事、更轻松”，Crawford 医生驳斥了这种误区。雌激素是大脑保持敏捷、精力充沛和思维清晰的必需物质；长期缺雌激素会导致严重的脑雾、常年慢性疲劳和情绪低落。无论是中枢信号关闭还是卵巢早衰，及时使用激素替代疗法补充雌激素，关乎女性的长期生存质量与寿命。 ### [01:37:02](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5822s) 什么是子宫内膜异位症？炎症、组织粘连与隐秘的疼痛当主持人提到“子宫内膜异位症”（Endometriosis，简称内异症）这一从未听过的词汇时，Crawford 医生通俗地拆解了其病理本质——这是一种**慢性炎症性、自身免疫性疾病**。子宫内膜是子宫最内层、每个月为胚胎着床做准备增厚并在经期剥脱出血的组织。在月经来潮时，子宫剧烈收缩挤压，经血和部分内膜细胞逆流穿过输卵管开口进入腹腔，这一现象在绝大多数女性身上都会自然发生（若在经期切除阑尾，盆腹腔内看见经血是非常普遍的生理现象）。 | 维度 | 正常生理反应 | 子宫内膜异位症（Endometriosis） | |:--- |:--- |:--- | | **经血逆流处理** | 免疫系统将其视为正常代谢产物，静默清除 | 免疫系统发生异常免疫反应，将其视作外来入侵细胞，发动全面攻击 | | **组织对激素的反应** | 随正常经期自然剥脱吸收 | 异位生长的内膜细胞对雌激素极度敏感，随每个排卵周期在腹腔内增生、出血、诱发剧烈炎症 | | **疼痛特征** | 轻度至中度痉挛，非全身性持续剧痛 | **极度严重的经期痛经**；**性交深部疼痛**（尤其女上男下等特定体位撞击深部病灶时产生剧痛） | | **对生育力的破坏** | 无负面影响 | 慢性毒性炎症直接损伤卵子、精子与早期胚胎；后期病灶纤维化形成广泛瘢痕黏连，甚至**完全堵塞输卵管** | | **临床确诊途径** | 无需特殊检查 | **无法通过血液检查诊断**；必须通过**腹腔镜手术**在全身麻醉下直视确诊 | Crawford 医生特别指出，虽然剧烈痛经是该病最典型的标志，但也有一部分患者并没有明显的经期疼痛。此外，“性交疼痛”具有明显的深部解剖学特征，患者常抱怨“在特定姿势（如女性在上方）下感到腹腔深部刺痛”，这是因为该姿势的插入角度直接挤压到了盆腔腹膜上的异位病灶。在生育影响方面，自身免疫攻击引发的慢性微环境毒性不仅会扼杀早期胚胎的发育导致不孕和复发性流产，长期反复的炎症还会转化为坚硬的瘢痕组织，破坏骨盆解剖结构，引发输卵管不可逆的物理梗阻。诊断内异症极其困难，目前血液中尚无明确的生物标志物，**唯一的金标准确诊手段是经腹部微创手术（腹腔镜，Laparoscopy）**：外科医生在患者肚脐处切开小口，向腹腔内充入气体膨胀视野，置入医用内窥摄像头，用肉眼直接观察并识别散布在盆腹腔各处的异位病灶。 ### [01:40:49](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6049s) 子宫内膜异位症的严重疼痛与诊疗困境正常的经期疼痛绝不应该严重到破坏生活质量的程度。Natalie Crawford 医生特别强调，如果一名女性每个月都因为剧烈的痛经而不得不取消聚餐、请假缺勤、无法参与日常活动，这绝对不是正常的生理现象，而是高度提示可能患有子宫内膜异位症（Endometriosis）。然而，许多女性甚至从未接受过腹腔镜手术来确诊。医生指出这也可以理解，因为等到真正开刀确诊时，盆腔内的慢性炎症和组织损伤往往已经形成多年。子宫内膜异位症最棘手的医疗矛盾在于治疗与备孕的天然对立。治疗该病的核心手段是抑制排卵，因为女性自身分泌的雌激素会持续刺激异位的内膜细胞增殖生长；但如果想要自然怀孕，女性又必须恢复排卵。这就导致患者在尝试怀孕的每个排卵周期中，体内的病灶和炎症都在不可逆地逐渐加重。 - 普通人群中约有 10% 的女性患有子宫内膜异位症，但在生殖医学中心的就诊人群中，该病的患病率骤升至 30% 到 50%。 - 很多女性处于“未确诊”状态，因为子宫内膜异位症并不破坏下丘脑-垂体-卵巢轴（HPO轴）的内分泌信号，患者通常周期规律、正常排卵，因而极易被草率归类为“不明原因不孕”（Unexplained Infertility）。 - 即使性生活正常甚至伴有深部性交痛，患者也极难受孕，其根本原因在于盆腔内长期存在的重度炎性微环境阻碍了精卵结合。 --- ### [01:43:08](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6188s) 试管婴儿（IVF）与药物抑制周期的协同治疗面对子宫内膜异位症带来的恶劣微环境，试管婴儿（IVF）展现出无可比拟的优势。通过体外受精，医生能绕过母体腹腔的慢性炎性毒性环境，将卵子取出并在实验室经过严格调控的恒温恒湿、理想酸碱度（pH）介质中完成受精并培养成囊胚。在囊胚培养并冷冻保存后，医生可以全力治疗子宫内膜异位症：利用药物强力抑制病灶活性、消除内膜炎症。此时患者是否自主排卵已经完全不重要，医生只需通过外源性雌激素与孕激素精准调理内膜厚度与转化窗口，在恰当的时间将优质胚胎移植回宫腔，从而获得极佳的临床妊娠率。 ```mermaid flowchart TD accTitle: 子宫内膜异位症的IVF干预路径 accDescr: 展示体外受精避开炎性环境、促排冻胚后药物抑制病灶再择期移植的全流程。 subgraph Lab ["体外取卵与受精"] A["促排卵并体外取卵"] --> B["实验室最优环境受精与培养"] B --> C["形成囊胚并冷冻保存"] end subgraph Clinic ["病灶抑制与子宫内膜准备"] C --> D["使用药物（如 Lupron）深度抑制异位病灶与炎症"] D --> E["外源性激素精确准备子宫内膜"] E --> F["择期冻胚移植（FET）获得高着床率"] end ``` 针对避孕药能否长期用于压制病情的疑问，Crawford 医生澄清了长期以来的误解。口服避孕药（含有合成雌激素和孕激素）能让卵巢进入休眠状态，其合成成分并不会像内源性卵巢雌激素那样滋养异位病灶。长期服药的子宫内膜异位症患者在停药后，生育力非但没有下降，反而往往高于同龄未服药的患病同伴——因为长达 5 到 10 年的无排卵期实际上“按下了病灶进展的暂停键”。虽然避孕药或亮丙瑞林（Lupron）等药物无法根除已有的病灶，但它们能有效阻断病情的恶化。 --- ### [01:45:57](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6357s) 拒绝“被动反应”：针对内异症与多囊的高前瞻性家庭规划对于确诊子宫内膜异位症并前来咨询生育的女性，Crawford 医生主张采取完全主动的评估，而非遵循常规妇科“先自己试一年怀不上再检查”的被动思路。内异症长期的慢性炎症会直接损耗卵巢内部“卵子保险库”的库存，导致卵子储备过早衰竭。如果一位 25 岁的女性计划 30 岁才开始备孕、且期望生育多胎（例如 4 个孩子），医生第一步便会全面评估卵巢储备功能（如 AMH 和基础窦卵泡计数），排查输卵管通畅度及伴侣精液质量。按照自然生育的生理规律，若 30 岁开始生第一胎，接连生育二胎、三胎、四胎时，女性年龄将逼近 38 至 40 岁，此时高比例的卵子染色体异常和过低卵巢储备会让第四胎几乎变得难以实现。在统计学上，如果一个女性希望自然拥有 4 个孩子，最佳的起步年龄通常在 28 岁之前。 - 传统医疗体系往往是“被动反应式生育”（Family Reaction），即直到遇到不孕挫折才排查原因；但对多囊卵巢综合征（PCOS）或内异症等明确的高危群体，必须转变为“前瞻式家庭规划”（Family Planning）。 - 若患者已有稳定伴侣但暂不打算立即怀孕，冻胚储备（Embryo Banking）是打破年龄衰退曲线的杀手锏。 - PCOS 患者因为基础窦卵泡数量庞大，单次促排获卵量高，进行胚胎冷冻的投资回报率（ROI）极高。 - 提取卵子与精子体外受精后，可通过胚胎植入前遗传学筛查（PGT-A）挑选染色体正常的囊胚长期冷冻，从而将 20 多岁时的黄金卵子质量永久锁定，为未来生育多胎提供充足的保障。 ### [01:50:20](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6620s) 冻卵与冻胚胎的本质区别：概率漏斗与生存率差异主持人询问，如果现在通过试管婴儿（IVF）培育并冷冻胚胎，日后再尝试自然受孕，这与单纯冷冻卵子和精子究竟有何区别？Natalie Crawford 医生指出，提前冷冻胚胎是一种极佳的保障手段。39 岁时女性体内的卵子数量显著锐减且绝大多数染色体异常，而在年轻时冻结胚胎，可以锁定质量更优的基因状态。对女性而言，取卵的手术流程毫无二致：都是通过连续注射约两周的促卵泡生成素（FSH）促使当月的一批卵泡同步生长，随后在全麻下进行快速的穿刺取卵手术。真正的差距存在于取卵后的细胞形态与后续变数之中。 Crawford 医生强调，冻卵绝对不是生育的“保险单”。"保险单是在坏事发生时进行赔付，而冻卵是一项投资，好比你在涉足股市。" 投入股票市场是否明智，取决于你变现时的外部环境。卵子代表的是潜在的机会与可能性，它远胜于一无所有，但无法提供确定性的结果。即使精子和卵子在显微镜下看起来完全正常，真正的考验依然是后续胚胎能否顺利受精、发育并形成整倍体（染色体正常）。 ```mermaid flowchart TD accTitle: 30岁女性20颗冷冻卵子损耗漏斗图 accDescr: 展示从20颗冷冻卵子解冻、受精、发育为囊胚至最终获得染色体正常胚胎的逐级递减过程。 A["冷冻 20 颗卵子"] -->|解冻存活率约 90%| B["18 颗卵子存活"] B -->|受精率约 75%-80%| C["约 14 颗成功受精"] C -->|约 50% 阻滞在发育途中| D["7 颗发育至囊胚（着床阶段）"] D -->|30岁正常率约 60%-70%| E["最终获得约 4 颗整倍体胚胎"] ``` 两者的生物学物理属性也截然不同。卵子是单个巨型细胞，内部主要充斥着水分与单套 DNA，极其脆弱。而冷冻阶段的胚胎（囊胚）已发育为 300 到 500 个细胞的致密团块，抗逆性极强，复苏存活率超过 99%。在十年前技术受限时，冻卵根本无法临床普及，因为当时卵子解冻存活率仅约 40%；如今借助玻璃化冷冻技术，卵子解冻存活率已提升至 90%，但依然存在 10% 的物理损耗。 - **解冻与发育漏斗模型（以 30 岁女性获卵 20 颗为例）**： - **解冻损耗**：20 颗卵子复苏后损耗约 2 颗，剩余 18 颗存活。 - **受精损耗**：采用优质精子显微注射，平均受精率为 75%～80%，约 14 颗卵子成功受精。 - **囊胚培养阻滞**：即使外部条件完美，受精卵发育到着床期囊胚（Blastocyst）过程中会损耗约一半，最终仅剩 7 颗囊胚。 - **染色体异常率与年龄强相关**：在 7 颗囊胚中，染色体正常率（Euploid rate）随母亲年龄骤降： - 30 岁：约 60%～70% 正常（最终可得约 4 颗正常胚胎）； - 35 岁：约 50% 正常； - 38 岁：仅约 1/3（33%）正常； - 40 岁：跌至 20%～25% 正常。 --- ### [01:54:04](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6844s) 活产成功率与冷冻储存的经济成本账面对主持人关于“冷冻库里能存多少胚胎”的疑问，Crawford 医生建议：为了确保日后万无一失，**每计划生育一个孩子，建议冷冻储备 2 到 3 颗染色体正常的整倍体胚胎**。单次移植一颗染色体正常的胚胎，活产率（Live birth rate）约为 65%。如果单次未受孕，进行第二次解冻移植，累计活产率升至 88%；若累计移植三颗，成功率则高达 95%。这一数据揭示了辅助生殖中最残酷的真相：人们进行试管婴儿失败的首要原因，从来不是子宫内膜容受性或着床机制失效，而是**手里根本没有足够数量的染色体正常胚胎**。冷冻 20 颗卵子表面上让人产生“卵子财富富足”的错觉，但真正能转化出几颗健康胚胎完全是未知数。在母体承载方面，只要胚胎在年轻时冷冻，即便女性在 45 岁时将其植入体内，胚胎的着床几率依然保持其冷冻时的年轻活力，直到 45 岁之后子宫生理环境才会显现微弱的自然衰退。这一事实让主持人直呼：“我现在就得赶紧把那些该死的胚胎弄进冷冻库！” | 项目分类 | 单纯冷冻卵子（Egg Freezing） | 完整试管婴儿（IVF + 胚胎冷冻及活检） | |:--- |:--- |:--- | | **平均手术及医疗费用（美国）** | 约 $10,000 美元 | 约 $20,000 美元（含基因检测 PGT） | | **技术流程占比** | 仅前半段（促排、穿刺取卵、脱水冷冻） | 全流程（促排、取卵、受精、囊胚培养、基因筛查、冷冻） | | **年度液氮储存保管费** | 每年约 $500 - $1,500 美元 | 每年约 $500 - $1,500 美元 | | **适用人群建议** | 单身无伴侣者；卵巢早衰且当期预算极有限者 | 有稳定伴侣、希望明确锁定生育结果的家庭 | 对于卵巢储备极低（DOR）且经济紧张的女性，冻卵具备资金分摊的优势：如果一次促排只能取到 5 颗卵子，分两次攒下 10 颗卵子的费用大约等同于一次完整的试管婴儿。与其在缺乏弹药时仓促受精并面对可能全军覆没的诊断，不如先在资金有限的情况下尽可能收集两个周期的遗传物质，将后续培育的费用延后支付。 --- ### [01:56:40](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7000s) 破除辅助生殖的社会病耻感与生育时间线主持人坦言，许多二三十岁的年轻人对冻卵和 IVF 怀有本能的抗拒心理。社会文化制造了一种“只有身体有残缺、不健全的人才需要做试管”的病耻感（Stigma），好莱坞电影和社交媒体不断灌输虚假神话——仿佛伴侣只要随意同房一次，健康可爱的宝宝就会自然降临。甚至当主持人自己打算向伴侣开口建议“我们应该去冻卵、冻精”时，内心也充满恐惧与情感负担。 Crawford 医生对此高度肯定了主持人勇于沟通的姿态。临床上大量伴侣在进入诊室前，甚至从未坐下来认真核对过彼此究竟想要几个孩子、家庭规划的目标规模到底多大。社会病耻感的核心往往滋生于对未知和不确定性的恐惧，而破除它的唯一途径就是将这些医学现实搬到台面上公开探讨并将其正常化。女性必须认清时间的不可逆性。虽然民间和媒体总在津津乐道某些大龄女性自然受孕的个案传奇，但统计学上超过一定年龄后自然受孕几率往往只有 3% 左右。"3% 的概率并不是零，但这真的会降临在你头上吗？" Crawford 医生尖锐地指出，把人生的重大核心目标寄托在只有 3% 胜率的赌注上，是极其低效且不理智的策略。 --- ### [01:58:42](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7122s) 赞助商插播：商业出海建站平台 Shopify 随后节目插播了由主持人 Steven 带来的 Shopify 赞助广告。他谈到，在过去启动一项商业创意极度繁琐艰难，而如今借助 Shopify 可以在数键之内搭建面向全球交易的网店（例如他们团队发售的话题卡牌套组）。选择该平台的核心优势在于其结账转化率比其他竞品系统高出 36%。节目听众可通过专属链接以每月 1 美元的优惠价格体验试用。广告结束后，主持人引用《时代周刊》（Time Magazine）1970 年以来的生育历史数据，重新切入现代生殖危机的时间背景。 ### [01:59:46](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7186s) 晚育趋势、冻卵时机与主动做出的选择社会形态与生育年龄正在发生剧烈转变。以美国女性为例，过去生育第一胎的平均年龄是 21 岁，而到 2022 年这一数字已跃升至 27 岁，整整推迟了 6 年，绝大多数女性都在 20 多岁尾声才迎来首个孩子。追求更长的事业黄金期、在青年时期拥有更多自由无可厚非，但这必然伴随着取舍——然而，这个“取舍”绝不应以牺牲拥有完整家庭或被迫少要一个孩子为代价，而是需要借助科学手段提前布局。关于何时该考虑介入冷冻卵子，研究指出：**如果你到了 32 或 33 岁仍未准备好组建家庭，那便是平均而言采取行动介入并冻卵的最佳时间点。** 该结论是综合权衡了未来的受孕计划、不孕症发生率，以及超过该年龄后卵子数量与质量加速衰减的曲线得出的。年轻时的卵子质量无疑更好、储备更多，因此若早就打定主意要冻卵，完全不必非得等到 32 岁；但若接近这个年龄门槛且人生愿景中想要孩子，却又没准备好立刻生育，就必须去面诊生殖科医生，"没有借口，就此打住"（period the end）。去医院并不意味着一定要冻卵，关键在于弄清自身的卵巢储备与健康指标，在掌握充分信息后做出清醒抉择。哪怕最终决定不冻卵，也是出于深思熟虑的主动决策，未来回头看时产生后悔的风险远低于“当初毫不知情、从未获得机会”所带来的无尽遗憾。 --- ### [02:01:45](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7305s) 现代试管婴儿（IVF）机制与基因筛查大众通常将试管婴儿（IVF）极简概括为“提取精子和卵子、在体外注射受精，然后放回女性子宫”。IVF（in vitro fertilization）字面意思为“体外受精”，在现代医学实验室里，操作早已超越了单纯的培养皿受精：医生会促排获取一个月周期的卵子并培养至囊胚阶段，随后进行胚胎基因检测并冷冻保存。 ```mermaid flowchart LR accTitle: 现代IVF与PGT-A/M检测流程 accDescr: 展现从卵子精子体外受精、胚胎活检筛查到单胚胎移植的完整路径 subgraph LAB ["实验室培养与筛查"] A["提取精卵与体外受精"] --> B["囊胚培养 (第5-6天)"] B --> C["滋养外胚层活检 (取 5-8 个细胞)"] C --> D{"染色体与基因检测"} D -->|筛查数目异常| E["排除非整倍体 (唐氏/缺失/多倍)"] D -->|单基因探针针对性筛查| F["排除单基因遗传病 (囊性纤维化/亨廷顿)"] end subgraph TRANSFER ["冻融移植"] E --> G["筛选出健康整倍体胚胎"] F --> G G --> H["单胚胎移植 (SET)"] end ``` 这种检测主要聚焦染色体数目异常（即非整倍体，Aneuploidy）。随着年龄增加，卵子减数分裂时染色体极易排错位置。通过对胚胎活检取出 5 至 8 个细胞进行采样，能够确认全部染色体的完整性： - 缺少一整条染色体必然导致流产停育； - 多出一条染色体（例如 21 号三体导致唐氏综合征）则伴随严重的出生缺陷与胎停风险。因此筛选出染色体数目正常的“整倍体胚胎”（Euploid embryo）是保障高着床率与活产率的前提。此外，IVF 基因检测能彻底阻断严重的遗传疾病： - **常染色体隐性遗传病**：如囊性纤维化（Cystic Fibrosis）。若夫妻双方均为携带者，子代有 25% 几率发病。医生可在 7 号染色体的突变位点设计特异性探针，检测胚胎活检样本，准确分辨胚胎携带 0 个、1 个还是 2 个致病突变拷贝，从而坚决不移植纯合患病胚胎。 - **常染色体显性遗传病与遗传性肿瘤**：如亨廷顿舞蹈症（Huntington's disease）或遗传性癌症综合征，可直接从家族血脉中彻底清除致病突变。 --- ### [02:04:18](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7458s) 单胚胎移植演进与同卵双胞胎风险针对胚胎移植策略，现代医学已全面转向**单胚胎移植（Single Embryo Transfer, SET）**。过去多囊胚同时移植的做法源自技术局限：例如一位 40 岁女性拥有 4 枚冷冻胚胎，在没有基因筛查技术的年代，医生无法判断哪一枚染色体正常，单次移植成功率很低，只能一次性放入多枚胚胎以“碰运气”捕捉那枚健康胚胎。如今通过整倍体筛选，医生确切知道哪一枚是正常的，只需移植这一枚即可。单胚胎移植的核心逻辑是“不要让胚胎相互竞争子宫资源”： - 赋予单个胚胎整片子宫内膜面积，能发育出供血充足、结构优良的胎盘，极大降低晚期流产及产科并发症的概率； - 移植两枚胚胎并不会实质性提升总体怀孕率，只会急剧拉高双胞胎率与多胎妊娠风险。值得注意的是，即便仅移植一枚胚胎，发生**同卵双胞胎（Identical twins）**的概率也明显高于自然受孕。在自然受孕中单个受精卵分裂发育成同卵双胎的概率约为 0.5%，而在 IVF 周期中，该概率上升至 2% 到 3%。这可能是由于胚胎在装载进移植导管时受到微小机械挤压，或其外层透明带受到物理触碰，使其在植入子宫后更容易发生分裂。虽然绝对几率依然不高，但以生殖医生每年操作约 400 例移植的体量来看，临床上屡见不鲜。这也进一步强化了单胚胎移植的必要性——若植入两枚胚胎而其中一枚甚至两枚均发生分裂，孕妇将面临三胞胎甚至四胞胎的极端高危妊娠局限。 --- ### [02:06:28](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7588s) 破解自然备孕迷思：同房频率、体位与精子游动真相围绕自然受孕（“传统方式”）存在大量广为流传的荒谬误区，生殖医生对此进行了全面拆解： - **误区一：为了排卵期需要提前“攒精子”** 许多夫妻在排卵期前刻意禁欲数日，试图把精子攒到排卵当天一次性释放。这种做法完全不可取。长时间不禁欲会导致附睾内衰老和死亡精子堆积，必须定期“疏通管道”（clear the pipes）以维持排出精子的活力与新陈代谢。精子在女性生殖道内可存活长达 5 天，只要在排卵窗口期前保持规律性生活即可。无论是隔天一次、每天一次还是每三天一次均属健康频次，原本习惯每天同房的夫妻绝不需要因为备孕而刻意减少频率。 - **误区二：事后必须倒立抬腿、不能立即排尿** 民间常建议女性同房后在臀部垫枕头 30 分钟，甚至将双腿高高倒立在墙上，或者坚信一起床上厕所就会“把精子尿出来”。这在解剖学上是无稽之谈：精液射入阴道后，精子在 2 分钟之内就会穿透宫颈黏液屏障进入宫颈管，并在 5 分钟内快速上行穿过子宫腔到达输卵管。女性起身、下床走动去洗手间所耗费的两分钟，对精子受精毫无影响。精子不会从尿道排出，女性更无须使用任何辅助堵塞装置或强行卧床。相反，女性同房后及时排尿是预防尿路感染（UTI）的重要医学共识。受精与着床本就是在女性正常日常活动中自然发生的，完全不必保持水平静卧。 - **误区三：特定性交姿势能提高受孕率或决定生男生女** 临床上没有任何姿势被证实比其他姿势更容易受孕，更不可能决定胎儿性别。备孕期间频繁的“按表做功课”极易使性生活沦为枯燥沉重的心理差事（chore）。此时保持多样性反而更为重要，只要某种姿势能让男方顺利完成体内射精，它就是合格且有效的受孕姿势。 ### [02:09:10](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7750s) 女性高潮与阴茎尺寸对受孕的影响探讨受孕机制时，史蒂文·巴特利特（Steven Bartlett）向娜塔莉·克劳福德医生（Dr. Natalie Crawford）询问女性高潮是否能增加受孕概率。克劳福德医生明确表示，医学研究证实女性高潮确实有助于受孕：高潮时引发的子宫收缩能够形成机械性推进力，帮助精子以更快的速度穿过宫颈并到达输卵管与卵子相遇。相关临床研究曾专门观察并测定过性高潮与精子到达输卵管速度之间的直接正相关联系。针对大众普遍关注的阴茎尺寸问题，克劳福德医生直言“尺寸完全不重要”。虽然不同种族或族裔之间，阴茎长度往往与阴道深度存在某种天然的演化对应关系，但受孕并不需要极端偏大或偏小的尺寸。射精时精子会自动进入需要到达的解剖位置，根本不需要依靠更长的阴茎刻意将精子送入离宫颈更近的地方。 --- ### [02:10:33](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7833s) 避妊药的真相：治疗、掩盖问题与生育认知误区谈到避孕药及各种避孕器具对健康的长期影响，克劳福德医生指出，口服避孕药本身并非“不健康”，当下社交媒体上充斥着将避孕药妖魔化、宣称其极具毒害的言论是不准确的。然而，现代妇科医疗体系存在一个严重的系统性缺陷：整整一代女性在年轻时只要出现月经紊乱等异常症状，往往在没有查明根本病因的情况下，就被直接开具口服避孕药来“调理”。这种做法本质上是将潜在的病理诊断推迟了十几年——许多女性从二十岁服药到三十五岁停药备孕，才发现月经依然紊乱且错过了最佳排查时机，陷入巨大的焦虑与挫败感中。克劳福德医生强调，口服避孕药既不改善也不会损害卵子库存（The Egg Vault）的质量与数量；它通过雌激素和孕激素抑制脑垂体释放促卵泡激素（FSH），阻止优势卵泡排卵，但基础卵泡在闭锁过程中依然会自然消耗。同时，避孕药在临床上具有极高且不可替代的治疗价值：它可以预防多囊卵巢综合征（PCOS）可能引发的子宫内膜癌、遏制子宫内膜异位症的病灶恶化、治疗严重痛经，并能平稳经前期烦躁障碍（PMDD）患者剧烈的激素波动与心理抑郁。为了避免备孕时陷入被动，克劳福德医生强烈建议女性在真正打算怀孕前就应提前停用避孕药，观察自身的自然月经周期是否规律，及早发现潜在问题。 ```mermaid flowchart TD accTitle: 避孕药对女性健康与受孕决策的双重影响 accDescr: 展示口服避孕药在临床治疗上的益处，以及掩盖病因导致的备孕推迟风险 subgraph ClinicalBenefits ["临床治疗益处"] A["口服避孕药 雌激素 + 孕激素"] --> B["抑制垂体分泌 FSH 阻止优势卵泡排卵"] B --> C1["遏制内膜异位症病灶恶化"] B --> C2["降低 PCOS 内膜癌风险"] B --> C3["缓解严重痛经与 PMDD 情绪波动"] end subgraph DiagnosisRisk ["医疗误区与备孕盲区"] D["月经不调时未查明病因"] --> E["直接服用避孕药 10-15 年"] E --> F["掩盖真实内分泌与生殖病变"] F --> G["35 岁停药备孕时直面病症 痛失宝贵生殖窗口"] end ``` - 卵子库存与避孕药：服用避孕药不会“保住”卵子，卵巢内的储备卵泡每个月依然在持续萎缩消耗。 - 代谢反应：避孕药会轻微改变人体的某些维生素水平与代谢参数，每个人的适应度因人而异。 - 备孕行动准则：计划怀孕前提前停药，监测周期是否健康，严防在不明病因的状态下盲目进入受孕阶段。 --- ### [02:13:36](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8016s) 面对不孕不育：行动建议与医疗自主权面对正在与 PCOS、子宫内膜异位症、久备不孕或多次试管婴儿（IVF）胚胎移植失败抗争的听众，克劳福德医生给出了务实而坚定的指导。首先，患者应秉持“控制自己所能控制的”原则，毫不犹豫地将作息睡眠、营养饮食和生活方式优化做到极致。其次，在长期的不孕治疗中，患者切忌在同一方案中机械重复失败的过程；寻求“第二诊疗意见”（Second Opinion）至关重要。克劳福德医生坦言，当患者在自己诊所经历多次挫折时，她会主动鼓励并支持他们去找其他专家换个视角审视病情。鉴于女性生育窗口期极其有限，患者必须拥有完全的知情权与决策舒适度。若主治医生拒绝充分沟通、无法解答疑问，这就是明确的危险信号（Red Flag）。此外，切忌在明确已知患有生殖系统疾病（如 PCOS、严重痛经）的情况下盲目等待自然尝试 12 个月才就医；一旦存在已知的生殖风险，必须立即提前进行医学评估，制定清晰的战略方案。 - 寻求第二意见：换一组医疗团队的眼光重新审视胚胎和病历，避免时间和经济成本的无谓损耗。 - 就医警示信号：如果月经严重痛到影响正常生活、周期毫无规律，或完全无法直接接触到主治医生交流病情，必须立刻就医或更换医疗机构。 - 杜绝被动等待：明确确诊为 PCOS 或内膜异位症的患者，不要按传统的不孕标准被动尝试一年，备孕伊始就应由专科医生介入评估。 --- ### [02:15:40](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8140s) 最艰难的对话：身为妇产科主任的流产之痛与生命信仰节目进入传统环节，克劳福德医生回答了上一位嘉宾留下的问题：“哪一次最艰难的对话改变了你的人生？”克劳福德医生讲述了自己身为产科总住院医师（Chief Resident）时经历第二次流产的刻骨往事。当时，她正负责管理全美最繁忙的产房，在极其繁重的高压轮班过程中，她在洗手间发现自己开始大出血。由于没有人知道她怀孕，她强忍着身体剧痛与精神崩溃，继续在手术台上为其他产妇做剖宫产、接生新生儿，亲眼目睹无数家庭迎来新生命，而自己的孩子却在腹中流逝。下班后，极度绝望的克劳福德医生赶到自己的妇产科医生那里确认了流产。面对悲痛欲绝的她，那位医生说了一段深远改变她一生的对话： > “当你身处旅途当中时，往往很难看清这一切的意义；但总有一天，这个世界会重新变得合情合理。你的职责是不要放弃希望，继续前行。我坚信你终将成为一名母亲；也许我现在无法解释你此刻为何要承受这些苦难，但我深信只要你坚持下去，你最终一定会迎来那个注定属于你的孩子。” 克劳福德医生在现场动容落泪，她表示如果此前任何一次流产的孩子成功降生，她后来就不会拥有现在的儿女——在怀孕期间，卵巢库存中的其他卵泡依然在被消耗，正是因为经历了那些痛苦的擦肩而过，孕育她现在女儿的那颗宝贵卵子才得以在后来的月份里排卵并成熟。这段艰难时刻获得的信念，如今成了她抚慰自己患者的核心力量：在漫长黑暗的求子之路上，患者不必强求在当下参透所有的“为什么”，最重要的是保持信念，不要放弃。谈及如何承受患者巨大的痛苦时，克劳福德医生坦言自己无法对患者的伤痛置身事外，每一次心碎与眼泪，她都会带回家中并与患者一同真切地经历。 ### [02:18:36](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8316s) 医患之间的诚实对话与家庭组建的替代方案 Natalie Crawford 医生谈到了她在诊疗过程中的深刻情感投入。她坦言，自己会陪着患者一同哭泣、拥抱他们，而回到家后，她会紧紧拥抱自己的孩子，深深感念自己能拥有他们是多么幸运。她为所有患者建立的沟通基调始终是：绝不粉饰太平（"never going to sugarcoat it"）。她会毫无保留地告知患者真相，即便这些真相有时极其残酷刺耳。但正是建立在这种信任的基础上，患者知道医生给予的是最客观、最优质的专业医疗建议。当被问及是否有时不得不残忍地告诉患者“已经没有怀孕可能”时，Natalie 证实了这一点。她每周都必须面对这样的情景，不得不告诉某些患者既定方案已经走不通了，必须停下脚步，重新审视组建家庭的真正目标。许多夫妻在检查前甚至完全不知道男方患有无精症，导致整个家庭的规划被彻底颠覆。此时，大家需要退后一步思考：最初的“A计划”或许是想要一个带有双方基因的孩子，但在无法实现的情况下，目标是否可以转变为“单纯拥有一个孩子、迎接一个生命”？ ```mermaid flowchart TD accTitle: 面对生育困境时的家庭规划重构流程 accDescr: 展示当原本的亲生子女计划不可行时，医生引导患者重新思考家庭定义并转向替代方案的路径。 subgraph 原定规划 A["Plan A: 带有双方基因的亲生孩子"] --> B{"方案是否仍可行？"} end subgraph 医疗现实与重构 B -- "无法继续推进" --> C["面对现实与哀伤停顿"] C --> D["重新审视家庭核心目标 （成为父母 vs 追求基因延续）"] end subgraph 替代助孕途径 D --> E["供卵 (Donor Egg)"] D --> F["供精 (Donor Sperm)"] D --> G["捐赠胚胎 (Donor Embryo)"] D --> H["其他收养与抚养途径"] end ``` - **告知不可行的沉重时刻**：每周 Natalie 医生都要向部分患者传达既定治疗路径彻底失效的消息，并引导他们面对残酷现实。 - **重新定义家庭构成**：当常规受孕无法实现时，家庭组建可以通过供卵（donor egg）、供精（donor sperm）或捐赠胚胎（donor embryo）等替代方案继续推进。 - **职业的情感两极**：Natalie 形容自己的工作是“在同一天里经历最好的工作与最糟糕的工作”（"the best job and the worst job in the same day every day"），伴随着巨大的职业痛感与喜悦。 --- ### [02:19:49](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8389s) 最艰难的职业时刻与妊娠并发症的现实谈到职业生涯中最艰难的日子，Natalie 回忆起自己在妇产科（Obstetrics）规培训练时期的经历。对她而言，最沉重、最无法释怀的创伤永远是生命的逝去——包括胎死宫内（fetal death）、死产（stillbirth）以及失去一个备受期盼的胎儿。她动容地提到，那些失去孩子的父母发出的绝望哭喊声，一生都会在脑海中回荡，永远无法磨灭（"those screams of those parents, I'll never escape them"）。 Natalie 特别强调，社会大众往往存在一种认知误区，认为“只要怀上了就万事大吉”，但事实上“怀孕绝非对健康毫无影响的中性事件”（"pregnancy is not health neutral"）。每一次妊娠都潜藏着出现严重并发症的风险。她认为大众在迈入备孕与生育阶段时，必须保持清醒理智的认知，清楚理解怀孕的真实代价、潜在风险以及它的局限性，而不是抱有不切实际的幻想；因为在这个领域里，生命的骤然逝去永远是最令人心碎的打击。 - **妇产科训练时期的创伤印记**：胎死宫内与死产带来的惨烈失去，以及撕心裂肺的家属哀号，构成了医生生涯中最难熬的记忆。 - **警惕“怀上就安全”的误区**：妊娠全过程伴随着母婴各类临床风险与不可预测的并发症，并非一帆风顺的“健康中性”状态。 --- ### [02:20:37](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8437s) 打破生育羞耻与知识普及的长远价值主持人 Steven Bartlett 代表广大听众向 Natalie 医生表达了由衷的敬意与感谢。他指出 Natalie 的工作具有双重意义：一方面，她通过诊所临床工作，以极富同理心、人道关怀且坦诚的方式，驱散了求子家庭面临的迷茫与阴霾，帮助无数人实现了建立家庭的梦想；另一方面，她突破了诊室的物理界限，将宝贵、专业的医学知识通过播客等大众媒体无私分享出来。许多人受限于所在国家的医疗条件、经济成本或时间精力，根本没有机会坐下来咨询生育专家，而这种公开透明的内容让千百万人获益匪浅。 Natalie 也对节目的邀请与主持人的倾听表达了真诚谢意。她坦言，生育困境是一个充满社会耻感（stigma）的话题，绝非一个轻松愉快的谈资，很多人往往避而不谈。正因为《CEO的日记》这样一个极具影响力的平台愿意为这一主题留出深度探讨的空间，才能把这些至关重要的生理与生育知识，推送到那些原本不会主动搜索相关内容但迫切需要了解的人群面前，让科学的力量在无形中改变更多人的人生轨迹。 ## Notable quotes > [39:33](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2373s) 这就像让一群幼儿园小朋友整整齐齐地排成一队站立 40 年——总会有人忍不住乱跑出列的。 — Natalie Crawford 医生 > [45:23](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=2723s) 没有数据，你根本无法做出明智的人生决定。 — Natalie Crawford 医生 > [01:24:48](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5088s) 所有人都以为卵巢的主要功能是产生卵子，但它真正的挚爱其实是制造激素。 — Natalie Crawford 医生 > [01:28:06](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5286s) 即便你过着最健康的生活、远离一切炎症和压力，你依然可能患上 PCOS，这是一种真正的疾病。在育龄期无法规律排卵不是你的失败，也绝不是你的过错。 — Natalie Crawford 医生 > [01:33:50](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=5630s) 在没有服用避孕药等外源激素的情况下，不来月经绝对是不正常的，且对全身健康危害极大。 — Natalie Crawford 医生 > [01:50:20](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=6620s) 保险单是在坏事发生时进行赔付，而冻卵是一项投资，好比你在涉足股市。 — Natalie Crawford 医生 > [01:59:46](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=7186s) 如果你到了 32 或 33 岁仍未准备好组建家庭，那便是平均而言采取行动介入并冻卵的最佳时间点。 — Natalie Crawford 医生 > [02:15:40](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8140s) 当你身处旅途当中时，往往很难看清这一切的意义；但总有一天，这个世界会重新变得合情合理。你的职责是不要放弃希望，继续前行。我坚信你终将成为一名母亲；也许我现在无法解释你此刻为何要承受这些苦难，但我深信只要你坚持下去，你最终一定会迎来那个注定属于你的孩子。 — Natalie Crawford 医生的妇产科医生 > [02:19:49](https://www.youtube.com/watch?v=w8h4qksd6Yw&t=8389s) 怀孕绝非对健康毫无影响的中性事件。 — Natalie Crawford 医生 ## Mentioned Natalie Crawford 博士, Stephen Bartlett, The Diary Of A CEO, Fora Fertility 诊所, Amanda Skillern 博士, Pinnacle Conference, Shopify, 世界卫生组织 (WHO), 美国疾病控制与预防中心 (CDC), 美国妇产科医师学会 (ACOG), 《时代周刊》 (Time Magazine), 多囊卵巢综合征 (PCOS), 子宫内膜异位症 (Endometriosis), 试管婴儿 (IVF), 宫腔内人工授精 (IUI), 胚胎植入前遗传学筛查 (PGT-A), 抗缪勒管激素 (AMH), 促卵泡生成素 (FSH), 促黄体生成素 (LH), 人绒毛膜促性腺激素 (hCG), 睾酮替代疗法 (TRT), 双酚 A (BPA), 克罗米芬 (Clomid), 来曲唑 (Letrozole), 二甲双胍 (Metformin), 螺内酯 (Spironolactone), 亮丙瑞林 (Lupron), 性激素结合球蛋白 (SHBG) ## Video description Dr Natalie Crawford is a double board-certified fertility doctor. She is also the co-founder of Fora Fertility clinic and Pinnacle Conference, a leadership conference for women in medicine. 00:00 Intro 02:24 You Need To Look After Your Fertility Even Before You Want Children 04:31 We're Struggling More Than Ever To Have Children 07:00 Are We Having Less Sex? 07:47 Sperm Count Is Declining At Scary Risk 10:38 I Had 4 Pregnancy Losses And It's Devastating 13:36 The Stigma Of Infertility 16:15 Infertility Is Not Just A Female Issue, Men Are Affected Too 18:49 Understanding The Basics Of Fertility 22:26 Environmental Factors Affecting Male And Female Fertility 26:32 Are Phones And Laptops Bad For Fertility? 29:40 Heat And Infertility 30:15 What Testosterone Replacement Therapy Does To Your Sperm 31:45 The Egg Vault 35:25 Egg Production And Anomalies 42:41 Regret, Hindsight Of Patients And What You Can Do 47:16 What Has Changed Since Our Parents 49:06 The Effects Of An Unhealthy Lifestyle 54:07 Sleep Is Crucial In Your Reproductive Hormone System 55:07 How Stress Impacts Fertility 57:14 The Best Diets For Good Fertility 59:11 How Dairy Impacts Your Fertility 01:01:05 You Need To Understand The Reproductive Cycle To Know How Exercise Impacts It 01:10:58 Menstrual Irregularities And What's Normal 01:16:57 How Long Does It Take To Get Pregnant? 01:17:50 When Trying To Have Children Sex Can Become A Chore 01:21:43 Purchasing Sperm From The Black Market 01:24:48 PCOS Explained 01:30:59 PCOS Diagnosis 01:33:50 Link Between PCOS & Endometrial Cancer 01:37:02 What Is Endometriosis & How Do You Know You Have It 01:43:55 What Happens When You Come Off The Pill And Want To Have Children 01:46:25 Advice For People With Endometriosis And PCOS, If They Want To Have Children 01:49:36 Getting Started With Freezing Eggs And Embryos And Success Rate 01:55:15 The Cost Of Fertility Procedures 01:56:40 IVF Stigma 01:58:42 Ads 01:59:32 When To Think About Fertility Treatment 02:01:54 Dummies Guide To IVF 02:06:38 Myths Of Conception 02:08:54 Best Sex Position To Get Pregnant 02:10:33 Is Birth Control Healthy? 02:13:36 What Can People Do If They Struggle With Infertility? 02:15:40 Last Guest Question Follow Natalie: Instagram - https://bit.ly/3yIQJ9L Twitter - https://bit.ly/3wLxtb6 YouTube - https://bit.ly/4551ZZY Follow me: https://beacons.ai/diaryofaceo Sponsors: Shopify: http://shopify.com/bartlett [Source](https://www.youtube.com/watch?v=w8h4qksd6Yw)

Source quotes

[39:33] Natalie Crawford 医生: 这就像让一群幼儿园小朋友整整齐齐地排成一队站立 40 年——总会有人忍不住乱跑出列的。 [45:23] Natalie Crawford 医生: 没有数据，你根本无法做出明智的人生决定。 [84:48] Natalie Crawford 医生: 所有人都以为卵巢的主要功能是产生卵子，但它真正的挚爱其实是制造激素。 [88:06] Natalie Crawford 医生: 即便你过着最健康的生活、远离一切炎症和压力，你依然可能患上 PCOS，这是一种真正的疾病。在育龄期无法规律排卵不是你的失败，也绝不是你的过错。 [93:50] Natalie Crawford 医生: 在没有服用避孕药等外源激素的情况下，不来月经绝对是不正常的，且对全身健康危害极大。 [110:20] Natalie Crawford 医生: 保险单是在坏事发生时进行赔付，而冻卵是一项投资，好比你在涉足股市。 [119:46] Natalie Crawford 医生: 如果你到了 32 或 33 岁仍未准备好组建家庭，那便是平均而言采取行动介入并冻卵的最佳时间点。 [135:40] Natalie Crawford 医生的妇产科医生: 当你身处旅途当中时，往往很难看清这一切的意义；但总有一天，这个世界会重新变得合情合理。你的职责是不要放弃希望，继续前行。我坚信你终将成为一名母亲；也许我现在无法解释你此刻为何要承受这些苦难，但我深信只要你坚持下去，你最终一定会迎来那个注定属于你的孩子。 [139:49] Natalie Crawford 医生: 怀孕绝非对健康毫无影响的中性事件。

Source quotes

[18:49] Dr. Natalie Crawford: If you're having very long abstinence periods in between your intercourse times, you're going to have a sample that has so much debris and dead sperm in it that it's going to make it hard for the good guys to do their job. [140:15] Dr. Natalie Crawford: Taking testosterone yourself is telling your brain that there is testosterone present... the hormones from your brain stop being sent out and no longer tell your testicle to make any more testosterone or any more sperm. [39:33] Dr. Natalie Crawford: It is like having kindergarteners stand in a line for 40 years—somebody's going to get out of line. [42:31] Stephen Bartlett: the opposite of confronting the truth is regret. [45:23] Dr. Natalie Crawford: You can't make decisions on data you don't know. [66:09] Dr. Natalie Crawford: When the brain is turned off... it takes years of being in recovery for it to turn back on. [74:50] Dr. Natalie Crawford: Sperm can live in the female reproductive tract for 5 days... put some of that sperm from the locker there a little bit earlier, and then get some there right at the time when you're ovulating to see if you can fertilize that egg. [106:13] Dr. Natalie Crawford: a very inefficient way to try to achieve a life goal [112:58] Dr. Natalie Crawford: don't make them compete for resources. Let that embryo have the full surface area of the uterus to have a really nice placenta to grow into. [122:04] Dr. Natalie Crawford: You can't control everything, but you should control what you can. [124:10] Dr. Natalie Crawford's OB-GYN: It's really hard to understand the meaning when you're in the middle of the journey, but one day the world makes sense... it's your job to not give up hope and to stay on the path.

