transcript

Speaker 1:
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Speaker 2:
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Speaker 3:
[00:58] What's going on, everybody? It's episode 569 of The Genius Life. Let's go. The Genius Life. What's going on, everybody? I'm your host, Max Lugavere, and welcome back to The Genius Life, the show where we cut through the noise to get to what actually moves the needle. Today, we're diving into one of the most important and increasingly misunderstood topics in modern health. Fertility. Rates are falling. Sperm counts are dropping. More couples than ever are struggling to conceive, and most are being told to just try for a year before anyone looks under the hood. Meanwhile, we're living in a world of ultra-processed food, chronic stress, poor sleep, and environmental exposures that our biology simply didn't evolve for. So, what's really going on? Well, in this episode, I'm joined by Natalie Crawford. She's a board-certified reproductive endocrinologist and author of The Fertility Formula. We unpack what actually matters when it comes to getting and staying pregnant from metabolic health and insulin resistance to sperm quality, environmental toxins, and the often-overlooked role of lifestyle. We also get into why fertility may be one of the earliest warning signs of overall health, how modern life is quietly working against reproduction, and what most couples aren't being told before trying to conceive. This was a wide-ranging and at times eye-opening conversation. Whether you're actively trying to conceive, planning for the future, or just want to understand how your daily choices affect your long-term health, there's a lot here for you. So listen all the way through to the end. You're not going to want to miss a beat. And as always, don't forget to share this episode with friends and loved ones that you think may benefit from it. And now with all that out of the way, here's episode 569. Let's rock. Dr. Natalie Crawford, welcome to the show. How are you doing?

Speaker 4:
[02:50] Thanks so much for having me. I'm good.

Speaker 3:
[02:52] It's so fun. I'm excited to talk about all things fertility to celebrate your new book. It's a big topic. Headline from numerous publications that I saw that have gone seemingly viral. The US fertility rate dropped to another record low in 2025. What do you think's going on?

Speaker 4:
[03:11] I think there's two things going on. One is that we have a rise in infertility. It's definitely getting harder to get pregnant. But the second is it's not really a social climate where a lot of people are ready to get pregnant, whether it's economics, whether it's relationship status. We see more people delaying having a family. Women are getting pregnant at older ages. We know it gets harder to conceive as you get older. But we can't disacknowledge the fact that the world is more inflammatory. We have more toxins in our environment. We know there's a drop in sperm counts. So I think we see both people choosing not to get pregnant, and also it being harder to get pregnant when you want to.

Speaker 3:
[03:49] Interesting. When it comes to the environment, what would you say are the most nefarious players in terms of our exposome?

Speaker 4:
[03:57] There's actually a lot of different things at play. We see a lot of focus on endocrine-disrupting chemicals lately, rightfully so. And I often have people take this stance of, well, I can't control everything, so I'm not going to control anything, this all-or-nothing approach, right? But in reality, we're going to be exposed to endocrine-disrupting chemicals every single day. The way I want people to think about them, right? They mimic our hormones, which is not a good thing. Your hormones are a communication system between your body. Many of us don't realize that our brain doesn't really see what's happening in our other organs, right? Your brain doesn't know what's happening in your testes, or myovories, or adrenal glands, or a thyroid. It's relying on hormones to come back and talk to it. So if we have endocrine disruptors in our system, whether it's phthalates, or perfluorinated chemicals, or BPA, these are mimicking hormones, binding to our hormone receptors. Think about it like static interference in the radio. Now the brain can interpret them properly, or send out them properly. So we get dysfunction in that normal communication system. These are pervasive in our environment, especially in our food, in our food, in our water, in our kitchen, the utensils we use, what we cook on. We're starting to have more focus on this. We saw the Netflix documentary, the plastic detox.

Speaker 3:
[05:12] I haven't seen it yet, but I've heard good things, yeah.

Speaker 4:
[05:15] Okay, Shana Swan's lovely, right? Has talked a lot about sperm counts decreasing, more than 50% in 50 years. The point of this documentary was thinking about looking at six couples, a very small sample size. And they said they had unexplained infertility. I'll push back on that in a second. But the idea was, let's see if we take plastic out of their life in ways that maybe they don't realize, whether it's in the kitchen, if it's in their clothing, if it's in food packaging, to-go containers and see what happens over the period of 12 weeks. And many of the couples had decreasing levels of these endocrine disruptors in their blood. And then some of them got pregnant after they'd not been able to. The one thing about it though is they said these six couples had unexplained infertility. That by definition, which we can debate that, but that by definition means that you've been trying to get pregnant for a year and you have not. You ovulate, normal female anatomy and normal sperm counts. So they're trying to be a little sexy with the same plastics cause unexplained infertility. But five of the six couples actually had low sperm counts. So it's still a very important point. Sperm are highly sensitive to the environment. You know, men make 1,500 a second, a second, a second. They make so many sperm every second because they are so sensitive. You need a ton of them to get the job done. But the other great thing about sperm is that they're constantly being made. So you can make 1 change right now, get rid of all the plastic or stop smoking or stop cannabis or whatever it is. And 3 months from now have a completely different semen analysis. And that's very powerful. That's not something that female have quite as much agency over as men do. So when it comes to these endocrine disrupting chemicals, back to the first point, a lot of it where I tell patients to focus is in your home, where you spend the most of your time. I can't control what's in your home. I'm here just for a couple of hours. But the things in my home, what I cook with, what we eat food off of, our own water quality, the products I use on my face, in my shower, and my kids use, these are things that I can control. So we want to control what we can, making good decisions the majority of time, so that we can not worry about it when I'm at your home or a restaurant or I'm traveling, because we can't control everything.

