Latest / The XX Lab / Your Fertility Isn’t Just About Age | #4 with Dr. Natalie Crawford
Transcript
- speaker-0: We need to encourage earlier testing so that women can be armed with the information they need to make those good decisions. Each little piece of the pituitary makes different hormones. I think that's so fascinating. speaker-1: Oftentimes our body has different mechanisms that will purposefully interrupt ovulation to prevent having a baby or getting pregnant during a time when it just wouldn't be a very good idea. speaker-0: To feel your best, to feel like yourself, to have your best life, your longest health span. Women deserve that. speaker-1: Welcome to the XX Lab, where we explore the science and stories that matter to you. If you've ever felt confused and overwhelmed by anything related to fertility, whether it's the decision about when you should be having a baby or do you need to freeze your eggs or what to do if you're trying to get pregnant and can't get pregnant, this episode is for you. Today I'm going to be sitting down with Dr. Natalie Crawford, reproductive endocrinologist fertility expert. And one of the most trusted voices in translating fertility science to women in a way that's clear, grounded, and empowering. Dr. Crawford holds degrees in nutrition science, medicine, and clinical research. And she's the founder of For Fertility, a boutique fertility clinic in Austin, Texas. She's also a digital health educator on social media, YouTube, and beyond. Her podcast as a woman now has over six million downloads, and her debut book, The Fertility Formula, was released in April and is already changing women's lives. So today we're going to unpack how ovulation works, what defines the true fertile window, what happens to egg quality over time, how stress and lifestyle factors can play a role in reproductive health, and what women should realistically expect when trying to conceive. We're going to be separating fear from fact because understanding your fertility shouldn't feel mysterious or stressful. It should feel simple and empowering. This is the XX Lab. I'm Doctor Sarah Hill. Let's get started. Doctor Natalie Crawford, welcome to the XX Lab. Sarah. speaker-0: Thank you so much for having me. I'm so excited to be here with you. speaker-1: Well, I'm so excited too. ⁓ as I was just telling you off camera, ⁓ I have just like absolutely burned through the fertility formula and I absolutely loved it. I thought it was so like nicely written, very easy to understand, and ⁓ a really nicely updated guide. You know, I think a lot of us, ⁓ yeah, I'm Gen X and like everybody had like ⁓ you know, take control of your fertility. That was like the book back in the day. And so this ⁓ is so nice because in some ways it's like an almost like an updated, ⁓ you know, sort of different version of that where it really gives women the tools that they need themselves to understand fertility and then ⁓ also how to manage questions around whether, you know, it's time for infertility treatment and all the other stuff. So really, really well done. speaker-0: Well, thank you so much. That means the world to me, as you know also. Writing a book is so much about putting your own heart into it in addition to all of the time. And I was always so shocked by so much has to get cut and the editing process and trying to leave behind everything you want. So that means so much to me and I'm so excited to be here. speaker-1: Well, awesome. Well I wanna just start from the top and I want to ask you about like just explaining to everybody what is fertility and then what is infertility. speaker-0: Such a good question. Most of us don't even think about fertility until we're ready to get pregnant. We really think fertility equals conception or having a baby. And certainly that is one part of it. But fertility, really, to me is the overall sense that everything is working appropriately in your body, that your brain and your ovaries are communicating appropriately. It's a state of health that then allows you to get pregnant. But it's also important even if you don't want to get pregnant. I think that's a piece of the puzzle that we miss sometimes, is that. As a woman, our fertility, these normal hormonal functions, is really essential to your overall health and well-being. And that is an exclamation point at the end of it when we look at the literature suggesting that women who have infertility have higher rates of chronic disease later in life, specifically things like metabolic syndrome and heart attack and stroke and really scary statistics. That speaks to the sign that for a lot of young women, they're relatively healthy. And infertility might be one of the first red flags that their body is giving them. Yet if we learn to harness how do you know if your hormones are okay and learn about estrogen and progesterone and learn about the menstrual cycle, something you and I are co-passionate about, then we can leverage that knowledge even earlier than failing to get pregnant. Because officially, infertility is a medical diagnosis that means you've not gotten pregnant after trying to get pregnant for 12 months. And we recommend accelerating that workup if you're over age 35 to start at six months. But the question I'll pose to you here at the start of the episode is does that really make sense in today's world? When we see raising rates of infertility, we see that women are chasing big dreams and starting families later. Is it appropriate for us to say you have to fail first before we'll do an evaluation? And I think the answer is no. We need to more proactively think about our hormones and our fertility, encourage earlier testing. So that women can be armed with the information they need to make those good decisions about their reproductive journey. speaker-1: No, absolutely. I think that it's ⁓ I think it's crazy that most women don't start actually thinking about their fertility until they're trying to get pregnant because we're not really taught that this is not not only important for having a baby, but this is also how our body makes hormones. And ⁓ and when we're not ovulating, that's obviously means that we're not experiencing the full bandwidth of our hormones, which are very positive for health. And also, as you noted, it's ⁓ generally a canary in the coal mine, right? If you aren't ovulating or you are experiencing infertility, ⁓ it really is that, you know, is it the fifth vital or sixth vital sign? Is it the fifth or the sixth? I don't know why. speaker-0: So say your your period ⁓ your menstrual cycle is your fifth level. speaker-1: That's it. I'm like, I always mess that one up. So I'm like, is it's I always mess it up with like the sixth sense versus a fifth anyway. ⁓ yeah, so it's it's that extra vital sign where it's providing an important cue to health. And in fact, there was a a call out from the NIH ⁓ looking for research projects specifically looking at this issue and the extent to which fertility in women is in fact a you know, sort of diagnostic cue. ⁓ or you know they're getting their periods ⁓ is a diagnostic cue to overall health and the overwhelming ⁓ answer when you look at the research studies that have been published so far is yes it is and it is so important. And so I wanna I wanna talk about and because I think that this will be a good way to ⁓ structure the conversation about in order for conception to occur, right, you have to have a bunch of different pieces where you have to have successful ovulation. Right, you have to have successful fertilization of an egg, which means you have to have a happy sperm, right? So you have to have a sperm that's able to make its way to an egg. You have to have a happy sperm. A happy sperm who's able to make it to the egg. And then you have to have actually the you know, the con the conceptive event, right, where the sperm is fusing with the egg, and then you have to have successful implantation. Right. Did I miss any steps? Happy sperm, happy egg, the fusing of the two, implantation, are those kind of the four speaker-0: Those the big steps. And then I think just to also frame it that these steps take place in certain environments that are also important, right? Fertilization occurs in the fallopian tubes, implantation obviously in the uterus. And so anatomically having normal functioning anatomy is a big piece of those events happening