Original transcript

[0:00] people are waiting longer to get [0:02] pregnant but if we can imagine that [0:03] there is a vault of your eggs by the [0:05] time you're born you have 1 to 2 million [0:07] in your reproductive years 300,000 this [0:09] means if you and your partner wait till [0:10] 35 your chances of getting pregnant are [0:12] going to be [0:15] approximately I feel like I better get a [0:16] move on but there are things that we can [0:18] do to improve your reproduction and this [0:21] is information that nobody talks about [0:23] so let's get into it let's do it Dr [0:25] Natalie Crawford is a double certified [0:27] practicing fertility doctor helping [0:30] people to optimize their lifestyle to [0:32] improve fertility rates of infertility [0:34] are increasing one out of every eight [0:35] women would have infertility and now [0:37] it's one out of every five and there's [0:39] multiple factors that are contributing [0:41] including irregular or lack of having a [0:43] period there's more autoimmune disease [0:45] obesity chronic stress people are [0:47] waiting but at 40 your chance of [0:49] miscarriage is 50% and suddenly you're [0:52] left behind and I know that because I [0:55] had four pregnancy losses and I'm going [0:58] to cry now [1:02] lots of people will be struggling with a [1:03] variety of the things that you've talked [1:05] about what would you tell them you can't [1:06] control everything but you should be [1:08] able to control the factors you can so [1:10] what would my daily habits look like I [1:12] love that question so what have I got [1:14] misconceptions around how to increase [1:16] our odds of getting pregnant yes there's [1:17] so many myths if for female orgasms does [1:20] that increase the chance of fertility [1:22] this is super interesting and then what [1:24] is the number one thing that people [1:26] don't do that impacts their reproductive [1:28] system it seems is so straightforward [1:31] it's not a pill that you take or a major [1:32] change of behavior it is [1:35] simply we've just hit 6 million [1:37] subscribers on the dire of a CO um so me [1:39] and my team would like to do something [1:40] we've never done before as little thank [1:42] you and we're calling it The dire of a [1:43] CEO subscriber raffle and here is how it [1:46] works every episode this month we're [1:48] going to pick three current subscribers [1:49] at random and we'll send one of you a [1:51] 1,000 voucher one of you tickets to come [1:54] and watch the dver SE behind the scenes [1:56] live with our team and one of you will [1:57] have a 10-minute phone call with me to [1:59] discuss what ever you want to talk about [2:01] if you're a subscriber you're in the [2:03] raffle thank you from the bottom of my [2:06] heart for allowing me to do something [2:07] that me and my team love doing so much [2:09] it is the greatest honor of my lifetime [2:11] and I hope it I hope it continues uh off [2:13] into the Future Let's get to the [2:18] episode [2:20] Natalie who are you and what is the [2:22] mission that you're on hi Stephen I am a [2:26] fertility doctor which means that I help [2:29] people [2:30] grow their family or plan for their [2:32] family no matter what that looks like [2:35] but my mission started because early in [2:37] my career I realized I was seeing people [2:41] when they were already behind the game [2:43] they didn't have the basic knowledge [2:45] about how their body worked their [2:47] hormones their reproductive system and I [2:49] had to bring them up to speed and every [2:52] time somebody said I wish I'd known this [2:54] earlier I can't believe I wasn't taught [2:56] this why isn't this the stuff that we're [2:58] taught because I might have made [3:01] different decisions earlier in my life [3:03] and that was a pivotal moment for me [3:05] about 8 years ago when I started [3:06] wondering if I could reach people [3:08] earlier in their Journey before they had [3:10] infertility before they were in my [3:12] office if maybe that could change the [3:14] trajectory of their course if they could [3:16] be more empowered with that education to [3:18] make the decisions that are right for [3:20] them versus just letting time pass which [3:24] ultimately makes some decisions for [3:26] people and when we talk about getting [3:29] started earlier and thinking about this [3:31] earlier when we we we hear the topic of [3:33] fertility I think most of us think it's [3:34] something that people over the age of 35 [3:36] need to start worrying about or you know [3:39] once we get up until close to our 40s [3:41] then we need to start thinking about our [3:42] fertility more consciously but what [3:44] you're saying is is that fertility or [3:47] infertility starts much earlier in the [3:49] decisions we [3:50] make 100% if we view fertility as the [3:53] ability to get pregnant and infertility [3:56] is a disease the World Health [3:58] Organization the CDC everybody defines [4:00] infertility as a disease the inability [4:02] to get pregnant so then we can view [4:04] fertility as more of the health the [4:07] wellness State and just like we're [4:08] trying to prevent disease and other [4:10] aspects when it comes to cancer [4:12] Alzheimer's many other diseases we need [4:15] to be approaching our fertility as a [4:18] preventative action taking steps to make [4:20] sure that if having kids is one of your [4:23] life goals you're not making choices [4:25] that is going to make that impossible or [4:28] extremely difficult when you get to that [4:30] stage and what is the sort of macro [4:33] social cultural backdrop to this because [4:37] the conversation around fertility and [4:39] infertility to me and this might just be [4:41] a sort of perspective bias seems to have [4:43] suddenly increased over the last couple [4:44] of years um and I don't know whether [4:46] that's because I'm in that age range now [4:48] where my friends are having the [4:49] conversations or that I think socially [4:52] we're starting to think more about it [4:54] because there is some pretty alarming [4:55] data that's emerged around people [4:57] struggling more than ever to conceive [5:00] children because there's like social [5:01] factors at play exactly what are what is [5:03] that social backdrop so it's very [5:06] interesting when you try to put the [5:07] whole picture together one because we [5:10] are more aware of fertility we have [5:12] social media people are sharing their [5:14] stories 20 years ago you didn't know [5:18] somebody might have infertility or be [5:19] struggling similarly there was less [5:21] access to reproductive technology things [5:23] like egg freezing didn't exist you [5:25] couldn't do IVF unless you travel to a [5:28] city that had a big enough program and [5:30] so when there were limited ways to treat [5:32] something there was less access to get [5:35] into care to even be evaluated so one we [5:38] do have people more aware about their [5:39] fertility getting diagnosed earlier and [5:42] easier finding out problems sooner and [5:44] some of that is well I think all of [5:46] that's wonderful socially yes rates of [5:49] infertility are increasing we used to [5:51] say one out of every eight women would [5:52] have infertility and now in the US it's [5:54] one out of every five who's just trying [5:57] to conceive for the first time will have [5:59] infertility so that's a huge increase it [6:03] stays even when you confound studies for [6:06] age so the number one thing everybody [6:08] says is well people are waiting longer [6:10] to get pregnant which is absolutely true [6:13] I think only 5% of people started their [6:16] family overage 30 back in the 70s and [6:19] now it's 25 to 30% so we see a huge [6:23] increase and the number of people who [6:24] are waiting to start their family I did [6:27] you are especially as women are being [6:29] power to chase other dreams go to [6:31] professional school they're delaying [6:34] entry into childbearing so part of this [6:38] is that people are waiting later [6:40] diseases develop later but then also as [6:43] a society people are less healthy we see [6:45] more obesity we see more diabetes we see [6:48] more environmental toxins than we ever [6:50] have so I really think this is something [6:52] where there are multiple factors that [6:54] are all contributing to this alarming [6:57] rise of infertility that we're seeing [7:00] and are we having less sex than we used [7:03] to I think people are having less sex [7:06] yes especially as they age in the [7:09] reproductive age range it depends people [7:12] when they get married tend to be having [7:13] less sex but interestingly there's been [7:16] a really good study looking at marijuana [7:18] so we'll use it for example people who [7:20] smoke marijuana tend to get pregnant [7:23] less even though they're having more sex [7:26] than people who don't so when you say [7:29] this group's not smoking marijuana and [7:32] they're getting pregnant even though [7:34] they're having less sex than this other [7:35] group it's showing us that it's not just [7:38] timing or not having intercourse there [7:40] really are other factors at play that [7:42] are very socially acceptable that are [7:45] influencing the ability to get pregnant [7:47] I was reading through some research [7:49] earlier about fertility and the sort of [7:50] global Trends and I read this one St [7:52] that said the global fertility rate has [7:54] decreased from [7:56] 4.84 live births per woman in 1950 to [8:00] 2.23 in 2021 and it is expect to drop to [8:05] 1.59 births per Woman by [8:09] 2100 which means that we're there's [8:11] clearly a traj I mean if this is true [8:13] then there's a [8:15] trajectory to having less kids yeah in [8:18] the US it's 1.3 is the average right now [8:20] for a single woman or one person will [8:22] have on average 1.3 children that's very [8:25] alarming when you start thinking about [8:27] is that number just people are waiting [8:29] or what about all the people who just [8:30] can't get pregnant and I see those [8:33] people in my office over and over and [8:35] over again that are not able to get [8:38] pregnant even if they're starting young [8:40] so I think that we really have two [8:42] factors going into that statistic you [8:44] saw when it comes to sperm you know [8:46] study came out last year looking at [8:47] sperm counts and they've decreased 50% [8:51] in 50 years what's most alarming about [8:54] the sperm count decrease in men is that [8:58] in the past 10 years it's decreased at [9:01] Double the rate that it did the 40 years [9:03] prior so when we start looking at more [9:06] recently the rate of decline is [9:10] accelerating and that's got to be the [9:12] world around [9:13] us and you in 2020 founded the fora [9:17] Fertility clinic which is based over in [9:20] Austin how many couples women people [9:22] have you seen since you've opened that [9:24] clinic and what is the typical sort of [9:27] case study of why someone will come to [9:28] you in that clinic what are they [9:30] searching for what are they struggling [9:31] with I love that question so yes it [9:34] started fora in 2020 with my partner [9:36] Amanda Skiller and she and I have been [9:38] practicing for quite a while at this [9:40] time and realized that there wasn't an [9:42] approach at least in Austin for [9:43] personalized care because of that [9:46] probably the number one type of patient [9:48] that we see is coming in who's already [9:51] had lack of success somewhere else [9:54] meaning went to a clinic has been trying [9:57] the average patient is going to be [9:59] overage 36 has been trying for one to [10:02] two years learned about their Cycles [10:04] tracking their Cycles relatively normal [10:07] evaluation trying to do IVF and now is [10:10] not getting the result they wanted what [10:13] I find the hardest thing for people is [10:15] the isolation you're suddenly being left [10:18] behind in your friend and your peer [10:20] group when you're trying to have a child [10:23] and those in your world have succeeded [10:26] and suddenly you're left behind and the [10:28] stress and the isolation that causes [10:32] really makes the entire process so much [10:34] harder than many other medical diagnosis [10:36] that somebody might get and you give me [10:39] some more color on how that feels [10:40] because you you know how that feels I do [10:43] know how that feels so I had four [10:45] pregnancy losses before I have my two [10:48] children and this was a long time ago [10:51] and I was in the middle of training so I [10:53] was a resident and a fellow definitely [10:56] was not taking care of myself very well [10:58] because that was the life style of a [10:59] doctor in training and I didn't tell [11:02] anybody I was pregnant minus my husband [11:04] for the first three pregnancies because [11:08] people weren't sharing about their [11:09] pregnancies I had this idea I need to [11:11] wait till I'm in the safe zone I'm out [11:13] of that first trimester and so when I [11:16] started losing those pregnancies nobody [11:18] knew I was pregnant so it was so hard to [11:21] come and tell somebody that I was losing [11:23] the pregnancy when I hadn't even opened [11:25] that door to trust them with the first [11:27] piece of information it was very hard to [11:30] come in with [11:31] that subsequent request for support or [11:34] help and I just felt like that wasn't [11:36] what people were sharing or talking [11:38] about my fourth pregnancy loss was an [11:41] ectopic pregnancy which is a tubal [11:42] pregnancy so this is a pregnancy that [11:45] implants in the fallopian tube instead [11:47] of in the uterus those pregnancies [11:50] cannot grow the fallopian tube doesn't [11:52] have the blood supply to support a [11:54] placenta and the fallopian tube can [11:56] rupture and it can become a surgical [11:58] emergency in and be very scary that was [12:01] diagnosed for me when my husband was off [12:05] in a bachelor trip in Las Vegas and I [12:08] had to receive a medication in order to [12:11] try to stop the pregnancy from growing [12:13] but there was still a risk of the tube [12:16] rupturing and I was forced to call [12:19] friends have somebody come with me be [12:21] with [12:23] me and sharing it there was so much [12:26] support given that I realized that was [12:29] such a mistake of mine not that you need [12:31] to post every pregnancy announcement on [12:33] the Internet or tell everybody your job [12:36] but there are people in your life who [12:38] want to support you and they can't show [12:40] up if you don't let them know what's [12:41] going on and that's one of the things [12:43] that I tell my patients is that give the [12:46] people in your world the opportunity to [12:48] show up for you tell the people who are [12:51] asking who you turn to in other times of [12:55] Crisis tell them that you're struggling [12:57] with this let them show up and support [13:00] you because most of the time people will [13:02] they care about you and that is going to [13:05] lessen the burden because that isolating [13:08] peace the doubt and the fear especially [13:12] if you're a goal oriented person I have [13:14] set so many goals and I'm going to do [13:16] this and here's my path to do it so to [13:19] feel like I was failing at becoming a [13:21] mother when I didn't fail at anything [13:25] and now my body was failing me felt so [13:27] shameful so so much guilt and I had [13:31] nobody to share that with or to help [13:34] alleviate that burden from me you use [13:36] the word guilt there there's um complex [13:38] set of emotions that I've had described [13:40] when someone finds out that [13:42] their their pregnancy or even their sort [13:45] of their sexual organs more broadly are [13:48] struggling with something and I've got [13:50] lots of friends that have been diagnosed [13:52] with a variety of different conditions [13:55] um in that in that sort of with their [13:57] sort of sexual health and you almost [13:59] observe a feeling that they can often [14:02] feel like they are broken in some way [14:04] like they're not they're not you know [14:06] working they're like a broken [14:09] person and I I I say that to try and [14:13] highlight the fact that those that's [14:15] there's so many people going through [14:16] that exact same thing and that all of [14:17] these conditions are very um a lot of [14:21] people are struggling in Silence with [14:22] that feeling of of inadequacy you're so [14:25] right there's so much stigma to [14:27] infertility there there's so much [14:30] misinformation and uncertainty when it [14:32] comes to reproductive Health together [14:34] that makes it difficult for people to [14:37] talk about or ask questions and when you [14:40] feel like one of the things that you [14:43] always thought was certain about your [14:45] future if you were a child and you [14:47] envisioned your life 30 years from there [14:50] something if you envisioned having [14:53] children and suddenly you're faced with [14:55] the potential reality that that might [14:58] not happen or it might not happen [15:00] without [15:01] intervention that really crashes down a [15:04] piece of your own identity and and who [15:06] you saw yourself to be who you wanted to [15:09] be and trying to struggle with that true [15:12] identity crisis at that moment really [15:15] brings out so many emotions it's what so [15:17] many of the people who sit across from [15:18] me every day say I just I don't feel [15:21] like myself I feel like I'm stuck while [15:24] everybody else is moving on because I'm [15:27] broken my body is failing me it's so [15:30] hard to watch somebody go through it and [15:32] even if I can't get everybody pregnant [15:34] or control the outcome the thing that I [15:37] always say is that at a minimum you need [15:39] to understand how your body works at a [15:42] minimum you can know that you're making [15:44] the choices that are right for you you [15:45] can feel good that you did everything [15:47] that you could and that there wasn't [15:49] education you needed or choices you [15:51] would have made looking back in the [15:53] rearview mirror and even when somebody's [15:55] deep in the midst of failed IVF Cycles [15:57] or sitting across from me [15:59] I say the same thing that's that's our [16:01] minimum you deserve to understand why [16:03] we're making the choices so that this [16:05] can be a process where you can advocate [16:07] for your care and we can collaboratively [16:11] do everything we can to try to achieve [16:13] this goal for you I had um got a good [16:16] friend who's just um because OB I'm at [16:18] the age now where my friendship cycle is [16:20] starting to go and get fertility tests [16:22] done and such and they're trying for [16:23] kids many of them are have been very [16:24] successful but I've got one particular [16:26] friend who has been trying for some time [16:29] they're struggling so they went and got [16:30] the the tests done and it turns out that [16:33] one of them in that relationship has [16:37] some has some issues which are [16:39] complicating their chances of getting [16:41] pregnant and when I heard that God I [16:46] can't imagine how that person feels in [16:47] that relationship because it I can [16:49] imagine in your head how you can start [16:51] to overthink and you can feel that word [16:53] again that word guilt towards your [16:55] partner and you can start thinking oh my [16:56] God this person's going to leave me [16:57] because I can't give them what they want [16:59] and all of that sort of complex those [17:02] complex slightly irrational but [17:03] completely understandable [17:05] thoughts the relationship aspect is so [17:07] hard even going through it myself [17:10] because my husband wanted to support me [17:13] and of course he did but I felt like I [17:15] was the one failing not him right I'm [17:18] the one who's not bringing my aame to [17:20] the table this is a me problem and even [17:24] though it's an us problem it felt like a [17:26] me problem to the point where [17:29] I really try to level the playing field [17:32] to all of my patients at least when I [17:34] see them and say it's the two of you [17:36] you're a team this is a team it doesn't [17:39] matter whose diagnosis comes back as [17:41] what we are trying to get us pregnant [17:45] and really reframe everything that way I [17:48] have a patient story from the Past who [17:51] had been going through infertility been [17:54] going through IVF because she found out [17:55] she was running out of eggs early and [17:58] she had taken a lot of blame for not [18:01] freezing her eggs earlier for waiting [18:03] longer and going through [18:06] IVF her [18:08] husband turns out his sperm wasn't [18:10] functioning the way that it should and [18:13] we didn't know that until you fertilize [18:14] the eggs with it and really see how [18:16] embryos grow in the [18:18] lab and she said to me at our follow-up [18:21] visit even though the outcome of that [18:22] cycle was devastating to have no embryos [18:25] developed because they found this sperm [18:27] issue it improved their marriage so much [18:30] because For the First [18:32] Time her partner and her they felt like [18:35] they were on even playing field that [18:37] they were both part of the reason they [18:40] were in this situation and whether it [18:42] was imposed by him or not she had [18:44] carried that guilt that shame that [18:46] broken feeling alone like it was just [18:49] her so let's get into it then let's do [18:51] it let's talk about fertility where do [18:53] we need to start I was going to assume [18:54] where I need to start here but I'm an [18:55] absolute muggle and idiot as it relates [18:58] to fertility and female and male [19:01] reproductive health so where do we start [19:04] if we want to understand fertility I [19:06] always like to start with the ovary and [19:08] understanding the difference in eggs and [19:10] sperm so we'll do sperm first and we'll [19:13] do eggs okay do you know how many sperm [19:15] you make in a day do I know uh how about [19:18] how many you make in a [19:22] second no I have no idea the average man [19:25] makes 200 to 300 million sperm in a day [19:28] and 1,500 sperm a second so men 1500 a [19:33] second you're just [19:35] like so men in their testes have germ [19:39] cells meaning they can just produce [19:42] brand new sperm at very high rates every [19:45] single day and in the ovary for women [19:49] it's so different because you are born [19:51] with all the eggs you're ever going to [19:52] have and you run out of them over time [19:55] and this means that one the number of [19:58] eggs you have raining is a part of the [19:59] picture and two your eggs sit inside [20:02] your body and they absorb the wear and [20:04] The Tear and the world around you your [20:06] whole life where your sperm lifespan is [20:09] 90 days takes 72 days for a sperm to [20:12] grow across the testicle and then 18 [20:15] days to get out the ejaculatory system [20:18] so you have three months so you could [20:20] change your life and change your sperm [20:22] counts in three months why does it take [20:25] 18 days I thought if in my little idiot [20:28] head I thought that I make my sperm okay [20:31] today and then if I ejaculate that's the [20:34] sperm out no yeah those sperm those [20:35] sperm were made a couple months ago [20:37] really yeah they're like in storage [20:39] lockers so that you have some for every [20:40] day so they kind of get put in line so [20:44] that you can send them out at that right [20:45] time [20:46] period okay so but if you ejaculate [20:50] multiple times eventually you can't keep [20:53] producing more but so let's imagine that [20:56] you have lockers and we'll just pretend [20:58] that there's 200 million sperm in each [21:00] one if you ejaculate every single day [21:03] you're ejaculating 200 million sperm [21:05] each time now if you're saving up for a [21:07] couple days you're going to ejaculate [21:09] 400 million and now if you've waited [21:12] three days 600 million the catch here is [21:15] sperm are so fragile they're so fragile [21:17] they like to die they get tadp oh those [21:20] little tadpoles so if you wait too long [21:23] you're just going to have a bunch of [21:24] dead guys and then they're going to [21:26] impair the ability of the better sperm [21:29] to even function and I use the analogy [21:31] of imagining that this is a Highway and [21:33] the dead sperm are stalled cars all over [21:35] the freeway even if your sperm counts [21:37] normal if you're having very long [21:39] abstinence periods in between your [21:42] intercourse times you're going to have a [21:44] sample that has so much debris and dead [21:47] sperm in it that it's going to make it [21:48] hard for the good guys to do their job [21:51] okay so there is so you do need to keep [21:52] ejaculating to remain to optimize your [21:54] fertility your chances of fertilizing an [21:56] egg yes oh I didn't know that and how [21:58] often G I always say it's going to [22:01] there's a fine balance here somewhere [22:03] between every day to every 3 to four [22:06] days is going to be the best whether [22:09] that is ejaculation in any form what [22:12] whatever suits your fancy we see that [22:14] longer than seven days for the most for [22:17] most people will severely increase the [22:20] amount of debris that you see and the [22:22] proportion of the ejaculate that is dead [22:25] sperm super interesting so let's go [22:28] we'll stay at the the foundations we're [22:30] talking about sperm and eggs so is that [22:33] sperm covered off is there okay and [22:36] sperm counts as you said earlier have [22:38] been reducing over the last 50 years by [22:40] 50% which is horrifying um why is there [22:45] something in particular in our [22:46] environment that's causing that it's all [22:48] the things and some of them are [22:50] changeable and some of them are not so [22:51] we have to view the world as it is [22:53] certainly we see we've got more men who [22:55] are unhealthy who are overweight who [22:58] have other medical comorbidities that [23:00] are also impacting their ability to make [23:03] sperm like if you have high cholesterol [23:06] if you have diabetes some of those [23:08] things are going to impact your overall [23:10] health and the production of sperm so [23:12] this goes for sperm or egg the hormone [23:14] access from the brain to your gonad your [23:17] gonads are either your testes or your [23:19] ovaries your brain is constantly [23:21] interpreting signals from your whole [23:23] body and is trying to determine can [23:26] stepen have a kid right now and if you [23:28] become very stressed now back in the day [23:32] what was that there was a bear attacking [23:34] you there was a famine so you had no [23:36] food there was a plague going around [23:39] then it say this is not a good time to [23:41] have a child right now because because [23:44] you can't support your own body or the [23:47] world around you your adrenal glands are [23:49] making cortisol because it's so [23:51] stressful or your calorie intake went [23:54] down so your brain says this is too [23:57] difficult I'm going going to shut off [23:59] the system to make reproductive hormones [24:03] and that happens in both men and it can [24:05] happen in women so the brain is [24:06] constantly interpreting the world