Speaker 3:
[07:29] Yeah, you're so right. And it's impossible to eliminate all exposure today. But what you can do is you can reduce your exposure meaningfully.

Speaker 4:
[07:37] Meaningfully. And this idea that, well, if I can't get rid of all of it, I'm not going to worry about it. It's not serving us. Chemicals are not being regulated. We're just seeing increasing levels. And there's a clear association with making it harder to get pregnant both naturally and with IVF, with a decrease in sperm counts, decrease in egg counts and egg quality. So we want to think about fertility on a broader scale than just can you get pregnant right now. It's really a representation of your body's metabolic health, your hormonal health. And of course, we all want to be as healthy as we can. And this is a modifiable factor.

Speaker 3:
[08:10] You think we're just running like a giant human experiment?

Speaker 4:
[08:14] Of course we are.

Speaker 3:
[08:15] With like the ultra-processed foods, the microplastics, the endocrine disrupting chemicals.

Speaker 4:
[08:19] Absolutely. We have a culture where we introduce things into our world because they're convenient, easy, cheap, right? And then we wait to see what happens. Instead of studying, could this be good or bad for us, before it's introduced? That's exactly what's happened with food. We see this with chemicals. We see this with toxic substances, like cigarette smoke, right? It's introduce it first because it can make you money. This is corporate America, right? And then see what happens later. But we are all in a big experiment and we have to start treating our body like our own in of one experiment and taking care of it.

Speaker 3:
[08:53] What are the biggest sources of exposure to these types of chemicals?

Speaker 4:
[08:58] I think it's gonna be in your kitchen, for the most part, is where we are constantly exposed and we're not thinking about it. So let's break down. First, plastics. And I do think most of us think about that. But especially if you have children, I mean, I have kids, so many kid products are still marketed plastic when it comes to plastic cups, plates, bottles. We really wanna be transitioning over to stainless steel, to glass, especially if it gets heated. We know when plastic gets heated, that's when the chemicals leach into the substance, whether it's liquid or food. It's cutting boards, anything that's plastic, I tell my patients, just get it out of your home. You don't have to replace everything at once, but get one stainless steel pan, right? Or get one bowl that you can use for mixing. Teflon and nonstick also has PFCs in it, which are those forever chemicals. They stay in your body and they build up. So we wanna have stainless steel or cast iron. I think one of the biggest offenders right now is to go containers for food. People over eat and they're door dashing and they're getting food, obviously, because they have busy lives. And we don't control that food or how it's prepared, we know that. But we really should take it out of the container immediately and put it into a different dish to eat off of. I know we all don't wanna do dishes, so we're trying not to do that. But the plastic container the food is in is just leaching into that food. So if you sit there in front of the TV with your plastic container, we're just exposing, letting more chemicals get in that food than we need to. So just transport it to a different dish. That's one easy thing that we can do. And then back to the ultra-processed foods. Those wrappings often have chemicals in them as well. Even healthy foods that are processed and put in wrappers. And this is why, especially when you're in your home and you're in control, we should be reaching for whole foods, things that aren't in wrappers, where you have more control over the type of quality of the food that you're eating. And the last one here is gonna be water quality. Right? A lot of people think bottled water is better than tap water. I think we have well established now, or hopefully people know that's not really the case. Many bottled water is just tap water, except it's put in a plastic bottle, shipped on truck, stored hot, bad for you. But you can actually check the water in your own area. You can go onto the EPA, you can search in your zip code, you can see what is in your tap water, and what type of water filter do you need? Do you need a reverse osmosis filter? And even taking the time to get that into your tap water, now you know you have safe drinking water, similar to an air filtration system in your house, right? Just getting an air filter that can sit in the rooms that you're in the most. This is where you spend the majority of your time and poses the greatest opportunity to make a positive benefit in your health.

Speaker 3:
[11:44] I love that. Yeah, I was just reading, there was like a huge report put out by Greenpeace recently. I don't follow necessarily what that organization puts out year to year, but the report, it was like a systematic review of all of the research looking at our various exposures to microplastics. One source of exposure that it flagged in particular that I think is very common is microwaving, like reheating foods in plastic containers and the wrappings, as you described, like the grease-proof wrappers, that often you'll get like a sandwich delivered in or like a burger served in. Yeah, like I think microwaves are great, but it was just shocking the degree to which there's really rigorous, it's almost incontrovertible at this point that microwaving food in plastic wrappers transfers these particles into your food.