also. speaker-1: Awesome. So let's let's start with the first of those, which is ovulation. All right. And ⁓ and let's talk about what it is, let's talk about the fertile window, let's talk about what interferes with ovulation, ⁓ which there was a lot ⁓ in your wonderful book that talks about some of these factors that can lead to failure to ovulate. And so let's first just start by walking through what actually happens during ovulation. speaker-0: Let's do it. And I'll give my brief menstrual cycle overview. I know your listeners are going to be well familiar with part of the piece of the puzzle, but I think it frames what goes wrong when we think about what's normal. So I want everybody to imagine that inside your ovary is a vault where all your eggs are kept. And every month a group of eggs comes out of that vault. And we know women are born with all the eggs they have and they run out of them over time. But each egg grows inside a small fluid-filled structure called a follicle. So at the start of the month, the brain's going to send out follicle stimulating hormone or FSH. Gets one of those follicles to grow. As the follicle grows, the egg matures and makes estrogen, and this is the follicular phase. Remembering that the brain and the ovary don't see what's happening. They're listening for hormonal signals. So I sometimes say it's like text messages being sent between two friends. The brain has no idea the egg is growing until it gets the text message from estrogen. And so when estrogen levels are high enough for long enough, that is the sign, hey, we're mature and ready to ovulate. And then the brain has to interpret this and then appropriately send out. LH or lutonizing hormone. And the first time it sends it out is in a big surge, which allows that follicle to rupture the egg to actually be released into the peritoneal cavity or the abdominal cavity. And then the follicle that grew the egg is going to reform and become a cyst known as the corpus luteum. And that's the ovulatory event or ovulation. And then we're entering into the luteal phase, which is based by this corpus luteum, where the brain will send out LH impulses, stimulating the corpus luteum to make progesterone impulses. And if we're not Pregnant, that corpus luteum can only live about two weeks. It will then die. Hormone levels will then drop. So progesterone will drop. And that will be the cue to the body that time for the uterus to bleed and have the menstrual cycle, our outward sign. And the process in the ovaries, another group of eggs coming out of the vault is restarting. Ovulation in the menstrual cycle is really this beautifully, perfectly coordinated dance. And it's fascinating that, you know, The human species is so dependent on a process that is so sensitive to the environment of the female. And when we think about that evolutionary, one thing I always tell people is that your body at its foremost wants to protect you. And so the brain is not just listening for estrogen, but it's also listening for other signs and symptoms and triggers and hormones to make sure that you're of good health, that things aren't going to a level where you're too we'll say lack of a better word, we'll say stressed in this environment. And evolutionary, that makes sense to us because if it was, if there was a famine or you were migrating, or there was a war, this might not be a great time for you to conceive and have to nourish an ongoing pregnancy because it's such a huge demand. So the brain and ovary has this beautiful, delicate dance, but it's really requiring an overall sense of well-being to happen perfectly. And one thing that I want people to understand, because I ask patients all the time, do you track your cycles? Are your cycles regular? And they'll always say yes. But what most people do when they are tracking their cycles is they are simply marking day number one down in some app. So they have some cycle tracking app, they mark day one. The app is then using an old school method called the calendar method, just assuming the corpus luteum lives for 14 days and walking backwards to tell you when you ovulate and when your fertile window is. But we know that apps that use the calendar method only are only going to be accurate around 20% of the time, right? Isn't that while? speaker-1: Wild is not great. speaker-0: It's not great. And I think that speaks to the fact that often physicians are guilty of this too. They act like normal ovulation is just a yes-no event. It happens or it doesn't happen. But you and I live in the world where we know there's a spectrum of dysfunction. We're just simply ovulating is one piece of the puzzle. But for everything to happen, as you said earlier, we really have to ovulate in a way that is functional and not dysfunctional. And so there's stages of ovulatory dysfunction that we go through. Whether it's the luteal phase is short or the follicular phase is long, that are giving us clues that our ovulation maybe isn't quite as, we'll say, strong as it could be, even though it is still in fact happening. Yet we can see subfertility in all of those categories. Interestingly, the egg only lists for 24 hours. And I think that's like a really important point and so different than what we learned in sex ed back in school when it was like you can get pregnant any day of the month and don't ever have sex. And That is the basis of trying to time intercourse with ovulation. We know that having intercourse on the day that you ovulate, if everything else is normal, can have a 20 to 30% chance of pregnancy versus a zero percent when you're outside that 24-hour window. Sperm can live longer, can live for up to five days in the female reproductive tract, even though the vast majority of sperm is going to live one to two days. It can live up for five days. So the idea of the fertile window really comes from the camp of natural family planning where we're trying to like not have intercourse so we can prevent a pregnancy. But it is the six days where the last day is ovulation. So the five days before and ovulation day, those are the days in a month when you can get pregnant. So if we know when we're ovulating, we're automatically going to set ourselves up on a better pathway when we're trying to conceive, in addition to understanding that our brain and ovaries are actually communicating appropriately. speaker-1: Yeah, so how does somebody know whether they're ovulating? like what what do you tell women like in if they're trying to figure out whether they're ovulating or tract their ovulation, like what is the advice that the that the fertility doctor gives women for measuring? speaker-0: So I want people to utilize the signs their bodies are giving them. And these are those fertility awareness methods. So my favorite are going to be learning to leverage our basal body temperature, cervical mucus monitoring, and then urinary based hormone measurements. And none of these is better than the other. I think that's really important to say off the bat. We've done I even did research and fellowship comparing them head on head. And no method of fertility awareness is better than another, but all methods help you get pregnant more than nothing. And utilizing two can help you get pregnant. Even better. And I really recommend learning these much earlier before you even want to get pregnant. Because if we're saying relying on your app alone is not going to get the job done, yes, there's truth to if you have regular periods that are predictable, you are probably ovulating. But it's not a hundred percent. And I think knowing that you're really ovulating is very powerful if we say that's how your body is outwardly telling you that things are functioning appropriately. So basal body temp, I you know, complete 180 from earlier in my career, right? Basal body temperature is the fact that once the corpus lutia makes progesterone, progesterone raises your core body temperature. Once you have a temp of 0.4 degrees Fahrenheit for three days, that confirms ovulation. And in fact, you get an idea right before that. And early in my days as a fertility doctor, I hated BBT because it was the special thermometer and the right graph paper. And as a patient, I did this myself and it was very overwhelming and I would say a stress-inducing process and much less accurate. But now we can say this is where tech and wearables has really