around [24:08] you and then sending out signals to make [24:12] eggs or sperm like to make eggs grow or [24:15] to be making sperm and the hormones that [24:18] are associated with them so estrogen and [24:20] progesterone for women and testosterone [24:22] for men and so one we have anything that [24:25] interferes with this pathway people are [24:28] more ill there's more autoimmune disease [24:30] more [24:31] inflammation there's more stress chronic [24:33] stress there's more obesity but then we [24:36] also see the environmental impact as [24:39] well so [24:41] certainly there's so many toxins in our [24:43] world from the foods we eat from the air [24:46] we breathe from the type of you know [24:49] kitchen wear that we use what we put in [24:52] and on our body all of it makes a little [24:55] bit of a difference and we know some [24:58] people if you live in an area with high [25:00] pollution you're going to have lower [25:01] sperm counts and a reduced fertility [25:03] rate but that might not be something you [25:05] can change because that's where you live [25:08] but it might be even more important for [25:10] that person to understand it and then [25:13] want to not also smoke marijuana or [25:17] drink out of plastics or do other things [25:20] that might be adding to that burden so [25:24] smoking marijuana and smoking cigarettes [25:26] are no NOS if I absolute no no know so I [25:29] think cigarettes most people are pretty [25:31] aware cigarettes are pretty bad for your [25:33] health if we talk about reproductive [25:35] Health in general cigarette smoking for [25:38] for women and your eggs are going to [25:40] decrease your egg count your egg quality [25:42] and the rate of miscarriage [25:44] significantly significantly for men what [25:48] we see is it decreases your sperm count [25:51] your sperm motility and the quality the [25:54] shape of the sperm also increasing [25:57] miscarriage marijuana does this as well [25:59] if you smoke marijuana even if your [26:02] partner does not and is never around you [26:05] when you're using it she has a higher [26:07] chance of a miscarriage just because [26:09] you're smoking marijuana how because of [26:11] DNA damage inside the sperm's head okay [26:14] I'm giving out bad sperm you're giving [26:15] out bad sperm what about vaping we don't [26:18] know as much about vaping but it appears [26:20] in all the preliminary studies to be [26:22] similarly very bad that what is in um [26:26] what you're breathing with vaping [26:28] might even be more harmful than [26:30] cigarettes [26:31] potentially what about phones and [26:34] laptops oh I love this one okay so [26:36] that's a great question and people ask [26:38] about it two ways to look at it there [26:39] was a study that was published last year [26:41] that actually looked at this and we'll [26:43] talk about just having your phone using [26:45] your phone and then location of the [26:46] phone in the study what they looked at [26:48] is phone usage from 2005 to 2018 so we [26:52] have to remember in 2005 phones were [26:55] different it wasn't quite the same but [26:57] they had a much higher uh radiation [27:00] emitted from them so modern phones [27:02] actually emit much less radiation so [27:04] even though we keep them on our person [27:06] they're ultimately safer than what we [27:09] saw as origin phones from 2005 to 2010 [27:14] in this study that they looked at the [27:16] number of times that you used your phone [27:19] which is wild to us because we use our [27:20] phone constantly now but the number of [27:23] times you use your phone the more you [27:25] used it the less firm you [27:29] made okay [27:32] however that was most impactful for the [27:35] early generation phones from 2005 to [27:38] 2010 so when they stratified and looked [27:40] at some of the phones we have now we're [27:43] not seeing that same impact and I think [27:46] that is because there's less radiation [27:48] and also everybody uses their phone more [27:51] than 20 times per day right you're using [27:53] it all the time location didn't matter [27:56] there was no difference of location [27:57] whether you kept your phone in your [27:58] pocket your back pocket the counter off [28:01] your body there was no difference so I [28:05] think that helps us understand some of [28:06] the radiation aspect of the phone and if [28:10] that is impacting sperm heat of the [28:13] testicle is of course something very [28:15] very different I do think you talked to [28:16] Reena about this so when it comes to the [28:18] testicles they live outside your body [28:20] for a reason we know that men who have [28:22] an undescended testicle even if it's [28:24] surgically removed sorry what's an [28:26] undescended testicle you can be born [28:28] with one of your testicles in your [28:29] abdomen instead of in your scrotum okay [28:32] and that's usually surgically corrected [28:34] before the age of one because if it [28:36] stays internally the heat of the body is [28:39] too hot and it destroys the cells the [28:42] inability to make sperm inability to [28:45] make testosterone so the testicle is [28:48] outside the body in the scrotum so that [28:50] it can be kept at a lower body [28:52] temperature we know that things that [28:54] increase the temperature of the scrotum [28:56] do impact sperm production and [28:59] testosterone production testosterone and [29:01] sperm are made together so one thing is [29:04] going to influence one it will influence [29:05] the other this is sauna use every day [29:09] hot tub use every day laptop in your lap [29:13] if you are putting your phone [29:15] exactly by your scrotum every single day [29:18] then it might be having an impact if [29:20] it's heating up and it's the heat that's [29:23] causing the problem not the radiation [29:26] that's being emitted from it so we [29:28] always are asking if I see somebody for [29:30] infertility I'm going through any [29:32] behaviors that are significantly [29:34] increasing the temperature of the [29:37] scrotum to see if that is a modifiable [29:39] factor what about hot baths if we're [29:41] having lots of hot baths if it's daily [29:44] and you sit in there for you know more [29:46] than 15 minutes then I would cut that [29:48] down to not be daily I see this a lot in [29:50] Austin from people who love to cycle so [29:52] they're on a bike they're outside they [29:54] want to go ride for two to three hours [29:57] at a time time numerous times a week [30:00] that's a lot of [30:02] heat contained right to the scrotum area [30:05] and we often see significantly lower [30:07] sperm counts in men who cycle at that [30:10] intense [30:11] level interesting right very [30:15] interesting um what about trt you talked [30:17] about the the correlation there and the [30:19] relationship between sperm and um [30:22] testosterone levels if Men start taking [30:24] trt which is hormone replacement [30:26] therapies testosterone repl therapy um [30:29] does that impact the quality of my sperm [30:31] and my chances of fertility stepen at [30:33] least one time per week I will see a [30:35] couple who comes into my office who has [30:37] been trying to get pregnant and the male [30:40] partner went to a Hormone Clinic a men's [30:44] health and he was put on trt for libido [30:48] or fatigue or something and essentially [30:52] that is male birth control because [30:54] taking testosterone yourself is telling [30:57] your brain that there is testosterone [30:59] present because naturally testosterone [31:02] is made as sperm is made if your brain [31:05] thinks there's a lot of testosterone it [31:07] says hey we don't need to make much more [31:09] we're doing really good so the hormones [31:11] from your brain stop being sent out and [31:14] no longer tell your testicle to make any [31:18] more testosterone or any more sperm so [31:21] trt use makes men aspermic meaning [31:25] having no sperm in the ejaculate you [31:27] still have an ejaculate it looks the [31:28] same to you but when we go look at it [31:31] under the microscope there's no sperm in [31:33] it sometimes that is irreversible the [31:36] longer you've taken trt for there is a [31:39] chance that I might not be able to get [31:41] sperm to return to your ejaculate it [31:43] might be permanent let's talk about eggs [31:47] let's talk about eggs you have this um [31:49] wonderful example where I guess it's a [31:52] bit of an analogy called The Vault yes [31:54] I've got um some marbles over here in a [31:56] jar which I thought would um help us to [31:58] visualize this idea of a vault so I've [32:01] put about I don't know there looks like [32:03] there's about how many marbles do you [32:05] reckon there're in there if you uh get [32:06] it right you win the whole lot uh 200 [32:08] marbles 200 I'm going to say we'll count [32:11] after um well now you're counting that's [32:14] different than guessing no no no no I'm [32:15] not I'm not just go on have a guess how [32:17] many marbles are in there we'll count [32:18] after see who's right okay I said 200 [32:20] okay anyone in the comment section below [32:21] Al so you can you guys can also guess [32:23] don't cheat don't skip to the end I [32:25] think there's about [32:28] he is counting that is not I can't count [32:31] them all can I cuz I can't see them all [32:32] seven times nobody else can see them all [32:34] and count them 140 okay this is the [32:36] analogy I'm going to pass them over to [32:37] you um I'd love you to use this as an a [32:41] visual aid to explain to me this idea of [32:43] the vault as a as a way to understand [32:45] how many eggs women have and how that [32:47] changes over the course of Our Lives [32:48] love it all right so I like to think [32:50] about the ovary as inside your ovary if [32:53] we can imagine that there is a vault of [32:55] your eggs so that is what this jar is [32:57] representing so again in contrast in men [33:00] testes are making brand new sperm every [33:03] single day in women when you are a five [33:07] Monon baby inside your mother's womb you [33:09] have the most eggs you're ever going to [33:10] have you have six to seven million eggs [33:13] by the time you're born you have 1 to [33:14] two million by the time you start [33:17] puberty you have half a million your [33:20] reproductive years you're going to start [33:23] with about [33:24] 300,000 and by the time you go in to [33:27] menopause you'll have less than a [33:29] thousand left so you still have a few [33:30] eggs left women only ovulate about 400 [33:35] to 500 eggs over the course of their [33:37] lifetime so if you're born with 1 to two [33:39] million and you only ovulate 400 to 500 [33:42] that seems like confusing math so the [33:45] way that I think about it is that every [33:46] single month you are losing eggs from [33:50] this Vault and what is happening is that [33:52] the eggs are coming out in proportion to [33:55] how many are inside so when the vault is [33:58] more full more eggs come out that month [34:01] and when the vault is less full less [34:04] eggs come out so if we can imagine one [34:06] month you're going to have a group of [34:09] eggs all come out of the Vault and so if [34:12] this is our ovary what we would imagine [34:15] is that the Vault sent out all of these [34:17] small eggs and each egg grows inside a [34:19] follicle the brain is going to send out [34:22] follicle stimulating hormone once you [34:24] start puberty so before puberty all of [34:27] these eggs are just going to die after [34:30] that month is over but once you've [34:32] started puberty FSH so follicle [34:35] stimulating hormone from the brain will [34:36] come and stimulate one of these eggs why [34:39] only one because humans are not meant to [34:42] have litters you can only carry one [34:43] child at a time in our uterus so this is [34:46] the protective mechanism by which humans [34:48] don't have multiple children most of the [34:51] time so each egg grows inside what we [34:53] call a small follicle so the brain sends [34:56] out follicle stimulating hormone [34:58] this is one of the rare times where in [34:59] medicine hormones are named for what [35:02] they do in women not men because you [35:03] have FSH and lh2 FSH controls the [35:06] production of sperm for you and LH the [35:08] production of testosterone but for women [35:11] FSH controls the stimulation of one [35:13] follicle so this follicle will grow and [35:16] this one will ovulate and the rest of [35:17] them will die so that's one of the 400 [35:21] that I'm going to lose these just go [35:24] away I want to make sure I understand [35:26] this so in the J [35:28] is the Vault that's inside the woman y [35:31] um at every month this is what's [35:34] available this month okay she produces [35:36] quite a few like when you're younger [35:38] yeah CU there's more in my jar [35:39] proportionately there's like okay [35:41] there's 20 or 30 and they're [35:42] proportionately to a jar that has 200 [35:44] these numbers aren't obviously ratioed [35:45] but and then one of them is basically [35:48] selected to ovulate at random at random [35:52] so it's one of the great Mysteries if we [35:54] could control which one because it [35:56] doesn't have any more likelihood to be [35:58] genetically normal or good just because [36:00] it responds so what is interesting when [36:02] we think about this vault is as we said [36:05] when we have less eggs less are coming [36:06] out every month so you're going to start [36:08] to dump out less [36:10] eggs and the jar gets emptier what age [36:13] was I then and what age am I now so we [36:15] can say that you you know were 30 at one [36:17] point and now we're starting to get to [36:20] about age 34 at this point okay what [36:23] starts to happen just for numbers so at [36:25] age 30 you're going to have about 20 [36:27] eggs come out of the Vault every month [36:29] one EG will ovulate 19 will die next [36:31] month another group okay when you get to [36:34] about 35 you're going to have about 14 [36:37] to 15 so still pretty close when you get [36:39] to 40 it'll be about 8 to 10 per month [36:42] 44 closer to three to four per month so [36:45] you start to see that after age 37 [36:47] specifically a more rapid decline in how [36:51] many eggs are remaining therefore less [36:54] are coming out every month this idea is [36:57] really for two reasons one is that all [37:01] women run out of eggs when you run out [37:03] of eggs you're an ovarian failure also [37:06] known as menopause average age of [37:08] menopause is 51 to 52 I've seen somebody [37:11] have menopause at age 13 so I've seen [37:16] primary amenorrhea where somebody was [37:18] born with ovaries that never made [37:20] follicles I've had women who had their [37:22] periods and then they ran out of eggs in [37:24] their 20s so some people are on [37:27] different Pathways now maybe they were [37:29] born with less maybe something happened [37:32] to them along the way to make them run [37:34] out of them faster so certain things can [37:38] get in the vault and impact our ultimate [37:40] egg count so as we already said smoking [37:43] cigarettes marijuana use endometriosis [37:47] which we haven't touched on quite yet [37:48] but we will [37:49] chemotherapy environmental toxins so [37:52] certain things can get in here and make [37:56] us run out of eggs faster [37:58] what's also important to understand is [38:00] that the eggs that are out in one month [38:02] are all the eggs we have to work with so [38:05] when we start talking about egg freezing [38:07] or IVF I can only get the eggs that have [38:10] been sent out of the vault in that month [38:12] to grow I cannot tap into the Vault and [38:16] this is why if you've had friends go [38:19] through IVF or egg freezing and it [38:21] sounds random somebody got six eggs and [38:24] somebody had 24 somebody had to do [38:27] multiple Cycles or months sometimes in [38:30] order to help somebody get enough eggs [38:33] to have a normal embryo what we have to [38:36] do is multiple months so the 10 eggs [38:39] that are available this month I'm going [38:41] to get them all to grow not just the one [38:43] you are normally going to ovulate take [38:46] those eggs out of the body and then next [38:48] month when your body gives me another [38:49] group of 10 I'm going to get them all to [38:51] grow again and take those eggs out of [38:53] the body that is ovarian stimulation for [38:57] for either egg freezing or IVF trying to [38:59] say hey in this month I don't want to [39:01] let any of these eggs die because I need [39:04] more of them to get the job done or [39:06] we're running out of time and I'm trying [39:07] to expedite your opportunity for [39:11] conception so women have this decline in [39:14] the total number of eggs you're going to [39:16] have when you're 37 I think the number [39:19] is that you have close to 20,000 eggs [39:21] remaining so what a huge drop from when [39:24] you started puberty at half million so [39:26] it's just going down so fast every [39:29] single month what is also happening is [39:33] that because these this vaults inside [39:35] our [39:37] body when you smoke the cigarettes when [39:39] you eat processed foods when you get [39:42] sick if you have chronic inflammation [39:45] you're losing some but the ones that are [39:47] here at the bottom they've been here the [39:48] whole [39:50] time and so in addition to number of [39:53] eggs we have to talk about the quality [39:55] of the eggs because these [40:01] eggs down here at the bottom once you [40:04] get older they've been sitting here a [40:06] long time and that means that their [40:09] chromosomes inside of them are much more [40:13] likely to be abnormal than normal and [40:17] that's really the rate limiting step in [40:19] people getting pregnant when they're [40:20] older not that my vault is more empty [40:23] not that I'm sending out less per month [40:25] but that the ones that have been sitting [40:27] here have have been sitting here longer [40:29] and [40:30] they aren't as good I I use the analogy [40:34] for the chromosomes so if we [40:35] imagine your eggs hold your chromosomes [40:38] in perfect position so that they're [40:39] ready to then go be fertilized by sperm [40:42] it is like having kindergarteners stand [40:44] in a line for 40 years somebody's going [40:47] get out of line and when that happens [40:49] that increases the rate of genetic [40:51] abnormalities and most of those do not [40:54] fertilize do not implant or misc carry [40:58] at age 40 if you see a positive [41:00] pregnancy test your chance of [41:02] miscarriage is [41:05] 50% because they've been sitting here [41:07] even if you're very healthy just time [41:11] and normal life impacts things but [41:14] there's choices you make that cause them [41:17] to degrade faster and there's things [41:19] that you do that might be protective and [41:22] that is something that we don't ever [41:23] talk about we when you're 35 your chance [41:27] of miscarriage is 25% so there's a huge [41:30] change that happens between AG 35 and [41:33] age 40 when you're 35 and you start [41:37] trying to get pregnant so if you and [41:39] your partner wait and you say [41:41] everything's good we're going to wait [41:41] till we're 35 your chances of getting [41:43] pregnant per month are going to be [41:46] approximately 10 to 15% per month that's [41:49] not not very high it's not great not [41:51] great at 40 it's about 5% per month so [41:55] we've dropped dramatically and just see [41:57] the positive test and then if you see it [42:01] 50% are abnormal so the odds of the body [42:03] is going to choose from the eggs that [42:05] are sent out that one month when you're [42:09] 40 the odds [42:12] that your body is going to choose one of [42:15] the two eggs that is genetically normal [42:19] because six of them are abnormal it's [42:21] not very probable so most months your [42:24] body's ovulating one that's not going to [42:27] have the potential to become a liveborn [42:32] baby I feel like I better get a move on [42:34] Jesus Christ it's not information to [42:37] scare people but it is information that [42:40] nobody talks about well as you were sat [42:42] here talking to me about this the [42:45] opposite of [42:46] confronting the truth is Regret yes and [42:50] I can't imagine how much regret you've [42:51] seen I wanted to ask you about about [42:54] that regret because you must have to [42:57] deliver so much bad news to people and [42:58] you must see [43:01] the retrospective Clarity that those [43:04] people suddenly get when they realize [43:07] that those decisions they could have [43:09] made [43:11] earlier especially [43:14] for people who are not used to not being [43:18] in control of things and who just didn't [43:21] have the data they needed to make the [43:23] decision there are people who have been [43:25] with their partner for very long time [43:27] and maybe kids weren't in the plan [43:29] earlier but they could have been had [43:31] they known that it would have been so [43:34] hard or potentially impossible later on [43:37] one thing that I think is important to [43:39] discuss here when it comes to regret is [43:41] testing female fertility because there [43:43] is a marker of how many eggs do you have [43:47] we call this your ovarian reserve how [43:49] many eggs are left in the vault and one [43:52] way you can test this is with a blood [43:54] test called amh or antim malarian [43:56] hormone and the other way is to do an [43:59] ultrasound and see how many eggs are [44:02] outside the vault at that month so both [44:04] of these are actually quite important [44:06] when you're thinking about how many eggs [44:07] somebody [44:09] has that number does not impact you [44:13] getting pregnant in one month and I [44:15] think that that's important because if [44:17] you [44:19] have we'll use a whole group you could [44:21] have a whole group of eggs or you could [44:24] have less how many eggs is your body [44:27] ovulating in each group so this [44:29] person crazy this person who has more is [44:33] ovulating one this person who has left [44:36] is ovulating [44:38] one so if I have two people who are the [44:42] same age and they have different ovarian [44:44] reserves meaning they have a different [44:46] number of eggs left in their vault [44:47] they're going to send out a different [44:49] number of eggs each month how many eggs [44:51] are they ovulating each [44:53] month one one yes look at me learning [44:57] look at you so they're each going to [44:58] ovulate one egg so what are their [45:00] chances of getting [45:02] pregnant the same the same so having a [45:05] lower egg count does not impact your [45:07] monthly chance of getting pregnant [45:10] that's determined by age by the [45:12] proportion of these eggs that are normal [45:14] or abnormal however if you have fewer [45:16] eggs there's fewer that I can get to [45:18] grow with IVF and you have overall less [45:21] of an opportunity to grow your family [45:23] this is important because a lot of [45:25] societies will tell people not to check [45:28] somebody's ovarian reserve and this [45:30] blows my mind I have a really hard time [45:32] with this because they say if it doesn't [45:36] impact your monthly chance of pregnancy [45:38] having a low ovarian reserve is only [45:40] going to cause undue stress so the [45:43] American College of OBGYN recommends not [45:45] checking an amh level in women who are [45:48] not trying to get pregnant and who are [45:50] not having [45:51] infertility I completely disagree with [45:54] this because you can't make decisions on [45:56] data you don't know [45:57] and if you know you're running out of [45:59] eggs faster you very well might make [46:01] different decisions you might freeze [46:04] your eggs you might try to get pregnant [46:06] sooner you might try to just be [46:09] healthier if you are doing behaviors [46:11] that you know are decreasing your egg [46:13] count you might stop smoking pot but if [46:17] you're never giving that opportunity [46:19] you're going to live in the regret [46:21] category where when you find that out [46:25] later I wish I'd known this earlier I [46:27] wish I'd been able to make a choice when [46:30] I had the opportunity and I had the eggs [46:32] remaining and so by not testing by not [46:36] knowing we are hurting more women and I [46:39] always tell my obgy and friends this [46:41] conversation should be hand inand with [46:43] Stephen are you'all trying to get [46:44] pregnant yes or no no what birth control [46:48] might you want let's talk about it oh [46:50] should we check your ovarian reserve to [46:52] make sure that your time is okay again [46:55] having a good account does doesn't mean [46:57] you're going to get pregnant your chance [46:58] is the same however it means you have [47:02] more opportunity of time to try to grow [47:05] that family and ultimately a greater [47:07] chance of success when it comes to IVF [47:09] or egg freezing because the factors that [47:11] determine success are how many eggs you [47:13] have and how many are normal a lot of [47:16] people do ask that question they ask um [47:19] you know they'll say things like well my [47:20] parents didn't have to worry about this [47:21] or my grandparents didn't have to worry [47:23] about getting checked and seeing how big [47:25] my ovarian reserve is so you know why do [47:28] we have to all start doing that [47:30] now we know a lot more now and I think [47:32] the honest answer here is that one way [47:35] to look at this is that when I was your [47:38] age egg freezing didn't exist so I could [47:41] not have Frozen my eggs and my early 30s [47:43] had I wanted to meaning would you check [47:47] it if you really can't offer somebody [47:49] things to intervene or way to make a [47:52] change however now we know factors that [47:55] impact how many eggs you have [47:57] and we have the ability to freeze eggs [48:00] with very high success rates now it's [48:02] accessible in almost all fertility [48:04] clinics with really great egg [48:06] survival so this poses the question of [48:10] should you know earlier we also have [48:12] Generations where people are curious and [48:15] they see things online they're not [48:16] afraid of scary health information [48:19] instead younger Generations want to [48:21] understand their bodies and I love that [48:24] but there's so much misinformation [48:25] online too that it's really saying that [48:28] this is personal we can talk about eggs [48:30] and ofal every single day but until [48:33] somebody comes in to my office or [48:35] somebody else's office to get their own [48:37] evaluation done they're not going to [48:39] have the true data they need to make [48:41] that decision but I think it's great [48:44] that we are approaching fertility as a [48:46] health marker trying to look for signs [48:49] earlier that things might be wrong [48:51] especially given the opportunity to try [48:53] to intervene if you find out your sperm [48:55] counts lower we might be able to try [48:57] interventions for 3 to six months and [49:00] see if we can get a new group of sperm [49:02] that potentially has fixed that [49:05] problem so say I'm starting out in life [49:08] with a full ovarian reserve or say you [49:11] know here's my ovarian reserve at say 20 [49:14] years old if I start engaging in [49:18] unhealthy lifestyle choices if I start [49:20] eating process