Speaker 4:
[12:40] There's so much data that it's shocking. We're seemingly just having this conversation now. 12 years ago, when I was in fellowship, I was doing a research project, and many fellows who do a reproductive endocrinology fellowship, they do IVF lab research. It's a more controlled environment. And I was very adamant. I said, I want to study natural fertility. I want to see why some people get pregnant and why others don't. I got a master's in clinical research so we could understand trials. And so in this, I was studying vitamin levels and endocrine disrupting chemicals. And I did a paper, a big study, with the EPA looking at endocrine disrupting chemicals, PFCs specifically in North Carolina, and their outcome in ovarian reserve and getting pregnant. And I remember just being disgusted by the amount of high quality data showing how harmful these chemicals are to us. I was having my own infertility journey at the time, had many pregnancy losses. I remember my husband came home from work and cleaning out our whole kitchen thinking like we had plastic Tupperwares, Teflon, all the things that were starting to have more conversation about removing. And I couldn't believe I was going through all the papers. Like this is well demonstrated, yet why don't we know about this, right? And goes back to this idea that just because something is difficult or requires somebody to make a change or isn't news they want to hear doesn't mean they don't deserve to understand that information because you can't make decisions on data you don't know. We deserve to be presented with educational information about what's happening to our body and the world around us and then let individuals choose what they want to do with that information.

Speaker 3:
[14:16] Amen. Well, what do you say to skeptics who are like, you know, just raising the flag, raising the concern is fear mongering, it's alarmist. Like, what do you say to those people?

Speaker 4:
[14:26] I probably hear that every day, right? That this narrative is making people blame their infertility on the choices they're making. I take the other approach as somebody who walked this journey as a patient and as somebody who takes care of people. The unknown is the scariest thing that you go through, doubting every single thing that you're doing. Is this hurting me? Could this be helpful? There's very few neutral choices in our life, whether we realize it or not. Most decisions we make can improve our health or harm it in some way. There's no one single thing that's going to make or break it when it comes to you getting pregnant. But the sum of these choices can add up really significantly to benefit your health or to hold you back. My information is not to tell you this is the list and if you don't do this, it's all your fault. But again, to say these are actionable items that you can actually do. And I don't think that's fear mongering, that's empowering because there's so much you can't control in this life. When you tell somebody these are modifiable factors, do with this what you will. Now the power is in your hands instead of sitting across from me saying, well, had I known that, my girlfriend and I would have done something different all these years. Right?

Speaker 3:
[15:35] Gives you agency.

Speaker 4:
[15:36] Exactly.

Speaker 3:
[15:39] I've been thinking more about inflammation lately, especially in the context of long-term health. The challenge is that chronic inflammation is often silent. You don't feel it building, but over time, it's associated with things like cardiovascular disease and metabolic dysfunction. Now, there are a few markers that can help bring it into focus. HSCRP is one of the most well-validated indicators of systemic inflammation, and even modest elevations can be meaningful. Glucose and insulin matter, too, since blood sugar dysregulation and inflammation tend to reinforce one another. And vitamin D. Low levels are consistently linked with higher inflammatory activity. That's why I love Function. It gives you access to over 160 lab tests per year so that you can actually see trends in inflammation, metabolic health, and more, rather than guessing. If something starts moving in the wrong direction, it gives you the opportunity to address it early. Check your health with over 160 lab tests per year for $365. You can also explore your results with tools you already use like ChatGPT and Claude. Visit functionhealth.com/max and use code MAX25 for a $25 credit toward your membership. Again, that's functionhealth.com/max and use code MAX25 for a $25 credit off your membership. Enjoy. I'm about to tell you about one of the coolest contraptions that I've picked up recently. But first, food waste is one of those environmental problems that almost nobody talks about, but it's actually massive. In fact, food waste contributes more to climate change than a lot of things people argue about endlessly online, even more than eating meat. And the wild part is, most of it happens at home. That's why I love Mill. Mill is the odorless, fully automated food recycler that lives right in your kitchen. Every night, I scrape plates, potato peels, avocado pits, chicken bones, dairy leftovers straight into Mill. No smells, no mess, no fruit flies. While I sleep, Mill quietly transforms all of that into shelf-stable grounds. What surprised me most is how much cleaner my kitchen feels. The trash doesn't stink, I don't have to take it out constantly. Even fridge cleanouts are less stressful because I know that food isn't just rotting in a landfill somewhere. Mill can handle up to 10 pounds overnight, it works for weeks before needing attention, and you can use the grounds in your garden. Or Mill will even pick them up and get them to a small farm. How dope is that? The app also shows exactly how much food you're keeping out of landfills, which honestly feels great. If you want to reduce food waste without turning your life upside down, this is one of the easiest wins I've found. Now this episode is sponsored by Mill, and you can try out Mill risk-free for 90 days and get $75 off at mill.com/genius and use code genius at checkout. That's $75 at mill spelled mill.com/genius with code genius. Again, the contraption is dope, and if you have kids, they're going to find it super fun as well. Enjoy. I don't think anybody would expect a fertility expert to have gone through their own fertility challenges. What can you share about that?