changed the game for us because wearable technology, whether it's, you know, a band, your whoop, your Apple Watch, an Aura Ring, are taking temperature data points many times during the day. They have much more sensitivity when it's detecting that switch. And it's a little bit mindless for the young woman in a way, if you have access to the technology to say, I'm gonna wear my aura rings and you leverage that temperature change to know when I'm ovulating. You don't have to remember to take your temperature every single morning. So I think that there's a lot of power in BBT. And I highly recommend it now. I also, I mean, cervical mucus is free and easy. And we always love free and easy things. And I think sometimes people have this weirdness about their own body because there's a lot of stigma about our body. We don't talk about our vulva and our vagina. We don't talk about mucus or discharge. And so many patients think it's abnormal or gross. And what we want to say is that there's a reason why when your estrogen raises, The cervix is the entry point to the uterus, and the cervical mucus is a barrier to prevent anything from getting into that, we'll say sterile uterine environment. But it wants sperm to get in when you're ovulating. So when estrogen rises, the mucus becomes sticky and stretchy and egg-white, so the sperm can swim through it, creates little channels for the sperm. So if we check our cervical mucus, and this isn't anything crazy, you just wipe with toilet paper before you go to the bathroom and look at it. You'll be able to see what that type four is, that sticky, stretchy egg white. And that is those peak estrogen levels. So the last day of type four cervical mucus, if you have multiple days, is considered ovulation day. And that's really easy because it doesn't cost you anything. And then urinary hormone monitoring, most of the time, what we're really talking about is trying to detect the first LH surge. Because once we detect that surge, that is the stimulus to ovulate, usually the next day. So if we know when that's happening, we can confirm we're going to ovulate. We also can target when to have intercourse. OPKs or ovulation predictor kits are the OGs of this, and it's just an LH-based kit. Some OPKs now actually do estradiol and they do LH. And now there's fancy hormone monitors that can do a slew of urinary-based hormones or metabolites. And those are great too. But many people don't have to spend that much money in order to get the information. So I think it's up to what works for you. Many times patients will. you know, try different ones and you might say, I always get this LH surge and get the C cervical mucus the next day. So maybe I don't need to buy the urinary hormones. I will say for OPK, though, women with PCOS who tend to have a high endogenous LH tend to have higher false positives. And women who are going into perimenopause or have low ovarian reserve, they can have a higher baseline LH too. So sometimes we might need to think about our own unique situation when we're trying to determine what's going to be the best tool for us. speaker-1: Yeah, I've heard from so many women that, you know, ⁓ I've got a regular cycle and therefore I don't need to track and I know that, you know, I'm ovulating because I'm every twenty-eight days or every twenty-nine days. And ⁓ one thing that I was really shocked to learn when I first started in the research world in this particular research area, ⁓ was we would bring women into the research lab and ⁓ and we would only study women who had regular menstrual cycles. Right. And they had to have a healthy BMI so they couldn't be too light. They couldn't be too heavy. They couldn't have any endocrine disrupting ⁓ issues. So no PCOS, ⁓ no endometriosis. I mean, we're talking about an absolutely pristine sample. Perfect population. Perfect population. We have them come in, we're going to be looking at the effects of their ovarian hormones on different types of outcomes. And we are taking hormone ⁓ we're taking LH tests, we're ⁓ looking at temperature. ⁓ we get about thirty percent of them fail to ovulate on any given cycle that we're pulling data from. And at first I thought I was doing something wrong. Right. I'm like, I must be I must be messing this up. And so I talk to my colleagues who study the same ⁓ types of issues and they're like, No, it's usually any individual data pull, you get about thirty percent where they just fail to ovulate. And these women, their cycles, they get their periods on time the next month. And ⁓ and they just didn't ovulate that cycle. And I and now I will say this about our samples is that they're college students and they're incredibly stressed out. And ⁓ and so it's it's it's in some ways not surprising that you get such a high rate like within and this isn't to say that yeah, yeah. And this isn't to say folks that that there's a thirty percent chance it's just in one individual data poll, right, a thirty percent of the sample we fail to detect ovulation. So ⁓ it just means that it happens and and it happens a lot, I mean, in response to certain types of of contexts and ⁓ and and you write about these in in your book. So like what are some of the contextual factors that influence whether a woman is going to be successfully ovulating or not? So in other words, yeah, what affects ovulation? How speaker-0: A good question. And honestly, a little bit more complicated than sometimes we try to make it out to be in the field. What we like to think about in the brain is we've got, you know, the hypothalamic pituitary ovarian axis. So I think for the regular person listening, there's this twofold communication where the brain has to interpret hormone signals and then actually also appropriately send out hormone signals. So there's an extra layer where things can have interference. When we want to say what are some of like the big buckets that we fall into when we're not ovulating appropriately. We can have, you know, external factors outside the brain per se. So this is often going to be like the thyroid. So an abnormal thyroid gland is going to change how the brain is sending out TSH, which is one of the pituitary hormones. The interesting thing about the pituitary gland that I know you know that I love thinking about, imagine, you know, it's like a boxing bag, whatever that's called, hanging down. From the ceiling, but it's mapped, meaning each little piece of the pituitary makes different hormones. I think that's so fascinating. And your reproductive hormones, so FSH and LH, the ganadotropins, are the furthest away from the blood supply. That means that your body is, before you do anything, already determined this is the least important function that it does. Because if you know blood supply is decreased, it's going to go to more essential parts of the pituitary first, but also. When we'll say, you know, prolactin is being overproduced, or your thyroid gland, when areas of the pituitary are working harder, then this area that makes ganatotropins, the ganatotrophs, are not going to be able to respond as they should. So anybody who's having abnormal ovulation in any context always needs full thyroid panel and needs a prolactin, also, because prolactin is one of those pituitary hormones. And very often women are not getting these checked, and it's crazy, right? We know from prolactin specifically, as it elevates. You go through a very distinct pattern of ovulatory change, which is what I describe as the gradients of abnormal ovulation. So we have those perfect cycles, but then you're gonna have a short luteal phase where you're ovulating, but there's some mismatch and that corpus luteum can't live as long as it needs to. And then you're gonna have this delayed follicular phase where it's really taking the brain longer to send out what it needs to to get you to ovulate. And then you get into more Outward signs that it's abnormal, because in both of those scenarios, you would tell me you have a regular cycle. You would say, Yeah, my cycles are regular, but ovulation's not actually happening appropriately. Then we're going to say, Yeah, true irregularity, skipping months, and amenorrhea, those become way more obvious outward signs that something is wrong. When it comes kind of backwards, we'll say, like the most severe of this is going to be hypothalamic amenorrhea. So that is when the body has