food if I become obese [49:23] Etc does that take marbles out of this [49:26] jar does that take eggs out of my [49:28] Reserve or does that just damage the [49:31] quality of the eggs in the jar both both [49:34] okay so it pulls them out and it makes [49:36] them less effective the way I think [49:39] about it is not that it's pulling them [49:40] out giving them an opportunity but [49:41] essentially let's imagine it's getting [49:44] you smoke cigarettes the cigarette smoke [49:46] is getting inside the Vault it is [49:48] damaging the DNA and some of your eggs [49:50] but it's also just killing some of them [49:52] inside the Vault themselves so that you [49:54] are running out inside the vault [49:56] ultimately people who smoke cigarettes [49:59] go into menopause years earlier than the [50:01] average age really because they have had [50:05] a destruction of the eggs inside their [50:07] vault if I wanted to make sure that my [50:09] ovarian reserve was 10 out of 10 you [50:12] know I did if I was to live a perfect [50:14] life in terms of what my aarian Reserve [50:16] needs to be healthy how would I live [50:19] what what what would my daily habits [50:20] look like that's a great question I love [50:22] it so what can you try to do because you [50:24] can't control everything but you should [50:26] be able control the factors you can so [50:28] number one we're going to say avoid [50:30] toxic behaviors so toxic behaviors [50:33] that's going to be your cigarettes your [50:34] marijana cocaine you're going to H not [50:38] have any alcohol definitely alcohol [50:40] especially in proportion is showing an [50:43] increased risk of damage so a drink here [50:47] or there like that's not studied as well [50:49] but we know moderate to high drinking [50:51] levels is associated with reduced egg [50:54] quality what's moderate to usually [50:57] considered four drinks a week four [50:59] drinks a week so if I have four glasses [51:00] of champagne a week yep so you have four [51:03] glasses tonight at dinner you've hit [51:05] moderate that is I mean most people [51:08] especially in Britain oh well here too [51:11] and I mean honestly with Co especially [51:13] we saw so many people increase their [51:16] drinking substantially so you would [51:19] limit the toxic behaviors number two is [51:22] you're going to limit the toxins in your [51:23] world that you can again if you live in [51:26] an area [51:27] that is a high pollution area that just [51:29] might be where you live but you should [51:32] not cook in plastic put plastic in the [51:34] microwave or the dishwasher you [51:36] shouldn't use teflon on your pans you [51:39] shouldn't touch thermal paper receipts [51:43] like at the airport if they print off a [51:44] ticket for you or a receipt from the [51:46] grocery store that has chemicals in it [51:49] itself takeout food so when you order [51:51] your takeout food and it comes to you [51:53] and it sits in the containers that it [51:55] comes in if you're not eating it right [51:57] away or even when you do eat it you [51:59] should take it out of that container and [52:00] put it in something else put it in glass [52:03] put it on a plate because especially [52:05] with heat we see leeching of those toxic [52:08] chemicals into the food and then you're [52:10] consuming the food even if it's high [52:13] quality good food it now has absorbed [52:16] chemicals from the packaging that it was [52:18] in so microwave meals in plastic you [52:21] know you take the plastic and you [52:22] microwave it shouldn't do [52:25] it how do we we know this have they have [52:28] they done research on this or is this [52:30] just so there is research done on it [52:32] it's always hard to study lifestyle [52:34] factors in humans and when it comes to [52:37] fertility because what is the outcome is [52:39] it the positive pregnancy test the [52:42] having the baby the absence of getting [52:44] pregnant that your regular Cycles [52:46] there's so many different variables you [52:47] can look at at an endpoint a lot of the [52:49] environmental chemical studies are done [52:51] on animal studies looking at some of [52:54] these chemicals but also we can see in [52:57] populationbased studies we do have now [52:59] where they've done cohort studies mean [53:01] they take a group of people and they [53:03] follow them for years taking blood and [53:06] urine samples to measure some of these [53:07] chemicals and then watching what's [53:09] happening with their normal behavior no [53:11] intervention are they getting pregnant [53:13] when they're trying to or are they not [53:15] and we see that greater exposure to [53:18] these known toxic chemicals are making [53:20] it harder for people to get [53:23] pregnant when it comes to other factors [53:26] to try to have your healthiest Vault [53:28] possible decreasing inflammation is [53:31] going to be very important so we think [53:33] about inflammation and there's two types [53:36] so you have acute inflammation you cut [53:38] your arm and it's going to react and [53:40] heal and that's a normal bodily process [53:42] but then you have chronic inflammation [53:44] where your body is constantly spending [53:47] its energy fighting that inflammatory [53:50] State and that inflammation markers the [53:53] prostaglandins the factors in your body [53:55] that get really high [53:57] that's actually pretty toxic to our [53:58] quality as well and that can be disease [54:01] States as well so things like [54:03] endometriosis or other inflammatory or [54:05] autoimmune diseases what um what ways do [54:08] we voluntarily increase our inflammation [54:11] is that dietary predominantly yes so [54:13] number one is going to be not sleeping [54:15] enough so sleep is when your body heals [54:17] sleep is when your cells repair their [54:21] damage so you need to get S and a half [54:23] to eight hours of sleep per night I [54:25] heard you say in a sleep is probably the [54:27] number one thing that people don't do [54:30] that does impact their reproductive [54:32] hormone [54:34] system yes it seems so straightforward [54:37] to say it's not a pill that you take it [54:40] is not a major change of behavior it's [54:42] not missing out on something in your [54:44] life it is simply giving your body the [54:47] time that it needs to heal from the [54:50] normal inflammation that you're going to [54:51] encounter during the day simply [54:53] prioritizing getting enough sleep is the [54:55] simplest things somebody can do to try [54:58] to improve their reproduction and how [55:00] their hormones are made and [55:03] interpreted we talked about stress [55:05] earlier stress impacts the brain in a [55:07] similar way there's different types of [55:09] stressors very similarly you have your [55:11] acute stressor the bear you have the [55:14] stress of everyday life and modern world [55:18] is a lot more stressful in a lot of [55:20] different ways [55:22] constantly we also see that that stress [55:25] is so individualized so it's not like I [55:27] can say you need to go to yoga or you [55:29] need to do acupuncture or you need to go [55:31] to therapy I tell my patients for stress [55:34] reduction understanding that having a [55:37] constantly stressed State constantly may [55:39] have having cortisol be made is not [55:42] going to allow your brain to in to [55:44] interpret the other signals that are [55:46] being sent it's clouding its judgment [55:48] and it's going to think that you're not [55:50] at a place to maybe support a pregnancy [55:53] and your reproductive hormones are going [55:54] to show for that what that comes down to [55:57] is that you've got to modify stress in [55:58] some way for you so everybody's [56:01] different and maybe it is acupuncture [56:03] maybe it is Yoga I I like to sit on the [56:05] back porch in the morning hours with a [56:08] cup of coffee and hear the birds people [56:10] like to go on walks therapy mindfulness [56:12] meditation journaling everybody's [56:14] different but you deserve taking 20 [56:17] minutes every day and dedicating it to [56:19] something that doesn't have your iPad [56:21] your cell phone your computer the TV and [56:25] putting yourself in an environment where [56:27] you can [56:28] say like have that feeling of release [56:31] you get when your cortisol drops that's [56:34] important so that your body can then [56:37] properly respond when you do have a [56:38] stressful situation and can allow you to [56:42] heal not be under a constant attack [56:45] diet's going to be one of the hugest [56:46] things that people can make a change in [56:48] processed foods refined sugar processed [56:51] Meats those are not natural foods and [56:54] those are things that come with a lot of [56:57] chemicals inside of them a lot of [56:59] contaminants we know that processed [57:01] Meats for example type 1 carcinogens all [57:04] these sugars have a direct correlation [57:06] with somebody's ability to get pregnant [57:08] when it comes to the direct cause it's [57:10] usually going to be sperm quality or egg [57:12] quality depending on the study looked at [57:14] what about red meat oh I love that [57:17] question number one I think it's really [57:19] important that nutritional studies [57:21] people qualify meat differently so it [57:23] might be all meat it might be types of [57:25] meat so we have to take it with a in [57:28] perspective of the limitation of the [57:30] data we know that process Meats impact [57:33] fertility we know that red meats appear [57:38] to impact both sperm production and egg [57:42] and embryo quality there was an IVF [57:44] study done and the more servings of red [57:47] meat you had in a week the [57:50] less embryos you had developed [57:52] throughout the process than somebody who [57:54] had fewer servings [57:56] so that's telling us that [57:58] it's maybe not one red meat in general [58:00] is bad one serving but it's about the [58:03] amount right everything in moderation [58:05] nothing in excess we know that the [58:07] healthiest fertility diet high in fruits [58:10] and vegetables fruits and vegetables are [58:12] fiber sources they are antioxidants they [58:15] are helping our body function [58:18] appropriately they're helping our gut [58:19] function they are lowering inflammation [58:22] I say meat is okay I don't eat meat but [58:26] that doesn't mean that none of my [58:27] patients should eat meat I give them [58:29] this diet because I think you have to [58:31] make dietary change accessible if I told [58:33] everybody stop eating meat nobody's [58:35] going to listen to anything but we know [58:37] that it's the amount the quantity so I [58:39] say if you're going to eat an omnivore [58:42] diet which is going to be the majority [58:43] of people have a meatless Monday [58:46] meatless Monday you automatically can do [58:49] and you're going to have to substitute [58:50] in some of those other sources of [58:52] protein that are ultimately better for [58:54] you fish fish is great we should limit [58:57] fish to three times per week just due to [58:58] risk of mercury but fish is a wonderful [59:02] option it does have a lot of good [59:03] omega-3 fatty acids in it and ultimately [59:07] eating more fish and less red meat is [59:09] such a great substitute what about [59:11] skimmed milk and fertility I heard uh [59:14] I've heard you speak a little bit about [59:15] that past so what's interesting and I [59:17] think that we've grown up in this you [59:18] know fat obsessed culture that has [59:21] prioritized lowfat no fat foods and [59:25] number one [59:26] fat is important in the production of [59:29] steroid hormones estrogen progesterone [59:30] testosterone are steroid hormones so [59:32] they need cholesterol the source of that [59:34] cholesterol is important so we should [59:37] have those healthy fats the nuts the [59:39] avocados the oils fantastic healthy fats [59:41] are wonderful but when it comes to Dairy [59:46] we've seen that whole fat Dairy is [59:48] associated with better fertility better [59:50] ovulation than the skim dairy products [59:54] probably due to the processing if we [59:55] View skim milk as the processed version [59:58] if I'm going to take out the fat that [60:00] normally comes in the milk but still [60:02] want it to retain looking like milk it's [60:06] not just minus fat right it's minus fat [60:08] plus something else so in the production [60:11] process it's that or it's potentially [60:14] that the only benefit the dairy really [60:15] has is being a source of a healthy fat [60:19] option and that when you take out that [60:22] fat you lose that so I recommend that if [60:25] you consume Dairy [60:26] that you stick with the whole fat [60:27] versions you don't do skim or lowfat and [60:31] in moderation for for dairy consumption [60:34] I say that if you do meatless Monday the [60:36] rest of your meals for the week you [60:38] should have one serving a meat per day [60:40] that's going to make you just force you [60:42] to eat more fruits and vegetables and [60:44] then one of those meals you should have [60:46] red meat if you like red meat not [60:48] multiple times a week and then you [60:50] should limit processed foods [60:52] sugars processed Meats all those refined [60:56] carbohydrates all the packaged things [60:57] that are totally fake that should be [61:00] very rare those are your if occasion [61:03] type of foods not your everyday Foods um [61:06] the other thing we didn't talk about [61:07] regarding lifestyle choices is exercise [61:09] oh yes now there's kind of two schools [61:10] of thought here because I have some [61:13] friends who exercise a lot and they have [61:17] seen a [61:20] disregulated menstrual cycle yes all [61:22] their periods have completely stopped um [61:25] but I also read that exercise is good [61:27] for [61:29] fertility this is a great opportunity to [61:31] just think about how the ovaries work [61:33] like we've talked about having your eggs [61:35] but if we think about in a given month [61:36] you have that group of eggs that comes [61:38] out of the Vault each eggs in the [61:39] follicle we already said FS or follicle [61:42] stimulating hormone is the hormone from [61:44] the brain that goes and stimulates that [61:46] one egg to grow as that egg grows the [61:49] follicles growing and making estrogen [61:52] that process takes approximately two [61:53] weeks in the majority of women and when [61:55] you're estrogen level gets high enough [61:57] it tells the brain you have a mature egg [62:00] your brain doesn't know what's happening [62:01] in your ovary it can't see I always say [62:03] it's like having your best friend who [62:06] doesn't go on Instagram they have no [62:08] idea what's happening in your life [62:09] unless you tell them so the only way [62:11] that the ovary communicates with the [62:12] brain is actually through the production [62:14] of hormones so as that one follicle is [62:16] starting to grow it is making estrogen [62:18] and that estrogen is then telling our [62:20] brain we have a follicle growing that [62:23] follicle then is going to open up it [62:26] bursts it ruptures and what's a follicle [62:28] sorry oh a follicle is if we can imagine [62:32] this is a follicle the egg is [62:34] microscopic inside of it it is the fluid [62:36] filed structure that keeps your egg so [62:39] for people that are are just listening [62:40] and not can't see yes you're holding one [62:42] of the little eggs in your a marble I'm [62:44] holding a marble so if we can imagine a [62:46] follicle is a small fluid filed [62:47] structure in which the egg is kept okay [62:50] so the eggs inside the follicle exactly [62:52] and so the follicle gets bigger as the [62:55] egg gets more mature sure it makes more [62:57] estrogen that estrogen at a high enough [62:59] level and it's very specific 200 PS for [63:02] 50 hours tells the brain you have a [63:04] mature egg the brain will then send out [63:06] LH or lutenizing hormone it allows that [63:09] follicle to open up then the egg is [63:12] going to be released and hopefully get [63:14] captured by the fallopian tube so it'll [63:16] be sucked up into the fallopian tube but [63:19] that fle reforms so the egg is gone the [63:22] follicle reforms and it becomes a cyst [63:24] in your ovary called the Corpus ludum [63:27] and it is now stimulated by LH from the [63:29] brain telling it to make progesterone [63:32] okay and what am I going to do with the [63:32] progesterone progesterone opens and [63:34] closes the implantation window without [63:36] progesterone a pregnancy cannot implant [63:38] into the uterus so this progesterone is [63:42] going to allow your body to have that [63:45] egg if it becomes fertilized and [63:47] develops into an embryo the egg gets [63:50] fertilized in your fallopian tube it has [63:52] to grow and develop into a stage of an [63:54] embryo so the SP comes along sperm swim [63:57] through the uterus into the tubes and [63:59] that's where fertilization happens okay [64:01] so the sperm comes through the fallopian [64:02] tube it meets the egg which is chilling [64:04] there chilling there and then what [64:05] happens then well hopefully [64:08] fertilization happen which is like the [64:09] sperm which is like the tadpole's head [64:11] hits the egg it's the egg it actually [64:13] has a little fusion reaction and pushes [64:15] its DNA in there pretty cool it then has [64:18] to grow and develop so you have a single [64:20] cell egg a single cell sperm they come [64:23] together you have two different DNA [64:24] components and then you start seeing [64:26] cell division just like you would expect [64:28] exponentially two cells four cells eight [64:30] cells 16 cells into the point where on [64:33] day five or six that embryo is now a [64:38] what we call a blasticus it's 300ish [64:40] cells and it is now at the stage where [64:42] it can implant into the uterus what is [64:45] so interesting is [64:47] that most your eggs are never going to [64:50] fertilize they're not going to grow [64:52] appropriately they're not going to get [64:53] into that uterus but what's so important [64:56] is that if an egg is coming in or the [64:58] embryo is coming in and there's not just [65:00] the right amount of progesterone it [65:02] cannot implant that's really important [65:04] because that's the mechanism behind a [65:06] lot of birth control but when you think [65:08] about progesterone starts being made [65:10] from this Corpus ludum perfectly timed [65:12] after you ovulate to open and close that [65:14] implantation window so that when the [65:16] embryo gets there it's ready and if the [65:19] embryo doesn't implant hangs out too [65:21] long it's going to close the Corpus [65:23] ludum only lasts for 2 weeks if it is [65:26] not supported by a pregnancy meaning if [65:30] we pretend this month you don't get [65:31] pregnant you're just having natural [65:33] periods then the Corpus ludum after two [65:35] weeks it [65:36] dies your progesterone levels are going [65:39] to drop and that's the signal to your [65:41] uterus to shed the lining in preparation [65:44] for the new group of eggs that's your [65:45] body saying we did not get pregnant this [65:48] month let's try again when a pregnancy [65:51] implants that embryo makes a hormone [65:53] called HCG which is what we check on a [65:55] pregnancy test and HCG can stimulate the [65:58] Corpus ludum to keep making progesterone [66:01] and that is what allows you to sustain [66:04] an early pregnancy until there's a [66:06] placenta the point of thinking about [66:09] that which there's a lot to go into [66:10] about optimizing intercourse and trying [66:12] to get pregnant is that things that [66:14] disrupt the brain's interpretation of [66:17] estrogen is going to impact your ability [66:22] to sense ovulation or to ovulate and [66:25] going to lead to menstrual [66:26] irregularities or absent periods like [66:29] you mentioned in some of your friends [66:30] who exercise maybe more frequently so on [66:33] one end of the spectrum if you are [66:36] intensely exercising you're training for [66:38] the Olympics you're an elite athlete [66:41] your body is going to stop sending out [66:43] FSH and LH altogether it is going to say [66:46] that the calories you're receiving to [66:48] the energy you're expending do not match [66:51] up and you cannot support being pregnant [66:53] with another human so it is going to [66:55] stop the production of FSH and LH and [66:58] you're not going to ovulate you're [67:01] probably fine because you're training [67:02] for the Olympics and you don't want to [67:03] be pregnant right now this also happens [67:05] though with eating disorders anorexia [67:08] for example we can see that I will say [67:11] when the brain is turned off when your [67:12] brain has decided that you can't be [67:14] pregnant right now it takes years of [67:18] being in recovery for it to turn back on [67:22] it has to be convinced for years that [67:25] the system system is going to be intact [67:27] again in the part of the brain that [67:30] controls if FSH and LH are released from [67:32] the pituitary called the hypothalamus so [67:35] we call this hypothalamic dysfunction I [67:37] like to think about the hypothalamus as [67:39] the you know airport control station [67:42] they're watching the planes come in and [67:44] sending out other signals it is [67:46] interpreting what your body is giving it [67:48] and then it's directing what is [67:50] happening estrogen is also made from fat [67:54] cells and this is one of the reasons why [67:56] being [67:57] overweight is so impactful when it comes [68:00] to your reproduction because if your [68:03] body is making extra [68:05] estrogen your [68:07] brain thinks an egg is on the process of [68:11] growing so it's because right the brain [68:13] thinks estrogen's only made from an egg [68:15] so if it sees some extra estrogen [68:17] because you're obese it's not going to [68:20] send out a strong enough signal to get [68:23] an egg to grow because the brain wants [68:25] to send out just enough to get the one [68:27] egg to grow it doesn't want 20 eggs to [68:30] grow so if it sees that estrogen it's [68:32] going to say ooh an egg's already [68:34] growing I'm going to send out less but [68:36] there is no egg because you're [68:38] overweight it's the fat cells making [68:40] estrogen and so exercise comes into this [68:42] play where exercising if you're [68:46] overweight can be extremely beneficial [68:48] for your fertility because if you lose [68:50] weight you drop that Baseline estrogen [68:52] level down and now your brain can more [68:54] clearly interpret this signal from the [68:56] ovary so suddenly your system is back in [68:58] check same thing for men estrogen when [69:01] men are overweight Coes to the brain and [69:04] the Brain estrogen and testosterone are [69:06] on the same conversion pathway so the [69:08] brain says oh Steven's gained some [69:11] weight I I see his estrogen he's making [69:13] enough sperm we're good and it's not [69:15] going to tell you to make as much [69:17] testosterone or as much sperm as you [69:19] need and then you get on this pathway [69:21] where you have less energy because your [69:23] testosterone is low but you're gaining [69:25] weight and you can't get that [69:27] testosterone higher you go to The Men's [69:29] Health clinic and they're going to draw [69:30] your blood and your testosterone will be [69:32] low and they're going to put you on that [69:34] trt and now your sperm Count's going to [69:36] go to zero so sometimes that entry point [69:39] to the whole problem was having extra [69:43] fat tissue so exercising to lose weight [69:45] can be very beneficial for your [69:47] fertility for men and women there's a [69:49] lot of talk on hit exercise or moderate [69:52] activity and for the regular person [69:55] whatever you will stick with is the best [69:57] if you're trying to get pregnant you [69:59] should not be trying to stress your body [70:01] to new goals training for the marathon [70:04] doing something if you think going going [70:06] to the gym every single day is that too [70:08] much no I usually say going to the gym [70:10] every single day if we think about 60 [70:11] Minutes or Less is a normal amount of [70:15] inflammation from your muscles that is [70:17] good your body should encounter some [70:19] challenge along the day having more [70:22] muscle is also going to help combat [70:24] insulin resistance and other issues that [70:27] come in and interfere with our brain's [70:28] interpretation of our hormones as well [70:30] so we see that both overe exercising and [70:33] not exercising are the extremes that are [70:35] not going to be helpful for you but [70:37] moving your body in addition to helping [70:40] your hormones function better less [70:42] chance of becoming overweight better [70:44] interpretation by your brain of your [70:46] body's signals it's also a great way for [70:48] stress coping and lowering your cortisol [70:50] levels so exercise we should put there [70:53] right up there with the top thing [70:54] somebody can do get more sleep exercise [70:57] every day you mentioned menstrual cycles [70:59] there and how they can be disrupted for [71:01] long periods of time um my partner shed [71:03] quite openly um on her social media [71:05] channels her battle with this and she I [71:07] think she had a couple of dietary [71:09] changes she had some struggles with [71:11] eating and that resulted in her period [71:13] basically stopping for I think three or [71:14] four years um it's returned after sort [71:18] of three three or four years and she's [71:20] very happy about that but um lots of [71:22] people are going through irregular [71:24] period Cycles irregular menstrual [71:27] cycles what can you say to this I mean [71:29] what is what is quote unquote normal as [71:32] it relates to a normal healthy healthy [71:34] menstrual cycle into people that are [71:35] struggling what what would you advise [71:37] them and what would you tell them I love [71:39] it a normal period is one that is [71:42] regular and predictable so I'll tell a [71:44] patient you can look at a calendar and [71:45] you can say within a couple days of [71:47] certainty when you're going to have your [71:50] period now each individual person is [71:52] going to have a different cycle link [71:55] length meaning the day from the start of [71:57] your bleed that's day one of your cycle [71:59] until the last day before your next [72:02] period bleed you'll hear 28 days used a [72:05] lot that's not the average for every [72:07] single person usually it's going to be [72:10] between 24 to 35 days for the average [72:12] person can you explain this to me like [72:14] I've never heard of a menstrual cycle [72:15] before what is it what happens so the [72:18] menstrual cycle is essentially what [72:22] we've talked about with our whole eggs [72:23] right so you have your group of eggs [72:24] come out the ovary each eggs in a [72:26] follicle brain sends out follicle [72:28] stimulating hormone that egg is going to [72:30] grow develop and ovulate that's going to [72:32] put you a couple weeks into your [72:34] menstrual cycle from there it's going to [72:37] then make progesterone get you into that [72:39] back half of it that ludal phase because [72:41] the Corpus ludum is always set at two [72:43] weeks and then when you're not pregnant [72:45] you're