Speaker 4:
[18:27] Well, it was terrible. It completely changed how I practiced medicine. I was at the end of my OB-GYN residency, so you do four years of OB-GYN and then three years of fertility to be a fertility doctor. And my husband and I decided to start trying. And this is after years of what I think many people go through, because we've been together for a long time. When should we have a kid? When will be the right time with my job? Really, you know, preventing pregnancy for an extended amount of time. And then finally deciding this is the right moment. And I remember our first pregnancy loss. I was so clinical about it, Max. It's like, oh, one out of four pregnancies end in loss. It's not a big deal. Next one will be fine. It's better that it didn't work out. Something was wrong. And I remember the second pregnancy loss. I was actually in charge of labor and delivery. So I was the chief resident in charge. And I was further along and I started bleeding in the bathroom while I was working. And it was the era where nobody knew I was pregnant. Couldn't go tell somebody was not okay to leave my job to go do anything personal. Which hopefully times have changed in medical training. But I remember just kind of like bottling it inside and being devastated but going on and delivering babies that night. And then going home, pulling over my car, like throwing up on the side of the road because like the cramps were so intense and I sat there thinking, I've walked with so many women through miscarriage, but going through it yourself gives you such a different perspective. I went to my doctor after that and I said, okay, I've had two pregnancy losses, something's wrong, let's test. And I was told, well, we don't worry about it until you have a third pregnancy loss. So just must be bad luck, keep trying. And that was such a hurtful thing to hear. True or not true? It just felt so dismissive. I had questions and concerns and they were just brushed aside and really felt like, oh, I haven't failed bad enough to even get testing. Like to even get data about my body or about my husband. Isn't that crazy? And that's really a big premise of the book. But just in general, we have to understand, infertility is defined as trying to get pregnant for 12 months and not having success. Why? It's just population-based averages. Like when do you start to fall off the bell curve? And of course, infertility rates are rising. It was one out of eight a decade ago. We now say it's one out of six. It's actually one out of five for couples trying for the first time in the United States, meaning one out of five couples, 20 percent will not get pregnant in 12 months when they're trying. And then, and only then, do we now recommend a medical evaluation to see how's your sperm, or how many eggs does your girlfriend have? Are her fallopian tubes open? Is she ovulating? Things that can sometimes take a long time to resolve, sometimes can never be resolved and need intervention much earlier. And so why do we make you fail before we do any testing at all? I felt that personally and I feel that professionally too, that I should not be the gatekeeper to a patient wanting to get information about their body and about their health, regardless of what the medical definition of a word might mean. I don't think it serves us in the time where the world is more inflammatory, and we have more chemicals, and people are waiting longer, and birth rates are dropping, and infertility is rising to say, well, Max, I'll see you in a year when y'all don't get pregnant. Until then, just don't worry about it. But that's the message many patients are hearing. It's the message I heard. I hadn't failed bad enough. Lost the third pregnancy, got testing, everything was normal. I was told it was unexplained recurrent pregnancy loss. Lost a fourth pregnancy. I was told IVF was the only option. And I wasn't opposed to IVF. I do IVF every day. It's miraculous. But I couldn't do IVF because I was the IVF fellow. At this point, I was in my fellowship, and my job was to be the person there every single day, doing ultrasounds, doing procedures. I couldn't take time off to go through it myself. I needed to wait till that year was over, which I always wanted to be a doctor. I was fine with that. I said, okay, fine. But if I have to wait these six months, what will make my odds better? Surely, there's things I should be doing to prepare my body that can give me a higher odds of success. And the message I heard then was, it doesn't matter, just do IVF. There's nothing you can do that will change the outcome. I didn't believe it, right? Because even with IVF, I can only work with the sperm you give me, the eggs that I get. There have to be these extrinsic factors. And that's really why I said, I don't want to study IVF. I want to study why populations of people get pregnant and not. That's why all of my research was about what we call fecundability, natural fertility, and looking at these different groups. And that's really where I started to see the word inflammation in the literature over and over again, which luckily now we see talk about inflammation across many specialties. How many people have you had sitting across from you talking about chronic inflammation and whether it's gut health or cardiac health, right? We're talking about it a lot right now, which is incredible because that helps educate the general population. But back in that time, over a decade ago, we really only talked about inflammation in the disease state. We never talked about it predating disease, which is what we're really talking about now. This constant brewing activation of your immune system, fighting off the inflammation that you're exposed to, and how that breaks down your cellular health over time and causes chronic disease. That's why women who have infertility have higher rates of heart attack, stroke, metabolic syndrome, cancer and earlier death. None of those things are caused by not getting pregnant for 12 months, right? But if we think about it, the population of people who don't have a higher likelihood of having chronic inflammation and poor metabolic health predisposing them to later disease. And if we start viewing infertility as potentially a red flag, a sign of cellular health, we can start changing the health trajectory of people for the long term. But if we step back and zoom out even more, if we're more proactive about it and we don't let them get to the point of failing, we can help many more people take agency of their health earlier, understand the components, get earlier testing. It's not that we'll ever eliminate IVF. IVF is an amazing technology, but we'll help people navigate through this process faster and with more knowledge and have better outcomes, even if they're doing IVF, by taking control of their cellular and metabolic health early. I think your initial question that I got on my soapbox about was about my own pregnancy loss journey. And I, in this time when I started doing my research, started thinking about inflammation and saying, hmm, that's my own in a one experiment, what causes me to feel inflamed? Got rid of everything in the kitchen, we started really prioritizing sleep and going on walks after dinner and changing how we ate. And one thing I noticed was that I felt more bloated, more fatigued after I had, at the time, I would have said carbs, but let's say now it's gluten. And so when I got pregnant, getting pregnant and not doing IVF, I got pregnant with my kids in that time period where we were preparing. I got pregnant and stayed pregnant with my daughter and then got pregnant with my son pretty quickly, postpartum. And a decade later, I got diagnosed with celiac disease. Wow. Okay. Which is known to be associated with her current pregnancy loss. So my pregnancy losses weren't bad luck, right? IVF wasn't necessarily the answer. The answer for me was something else. And yes, sometimes things are hard to diagnose. Autoimmune disease is notably difficult to diagnose in patients. But that doesn't mean that simplifying things to say, just do IVF and nothing else that you can do matters, is the right answer either.