interpreted. A stressor is so great that it does not want to send out any gonadotropins anymore. Really wants you to conserve resources for yourself. And this can be, you know, caloric restriction, over exercising, chronic stress, trauma, chronic illness. There's a few different things. And we all have a different set point. And that's really important too. You know, just what your best friend can tolerate and what you can tolerate may not be the exact same thing. So this is when the brain is totally shut off. It's actually Very impactful for young women because they're totally hypoestrogenic, meaning they're gonna have low estrogen, they have no estrogen, they're gonna feel terrible. But also that has long-term health consequences. Your body is not meant to be without estrogen, especially in these young reproductive years. So you'll feel bad, but it's gonna impact your bones, you know, your brain, all parts of your well-being as well. So we really wanna make sure we're getting that evaluation earlier. I always say there's hypothalamic dysfunction as well, that it's a little bit of a misnomer to act like the switch is just totally on or off. That there's stages of gray where the brain is getting interference, but it hasn't totally shut off the switch. And I'll use a good example is we know that 58% of runners who are running, you know, high volume mileage are gonna have a luteal phase defect. This is that they're running to an extent or their calorie intake is telling their brain that if they're not quite at that stable place. So the brain is not sending out signals quite as strong to preserve the luteal phase as long as we need to. So they're still ovulating, but it's that red flag that if they don't change something, they're kind of going down a pathway where the brain might shut off. And so off topic, but like for my runners, because I'm in Austin, so very active patient population, we'll titrate to luteal phase. So say if your luteal phase starts shortening, you need to kind of cut back on running and build in strength training and look differently. Of course, that begs the question of you got to know when you're ovulating for that to be accurate, because the apps will always assume your luteal phase is 14 days. And that's one of the issues with them. And then probably the bucket I haven't talked about quite yet is going to be PCOS, which is one of the most prevalent causes of not ovulating. PCOS is a very complex disease, polycystic ovarian syndrome, which is named because of the ultrasound appearance of the ovaries, which has many follicles in it. There's a combination of genetics being born with a high account, and then also some environmental influence because there's a lot of metabolic dysfunction and insulin resistance with PCOS. So the simplest version is to say the brain and ovaries have a mismatch because the brain is sending out enough FSH to get one egg to grow out of a normal amount. But if you have double the amount of eggs, that FSH signal is going to be halved. So it's not a strong enough stimulus to get that follicle to grow, to get that estrogen made. And because the ovary loves making hormones, it starts to shift into an androgen-producing factory instead of one that makes estrogen. That's going to cause all the symptoms of PCOS, hair, hair growth, hair loss, acne, abdominal weight gain. It also worsens insulin resistance. Sorry. It also worsens insulin resistance. And that's why there's such a metabolic component. And It's a myth that all women with PCOS are overweight. You can have lean PCOS and you can be overweight. Certainly the insulin resistance predisposes you to gain weight and make it hard to lose. But it's not a hundred percent that, ⁓ you're thin, so you don't have PCOS. I have so many patients who are told that, or they're simply told, just lose weight. I think like the last piece of the puzzle to talk about too, really quickly. Is that being overweight or having additional fat cells? Fat cells can make a type of estrogen. And think about that feedback on the brain interfering with the hypothalamus being able to interpret, you know, what's coming from your ovary and what is excess estrogen. So there is truth to the fact that having, you know, excess estrogen on board, if that's from being overweight, can influence ovulation itself. Just like being too thin might make the brain not want to ovulate. Being overweight can influence it too. So that's why you and I both talk about being of a normal BMI or healthy body weight is an important piece of the puzzle because we want to rule out variables we can control. We want to understand what's really going on. And we want our brain and ovary to be able to communicate in that proper zone without this additional interference that comes in. speaker-1: Yeah, I think that one of the things that I found most interesting when I started reading about ovulation and the different factors that can potentially interfere with ovulation. ⁓ and as a psychologist, I look less at things like, you know, ⁓ what's happening with a thyroid and you know what's happening with ⁓ FSH. And instead, ⁓ looking at environmental factors and ⁓ and there's some really cool research that's come out in the last couple of years looking at the effects of social isolation, social exclusion, and that type of stress. on ⁓ on successful ovulation. And what the research finds is that ⁓ well one is that social isolation ⁓ increases the probability of f failure to ovulate, which ⁓ shouldn't be surprising to anyone. ⁓ but they also ⁓ there there's some research that came out a couple of years ago where they did a really cool experiment Where they had women ⁓ get socially excluded in ⁓ in a laboratory setting. And the way that we do this is just terrible. I mean you have people where they think that they're gonna be engaging in a cooperative activity, and then ⁓ everybody'll just kind of shut them out and just start talking to each other and then completely leaving this other person out. And we do this to study stress and we do this to study ⁓ social isolation stress. Is that terrible? It's really terrible, but we can learn so much ⁓ from these experiments. And this was no ⁓ this was no exception to this. And what they found was that ⁓ women who were in the follicular phase when they were ⁓ socially excluded, so this is early follicular phase, what they found is that ⁓ their bodies release ⁓ significantly higher levels of progesterone. So this is progesterone coming from the adrenals, right? Not from a corpus luteum. And this, of course, has the effect of getting picked up by the hypothalamus, which then inhibits ⁓ GNRH. Yes, it inhibits ovulation. And so essentially it's like the body is so smart that it picks up all of these different cues, right, ranging from your own internal physical condition, right? So like, do I have a lot of inflammation? Is my body in good condition? Do I have enough body weight? Am I getting enough calorie intake? Do I have social support or do I have too much stress? And then it uses this these different inputs and our brain is essentially making decisions, you know, about whether or not to ovulate. And if the environment is poor, right, meaning that our physical condition is poor or our social environment is poor, ⁓ oftentimes our body has different mechanisms that will purposefully interf interrupt ovulation. To prevent having a baby or getting pregnant during a time when it just wouldn't be a very good idea. speaker-0: You know, I love that you bring all that up and it just really drives home the point that and this one out of many different things, but that stress is much more than just something to tolerate or to deal with because chronic stress, you know, it creates inflammation and insulin resistance. Like stress in your body is meant to be a protective mechanism to save your life, right? We always use the old analogy of you see a bear and you want to run from the bear. But the things that cause us to be stressed in the modern world don't utilize the same, you know, energy expenditure. Plus, we cope with stress in different ways and they never go away. You know, it's just this kind of constant feeling that worsens itself. And that that really is such an inflammatory environment that it not only can inhibit fertility by ovulation, but also influences a quality directly as well and how the ovaries can function