going to bleed so bleeding is the [72:47] shutting of the lining that's your [72:49] period your ovaries are doing something [72:52] different throughout that process so [72:53] while you're bleeding and on your period [72:55] period your ovary is already starting to [72:57] grow the egg that's going to ovulate in [73:00] that month and as that egg makes [73:02] estrogen that's what stops you from [73:05] bleeding okay so when you have your [73:06] period That's the shedding of the lining [73:08] from the last month because you didn't [73:10] get pregnant and growing an egg this [73:13] month once there's enough estrogen is [73:15] going to stop that process and stabilize [73:17] that lining okay so typically when you [73:20] if if there's no other interventions if [73:21] you don't have your period it's because [73:23] you're pregnant because you're pregnant [73:24] or you didn't ovulate because you have [73:26] to have that [73:27] progesterone drop as the signal for your [73:30] body to bleed exactly so you either [73:32] problem a I didn't ovulate so that is [73:35] either I'm out of eggs I don't have any [73:38] eggs to ovulate or my brain didn't send [73:40] out the signals like we said [73:42] hypothalamic Amara that's often that OV [73:44] ex exercising or that calorie [73:47] restriction or chronic illness stress [73:49] stress sometimes I I like to think about [73:51] that one often more as hypothalamic [73:54] dysfunction like irregularity versus [73:56] absent but yes stress and then we've got [73:59] pituitary end thyroid disease prolactin [74:03] these are hormones from the pituitary [74:04] gland which is where FSH and LH come [74:06] from and if your pituitary sends a lot [74:08] of energy to making thyroid stimulating [74:11] hormone it's not going to send out FSH [74:14] quite as well and then you have [74:15] polycystic ovarian syndrome which is [74:17] going to be one of the most common [74:18] causes of female infertility and of [74:20] irregular periods and that is when your [74:23] ovary and your brain have a [74:26] miscommunication and so when we talk [74:28] about irregular Cycles because we should [74:30] dive into PCOS what we're saying is that [74:32] for one single person it's not occurring [74:35] at this regular interval for them so [74:38] maybe it's 25 days for Jill and 30 days [74:41] for Mary and 34 days for Susie but each [74:44] of those people should be able to know [74:46] when her period is coming the fertile [74:50] window for all of them is this is [74:52] different and that's why apps and cycle [74:54] tracking can be really problematic [74:56] because what the fertile window is is [74:59] going to be the 5 days before and then [75:02] the day you ovulate so an egg lives for [75:04] 24 hours the five days before you [75:06] ovulate okay okay so the 5 days before [75:08] you ovulate and then the day that you [75:10] ovulate the egg lives for 24 hours it [75:13] has to be fertilized while it is in the [75:14] fallopian tube in those first 24 hours [75:17] sperm can live in the female [75:19] reproductive tract for 5 days so that is [75:22] why we will tell people to have sex [75:25] before and then during ovulation put [75:28] some of that sperm from the locker there [75:30] a little bit earlier and then get some [75:32] there right right at the time when [75:34] you're ovulating to see if you can [75:36] fertilize that [75:37] egg if we think about understanding when [75:41] your fertile window is based on your [75:42] cycle length so if we say your cycle is [75:45] the the entire process and then your [75:47] period is just the bleeding days the [75:49] entire process if your Cycles are on [75:51] average 28 days the Corpus ludum lives [75:54] 14 days so 28 minus 14 you on average [75:58] would ovulate on day 14 so the 5 days [76:02] before and then day 14 are going to be [76:04] your most fertile days to try to Target [76:06] intercourse or avoid if you don't want [76:09] to be pregnant and if your Cycles are 35 [76:11] days though it's very different right [76:13] because now 35 days minus 14 is going to [76:16] be 21 here you go 21 so your fertile [76:20] window or for that person is going to be [76:21] cycle day 21 so now the 5 days before [76:24] and day 21 those are very different [76:27] fertile Windows days they should be [76:29] having sex it's a lot isn't it do we [76:31] just have sex every day if we can so [76:33] absolutely like if you can have sex [76:35] every day or every other day and you [76:37] don't have to track your Cycles if they [76:39] are coming regularly and you're putting [76:41] sperm in the presence of the egg by [76:44] every day or every other day sex [76:46] absolutely and that's one of the things [76:47] that I see people do wrong the most is [76:49] have less sex in the idea that they [76:52] should save it up to put more sperm [76:55] present when the egg is arriving I have [76:57] to say I mean there's a few things I [76:59] wanted to say about this so I think [77:00] what's the first thing I wanted to say [77:02] the first thing I want to to ask is how [77:06] long on average do different age groups [77:07] need to try before they hit the Bull's [77:12] Eye if you're age 30 and you're trying [77:15] to get pregnant you have a 20% chance of [77:17] pregnancy per month okay this means that [77:19] the majority of people should be [77:20] pregnant within 6 months infertility is [77:23] defined as trying for a year and not [77:25] getting pregnant within that year so [77:27] kind of going off the curve of that [77:29] standard deviation importantly trying to [77:32] get pregnant means that you're having [77:34] intercourse you're ejaculating inside [77:37] and you're having regular periods if [77:40] you're not able to complete the active [77:41] intercourse and you're not having [77:43] regular periods people should not wait x [77:46] amount of time to come see a doctor you [77:48] should go be seen right away when my [77:50] friends tell me that they've started [77:52] trying I always think God that doesn't [77:55] doesn't that just ruin the fun you know [77:57] what I mean because I have this one [77:58] friend who was telling me that um [78:00] because they're trying now sex has [78:01] become such a like chore like a chore [78:04] and if he's away when she's most fertile [78:09] then she gets annoyed at him and I just [78:10] think God it's so crazy what's happening [78:13] with sex in that regard that it's we're [78:16] now because we're having kids later and [78:17] later and we're leaving things a little [78:19] bit later than ever before we're now [78:21] having to treat making kids almost like [78:24] as you say like a chore it's becoming [78:26] like I don't know there's something [78:27] about that I'm like oh gosh like well [78:29] it's a point because if you're waiting [78:31] later and you still want to have more [78:33] than one child there's a lot of pressure [78:35] on it if you're starting at 35 and you [78:37] have that 10 to 15% chance per month if [78:40] you're starting at 38 and now it's 5 to [78:42] 8% per month if you're 40 it's 3 to 5% [78:45] isn't pressure like the opposite of sex [78:48] right it doesn't sound very fun I think [78:50] that one having realistic goals is [78:53] helpful because if you're trying to [78:54] start your family at 37 and you want [78:55] four kids it is very unlikely to happen [78:59] without intervention like IVF saving [79:02] embryos for the future which we can [79:03] absolutely do and we do that for people [79:06] sometimes so that they can go have fun [79:08] with their sex life again two you feel [79:12] like you have to track your cycles and [79:13] time intercourse appropriately when [79:15] you're older because there's so much [79:17] that you can't do right you only have so [79:20] many eggs you only have so much time and [79:22] you're trying to do what you can [79:24] understand your cycle tracking for a [79:26] woman is a reflection of her full health [79:28] how's your brain interpreting your [79:29] entire body so it is helpful because if [79:32] you have irregularity it is a sign that [79:35] things are not working normally that [79:37] being said regular sex is good for so [79:40] many reasons and in a relationship that [79:43] if you can establish sex more frequently [79:46] as just part of your relationship it [79:48] becomes less burdensome that you're here [79:51] recording a podcast at this time or [79:52] somebody's out of town this one given [79:54] month if we remember that sex or if we [79:57] remember that sperm live in the female [79:59] reproductive tract for up to 5 days most [80:02] of sperm is going to live there for two [80:03] to three days so five is kind of like [80:05] the longest it can what we have is that [80:08] okay have sex two or three times a week [80:11] what what about couples that can't [80:12] because I I've sat here and interviewed [80:14] so many sex therapists and sexologists [80:17] if that's even a thing and we often [80:19] speak about sexlessness people having [80:21] sex less and less than ever before [80:22] because they're so busy and they're so [80:24] stressed in their lives and you must [80:26] meet so many couples in your practice [80:27] that you know you you look at them and [80:29] go well really the problem here is [80:30] you're just not having sex with each [80:31] other 100% and sometimes it's [80:33] situational truck drivers Pilots there's [80:36] just a job where it is too hard to have [80:38] that intercourse during the fertile [80:40] window but then also yeah High [80:42] performing people or who just don't [80:44] prioritize or don't enjoy that part of [80:46] the relationship we certainly do what we [80:49] call IUI or intrauterine insemination [80:52] and this is where you take the sperm and [80:54] you're putting it inside the uterus so [80:55] instead of intercourse we are taking an [80:58] ejaculated sample and then processing it [81:00] and putting it in the uterus wait so yes [81:03] I could just ejaculate in a Petri dish [81:07] get get a little pet and I mean you [81:11] can't do it yourself but why Well [81:13] because most of the ejaculate of your [81:16] sperm is actually meant to protect the [81:18] sperm from the acidity of the vagina so [81:21] most of that is not ever going to see [81:22] the inside of a uterus and if we put the [81:25] whole sample up in the uterus it would [81:27] cause a huge inflammatory or infectious [81:30] process but if we clean that sample and [81:33] we pel it out centrifuge it and get just [81:35] the sperm we can then put the sperm into [81:38] the uterus and avoid having all that [81:41] protective ejaculate sample with it you [81:43] must hear couples doing this kind of [81:45] thing people do the craziest things tell [81:47] me about some of the crazy things people [81:48] do crazy things I mean definitely people [81:50] are having intercourse and then they're [81:52] putting they're putting tampons in [81:54] afterwards to try to keep the sperm in [81:56] place or diaphragm cups people are [81:59] trying to get their own versions of [82:02] pipets or turkey basters right that's [82:04] what people call it and try to pull up [82:06] sperm [82:07] and put just put in their vagina the [82:10] craziest stories of sperm procurement [82:13] come from people who are using donor [82:15] sperm as you may not know there is an [82:17] entire like dark web of sperm donation [82:21] being connected on Facebook groups and [82:23] other places is where people are not [82:25] going down traditional roads of using a [82:27] sperm bank a sperm bank pros and cons [82:31] but if you're using sperm if you're [82:33] using donor sperm a sperm bank is going [82:36] through a process to make sure there's [82:37] no infectious material in there that the [82:40] information is tested that there's [82:44] limitations But ultimately like legally [82:47] too that that is your sample these [82:51] Facebook groups people are just [82:53] connecting where you can meet in a [82:54] Walmart parking lot and drop somebody [82:56] your sperm out of the goodness of your [82:58] heart so that they can get pregnant and [83:00] there was a case in Oklahoma where there [83:02] was a lesbian couple who wanted some [83:05] sperm in their relationship and they [83:07] felt like going through the fertility [83:09] clinic or buying donor sperm from the [83:12] sperm bank was too expensive because it [83:14] is expensive and so they found a sperm [83:17] donor how much is it roughly for some I [83:19] have no idea so purchasing a violet [83:21] sperm itself is about $1,000 and then [83:23] each cycle goal with a clinic to kind [83:26] get the sperm inside is typically going [83:28] to be $1 to $2,000 so that's for each [83:30] month you're going to look at 2 to 3,000 [83:33] and your chance of it working is based [83:35] on your age so if you're 35 it's about [83:37] 10 to 15% so you're going to need to do [83:39] it numerous times so this couple in [83:43] Oklahoma they found a sperm donor on a [83:46] Facebook group went and conceived a [83:47] child and despite having some paper [83:50] document they signed saying that he gave [83:52] them their rights he sued for custody of [83:55] that child later and and won so they now [83:57] split custody with their sperm donor and [84:01] I think that this is why he changed his [84:05] mind he had who knows well he didn't get [84:07] he didn't get paid for this right so it [84:09] was out of the goodness of his heart he [84:10] just met them and gave the sample so [84:12] part of the issue too is that it's not a [84:16] exchange of a service for for a fee or a [84:19] good right it's just you're giving the [84:20] sperm so I believe in that case he said [84:23] he interpreted that was the situation [84:25] and they said of course it wasn't but [84:28] when we look at Family building a lot of [84:29] people are using what we call third [84:31] party options so donor X donor sperm [84:34] gational carriers donor embryos even and [84:37] there's a whole world to go into there [84:39] but protecting somebody's parental [84:41] rights is one of the top things that I'm [84:44] always thinking about when it comes to [84:46] helping them grow a family we were [84:49] talking about PCOS yes what I've I've [84:53] got a very close friend of mine that [84:55] struggled a lot with PCOS and I've been [84:56] there with them um as they've been [84:59] diagnosed and as they've kind of battled [85:01] with that over the years but I'm aware [85:03] that a lot of people struggle with PCOS [85:05] I think it's up to sort of 20% of the [85:07] population so officially people will say [85:09] that it's about 10 to 133% of the [85:11] population but that's 70% of people who [85:13] have PCOS are undiagnosed so much higher [85:16] than either of those numbers you I said [85:18] is going to be the real number and what [85:20] is [85:21] PCOS there's a couple different ways [85:23] that PCOS presents so how I like to [85:25] describe PCOS in essence is being born [85:29] with more eggs in your Vault okay so if [85:33] you're born with more eggs in your Vault [85:35] you are going to send out more eggs [85:38] every single month right because you're [85:40] sending out eggs in proportion to how [85:42] many you have why do you have pcus [85:45] likely this is due to something your [85:47] mother did when she was pregnant with [85:49] you or something she was exposed to [85:51] because you didn't have that normal [85:52] decline in eggs from 6 to 7 million at 5 [85:54] months to 1 to 2 million at 9 months so [85:58] you have more eggs more eggs come out of [86:00] the Vault every month the brain doesn't [86:02] know you have more eggs so it is sending [86:04] out the same amount of FSH as it [86:07] normally would for a normal egg count [86:10] but that FSH is getting diluted amongst [86:13] the more eggs that have come out if we [86:15] can imagine the same signal is going to [86:17] 20 eggs or it's going to 30 eggs so FSH [86:21] is the thing that basically picks the [86:22] egg yeah it's like food for the egg okay [86:24] the thing that selects the one egg and [86:25] gives it um Waters it like a plant [86:28] exactly so you have the same amount [86:30] coming but there's more eggs eating it [86:32] so nobody's getting a strong enough [86:34] signal to grow reliably predictably [86:38] meaning you're not going to have that [86:39] regular predictable cycle when an egg [86:42] grows that's when your body makes [86:44] estrogen that's when your ovary makes [86:45] estrogen and the ovary is a hormon [86:47] producing Factory everybody thinks about [86:49] the ovary as oh it's what makes the eggs [86:52] but its real job Its Real Love Is to [86:54] make hormones it makes estrogen as it [86:56] grows the egg it makes progesterone [86:58] after you ovulate if you have too many [87:01] small eggs come out of the Vault there's [87:03] not enough FSH to stimulate any of them [87:05] the ovary is not making estrogen and it [87:07] gets bored so what happens is the [87:10] pathway to make [87:12] testosterone becomes upregulated it [87:14] starts making testosterone in its boor [87:17] time what testosterone does in women [87:19] with PCOS is it then increases the risk [87:22] of insulin resistance it increases [87:25] abdominal weight so not that maybe like [87:28] female body shape we think about like [87:30] weight on the hips and thighs but more [87:31] of that man beer belly style abdominal [87:34] weight you also then are going to have [87:36] increase in acne facial hair and then [87:39] even male pattern baldness so you start [87:41] to see that you have these Androgen [87:43] symptoms that are negatively impacting [87:46] quality of life immensely and then as [87:48] you gain weight the estrogen confuses [87:51] the brain and it sends out even less FSH [87:53] so you get into to this really cyclic [87:56] pathway where the insulin resistance and [87:58] the testosterone change your entire [88:01] body's [88:01] metabolism but you're not going to go in [88:04] and make yourself have less eggs so how [88:06] do you combat [88:08] PCOS one way from if you're trying to [88:10] get pregnant is to try to give [88:13] medications that have the brain send out [88:15] a stronger signal of FSH so you might [88:17] have heard of medications like Clomid or [88:20] lrel these medications tell the brain to [88:22] send out more FSH so in essence that's [88:25] what we call ovulation induction helping [88:28] somebody ovulate by having the brain [88:30] send out a stronger signal but what we [88:33] try to do if you're in this PCOS pathway [88:35] is break down some of the production of [88:38] testosterone from the ovary stop that [88:40] cycle and try to see if you can reverse [88:43] back into having healthier normal Cycles [88:46] so sometimes that's from medications [88:48] like metformin you can have [88:50] spironolactone which is a medication [88:52] that stops testosterone produ ction this [88:55] is why women with PCS are given birth [88:56] control pills because birth control [88:59] pills one can come in and provide [89:02] estrogen and progesterone but two they [89:05] also make something in the liver called [89:07] sex hormone binding globulin that binds [89:10] to testosterone drops your testosterone [89:13] levels and clinically they make you feel [89:15] better your acne goes away some of those [89:18] Androgen signs go down and it can help [89:19] break the pattern and I see that people [89:22] with PCOS when they come off the birth [89:24] control pill they actually ovulate more [89:27] regularly at the beginning and then it [89:29] starts to get worse as more time goes on [89:32] as their androgens start to rise back up [89:34] to their Baseline because the birth [89:35] control pill was keeping them down so [89:38] focusing on some of the other factors [89:40] that really influence insulin resistance [89:42] and hormone production and [89:44] PCOS PCOS patients I always tell my [89:47] patients it's it's like a teeter totter [89:50] of balance meaning when you're too [89:52] stressed or or you're exposed to [89:55] something it can tip your hormones into [89:57] not ovulating so you have to view that [89:59] system as just very sensitive extra [90:02] stressors like the cortisol that's [90:05] coming in really influence people with [90:07] PCOS a lot as does being overweight and [90:10] that's why there's a lot of information [90:12] on trying to encourage PCS patients who [90:14] are overweight to lose weight [90:17] importantly not all women with PC are [90:19] overweight you definitely can be thin be [90:22] born with a lot of eggs inside Vault and [90:24] have the exact same problem and I want [90:27] to stress that some people even if you [90:29] live the healthiest life you don't ever [90:32] see inflammation you're not stressed but [90:34] you have PCOS it's a disease and you may [90:37] not ever get to a place where you can [90:40] reliably or regularly ovulate in your [90:43] reproductive years that you're wanting [90:44] to and that's not your fault it's not a [90:46] failure of you it's not your fault some [90:48] people truly do need intervention to try [90:50] to help them get pregnant and there's [90:52] interventions are freezing their eggs [90:54] IVF those kinds of things yep ovulation [90:55] induction freezing your eggs [90:58] IVF when you scan the ovaries can you [91:02] see PCOS mm PCOS is diagnosed by having [91:06] two out of three criteria so number one [91:10] seeing a lot of eggs on ultrasound yeah [91:12] number two having high Androgen signs so [91:16] whether it's a blood value of [91:17] testosterone that's higher than a normal [91:19] female should have or just having acne [91:22] or hair growth M and then then three is [91:24] irregularity or absent periods so two [91:27] out of the three of them so if you have [91:28] irregular periods and acne you've met [91:31] the diagnostic criteria what causes PCOS [91:34] you talked about maybe it's something [91:35] your mother might have done but there's [91:37] a lot of thought that PCOS is [91:39] largely genetic or epigenetic meaning [91:42] that when you're a baby inside your mom [91:44] that that environment influenced a lot [91:47] of how your OV is going to function [91:49] later and there's a huge correlation [91:51] between different exposure or whether it [91:55] is insulin resistance and pregnancy and [91:58] then women being born later in life with [92:00] a higher risk of PCOS [92:02] certainly you can back into PCOS by by [92:06] being overweight and what I mean by that [92:08] is often patients will present they'll [92:10] be diagnosed with PCOS but the ideolog [92:12] is a little bit different if you're very [92:15] obese that fat is going to make estrogen [92:19] the brain is going to send out less FSH [92:21] you're not going to be ovulating because [92:23] it's not a strong enough signal and the [92:25] ovaries are going to start making [92:27] testosterone because they're bored so [92:29] you have a PCOS [92:31] presentation but that mechanism is not [92:33] really necessarily having a large number [92:36] of eggs in your Vault when we have [92:38] syndromes we have to remember polycystic [92:40] ovarian syndrome syndromes are based on [92:42] the symptoms you present with so often [92:45] syndromes do have different Origins for [92:47] how they present is there a way to [92:49] completely heal from polycystic ovary [92:52] syndrome [92:54] for some people yes but have you seen [92:56] that yes I have seen people but most of [92:59] it correlates with an all women at some [93:02] point you're still losing eggs every [93:04] month right so at some point you are [93:05] going to get to a number where the eggs [93:08] that are coming out of the Vault are a [93:10] number that the brain is going to [93:11] respond to so what's interesting is I'll [93:14] have people say I cured my PCOS and I [93:17] say well really you just are age 38 and [93:20] at this point you don't have enough [93:22] remaining eggs to to ca cause this [93:24] dysfunctional problem anymore the eggs [93:26] that are coming out are now responsive [93:28] to your hormones yes they did do [93:31] lifestyle changes and improve things and [93:32] probably made it so that their ovaries [93:34] could respond to those signals so I [93:36] think it goes together but PCOS women [93:38] still go through menopausa the same age [93:40] they're born with more eggs and they go [93:41] through menopause at the same age so [93:43] what's happening is they're simply just [93:45] losing eggs at a more rapid Pace because [93:49] they have more and what impact does that [93:51] have on your ability to get pregnant [93:53] when you have more eggs and number one [93:54] is what we call an ovulation so the [93:56] irregular periods or lack of having a [93:58] period altogether that is one of the top [94:00] causes of infertility and certainly PCOS [94:02] is the top cause of that it's important [94:05] to say that not having a period is not [94:09] normal so if you're taking birth control [94:11] or contraception we'll just put that in [94:13] a different category for a minute but if [94:15] you're not taking any hormones and [94:17] you're not having a period it is [94:20] extremely bad for your health on both [94:23] ends and what what I mean by this is [94:25] It's either because your body has PCOS [94:29] and has all of these little follicles [94:31] making a tiny bit of estrogen each day [94:34] and in that [94:35] scenario you're not making your normal [94:37] hormones but also you're at risk for [94:39] metabolic disease high blood pressure [94:40] cholesterol diabetes but also that [94:44] constant estrogen production even though [94:46] it's not high levels but it's enough to [94:48] confuse the brain is stimulating the [94:50] lining of the uterus to grow and if you [94:52] never ovulate you don't make [94:54] progesterone so there's never the signal [94:56] to shed or to bleed the lining cancer [95:00] cancer so endometrial cancer is a very [95:02] significant risk in women with PCOS who [95:04] do not have periods and this is why you [95:07] will see people come in and say that you [95:09] need to take progesterone or you must be [95:11] on birth control pills because we've got [95:13] to give you that progesterone in some [95:15] form or fashion to bleed off those cells [95:19] so that they don't develop into cancer [95:21] so there must be a pretty strong link [95:22] then between PCOS and in demetrial [95:24] cancer uterine cancer yes if you think [95:27] about the other end of when people are [95:28] not having periods so I'm exercising and [95:32] I lost my periods for 3 to four years [95:35] you're not making any estrogen during [95:37] that time your brain shut off those FSH [95:40] signals the ovary never made estrogen [95:43] from those eggs and having low estrogen [95:46] is detrimental to your long-term Health [95:48] we see this even when women go through [95:50] menopause at the normal age right [95:52] suddenly you now have an increased risk [95:54] of heart disease stroke osteoporosis [95:56] dementia Alzheimer's once you've entered [95:58] menopause because estrogen was [96:00] protective against all of those if you [96:03] had that estrogen or that lack of [96:05] estrogen even earlier in life those [96:08] risks especially bone disease [96:10] osteoporosis hip fractures later in life [96:13] they can be extremely high so it's very [96:16] important that women know that if you're [96:18] not having