Speaker 3:
[26:14] Hmm, wow. So it was this dietary exposure for you that led to four miscarriages before you ended up being able to sustain a pregnancy.

Speaker 4:
[26:24] Isn't that crazy?

Speaker 3:
[26:24] Wow.

Speaker 4:
[26:26] I mean, I'll tell this to anybody who's listening who has infertility, because I never want somebody sitting here saying, I have to cut out gluten, that's the magic thing, right? But we all have to learn to listen to our bodies. And as women specifically, when you tend to get dismissed with your problems, so maybe you go in and you say your periods are really painful, and you're told that's just normal, you start to think you have a poor pain tolerance, that you don't tolerate things like everybody else. And you tend not to listen to your body, to this clue that it is giving you. And we really have to start learning to trust our body, to listen to it, and to feel that autonomy in saying something's wrong and I deserve an evaluation, I deserve treatment for this. Because that's really hard place to be. But when you're told, no, it's in your head, over time, whether you realize it or not, you change your narrative for that to be true. And then something has to get so sick, you have to get really sick to finally get attention to it. And that shouldn't be how it is, that shouldn't be how health is, but we have to help patients navigate a healthcare system in America that's not very patient-centric.

Speaker 3:
[27:34] It's also a very reactive system.

Speaker 4:
[27:36] It is, right, across the board, but especially when it comes to fertility.

Speaker 3:
[27:41] Crazy. What are the, so are there known risk factors at this point for miscarriage?

Speaker 4:
[27:45] Yeah, so we know that environmental exposures can be, so smoking cigarettes, cannabis use, even just the male partner uses cannabis as associated with miscarriage because of how it impacts the sperm damage, right, sperm are 50% of the equation. We also know that, you know, obesity of both men or women can be associated with a higher rate of miscarriage. Of course, advancing age for both men or women, men get to be a little bit older, but when men are 50 and older, or for women, as we start to advance past age 35, but more specifically after age 38, we see higher rates of miscarriage. So there are some known well-risk factor, but other things like autoimmune disease, PCOS, endometriosis, all of those also have an association with a higher risk of miscarriage, but many women go years and years without diagnosis.

Speaker 3:
[28:35] Wow, yeah, I mean, we had another conversation recently about fertility and it was mind-blowing to me that the health of a man's sperm can affect what is the placenta, the capacity of the placenta to adhere properly.

Speaker 4:
[28:47] To last as long as it needs to, higher rates of preeclampsia, preterm birth. Male health is so crucial. And I think one of the biggest opportunities for intervention is we talked about the sperm and its lifespan. So we really love the focus. What people are talking about now is this trimester zebra, right? Hey, we want to get pregnant. Let's together essentially get in our best metabolic health, control the factors we can, whether it's sleep, building muscle, how we manage stress, the foods that we're eating, our environmental chemicals that we're exposed to. That can make a meaningful difference in our egg and sperm quality, and therefore our ability to get, stay pregnant and have a healthy pregnancy.

Speaker 3:
[29:27] What's the role of metabolic health in fertility? I mean, you see these statistics that are utterly shocking. You know, 42% of the US adult population is now obese. By the year, what, 2030, it's going to be 50%. Half of us have either pre-diabetes or full-blown type 2 diabetes. Many people with pre-diabetes go undiagnosed. You have people with insulin resistance that probably make up a much broader proportion than that. What impact is that having on public, on our fertility?

Speaker 4:
[29:58] Oh, a ton. When it comes to looking at patients trying to get pregnant, let's use recurrent pregnancy loss again. 27% of patients with recurrent pregnancy loss, so losing multiple pregnancies, have insulin resistance compared to 9% of people who do not. So insulin resistance itself, hugely prevalent in people who are losing pregnancies over and over. In IVF studies, when you have insulin resistance, you have fewer eggs retrieved, fewer embryos made, lower life birth rates. Here's my really bad analogy. I know you know what insulin resistance is, and probably your audience does, but I really love analogies. I think they kind of bring us all to the table together. So I like to think about, you know, food that you eat is going to get broken down into glucose. Glucose is the fuel for the cell, and your pancreas is going to release insulin. I like to think about insulin being the salesman coming and knocking on the door of the cell. You open the door, and it allows glucose to go in. So it's helping. In a normal function, cell door opens, glucose comes in, salesman goes away, latte da. What would you do if a salesman comes to your door every single day?