and respond and implantation. So when we like go back to the first question you had. You know, I always think that so many patients are told don't stress about being stressed, which I think is the worst and terrible advice the least helpful advice. As somebody who had infertility and was told something similar, it's not really actionable. Yet if we know part of that, you know, cortisol release and that stress pathway is freeing up glucose into your bloodstream, yet you're not leveraging that glucose with any energy, it's going to just cause more insulin, which is a growth hormone, more. Chronic inflammation because of fat deposition, changing how the ovaries respond. If we kind of know this, we can start to work backwards and modifying the stress that we're exposed to, both by what we can cut out, how we deal with acute stress in the moment. And I always say, this extra glucose is freed up, go use it. Go leverage movement to some degree when you have these really, you know, stressful moments instead of stress eating or stress drinking or the typical dopamine hits that people try to seek, which actually worsen your hormones. And then really carving in a modality to get a release from some of these stress hormones each day. Because the body, the brain is so smart to your point. If we never take our foot off the gas pedal, if we never get that kind of release, the brain will go into survival mode and protect you. And if it does get these releases, even if they're small, they can be really impactful where the brain says, ⁓ okay, we had this moment and cortisol was not released and we got calm. Now I can I now know we're not quite in such a dire state as I was led to believe by the hormones that were being produced. That's really important in giving our brain the ability to then respond to hormones that are coming in. And I always say chronic inflammation, which we use a lot, is so important. And I talk about it a lot in the book because inflammation is causing interference on so many levels. And one is directly at the brain, right? It's kind of coming in, a static on the radio, so the brain cannot properly interpret hormones. Therefore, it can't send out hormones appropriately. It's also causing change to how our end organs are going to respond. And it's also influencing egg quality itself. So if we think about the fact that the egg doesn't just have to ovulate, it has to function, it has mitochondria inside of it, it needs to be able to properly divide into having half of its chromosomes, then allowing a sperm inside and everything that has to go on into forming into. an embryo of the sage which it can implant is all determined by the egg. So we want to really think about it more than just, ⁓ I the egg just needs to be released. It actually needs to grow in an environment that also cultivates proper functioning as well. speaker-1: So what are the biggest factors that influence egg quality that we have control over, right? 'Cause I mean clearly there's gonna be some things that we don't have control over. ⁓ like, you know, genetics and maybe our age, like we don't have a lot of control over that. But I guess I guess we have some control over that. I mean, just in terms of when we might want to have a baby. But when like like what types of things can we do to improve egg quality? speaker-0: That's good question. I always like to frame it to my patients that equality is not just one thing or another, right? Genetics are a piece of the puzzle, but so is what I call proper competency of the egg. So this is going to be the combination of metabolic health and how the egg actually can respond and do its function. So as an industry or as a field, a lot of fertility doctors have really simplified that equality equals age. And I think that's a harmful narrative, too, because you do feel like I can't rewind the clock. You know, if I'm already at a stage where I'm older, yeah, tincture of time is already added up. So why even worry about this? And there is truth. And I use the analogy of inside the eggs, your chromosomes are held in perfect position. They are lined up with their kind of match and they're held apart by these meiotic spindles, which are proteins. And the longer we ask them to stay in this perfect position, which is the time from when you're born to when you ovulate, the more opportunity there is for somebody to get out of line. If we act like kindergartners in alphabetical order, If I ask them to stand there for 25 years or 40 years, like more people will be out of line at 40 years. This is essentially what does happen to some degree that we don't have full agency over. But I would say there's a double hit with age because in general, the population gets more metabolically unhealthy as we get older, and chronic inflammation degrades our proteins faster throughout our body, including inside our egg. So the average person as they age not only has just time that maybe some Somebody's gotten out of line because of. They also have less competency of their eggs if they follow the general trajectory of the population because they have had more chronic inflammation for longer, proteins have degraded, mitochondria are not as healthy. And we see this in studies, right? That more mitochondria in women age 38 and older are abnormally shaped, that we see more chronic inflammatory markers and the follicular fluid in women's eggs who are 35 and older. So just on a population-based scale, we know that. There's some level of inflammation that's associated with age. But that to me is the exciting data because that's what you can to some degree control, right? Like we can't rewind the clock. We have to work with the clock. And part of that's understanding it. What causes chronic inflammation and how do we move the needle on that? And before I dive into kind of what I call my like five non-negotiables, I do think it's important to say that. Autoimmune disease and chronic inflammatory disorders add to this puzzle. And earlier we can get to a diagnosis and learn to treat those diseases are super important. So things like endometriosis, celiac disease, Hashimoto's. This is why when we start to get those red flags when you're bleeding through your clothes or your pain is so bad from your period that you can't go to work or go to school, or that you you're not ovulating regularly and you're not detecting it with any of the mechanisms we're determining. Trying to get to the bottom of what's going on can be so important because treating that can change parts of what we're going to say. But let's just act like two people have the same amount of inflammation that they're exposed to day to day. We make little choices that one-offs probably are not a huge deal, but when stacked together, they add up. And this is going to be, you know, how much we sleep or we don't sleep. If we are stressed, we can add to that list. ⁓ if we exercise or build muscle, we can decrease it. If we are in a position where we're eating a lot of inflammatory foods, we're worsening it. If we're exposed to a lot of toxins in our environment, you know, we can suddenly then be in a position where not one of these things maybe cured or caused your infertility, but altogether they're raising what we call your inflammatory burden and making it so that your body can't do these normal functions like ovulation or growing your eggs in the perfect environment or it's impacting their mitochondria. Because it's so busy trying to deal with that inflammation. Because your body is meant to have this acute response in the inflammatory system. It has an insult, it goes in, wants to fix it, and then inflammation goes back down. And chronic inflammation, this constant activation of your immune system, takes a lot of resources. It also takes away from how your body is supposed to function. And so when we think through those five: sleep, stress, movement, diet, and toxins. These are opportunities for us to say, how am I going to lower my inflammatory burden? And I like to think about it as trying to build resilience within our body, meaning we don't have to be perfect every day. And that's not where we won't have this list of rules and I can never do that. But it's to lower that day-to-day inflammatory burden as much as possible so that we have the resilience to tolerate life. Meaning some days you won't sleep or you will get sick or You'll want to have cake, or