periods that it's harmful for [96:21] your full body Health very often I see [96:24] young women their 20 say I'm not having [96:25] a period but who wants to bleed every [96:27] month anyway so not a big deal but their [96:30] brain's not functioning as great as it [96:32] can having estrogen helps the brain [96:35] think sharp and be productive and if [96:38] you're constantly lacking estrogen [96:40] you're going to be fatigued feel cloudy [96:43] you're not going to feel like yourself [96:46] replacing [96:47] estrogen in somebody whose ovaries are [96:49] not making it whether it's because the [96:52] brain's not sending the signals to or [96:54] you're simply out of eggs early [96:56] replacing estrogen is extremely [96:58] important for your quality of life and [97:00] your longevity you mentioned a word [97:03] earlier that I've not heard [97:04] before [97:06] endometriosis endometriosis yes what is [97:10] this endometriosis is essentially an [97:15] inflammatory autoimmune condition so we [97:18] already talked about I've said [97:20] endometrium a couple times do you know [97:22] what endometrium is no so the [97:23] endometrium is the lining of the uterus [97:26] so it is what grows in preparation for [97:29] that pregnancy to implant and it is what [97:31] bleeds when somebody has a period you're [97:33] shedding the endometrium okay so it's [97:36] that inside portion of the uterus in [97:39] every single person they bleed some of [97:42] those cells are going to migrate out the [97:44] Fallopian tubes which is pretty normal [97:46] if you can imagine the uterus is [97:48] Contracting it's squeezing some of those [97:50] cells are going to migrate out and in [97:53] cells from the endometrium endometrium [97:56] some of the cells from the endometrium [97:57] in addition to bleeding as that uterus [97:59] is Contracting you know the tubal [98:02] opening to the top some of the cells are [98:04] going to come out the Fallopian tubes [98:05] and that's that's normal okay so if I go [98:08] and do an appendectomy I take out [98:10] somebody's appendix while she's on her [98:12] period I'm going to see menstrual blood [98:14] in her abdominal cavity and that's [98:16] totally normal what is abnormal about [98:19] endometriosis is that your body has an [98:21] abnormal reaction to that and instead of [98:25] saying oh Natalie's on her period no big [98:27] deal your body would say oh my gosh [98:31] there's blood in here it's foreign cells [98:33] attack attack attack and so it becomes a [98:36] process where every time a woman is on [98:39] her period the body starts to attack [98:42] these cells and then because it is [98:44] endometrial tissue it's responsive to [98:46] estrogen so it grows with every [98:49] ovulatory cycle every follicle you make [98:52] it's characterized by inflammation and [98:54] inflammation is what causes pain so very [98:57] painful periods is the Hallmark of the [98:59] disease although importantly not [99:01] everybody who has Indo has pain pain [99:05] with intercourse is another one [99:07] especially in certain positions so not [99:09] pain with like insertion or penetration [99:12] but but deep pain so he's like oh the [99:15] classic is when a patient will tell me I [99:18] don't like being on top it's painful [99:20] inside because of the angle that [99:23] intercourse is happening it is where she [99:26] has these implants of endometriosis [99:28] inside her body these inflammatory [99:31] implants endometriosis because it causes [99:34] inflammation makes the environment more [99:36] toxic so the number one way that all [99:38] autoimmune disease is contributing to [99:40] infertility is by this inflammatory [99:43] process which is just toxic to cell [99:45] growth and toxic to early embryo growth [99:48] and we see infertility rates and higher [99:51] miscarriage rates in Demetrio is as [99:54] inflammation lives there can also turn [99:56] into scar so you can have destruction of [99:58] the internal anatomy and total blockage [100:00] of the flan tubes so it can go from an [100:03] inflammatory process to also a complete [100:05] destructive and obstructive [100:07] process it is only a surgical diagnosis [100:10] and that's one of the hardest things is [100:12] that you can't just say I'm going to run [100:15] a blood test and see if you have [100:17] endometriosis we don't know what markers [100:20] to cheuck in your blood yet so the only [100:22] way to diagnos the disease is by looking [100:25] doing surgery putting a camera in [100:27] somebody's abdomen and physically seeing [100:30] these endometriosis [100:32] implants the hard thing is sorry just on [100:35] the point of surgery where does the [100:37] camera go in the camera goes in through [100:38] the belly button so that's called [100:39] laparoscopy so you put a camera in [100:41] through the belly button inflate the [100:43] abdomen and you can go and see what is [100:46] going on and so somebody who's got very [100:49] significant pain your period pain should [100:52] not impact your quality of life to the [100:55] point that you want to cancel plans not [100:57] participate in your normal activities if [100:59] you're canceling dinner not going to [101:01] school those are not normal findings and [101:04] if that is the level of pain somebody is [101:07] experiencing I'm very concerned that she [101:09] could have [101:11] endometriosis many people don't ever go [101:14] to surgery and get that diagnosis and [101:16] that's okay too if we think we have it [101:19] or your doctor's approaching it in a [101:21] certain way because by the time that you [101:23] can even diagnose it the damage is done [101:25] the inflammation is there you've been [101:27] living with it and one of the hardest [101:29] things for us with [101:30] endometriosis treatment of the disease [101:33] there's treatment but I have to stop you [101:35] from ovulating because estrogen will [101:37] always stimulate even if there's one [101:39] little cell so if you're trying to get [101:41] pregnant you have to ovulate so the [101:45] treatment for the disease does not allow [101:47] you to get pregnant and be treated so if [101:51] you stop that and you're trying to get [101:53] pregnant each ovulatory month the [101:55] disease is progressively getting worse [101:58] so it's one of these places where it is [102:02] very tough because we don't want people [102:04] suffering in pain but also getting [102:07] pregnant is so difficult in those [102:10] circumstances [102:12] in prevalence of endometriosis we say is [102:14] about 10% of all women in fertility [102:17] clinics patients with infertility it's a [102:19] 30 to 50% prevalence so in my mind [102:23] there are a ton of people walking around [102:25] with endometriosis or inflammation who [102:28] do not know that they have it this is [102:30] why that falls into the category of [102:33] sometimes what we call unexplained [102:35] infertility somebody has regular periods [102:38] because endometriosis does not impact [102:41] your period pattern it might cause pain [102:45] but nothing about that process is [102:47] interfering with your brain and your [102:48] ovary communicating and your ovulatory [102:50] pattern so you're still having regular [102:52] periods [102:53] and you're having sex even if it's [102:56] painful but you're not getting [102:58] pregnant that there's something else [103:01] going on and so a lot of patients with [103:04] endometriosis end up having to come to [103:06] the fertility clinic and many of them [103:08] end up going through IVF because it is [103:11] one of the only ways we can change the [103:12] environment of which EG and sperm meet [103:15] is to allow them to meet in a [103:16] non-inflammatory environment in an IVF [103:18] lab I can then drop your inflammation [103:22] and treat your indom rosis and then put [103:24] an embryo back inside because I don't [103:26] need you to ovulate as a part of that [103:28] process so IVF controls So Many Factors [103:31] at once because I take the eggs I grow [103:33] them I take them out of the body now I [103:36] can fertilize them in the lab in that [103:38] perfect environment with the perfect [103:40] temperature and pH grow that embryo I [103:43] can then have you have a period and [103:45] suppress your endometriosis I don't care [103:48] that you're not ovulating now cuz I can [103:50] give you some estrogen and grow the [103:51] lining and then just put the embryo back [103:54] in at the right day and I can see [103:56] wonderful success rates with that with [103:58] patients with endometriosis just on that [104:00] point you said about you'll give them a [104:02] medication that suppresses the cycle and [104:05] but it stops the pain could you be on [104:07] that medication for say 5 10 years and [104:10] then come off it when you want to get [104:12] start getting [104:13] pregnant yes and no one thing that's [104:16] very interesting so a good example of [104:17] one medication not our drug of choice [104:20] but one thing that's used for [104:21] endometriosis is the combined birth [104:23] control pill the birth control pill is [104:26] estrogen and progesterone if you're [104:28] taking that pill your brain is no longer [104:31] ovulating because it's seeing estrogen [104:33] and that's not the same estrogen that [104:36] the ovaries make so it's not the type of [104:38] estrogen that stimulates those [104:39] endometriosis cells women who've been on [104:42] the birth control pill for prolonged [104:44] periods of time do not have diminished [104:46] fertility when they come off of the pill [104:49] and in fact most of them have higher [104:51] fertility rates than their age Rel ated [104:53] peers who were never on the pill and if [104:56] we think about it the hypothesis is that [104:58] if you suppressed ovulation for 10 years [105:02] versus your best friend who didn't and [105:05] you both had [105:06] endometriosis you are now starting your [105:08] ovulatory cycles and you put a pause in [105:11] the development of your endometriosis [105:13] it's not going to get rid of it no [105:14] medication's going to reverse the [105:16] process or treat it per se like cure it [105:20] but we can halt it from getting worse [105:22] and so if you're on the birth control [105:24] pill or you're on a medication called [105:26] Lupron there's some different options [105:28] that essentially stop the body from [105:31] ovulating therefore you're not [105:33] progressively letting that Indo get [105:35] worse and then you do have higher rates [105:37] of success when you come off of that [105:39] than people who are your age who weren't [105:41] so that's one strategy if you know you [105:46] have it you have to know you have the [105:48] disease or have a high suspicion that [105:50] you do in order to be preventing [105:54] ovulation all those months someone comes [105:57] to you and they've been diagnosed with [105:59] endometriosis what is your first sort of [106:01] Port of Call for them what's the first [106:03] piece of advice you you'd give them or [106:04] the first suggestion you'd make [106:06] medically or otherwise yeah so for real [106:08] honest talk about how old they are how [106:11] many kids they want we know that women [106:12] with endometriosis run out of eggs at a [106:15] faster pathway because endometriosis is [106:18] inflammatory and destroys the eggs [106:20] inside the Vault so you're going to run [106:22] out of eggs EGS faster I want four kids [106:25] how old are you I'm 25 that's okay so [106:28] when do you want to start trying to have [106:30] them let's say 30 say 30 and you want a [106:33] large number of children well I want to [106:35] know how everything is Right This Minute [106:37] right so we're going to check your [106:38] ovarian reserve we're going to make sure [106:41] that we're not already on a pathway of [106:43] accelerated destruction because if we [106:45] already have a low egg count now now is [106:47] the time to intervene egg freezing or [106:50] embryo freezing meaning taking some of [106:53] those eggs out so I can save them for [106:54] later when I know you're going to have a [106:56] hard time also setting different [106:58] parameters for the Endo patient I don't [107:00] let somebody who has endometriosis just [107:03] pull the goalie and try when they're [107:04] ready to get pregnant I'm going say we [107:06] know you have something that increases [107:08] the odds that you're going to have a [107:10] hard time so are your fallopian tubes [107:13] open how is your partner sperm I want [107:15] that data before you start trying to get [107:17] pregnant the traditional mentality to [107:20] infertility is so reactive you have to [107:22] prove to me you have a problem before I [107:25] go and test it that's the classic [107:26] mentality you got to try for a year [107:29] before we'll go test these different [107:30] variables of course we're challenging [107:32] that narrative and we're saying no go [107:34] get tested beforehand but an endo [107:36] patient is 100% somebody who should same [107:39] with the patient with PCOS you're not an [107:42] average person on the street you have a [107:45] medical diagnosis that is significantly [107:50] associated with infertility you need to [107:52] approach roach your family planning [107:53] Journey differently you need to test all [107:56] the variables we can before you start [107:57] trying to conceive and we need to have [107:59] an honest talk about your family size [108:01] because if you want four kids and you [108:02] start at age 30 and you have no problems [108:06] and you have your kids really closely [108:08] together so you what 30 [108:11] 32 when's your next one 35 36 when are [108:15] you having baby four you're you're [108:18] pushing 38 to 40 and we know that rates [108:20] are going to be harder because you're [108:23] going to have more genetically abnormal [108:24] eggs at that age so a lot of people [108:27] don't even talk about this stuff do they [108:29] like in terms if you use that word [108:30] Family Planning I think really that's at [108:33] the heart of what's missing here is we [108:34] don't do Family Planning we do like [108:37] family reaction yeah we're like oh crap [108:40] no family and then oh my God I want to [108:42] have a family I want here's what I say [108:45] to somebody who has will say PCOS or [108:47] endometriosis and they want to have a [108:49] bigger family and they're not quite [108:51] ready to start but let's say they have a [108:53] partner this is the perfect opportunity [108:55] to do what we call embryo banking so [108:58] it's very similar to to egg freezing but [109:00] it's IVF so it means right now I'm going [109:03] to get a group of your eggs to grow [109:05] we're going to go through the IVF [109:07] process IVF is in vitro fertilization so [109:10] one month's group of eggs I'm going to [109:11] get them all to grow people with PCOS [109:14] are fabulous candidates for this because [109:15] they have so many eggs the ROI on that [109:18] investment is very high because number [109:21] of eggs and age are the two most [109:22] important factors I'm going to get that [109:24] month of eggs to grow I'm going to take [109:25] them out of the body I'm going to [109:27] fertilize them with sperm grow out [109:29] embryos and I can do genetic testing to [109:31] see which ones are chromosomally normal [109:33] and they can stay in the freezer until [109:35] you're ready for them what well I can [109:37] what I can you can put fertilized eggs [109:40] in the freezer yeah those are embryos [109:42] you can put embo embryos in the freezer [109:43] yes sir and that is going to allow us to [109:47] change the trajectory of somebody who [109:50] wants four kids and isn't starting till [109:52] 2 33 because now naturally having that [109:56] fourth baby becomes statistically very [109:59] unprobable in order to have four [110:01] children most people will need to start [110:03] before age 28 now that's not everybody [110:06] but most people so if you want that big [110:09] family because that's like we said a [110:12] child to person it's a whole different [110:14] life you're going to have with that [110:16] person in it then we need to say hey [110:18] well that's a lot easier to go through [110:20] IVF right now freeze those embryos then [110:24] start trying to get pregnant what's the [110:25] difference between me freezing eggs and [110:27] sperm versus freezing the embryos so [110:29] this is a good point so freezing embryos [110:31] even if you're going to try to naturally [110:32] get pregnant later is helping you know [110:34] that you can tap into those embryos you [110:36] know later in life so versus doing IVF [110:39] at age 39 where you have less eggs and [110:42] the vast majority are abnormal you're [110:44] making those embryos now where they're [110:46] much better the process for the woman is [110:48] exactly the same whether you're freezing [110:50] eggs or embryos you are taking shots of [110:52] FSH to get one month's group of eggs to [110:55] grow that takes about two weeks and then [110:57] we do a quick procedure to take the eggs [110:59] out of the body under anesthesia so none [111:01] of that is different what happens is the [111:03] differen is in the eggs I always say if [111:07] you're freezing eggs it is not an [111:09] insurance policy on your fertility an [111:11] insurance policy pays off when something [111:14] bad happens this is an investment you're [111:17] playing the stock market is it smart to [111:19] put your money in Investments does it [111:21] usually pay off well it depends on the [111:23] environment when you go to pull that [111:25] money out eggs are potential [111:28] opportunities it's [111:30] fantastic and it's much better than [111:32] nothing but it's not giving us all of [111:35] the information because even if the [111:37] sperm looks normal and even if the eggs [111:39] look normal the real proof of the [111:41] pudding is seeing how the embryos grow [111:43] and develop because not every egg is [111:45] going to fertilize become an embryo or [111:48] be genetically normal and even every [111:50] genetically normal embryo is not going [111:52] to become a baby so if I take an average [111:55] person who is age 30 and let's say we [111:58] get 20 eggs from going through egg [112:00] freezing that is fantastic you feel [112:03] super egg Rich that sounds awesome now [112:06] if we make them into embryos or when we [112:09] go make them into embryos you do often [112:12] lose some eggs in the freeze thaw of the [112:14] eggs eggs are a single cell mostly [112:17] filled with like liquid like water and [112:19] then DNA and embryo is 300 to 500 cells [112:23] when we freeze it so embryos are much [112:25] much stronger they survive over 99% of [112:28] the time egg freezing I told you earlier [112:31] it wasn't available 10 years ago when I [112:33] was your age because eggs didn't survive [112:36] the free we were trying it but they're [112:38] so fragile it just took a while to get [112:39] the tech there eggs now survive 90% of [112:43] the time going through the free saww [112:44] which is great way better than 40% but [112:47] it's also not 100 so we have to kind of [112:50] account for that loss in our equation so [112:52] if I have 20 eggs now I go to thaw them [112:55] whenever we're ready and now I have two [112:57] that don't survive so I have 18 I'm [112:59] going to go inject them with the perfect [113:01] sperm and I would have on average [113:03] fertilization rates of about 75 to 80% [113:06] so let's say 14 of them fertilize half [113:09] of those are not going to make it to an [113:11] implantation stage embryo even if [113:12] everything's perfect so now I have seven [113:15] that have made it to an implantation [113:16] stage embryo and then my proportion of [113:19] normal is based on my age so if I'm 30 [113:22] I'm pretty good because i' about 60 to [113:24] 70% normal if I'm 35 it's about [113:27] 50/50 if I'm 38 it's a third normal if [113:31] I'm 40 it's about 20 to 25% normal so [113:34] you can see how that number of eggs that [113:36] you have and the outcome differs for the [113:40] 30-year-old the seven embryos if [113:43] everything falls perfect she should have [113:45] four normal [113:47] embryos but that's if everything falls [113:50] perfect and what if it doesn't what if [113:51] our ferti I ization rates are lower or [113:54] not as many embryos grow through the [113:55] process average means that some people [113:58] do better than average and some people [113:59] do below and we don't know that about an [114:02] individual couple until we put them [114:04] through the process how many embryos can [114:05] I put in the freezer you can put as many [114:07] as you want if you're trying to optimize [114:09] your chance of success you're going to [114:10] want two to three genetically normal [114:12] embryos for every child that you want to [114:14] have in the future one genetically [114:16] normal embryo put inside a body has a [114:19] 65% chance of live birth and what a is [114:22] there an age component to whether the [114:24] embryo will be successful so if if my [114:26] partner put one of those embryos out the [114:28] freezer into her at 45 are the odds [114:31] still the same up until 45 yes after 45 [114:34] you start to see a decline but still [114:36] ultimately quite successful I need to [114:38] get some of these bloody embryos in the [114:41] freezer yes so cumulatively after two [114:43] embryos are put inside not at once so I [114:45] put one transfer or you're not pregnant [114:48] and then you do the second one 88% of [114:50] people have had a live birth and after [114:52] three uplate embryos it's 95% of people [114:56] 95% of people that means that the number [114:58] one reason why people don't have success [115:00] with IVF is they don't have enough [115:02] genetically normal embryos nothing about [115:05] failure to implant or these other [115:07] factors but that they didn't have enough [115:09] the problem with eggs is if I have 20 [115:11] eggs in the freezer how many embryos do [115:13] I have you don't know yet I'm making a [115:15] whole lot of assumptions yeah and what's [115:17] the the cost difference of freezing eggs [115:20] it is about half as much to freeze eggs [115:21] as in [115:23] okay so if you don't have a partner [115:25] obviously eggs are the way to go [115:27] sometimes in somebody who has very low [115:29] ovarian reserve and they only have a [115:31] limited amount of funds it makes sense [115:34] to do eggs because I could get five eggs [115:37] and five eggs and have 10 eggs and even [115:40] if I don't know the outcome of it if [115:41] that's all the money you had to spend it [115:43] was better served to get two months [115:45] worth than to make embryos and find out [115:48] that I have maybe one normal how much [115:51] does this cost on average we'll say egg [115:52] freezing is going to be about 10,000 and [115:54] IVF is going to be about 20,000 okay I [115:57] don't know the the UK equivalent for [115:59] that but um chat GPT is telling us that [116:02] on average IVF in the UK is about £3,500 [116:06] and in the US it's about $10,000 IVF is [116:10] $20,000 $220,000 genetic testing yes [116:13] freezing the eggs yes how much does that [116:16] cost it's about half as much and that [116:18] makes sense because you're doing about [116:19] half the process you're still growing [116:21] the eggs taking them the body freezing [116:23] them you'll have to pay the second cost [116:25] eventually but it's easier to spend your [116:27] future money than your current money and [116:29] do you have to pay yearly to keep them [116:32] in the fridge you do have to pay annual [116:33] storage fees how much is that on average [116:35] it depends typically it's between 500 to [116:38] $1,500 a year we have to talk about the [116:41] stigma around IVF we've talked about [116:43] stigma a few times and I I can imagine [116:46] that a lot of people when they hear [116:47] about freezing your eggs and IVF [116:49] especially people who are maybe in their [116:51] early 30s or in their late 20s they will [116:55] reject the idea because of the stigma [116:57] that that means you're broken and that's [116:59] not natural and we've got to do it like [117:02] this and in the movies it happens like [117:03] this on Instagram and with that couple [117:05] over there they just had sex and then [117:06] little Bernie was born like you know all [117:08] of that stuff and I think a lot of that [117:09] stuff actually gets in the way of even [117:11] the conversation in the first place I [117:12] think um I had this conversation with my [117:15] partner but I I was scared to have the [117:19] conversation because turning to my [117:21] partner and going hey babe I think we [117:22] should you should freeze your eggs and I [117:23] should it's there it's like loaded with [117:26] a bunch of it's a bunch of feelings yeah [117:28] yeah yeah but the truth is that beat one [117:31] as a couple beat on the same page is so [117:33] important so that conversation that you [117:35] had I'm so proud of you because so [117:36] people don't have it and I'm the first [117:38] person to ask them how many kids do you [117:41] want what does our family size look like [117:44] and people have never had that [117:45] conversation so it makes it very [117:47] difficult for Family Planning there's a [117:49] huge stigma about going through [117:51] fertility treatments having infertility [117:53] freezing your eggs the whole gamut a lot [117:57] of that is because stigma often comes [117:59] from things that are unknown or [118:00] uncertain so simply by having these [118:03] conversations and talking about it more [118:05] that is so impactful and breaking the [118:07] stigma because we start to normalize [118:09] these terms and [118:12] understand for [118:14] women time matters and yes there's going [118:18] to be stories of people who are able to [118:21] wait later and get pregnant and that's [118:23] wonderful 3% is not no nobody but is [118:26] that likely to be you and that's the [118:28] question I always say it's a very [118:30] inefficient way to try to achieve a life [118:33] goal let's have a life goal of ours and [118:36] settle for something that's going to [118:37] give you a 3% chance of success that [118:39] doesn't make any sense to me once upon a [118:42] time if you had a business idea it was [118:45] exceptionally difficult to get going but [118:47] now in the age of Shopify it is [118:50] exceptionally easy as many of you will [118:53] know Shopify are a sponsor of this [118:55] podcast if you don't know Shopify it's [118:57] an exceptionally simple web platform for [118:59] anybody that's got an idea that wants to [119:01] transact on a global scale so things [119:04] like these conversation cards which we [119:05] sell we've sold using Shopify and it [119:08] only took us a couple of clicks to get [119:11] going so why did we choose Shopify for a [119:13] number of reasons but I think one of the [119:14] big ones which goes an appreciated is [119:16] their checkout system converts 36% [119:19] better compared to other platforms and [119:22] what I'm going to do to remove the cost [119:23] for you if you go to shopify.com Bartlet [119:27] you'll be able to try Shopify for $1 do [119:30] a month I've seen Shopify completely [119:33] change people's lives and for many of [119:35] you