Speaker 3:
[31:07] Probably at a certain point, learn to ignore him.

Speaker 4:
[31:09] You ignore him. This is insulin resistance. So your glucose levels are higher for longer, whether it's the foods that you eat, the frequency of what you're eating, you're not sleeping enough, chronic stress, variety of reasons. Glucose levels are higher. So insulin is being released more. And your cell says, I'm so sick of seeing that salesman. I am not going to answer. And so the salesman, insulin level gets higher, there's a group of them, and now they're banging on the door. Fine. You finally go and open it. Glucose comes in, they go away. To add to this mix, during the time when the salesmen are outside the door, the cell is hungry because glucose is what it needs, but it's ignoring the insulin signal. So your cells are starving and you start breaking down your stored glucose, so in your liver, you can undergo a process called gluconeogenesis, where your stored glycogen, which is the form of glucose stored, gets broken down, and now you have even more glucose in your bloodstream. So now even more insulin is released. So this cell starting to ignore and needing the salesmen to bang on the door is what's happening when we develop insulin resistance, and you can see that that's a very hard cycle to break because cells are starving, but inside your bloodstream, something bad is happening. What people should know is that insulin itself is not a benign hormone. It's a growth hormone. So when it is high, your body thinks it's in such a state that it needs to store some of this other glucose as fats. You start getting the central weight gain. Think of that beer belly, the visceral fat that's highly inflammatory. If we want to be really specific at the ovarian level, insulin actually changes how your ovary responds to the hormones from the brain, switches it to be more what we call androgenic, making more male hormones over female hormones, needs higher hormone signal to respond, delay an ovulation. It can actually deplete your egg count based on that chronic localized inflammation that can come. It also comes back to the brain. If we think of the brain being central command station, waiting for these hormone signals to come in, when it has this high insulin level, it says something's not right. I don't know what's going on, but this is not normal. Why is it taking so much insulin? And it starts blunting its response and then not sending out enough hormones. So we can see on multiple different levels when it comes to your fertility, it can be harder to ovulate, you're impacting your egg quality, you're changing the inflammation inside your body. So it's gonna make it harder to get pregnant and stay pregnant. And all of this creates a cycle that we have to actively break through multiple lifestyle decisions at once and active choices. And sometimes that includes medication, but very often to break the cycle, we have to change our behaviors more than anything. And the thing that I find so interesting is what I try to talk to patients about insulin resistance. And they say, well, I don't have diabetes in my family, I'm good. They just think it absolutely does not impact them. Or they'll say, my last hemoglobin A1C was normal, so it's fine. But truly, that's not the world's best test. And we have to remember that a lot of lab tests, hemoglobin A1C specifically, is looking at population-based norms, not optimal levels. So I love a fasting insulin, and I find that that really can show patients, look how much insulin your body's needing in this fasting state right now. And then we have to start talking about ways that we can combat insulin resistance to actively decrease our inflammation. And honestly, regardless if you want to be pregnant or not, you want to be healthy. So this is a really important conversation to have.

Speaker 3:
[34:37] Definitely. And what's the relationship between insulin resistance and PCOS?