there'll, you know, be something that goes on that causes you to have more stress. We are not going to be perfect every day, nor is this an all or nothing mentality. But it's about if all of our little decisions matter, the sum of them matter, we should at least be in the position to know these and influence w the how we make decisions versus just the mindlessness to what so many of us do. This is just the shampoo I use, or this is just. I I function off of five hours of sleep and we just let ourselves be in that place that's actually harming us in the long term. speaker-1: Yeah, and I think that so many women are led to believe that the only thing that really matters with their fertility is their age. Right. And there's this idea that your fertility, you know, peaks at a certain age. And ⁓ in the evolutionary literature, you know, when we're talking about humans, we generally talk about the peak from the literature I'm in. It'll be interesting to see how it differs or is similar to the literature you're in, but that it peaks, you know, in your mid-twenties and then it's twenty five to thirty twenty-five to thirty, and then You know, it begins its slow march down with its ⁓ decline being much more precipitous after thirty five or so. And so we hear this and and then we think that it's totally out of our control, right? That we have no impact, ⁓ anything that we do doesn't have any sort of an impact on our ability to be able to get pregnant later in a later in life or or whatever it is. And ⁓ what I liked about your book and I also like what about what you just said there is that it really does give us with some, you know, give us things that we can do. Right. And and and not in a way that's like overly you know prohibitive where all of a sudden your life is made completely miserable because you're trying to mind your fertility. And it's just really a matter of taking care of the basic building blocks of good health, which is you know, sort of sleep and avoiding toxins, making sure you're moving your body, eating real food, and and and allowing yourself to be able to, as you noted, if you want a piece of cake, which I frequently do. ⁓ like y you have one, you know, and ⁓ because joy also is you know part of the equation. Yes. speaker-0: I think it's just it's, you know, when I view how do you take control of your reproductive health, right? To me, there's three big things I want people to think about. You know, when somebody people will be like, ⁓ well, there's no formula to fertility. And I'll well, you know what? We have to educate ourselves because you've got to know what's normal to know what's not. We have to learn how to advocate for ourselves because as women specifically, we have often been gaslit when we experience certain symptoms. Therefore, we start to doubt our own body. So we have to learn how to listen to our body. And how to advocate and say, I know I need this, or really feeling confident saying something's not right and I need help here. And the third piece is optimize because your body is meant to respond to the world around you. I almost am gonna be like, it's wild to me that people wanna sit here and act like, ⁓ just do IVF, nothing else matters, which is something commonly said in in my field. And we say, even with IVF, I'm working with the eggs and the sperm that you give me. And you and I talk about all the time, your body is literally responding to the world around you every single moment of the day. And so of course, these decisions that you make, you should at least be making them from a place of knowledge, right? And not saying, ⁓ I'm eating the cake because I'm stressed and I'm trying to really, you know, fix my stress response instead of which actually worsens insulin resistance, right? If you have more glucose in your bloodstream, then you eat cake, you raise it more, you're gonna have more insulin, more inflammation. Instead of saying, I'm so stressed, I really want cake. Well, you know what? Glucose was just freed up from my liver, so I could go run from the bear, but there is no bear, so I'm gonna go for a five minute walk. Like that knowledge right there is going to allow you to leverage your own physiology, making an active choice that's really smart. And then if you come home and you still want cake, have cake 'cause it makes you happy, right? Yeah. speaker-1: No, it and it's it's it's it's so interesting because I think that like when we medicalize things, right, and in including conception, ⁓ that there is this tendency to like almost remove the self, right? Where it's like, well, ⁓ okay, well, I'm doing IVF, so it just doesn't matter anymore. So, you know, I don't need to sleep and I don't need to eat well. And it's like, no, ⁓ as you noted, it's like your your success rate is only as good as the cells that you get, right? And the cells the quality of the cells that you get is gonna be influenced by the behavior of the organism from whom they were harvested. Absolutely. And so so I got another ⁓ and it's it's a related question about like are the factors that influence the quality of eggs the same types of factors that influence the quality of sperm? speaker-0: They are, with the only exception being that since sperm are more sensitive to heat because the scrotium is outside the body, because it sperm need to be created in a lower core body temperature. So whereas, like I will get asked every single day about sauna use. So whereas using the sauna, if you're a woman, you're trying to get pregnant, is not going to harm your egg quality in any way, potentially could be advantageous for lowering stress or other mechanisms. But for men, we don't want men, you know, we don't want your partner to get in the sauna with you. Because raising the temperature of the scrotum is going to dramatically change the sperm, the sperm quality. But outside of that one variable, which makes sense because the testes are outside of our body, well, our ⁓ ovaries are inside our body at a higher body temperature, everything else is really the same, right? Meaning eggs and sperm are a really similar cell at their core. I mean, the sperm have a cilia flagella because they gotta go somewhere, but their job is meant to. Protect the chromosomes that are inside of it. It's largely chromosomes inside, you know, cytoplasm. The egg has a mitochondria, but really they're influenced by so many of the similar things. So those five kind of five basic principles. Sperm are much more sensitive than eggs, right? You're born with eggs. They've got to live in your body your entire life until you run out of them. So they're a little bit hardier for lack of a word, but they are more sensitive to the world around you in about the 60 days before you ovulate. Sperm have a 72-day lifespan, then it takes them about 18 days to get outside the ejaculatory system. So we simplify it to be three months. The nice thing about that is being so sensitive is that truly one single change for a man can be the make or break it. The top one I see in clinical practice right now is cannabis use. In addition to how cannabis is impacting, you know, brain and just production of sperm, we also see just dramatic impact on the fragmentation of this DNA inside the sperm head. To the degree that men who use cannabis, their partners have a higher rate of miscarriage. And then that can be reversed by if they stop cannabis for three months and then try to conceive again. So it is I see that in clinical practice every single day. And to go back to the point we said earlier, even with IVF, I can only work with the eggs and sperm I'm given. So when I sometimes have an IVF outcome, the egg controls fertilization. speaker-1: Yeah. speaker-0: The egg controls the first three days of embryo growth. The male genome kicks in on day three. And then it's both egg and sperm factors that get us to the implantation stage of oblastasis on day five or six. When I see embryos that just totally stop developing on day three, go back to a couple and say, Hey, is there a male factor involved? You know, nine times out of ten, there is cannabis use that has not been disclosed in the male partner. And if we stop that and then redo a cycle after a couple months, we're in very different outcomes. But I mean, IVF is very expensive, emotionally, physically draining, takes up a ton of time. And of course, we would rather go into it optimizing