I think it could change [119:37] yours it's also a unavoidable reality of [119:42] the world we live in I was reading the [119:44] Time Magazine and it says that in 1970 [119:46] the average US woman had her first baby [119:48] age 21 and this increased to age 27 by [119:52] 2022 so the time that we typically have [119:56] our first baby has increased by six [119:58] years most people are having it in their [120:00] late 20s having their first baby in [120:01] their late 20s that's again a [120:04] consequence of the social factors we [120:05] talked about so because of this there's [120:08] always trade-offs in life right there [120:09] are we want longer careers and we want [120:12] more quote unquote freedom in you know [120:15] early seasons of our life then there's [120:18] going to be a a trade-off well the [120:21] trade-off shouldn't be that you have one [120:23] less human in your family that you want [120:25] it might just be that you have to do [120:26] something different to make sure that [120:27] goal is achieved you said in um a recent [120:30] podcast you did that studies tell us [120:31] that if you're not ready to have a [120:32] family by 20 sorry 32 or [120:35] 33 then that is the optimal time for the [120:38] average person to intervene and start [120:39] freezing their eggs it is and it comes [120:41] from the way that study was based on the [120:43] odds of you when you'd be likely to [120:46] start trying to conceive and the rate of [120:48] infertility coupled with the rate of [120:51] decline in count an egg quality as you [120:53] get older than that certainly your eggs [120:56] are better quality and you have more of [120:57] them younger than that so if you know [121:00] you want to freeze your eggs do not wait [121:02] until you're 32 but if you are [121:04] approaching that age and want to have [121:06] children as a life goal and you're not [121:09] ready to have them now you need to go [121:11] see a fertility doctor period the end [121:14] and what I mean by that is maybe you [121:16] freeze your eggs and maybe you don't but [121:18] you owe it to yourself to be the one to [121:20] make the decision and you can't make [121:21] make it unless you understand how many [121:24] eggs do I have are things normal for me [121:27] and evaluate that information hear about [121:30] what the process will be like you can [121:31] choose to not do it but then you made [121:34] the choice and the risk of regret is [121:35] going to be lower in the future if you [121:38] actively made the choice versus I didn't [121:41] know and I never got the chance IVF [121:45] simply is extracting an egg and a sperm [121:48] injecting the sperm into the egg and [121:51] basically putting it back inside the [121:54] woman that's the simplified version for [121:57] dummies yes so IVF in vitro [122:00] fertilization we're fertilizing the egg [122:03] outside the body so in vitro is in glass [122:06] but in the lab in the P tree dish now [122:08] modern IVF we are taking one month's [122:10] group of eggs growing them to embryos [122:13] and doing genetic testing and we're [122:15] freezing them what are you testing them [122:17] for we're testing them for chromosome [122:18] number what we call anupy as we talked [122:20] about the chromosomes getting out of [122:22] line as you get older you can check the [122:25] number of chromosomes the presence or [122:27] absence of each chromosome in a five to [122:30] eight cell sample from the embryo biopsy [122:34] to make sure they're [122:35] healthy we'll use healthy as the embryo [122:38] needs to be genetically normal it needs [122:41] to have the right number of chromosomes [122:43] to have the highest potential for [122:45] success if you're missing a full [122:47] chromosome that's going to end up in a [122:48] miscarriage if you have extra [122:50] chromosomes like an extra or copy of [122:52] chromosome 21 is Down syndrome that [122:54] carries its own risks and many of those [122:57] are pregnancy loss as well so we're [122:59] looking for what we call a upid embryo a [123:01] genetically normal meaning it has the [123:04] right number of chromosomes importantly [123:07] IVF can also be used to eliminate [123:09] genetic diseases that can be extremely [123:11] impactful when we talk about genetic [123:13] testing the way that I just defined it [123:15] testing for euploidy you have more eggs [123:20] that are genetically abnormal as you ate [123:22] that's one of the top barriers to [123:23] getting pregnant but if you and your [123:25] partner both carry cystic fibrosis for [123:27] example that's a disease that you are [123:30] going to exhibit the characteristics of [123:31] if you have a copy of the gene from Mom [123:34] and a copy of the gene from Dad you have [123:36] about a 25% chance of having a child who [123:38] would be severely ill or sick with [123:40] cystic fibrosis we can make a probe for [123:44] where your cystic fibrosis mutation is [123:47] on chromosome 7 and then we can apply [123:50] that probe to that sample that's been [123:52] biopsied from the embryo and find out [123:54] which [123:55] embryos have zero one or two copies of [123:59] that mutation essentially not [124:02] transferring the ones that are going to [124:04] result in the disease State and for [124:06] lethal abnormalities this is huge and [124:08] then for autosomal dominant diseases [124:10] like Huntington's disease or cancer [124:12] hearing syndromes you can eliminate that [124:15] from the family line do you then put one [124:18] embryo into the woman at a time we do [124:20] and so this has changed over time and I [124:22] think this is where a lot of [124:23] misconceptions come from IVF if we can [124:26] imagine the world where I have a [124:27] 40-year-old with four Frozen embryos if [124:31] I've done genetic testing on them I [124:33] would know that she has one normal and I [124:36] would just go put that normal one in [124:38] before genetic testing existed she had [124:41] the same four embryos but I didn't know [124:42] which one was normal so her odds of [124:44] pregnancy for a single Embryo transfer [124:46] work much much lower so it was common [124:49] place to put more embryos in then to try [124:52] to up the odds that you'd capture the [124:54] normal one now that we know which [124:56] embryos are genetically normal we want [124:59] to transfer one embryo at a time and I [125:01] always say it's don't make them compete [125:03] for resources let that embryo have the [125:06] full surface area of the uterus to have [125:07] a really nice placenta to grow into [125:11] decrease the chance of loss or pregnancy [125:13] complication down the road interestingly [125:16] if you transfer to embryos of course you [125:18] have a higher chance of twins you don't [125:20] see much of a change in the pregnant [125:22] rate just the Twining rate but even [125:24] without transferring to embryos a single [125:27] Embryo [125:28] transfer significantly increases the [125:30] chance of identical twinning now overall [125:33] it's still very low but identical [125:35] twinning where one embryo splits so you [125:38] have two children who are genetically [125:40] the same in nature that happens at about [125:43] a half a percent in IVF it happens [125:47] closer to 2 to 3% of the time probably [125:50] just because of that embryo being loaded [125:52] into a a catheter maybe its external [125:55] surface is touched in some way makes it [125:58] more predisposed to split after we put [126:00] it inside the body that's still [126:02] ultimately a very low odds of it [126:04] happening but if you put it in context [126:06] of I do 400 embryo transfers a year then [126:10] I'm going to definitely see some [126:11] patients who are having identical [126:13] twinning from a single Embryo transfer [126:16] also you know importantly justifying [126:19] just putting one in at a time because if [126:20] you put two in and one of them split or [126:24] both of them split you could have [126:25] triplets or [126:27] quadruplets if we talk about doing it [126:28] the old fashioned way yeah you know sex [126:32] there's a lot of misconceptions around [126:34] how to increase our odds of getting [126:35] pregnant you hear about women putting [126:36] their legs in the air after sex or um [126:40] things like [126:42] uh people think if you go for a Wei then [126:44] you're going to we out all the sperm and [126:46] that's not going to make you pregnant um [126:48] are any of these things true there's so [126:50] many myths when it comes to trying to [126:53] get pregnant the good old fashioned way [126:54] with intercourse so certainly we can go [126:57] through a few of them one of them we [126:59] already touched on which is oh you [127:00] should save up sperm for when you're [127:02] ovulating so we see that sometimes men [127:05] will ejaculate less or couples will [127:07] actually not have sex trying to save up [127:10] for that exact day of ovulation but [127:12] there's no need to do that as we know we [127:14] want to clear the pipes to keep the [127:16] sperm coming out healthy and alive and [127:17] not have dead sperm and that you can [127:20] have sperm survive in the productive [127:21] track for up to 5 days so you want to be [127:24] having intercourse up until that [127:26] ovulatory day so every other day sex [127:29] everyday sex every 3-day sex those are [127:31] all fine nobody ever needs to have less [127:34] sex so if you and your partner have sex [127:36] every day please don't have less sex [127:38] because you're trying to get pregnant [127:39] number two the sperm are inside the [127:42] Fallopian tubes within minutes they have [127:46] gone from the vagina gotten through that [127:49] seminal fluid in the ejaculate through [127:51] the the cervix through the uterus and [127:52] into the fallopian tube within minutes [127:55] under five minutes so there's no need to [127:58] prop your hips up on a pillow for 30 [127:59] minutes or put your feet in the air [128:02] truly the sperm are into the cervix [128:04] within 2 minutes and the cervix is where [128:07] they then sit for up to the five days so [128:10] the two minutes time that it's going to [128:12] take you to withdraw get up go to the [128:15] bathroom the sperm are fine you're not [128:17] going to pee out any sperm you don't [128:19] need to put any device in to keep sperm [128:20] in place keep keep your feet up lay in [128:22] bed you can go and do whatever you want [128:25] to do and in fact we know that urinating [128:27] after intercourse for women decreases [128:29] the risk of a urinary tract infection so [128:31] we try to encourage people to get up and [128:33] be normal I also tell people all the [128:35] time embryos and plant eggs fertilize [128:37] when you are up and living your life so [128:39] you don't need to just be horizontal to [128:42] have fertilization occur so what about [128:44] sex positions are there any sex [128:45] positions that are more conducive with [128:47] uh yeah whatever whatever position uh [128:50] allows for ejacul ation so this is where [128:53] variety is the spice of life because as [128:55] you alluded to earlier sex can feel a [128:57] little bit more of a chore when you're [128:58] trying to get pregnant or you're [128:59] struggling so making sure that [129:01] ejaculation can happen there's not any [129:03] position that is going to be better or [129:05] worse or going to have higher chance of [129:07] a boy or a girl or any of that kind of [129:10] knowledge if the female orgasms does [129:13] that increase the chance of fertility we [129:16] do know that orgasm does help uterine [129:19] contractions help get the sperm to the [129:21] eggs faster so we do know that so how do [129:24] we know that we would hyp how do we know [129:26] that yeah there have been studies [129:29] looking at there have been studies [129:31] looking at orgasm and then the speed of [129:32] which sperm gets to the Fallopian [129:34] tubes we'll just say that factors it's [129:37] like maybe it's just bigger and that's [129:39] just no so yeah just that those [129:42] contractions are helping kind of propel [129:43] the sperm up there what about penis size [129:46] so penis size really doesn't matter [129:48] what's interesting is that penis size [129:49] does tend to correlate with different [129:51] race and ethnicity also with vaginal [129:53] length so we tend to see different [129:55] vaginal lengths in correlation with what [129:57] tends to be a similar penis length based [130:00] on that ethnicity or where that person [130:05] originated from which is super [130:06] interesting but you don't need to you [130:08] don't need a smaller penis or a bigger [130:09] penis as long the sperm doesn't need to [130:12] get closer to the cervix A lot of people [130:14] obviously think that we when you eulate [130:17] it goes it gets right where it needs to [130:19] go okay crazy it's super interesting [130:23] I've learned so much about um all of [130:26] this stuff today I think there's [130:27] probably just two more things I wanted [130:29] to ask you about one of them is um you [130:30] mentioned birth control earlier and [130:32] there's lots of conversation at the [130:34] moment as to whether birth control is [130:36] healthy or not and the sort of side [130:38] effects and risks associated with it we [130:39] know everything and nothing in life has [130:41] is a free lunch there's always [130:42] trade-offs and side effects and would [130:45] you say that birth control and obviously [130:47] birth control comes in many forms as [130:48] well it's not just a pill there's you [130:51] know the coil and all these other types [130:53] of birth control is the pill [130:57] healthy I'll reframe and say the pill is [130:59] not necessarily unhealthy however it's [131:03] very important to understand that we now [131:04] have a generation of women who were [131:07] given the birth control pill when they [131:09] had a sign that something was wrong with [131:11] their body without getting to the bottom [131:13] of what it was which means we're just [131:16] kicking that can to trying to find that [131:18] diagnosis now later in life and causing [131:20] a of frustration so if your periods were [131:23] irregular you got start on the pill you [131:25] took it for 15 years now you're 35 and [131:29] you come off of it your periods are [131:31] probably still going to be irregular but [131:32] now you don't know why you're ready to [131:34] get pregnant and it can be very [131:36] frustrating so the use of the birth [131:38] control pill as treatment without [131:40] getting to the basis of diagnosis has [131:42] been a huge problem in women's health [131:45] the birth control pill itself does not [131:46] cause infertility it changes nothing [131:49] about the Vault the eggs are still [131:50] coming out every month you're just [131:52] losing them none of them are ovulating [131:54] the birth control pill itself combined [131:56] estrogen and progesterone the brain [131:58] doesn't send out that FSH so it's not [132:00] impacting the quality or the quantity of [132:03] the eggs that you have it does change [132:06] some of your metabolic parameters it [132:08] does change some of your vitamins and [132:10] every person's going to have a different [132:12] reaction to the pill so certainly some [132:15] people hate it but some people love it [132:17] for [132:18] endometriosis or you can have really [132:20] terrible PMS or what we call pmdd which [132:23] is like premenstrual dysphoric disorder [132:26] where you have these mental health [132:28] changes as your hormones change having [132:30] stable hormone levels can be [132:33] lifechanging so the pill definitely has [132:35] Medical Treatments it prevents the [132:37] cancer from PCOS it prevents [132:39] endometriosis progression it can treat [132:42] pain it can be something that can be [132:44] very beneficial and unfortunately we see [132:46] a lot of stigma with the birth control [132:47] pill right now on social media we see so [132:50] many people [132:51] talking about how bad it is and how [132:53] negative it is and how you're harming [132:55] your health by taking the birth control [132:57] pill you're not harming your health [132:59] however it's allowing too many people to [133:02] not have that discussion about their [133:04] family planning and not understand how [133:07] their hormones work so I always [133:09] recommend that somebody stops [133:11] contraception before they're ready to [133:13] get pregnant that way you can understand [133:15] are your periods coming regularly what [133:17] are the signs and symptoms that [133:20] something could be wrong so that you're [133:22] not behind the game when you're trying [133:23] to get [133:24] pregnant lots of people will be [133:26] listening to this now that are [133:27] struggling with a variety of the things [133:28] that you've talked about whether it's um [133:31] PCOS or whether they've been trying to [133:33] conceive a child for some time um [133:36] whether it's this new word that I [133:37] learned today [133:39] endometriosis whether they're in late [133:42] stage sort of IVF treatment and many of [133:44] the embryos have failed what is your [133:46] message to those people there'll be I'm [133:48] sure hundreds of thousands of them that [133:50] are listening right now [133:52] number one you can't control everything [133:54] but you should control what you can so [133:57] understanding getting the Sleep [133:59] optimizing your lifestyle you should [134:02] eliminate those questions from your mind [134:04] should you do it you should do it number [134:06] two there's no reason why you cannot [134:10] ever get let's say a second opinion if [134:12] you're deep in the fertility treatment [134:14] two often I see people who do the same [134:17] thing over and over and it's [134:18] heartbreaking because they're using [134:19] their time and their money and you might [134:22] need a new set of eyes and I'll even [134:23] tell my patients that if they're not [134:24] having success if you want to go get [134:26] another opinion go get it I support you [134:29] we support our patients getting those [134:32] extra sets of eyes extra input because [134:35] this is your one chance there's such a [134:36] limited amount of time from when most [134:39] people start trying to when your [134:41] reproductive window is closed that you [134:43] owe it to yourself to feel comfortable [134:45] with the choices that you are making if [134:47] you are not getting the information you [134:49] need from your doctor that's a red flag [134:51] if you can never talk to a doctor that's [134:52] a red flag if your periods are irregular [134:55] and you don't know why you need to see a [134:57] doctor if your periods are so painful [134:59] that it's interfering with your life you [135:01] need to go see a doctor if you know [135:04] you've been diagnosed with something [135:06] that somebody told you is going to make [135:08] it hard for you to get pregnant please [135:10] don't be reactive once you don't get [135:12] pregnant once you have infertility don't [135:15] try for 12 months and then come see me [135:17] if you know you have PCOS let's test you [135:20] now let's try to is start out on the [135:22] right foot to know that everything else [135:23] is working and have a game plan to [135:26] really try to help you achieve this life [135:29] goal Natalie thank you we have a closing [135:32] tradition on this podcast where the last [135:33] guest leaves a question for the next [135:34] guest not knowing who they're going to [135:35] be leaving it for and the question that [135:38] has been left for you inside the Diary [135:40] of a CEO [135:41] is What is the most difficult [135:45] conversation that changed your life [135:52] that's such a great question and I I've [135:55] been in a position to have a lot of [135:57] really difficult conversations both for [136:00] my own personal decision- making [136:02] changing career Pathways having my own [136:04] infertility Journey but the most [136:07] impactful conversation I ever have and [136:09] one that I react to my patients was [136:11] after my second pregnancy loss I [136:15] was the chief resident I was the [136:18] resident in charge of the busiest labor [136:20] and deliver unit in America and I [136:23] started miscarrying while I was on my [136:24] shift so I was bleeding in the bathroom [136:27] and nobody knew I was pregnant so I had [136:29] to carry on so I carried on did [136:33] C-sections delivered people's babies and [136:36] I left and went to my own OB when that [136:38] shift was [136:40] over distraught because I knew that I [136:43] was losing this pregnancy and I just had [136:45] to witness so many families achieve what [136:48] I wanted to achieve and my my OB when I [136:51] got there and she confirmed that I was [136:54] miscarrying and she said to [136:56] me it's really hard to [136:59] understand the meaning when you're in [137:02] the middle of the journey but one [137:05] day the world makes sense and it's your [137:08] job to not give up hope and to stay on [137:10] the path and that I believe that this is [137:14] going to happen that you're going to be [137:15] a mom and I may not have all the answers [137:17] why you're struggling right now but I [137:20] trust that if you keep going the odds [137:23] are that you're going to have the baby [137:25] that you're meant to have and when I [137:28] went on to have subsequent losses that [137:29] stayed with me that she believed I was [137:31] going to have the baby I was meant to [137:33] have and I'm going to cry now my [137:36] daughter like if any of those other [137:37] losses had worked out I wouldn't have my [137:39] kids the ones that are my everything [137:42] they're meant to be my children right my [137:44] daughter that egg that was in the vault [137:47] I would have lost when I was pregnant [137:49] because you still lose eggs when you're [137:50] pregnant [137:51] so I wouldn't have her if any of those [137:53] had worked out so the world has a way of [137:56] sometimes making sense that are so hard [137:58] when you're in the midst of the pain to [138:00] understand and I tell my patients that [138:03] same thing over and over that in the [138:05] journey it doesn't make sense but that's [138:07] not your job in the journey to [138:09] understand the wise it's to to keep [138:12] going and not give [138:15] up you must see so much of that pain how [138:17] do you [138:19] not you know how does that not come home [138:22] with you and oh it comes home with me [138:25] and I live it in the moment so I'm not [138:28] going to be the type of person who can [138:31] experience your heartbreak and not [138:33] experience it with you so I'm going to [138:36] cry with you and hug you and I'm going [138:38] to take it home and hug my kids and know [138:41] how happy and how lucky I am to have [138:45] them I frame it for all my patients as [138:47] I'm never going to sugar coat it for you [138:49] you know that I'm going to give you the [138:51] truth it's going to be hard to hear [138:53] sometimes but we know that we have the [138:55] type of relationship that you can trust [138:58] that I am giving you the best [139:00] information that there is sometimes do [139:02] you have to tell them that it's not [139:03] possible I do sometimes I have to tell [139:05] them it's not possible it's not going to [139:07] happen we need to look at other [139:09] alternatives for family building donor [139:11] egg donor embryo donor sperm I have [139:14] couples who sometimes had no idea the [139:17] man had no sperm and we have to [139:18] completely change what we thought a [139:20] family would be so I do tell patients [139:24] you know every week that this plan's not [139:26] going to work anymore and it's time for [139:28] us to step back and really think about [139:32] what that goal is is it a genetic child [139:35] I mean that was plan a but maybe it's [139:37] just a child a life you know maybe [139:39] there's other ways to get there than [139:40] what we were trying for so there's a lot [139:44] of pain in the job I always say I have [139:45] the best job and the worst job in the [139:47] same day every day what's been your [139:49] hardest day in work [139:52] the hard the hardest for me are are [139:54] going to be mostly in my past you know [139:57] training and obstetrics you know fetal [140:02] death still birth loss of a highly [140:06] desired I mean loss of any pregnancy [140:08] loss of [140:08] life [140:10] um I I those screams of those parents [140:14] you'll I'll never Escape them so [140:17] pregnancy is not Health neutral we act [140:20] like it's our once you get pregnant [140:23] everything will be fine every single [140:24] pregnancy could have [140:26] complications and I think it's really [140:29] important that we enter into that space [140:32] with the knowledge of what it is and [140:33] what it isn't but I the loss of life is [140:35] always going to be the [140:37] hardest Natalie thank you thank you so [140:40] much Stephen thank you so much it's um [140:42] you're doing you know there's kind of [140:44] two sides to this there's I I have a [140:45] huge amount of gratitude for the fact [140:47] that you're through your clinic and your [140:49] work you're helping people to realize [140:51] these very important dreams that they [140:52] have and you're Illuminating all of [140:56] the the darkness that causes the [141:01] uncertainty and the doubt and all of the [141:04] the things that come with trying to [141:06] build a family and you're doing that [141:08] through information but you're also [141:09] doing that in such a compassionate human [141:10] honest way and then [141:13] secondly because you do things like this [141:16] and there are so many people that don't [141:17] have the opportunity to go to a you know [141:20] a doctor or a fertility expert and sit [141:23] down with them because of the country [141:24] that they're in or the or the cost of it [141:26] or the the time they have or whatever [141:28] but by making this type of information [141:30] accessible to millions of people by you [141:32] know committing your time to do podcasts [141:34] and things like that I think you're [141:36] going to be helping so many hundreds of [141:39] thousands and millions of people that [141:40] you'll never get to meet so on behalf of [141:42] all of those people who I can feel at [141:44] home on the tube on the train on the [141:46] plane right now that are that want to [141:48] express their gratitude to you and I'm [141:49] sure that they will message to do such [141:51] exactly that I want to say thank you on [141:52] behalf of all of them as well um I've [141:54] learned so much I've learned so much and [141:56] my mind has been changed so I have no [141:57] doubt that there's millions of people [141:59] listening right now that have also [142:00] experienced the same thing so thank you [142:01] Natalie thank you and thank you for [142:03] holding space for this discussion [142:05] there's stigma here it's not the most [142:07] fun topic to always discuss about and [142:10] it's something that you're bringing it [142:12] to those people who might not come to my [142:15] channel searching for it but they need [142:17] to know the information so by putting it [142:19] in a place where they're looking for [142:20] other things thank you [142:22] [Music] [142:42] [Music]