Speaker 4:
[34:41] So PCOS is a fascinating syndrome, right? Polycystic ovarian syndrome. In its simplest, okay, we're gonna go over my analogy for PCOS. Okay, inside your ovary, Max, let's imagine you've got a vault where all your eggs are kept, if you're a woman, so not you, but me. Okay, I'm born with all the eggs I'm ever going to have. Very interesting is that the vault releases a group of eggs every single month, no matter what. The number is proportional to how many are inside. So when you're younger, you send out more eggs. So let's say an average 30-year-old has 20 eggs coming out of the vault. An average 40-year-old is going to have eight. So as the vault gets emptier, fewer come out every month. Those eggs outside the vault, we can measure them on ultrasound or do blood testing. That's what we call checking your ovarian reserve or your egg count. Well, in PCOS, one thing that happens is that you have more eggs in the vault, probably because of certain exposures your mom had when she was pregnant with you. Women lose the majority of their eggs between being a five-month-old baby and birth. They go from six to seven million to one to two million. Because when you have more, you lose more. You lose the next biggest group between birth and your first period you ever have. You get down to half a million at the most. So ovulation is not what causes you to lose eggs. The ovaries are just constantly losing eggs that whole time. We don't have a way currently to slow down that process. Okay, so you're born with more eggs if you have PCOS. More eggs are coming out of the vault. And we want to think about it. The brain sends out a hormone called FSH, follicle stimulating hormone, well named because each egg grows inside a follicle. So FSH gets one follicle to grow and respond. Well, if you now have 40 eggs outside your vault, because you have more remaining, your brain doesn't know that because the brain doesn't know what's happening in the ovary. So it sends out the normal amount of FSH and it gets diluted. So now each egg gets half as much because you have 40 instead of 20. So you are not starting to grow an egg, usually when you grow an egg, you make estrogen, that estrogen level, when the egg gets high enough, tells your brain it's time to ovulate. It's gonna take a longer signal to get that egg to grow because the FSH is not strong enough. And during that time period, what starts to happen is that the ovary loves to make hormones. Estrogen is its hormone du jour, but if you're not making estrogen because you make estrogen when you're growing an egg, it'll start to make testosterone. So the pathway from LH to make testosterone becomes very favored. And this worsens with insulin resistance because testosterone then causes more central weight gain for women. We see a lot of insulin resistance with PCOS. You'll hear us call it a metabolic syndrome as well. Regardless of body size, there's this misconception that PCOS is a disease of obesity. The reality is PCOS is an ovarian disorder that has metabolic consequences. Over 80% of women with PCOS will have insulin resistance regardless of their underweight, overweight. It doesn't matter. Their ovary has shifted how it functions. And so it's really important those patients specifically to talk about how they can control insulin resistance, whether it's supplements, medications, these lifestyle decisions that they're making. And I think one of the biggest disservices we've done is when young women don't get told they have PCOS when they have obvious clinical symptoms. What I mean is the diagnosis is made two out of three. One is having a high egg count. So I do an ultrasound, I see a high egg count. The second is having irregular or absent periods. The third is going to be clinical or lab signs of high androgens. So you could have acne, hair growth, or you could have high testosterone or DHAs. So if you have irregular cycles and acne, you meet the clinical criteria for PCOS. You do. So we have a generation of women who went to their doctor, chief complaint, irregular cycles. They went in because their periods irregular, they had acne, and their doctor said here, this birth control will help you. And they're not wrong. The birth control did help. It increases sex hormone binding globulin, which binds up testosterone, lowers their testosterone, improves their acne, helps with some of this insulin resistance. Obviously the combined birth control pill has estrogen progesterone. So it wasn't the wrong quote treatment, but they were never told, you have PCOS. The birth control pill can help these ways. However, underlying this is a metabolic disorder that you should start to learn to work on, because when you stop the pill, all these problems are going to come back. And so we have a generation of women who are on the pill. I promise their doctor said in their brain, oh, she's got PCOS, but she was never told this. Then when she stops the pill because she wants to get pregnant, now suddenly her cycles are spacing out, acne is coming back, she's gaining weight, feeling terrible and has no idea what's happening. So we've lost that agency again, that opportunity to know information about our body, learn to make decisions and choices and decrease inflammation earlier by controlling our metabolic health simply because we weren't giving information or data about our bodies that was readily available. So PCOS is really important, it's really prevalent, but we have to, I think, really change the conversation in how we approach contraception too. Unfortunately, because of this, we've now demonized the birth control pill, right? Because you can imagine if you were on something, and then you come off of it and all these problems come, you think it's the pill's fault or you think the pill caused this. And the reality is the birth control pill can be used for contraception, highly effective. It has medical reasons that it can be really helpful as well for heavy bleeding, for PCOS, for endometriosis, for premenstrual depression and PMS symptoms. There's many reasons why it can be advantageous. It's not for everybody. We have to have that conversation about what is underlying, what's the root cause of these symptoms that's causing us to potentially want to use this as a medical treatment instead of just short visits, here's a prescription, go on your way because people can make change to their lifestyle if they understand what's happening inside their body.

Speaker 3:
[40:48] What do you say to people, to women listening who are like, well, I'm of a normal, healthy weight.

Speaker 4:
[40:53] Yeah, excellent.

Speaker 3:
[40:55] Yeah, so I'm impervious to these sorts of metabolic problems.

Speaker 4:
[41:00] I would say the majority of people who I see, and maybe I have selection bias because I'm in Austin, Texas, I see ultimately a really healthy population, most of my patients will have insulin resistance and they will sit across from me and tell me that they're healthy. One way to think about this is let's think of two of the other top causes of insulin resistance besides just the foods you eat or your body size or PCOS are stress and sleep. Okay, let's think about stress, okay? Your stress, your body is meant to respond to stress in a certain way, and obviously the world we live in is not the world our bodies were meant to live in, but let's use the good old bear analogy. So if you see a bear, your body wants you to be able to run from the bear. It doesn't want your survival to depend on when your last meal was, right? Like you need glucose to fuel your cells or your muscles, so it doesn't want to say, do you have enough of that? So immediately upon that high cortisol, you're going to start to break down that stored glucose and throw that into your bloodstream so you can run from the bear. Now, in the olden days, you would run from the bear and use up that glucose and go back to normal. But now, what causes us stress?

Speaker 3:
[42:06] We're sitting at our desks.

Speaker 4:
[42:07] Oh, right here.

Speaker 3:
[42:07] And we're still getting that glucose dump. Yeah, exactly.

Speaker 4:
[42:10] We're sitting at our desks, it's emails, it's meetings, it's conversations, it's the internet, all the things. And so we're not getting up and using our glucose. And so it's one way we can modify that. We can start to say, gosh, you just got out of this really terrible meeting or appointment. I mean, even doing 10 squats can use some glucose into your skeletal muscle right away and help that not predispose you to more insulin resistance.