those cells beforehand. And that's why part of this discussion before we're really trying or before we're doing fertility treatment is so important. We think about how our body is made. speaker-1: Sometimes there's female infertility, right? There's male infert male factor infertility. ⁓ and then like w and then there's unexplained infertility. Is that right? Are those like the big categories like speaker-0: I mean also tubal factor and ovulation. So but those will go into female. So you can say fifty percent female, fifty percent male, and unexplained infertility is the bucket of happens, you know, twenty to thirty percent of the time. What it means to cut your question off is that you ovulate, the anatomy is normal, right, and the semen analysis is normal, yet you're not getting pregnant. speaker-1: So what is your theory on what's happening there? speaker-0: I view unexplained infertility as undiagnosed infertility, meaning these other things we listed out are easy to test. We it's easy to test if you're ovulating, it's easy to test anatomy relatively, it's easy to do a seam analysis. So those are capturing the majority of people. When you're falling outside of that, the majority of unexplained infertility is related to chronic inflammation, some type of chronic inflammatory disease or environmental exposure. Whether it's endometriosis or adenomiosis, whether it is ⁓ an autoimmune disease, whether there's just this inflammatory burden, you know, the cannabis use situation I just explained would officially fall into unexplained infertility. And sometimes fertility doctors will often say sometimes IVF can be diagnostic, meaning we just get more data points. We get to see what happens with fertilization, we get to see how the embryos grow. We're controlling more. Because we're taking inflammation out of the lab. So we can see how do embryos grow when they're most sensitive in this pure environment. But it's not everything. It's gonna get us our highest rates of conception. IVF's incredible is the only thing that's gonna exceed natural conception rates. But even with a genetically normal embryo in the perfect person, you know, we only have a 65% chance of live birth. Now that cumulatively can be higher with multiple transfers. But that tells us there's a lot still that we don't understand when it comes to reproduction, even when you're doing IVF, it's by no means a guarantee. But a lot of people with unexplained infertility get pushed towards IVF faster because that's the research suggests that it's one of the only things modifying the environment. And if we think there's inflammatory factors involved, simply giving you meds to help you ovulate if you're already ovulating, well, that doesn't change anything. Or, you know, putting the sperm in the uterus as opposed to having it be in the vagina. We already have normal sperm count. So that doesn't move the needle much. So a lot of unexplained infertility, the lesser aggressive treatments like ovulation induction or IUI don't really improve conception rates, but IVF does because we are changing the environment to such a degree. That being said, I think there's a lot of endometriosis. It's gonna be the top cause. 50% of unexplained infertility is probably due to endometriosis that's not been diagnosed. And We can admit that endo is a really hard diagnosis to get. It's a chronic inflammatory disease where your body's having an autoimmune reaction to a normal process. So those endometrial implants are outside the body and they cause a lot of inflammation. Women will suffer with terrible period pain or symptoms of chronic inflammation on average seven to ten years before a diagnosis. And the reason why it's so hard is the gold standard of diagnosis with a laparoscopy, so a surgical evaluation. And of course, that's just a lot tougher than a blood test. I do think we're seeing a lot. Luckily, you know, women women have so much power as the population of driving change. So we're seeing such a narrative now where women are saying, I'm not going accept this anymore. They're talking about their endo. We have more people coming to the table. That drives more research dollars. Ultimately, you know, what the public is interested in tends to drive what research we do, also. So I think. Or I'm hopeful that you know in the next decade we'll see a better way to diagnose endo than what we see now. Sometimes we can see it on imaging, but not always. And I think that will really change the ballgame for people who have unexplained infertility to be able to narrow in on what is happening that's probably causing inflammation that's contributing. But this is why lowering that inflammatory burden improves outcomes even with unexplained infertility, because That's something that's probably under the surface brewing, contributing to this puzzle. speaker-1: Yeah, it's really crazy to me that ⁓ endometriosis still is like it it's it feels medieval the way that we that we have to diagnose it, that you have to do the surgery. And then when my niece who has endometriosis who is just diagnosed, and as you said, it's one of these things that even having me as her aunt and saying, like, hey, you know, this sounds an awful lot like endometriosis, ⁓ it took her five years to get diagnosed, and then when they diagnosed her, they just ⁓ you know, they did the surgery to get a diagnosis and then she's gotta have another surgery if she wants to have speaker-0: That's the least that's my least favorite one. speaker-1: I mean, yeah, it's just it's just it's just the worst. And ⁓ and so I'm like you, I I remain hopeful that increased interest is something that's going to ⁓ lead to better diagnosis for you know, for for women and and sort of shorten the window a little bit. ⁓ speaker-0: It's important to say just real quickly that nobody is has to feel compelled to share their own personal story, you know, with strangers on the internet. But that when you do, it really is huge as far as breaking stigma and increasing awareness. Because so many people, especially when it comes to pain, are told in narrative that they just have a poor pain tolerance or that they must not tolerate something well. And not till they hear other women sharing stories and talking about this, do they realize, ⁓ That sounds a lot like me, and maybe I should go get help. So when people do feel compelled to share, it really has such a domino effect of how impactful it can be. speaker-1: I think that's very well said. I think it's very true also. ⁓ I wanna ask you about younger women. ⁓ and I so I have been hearing from twenty-year-olds now, like in women who are in their twenties, where they're being encouraged to start freezing their eggs now, ⁓ because ⁓ presumably egg quality is going to be higher ⁓ when you're younger compared to when you're older. ⁓ what should women be doing? Is that necessary? Is is it too much? ⁓ at what like at what point Can you be are can you be too proactive with your fertility and and sort of planning about, you know, when you want to have children or if you want to have children? Like what what kind of advice would you give a woman, like let's say that she's in her mid twenties, she doesn't have a romantic partner, she knows she wants to have children someday. Like what what how should she go about her life and and and sort of her fertility journey, like planning? speaker-0: It's really good question. I think there's not a one size fits all, but what I think is really important is to say, I think it's important to at least, if you want to have children one day, of course, all the things we talked about that can improve egg quality, the sooner you start to implement those as part of your lifestyle, the longer it appears you're going to have good ovarian function. So let's leverage that. But also get your ovarian reserve checked. There's a blood test called AMH, which is going to be an estimate of how many eggs you have available. It's not a perfect test. It's not Telling you if you're fertile or if you'll have infertility. Because of that, there's a lot of nuance and recommendation about it. But what I find is that if you find out your AMH is low, and we know that a low AMH is so associated with certain environmental exposures, but also an autoimmune disease, for example, endometriosis, these things can cause a lower AMH at an earlier age. You will have less time to intervene. And that is the person that would want to freeze her eggs in her 20s. So we never want to sit here and say, ⁓ you can just wait till later because there will be one-offs who are going to fall outside this realm, especially as we see more autoimmune disease. That detecting this earlier for a young woman who wants to have kids one day is going to put her in the position to at least make the decision for herself. And she may say, ⁓ I talked to the fertility doctor and I learned about it, it's not for me, or I'm actively choosing not to do this. But then you made the choice, not having time make the decision for you. And I think that that's really important. If we want look at cost effectiveness studies, now of course those are nuanced because cost isn't everything. But cost effectiveness studies leverage the likelihood of you needing to use the eggs based on average fecundability rates, when based on if you're ready to get pregnant at what age, et cetera, et cetera, and what happens on a population, would show that for the average woman, if she's not ready to get pregnant by 31 to 32, then that is a great time to go freeze her eggs because they tend to maintain good quality. Yet she's at a place where the odds of her needing them are increased. And meaning that study saying the money you spend on this is worth it because you're probably going to need them to grow your family. At a younger age, we don't know that because maybe you don't need them or not. That being said, I think if you know you're on a pathway where you say, I'm going to med school or I'm doing this, and ⁓ of course I'm gonna be 31, 30 if I'm not gonna be ready to have a kid yet, then. Yeah, if you're at a place in, you know, your mid-20s, maybe it makes sense for you to just put eggs in the freezer at an earlier age where you will get more of them and they will be better quality for the most part. It's not hugely different between 25 and 30. But if your parents are willing to pay for it at this stage, you know, versus you paying for it later, it could make sense. I think all of us who are fertility doctors have have, I won't call them one-off cases, but enough one-off cases of women in their 20s who end up going into premature ovarian failure. That it makes us nervous giving a blanket statement of saying that the 20s are too young. Because for some women, it might be their only shot. So I think that getting the data about your own body is the key here. And I'm a huge advocate for my friends who are OBGYNs and you go in for your annual. They say, Do you want to have kids one day? ⁓ no, what do you want for birth control pills? Saying, Hey, can I check my AMH or can I see what my ed count is? And understanding that if it's slow, you're gonna have to come see a fertility doctor. They're not gonna be the person to help you work it up. But that's really important because then you can play a more active role in one, getting to the root cause. Why is it low? That you may have an autoimmune disease. You might get your Hashimoto's diagnosed right now. But two, thinking about how that's going to impact your reproductive future and you might change your game plan once you get that data. speaker-1: Yeah, I think it's so interesting, like when when you say that, it occurs to me it like occurred to me how dumb it is that we don't do that now. You know, like I never I never had, you know, and I I went I was in a PhD program and I I ultimately ended up ⁓ I decided to have my first child when I was still finishing my PhD because I wanted to have my first child before I was thirty, just because my mom went into early menopause and I was concerned that I wasn't gonna be able to have the family of the size that I wanted. ⁓ and so I was just like, you know, I whatever, you know, I'm gonna throw caution to the wind and fig and just figure it out. And and you know, I was able to do that. But ⁓ all of my doctor's appointments, like my well-woman visits, were all about ⁓ you know, making sure I had birth control, but not so much ever asking any questions about ⁓ my fertility. Like I ⁓ I had my own internal knowledge about my mom's, you know, early menopause. Nobody asked me about that. No I mean, you know, and and and that would have been important information to have. And and I think that that is so smart and and for especially for women who ⁓ you know, if you're in your late twenties even and you're thinking that maybe you want to have children one day, or you just don't know whether you want to have children one day, that you can ⁓ ask your doctor about taking ⁓ you know, getting some of this blood work done that might be able to give you some insight into ⁓ whether you might want to, you know, What what types of steps you might want to take to ensure your fertility when you're ready to have a baby? Absolutely. So ⁓ I want to talk about your amazing book, The Fertility Formula. And I want to ask you ⁓ what inspired you to write the this book? And then also like what are some of the things that ⁓ you just like really hope that readers are able to get, or like what are some of the things that that readers can find in this book? speaker-0: Sarah, thank you. And I'll say a lot of the stuff that we barely touched on, you know, we do go into much more detail in the book. The fertility formula is really inspired by, you know, my own journey. I had multiple pregnancy losses despite being an OBGYN and in fellowship at the time. And I felt dismissed and was told there was nothing I could do and that it was bad luck. And decided to go against the normal tidal wave of fellows who do IVF lab research. And I studied fecundability and natural fertility, and I really wanted to know. Why some populations of people got pregnant and others had a harder time. And we looked at vitamin levels and ovarian reserve and environmental chemicals and really saw that, you know, inflammation was all over that literature, even though day-to-day as a doctor, it wasn't something we talked about unless we were talking about a true disease state. And it really made me start thinking about the fact that inflammation predates, you know, disease and symptoms. And if we start thinking about infertility on a bigger scale as a symptom, as that red flag, like we talked about, how do we try to make that you know, less common slash how do we take control if we find ourselves in that position with the questions that I had as a patient at the time, right? The things that I can do and how to give those tools to women and the patients that I sit across from every single day. You know, the one thing I always say is, I want to give you data and you make decisions. That that's how it is. But you shouldn't be making them from a place where you don't know the fundamentals to make the decision from. And I have sat across from women my entire professional career who said, if I'd only known that, I would have made a different choice. And that is the statement I want gone. I want you to sit here and say, I made the best choices I could with the data I had, and this is where we are because of it, and feel confident moving through your reproductive life because it impacts not just your ability to get pregnant. And yes, kids can be a huge life goal for so many, but also to feel your best, to feel like yourself, to have your best life, your longest health span. And women deserve that. So that's really what the fertility formula is to me. And it's hopefully my, you know, little toolbox to give people so that they have access to this information. speaker-1: That's awesome. And I'll say that it also I love your little science nuggets and boxes where you have like the results of research and ⁓ I really appreciated that. Dr. Natalie Crawford ⁓ and the fertility formula is available now and I encourage you to pick it up. It will be even if you're not thinking about getting pregnant just yet, ⁓ and you just wanna make sure that you're ovulating regularly, this is going to really ⁓ be something that's gonna help you move your move the needle in terms of ovulation. So Thank you, Doctor Crawford. Wonderful to see you as always. speaker-0: Great to see you. Thank you, Sarah. speaker-1: Alright bye. And that's it for today's episode of the XX Lab. If you want more, subscribe wherever you get your podcasts. And if you're enjoying the show, a rating or review helps other people find it. See you next episode.