Speaker 3:
[42:35] Independent of insulin's action, actually. You get insulin-independent glucose uptake.

Speaker 4:
[42:41] That's why building and using skeletal muscle is one of the keys to hormonal health because we can now fight insulin resistance actually quite profoundly by using that glucose not needing insulin. It's because the muscle, as you know, has Glut4, a transporter in it, that can use up glucose without needing insulin. I call that giving glucose a key. I don't need the salesman anymore. Glucose is a key to the cell. But let's talk about women. A lot of women, especially in these reproductive years, have not been focusing on building skeletal muscle. A lot of their exercise has been more cardio-focused, aerobic, right? So they don't have the same skeletal muscle mass to leverage using up that glucose in the same way. So building muscle can be a tool. We have to tell women that, right? So chronic stress is a huge driver of insulin resistance, both because it happens, but also how we manage it. Because how do a lot of people manage their stress?

Speaker 3:
[43:33] Alcohol. Exactly.

Speaker 4:
[43:36] Stress eating, stress drinking, ice cream, wine. We're just piling on. So it's both what's actively happening in our body, which is a physiologic adaptation for survival, run from the bear, except we double down on it by how much we're exposed. What we don't do, use our muscle, and what we do do, seek other dopamine releasing behaviors to try to counter it, which ultimately makes us worse. And the other thing is people don't sleep enough. If we like to think about sleep as one of the most profound tools we can have to decrease our inflammation, allow ourselves to become more insulin sensitive, right? I haven't seen that salesman in a long time, so I'm okay opening the door up when he comes around. I see so many high functioning, really successful women and men who wear their five hours of sleep like a badge of honor. Crazy. But they do. They say, I only need five hours of sleep. I don't need any more than that. The truth is, their body does. If they're still able to function on five hours of sleep, I'm highly impressed, but we will adjust to the world around us. When I was a medical resident, I would work 36 hours plus. I would get very little sleep. If you don't give your body sleep, it will get up and do the job, but there will be consequences. So regardless of our weight, there's these things, levers that we are pulling, whether we realize it or not, that control our body's response, ultimately if we develop insulin resistance.

Speaker 3:
[45:03] And being underslept makes you more inclined to reaching for ultra-processed junk foods the following day, compounding the harm. I mean, something like 400 additional calories a person's inclined to consume, mainly from sugar, ultra-processed-

Speaker 4:
[45:17] Because they're looking for that energy from a different source. So we see how, that's a great example, right? Sleep, stress, you have the harm from one, what's happening, and then there's that doubling impact because of what you do to cope with it, because we're not allowing our body the ability to function how it was meant to. Hmm.

Speaker 3:
[45:37] Man. Yeah, it's such a problem. I mean, today, the 60% of calories that your average adult ingests coming from ultra-processed foods, the chronic stress, the just the always-on nature of modern life, it's yeah, it's like a perfect storm for infertility.

Speaker 4:
[45:56] It is. And when we simplified infertility in a way to say, we're not going to do any testing, just try to get pregnant, we've lost the ability to understand how all these things are making it harder for us and have so many people who have the outward appearance of being healthy. Ray, they will even sit across and say, I'm really healthy. And then we start diving into it. Maybe they're not consuming enough calories, or it's where the food is coming from, the type of exercise they're doing, how much they're sleeping, how stressed they are, toxins they're exposed to. These decisions, knowing it or not, right? They increase inflammation, they kind of add up. Likewise, we can decrease that inflammatory burden by making them proactively. And it's not about being perfect every single day, not a list of things to do. The idea here is to develop resilience within your body, because your body is meant to be exposed to inflammation, right? You have an immune system that has an acute inflammatory response that it's supposed to respond. But when it's constantly being challenged and turned on, that's when we start to really see the damage being done, because you'll have a night where you won't get great sleep, right? You'll go to a party and you'll eat a bunch of cake and things that you don't normally consume. And those things on one offs are not a big deal when day to day, most of your choices, most of the time, is working to decrease your inflammation, you have that resilience to be exposed to it, and we don't have to worry about it. So I try not to let this be, again, a fear-mongering narrative. It's an empowering one. It's saying, if we learn this and then we cultivate a life where we have actively made choices to decrease our inflammation on the day to day, then we're actually not stressed about it. We know we're doing the best that we can. We don't worry about these one-off encounters or experiences that we're going to have, because we've developed that within our body. And the last thing I want to say here, because patients will ask me all the time, they'll say, well, why can't I just take medication to get rid of the inflammation? We're in America, so there's always a medication to treat the symptom that's happening. Inflammation and acute inflammation specifically is important in reproduction. So for ovulation to occur, that follicle that grew the egg has to rupture and allow the egg to be released. The follicle then reforms and becomes the corpus luteum that makes progesterone. If you don't have inflammation, the follicle can't rupture and release the egg. And in fact, we know that if women are taking NSAIDs around the time of ovulation, like Advil, Motrin, Aleve, Ibuprofen, their follicle won't rupture. So they'll go through the hormonal changes of ovulation, but the egg will not be released. Okay, so if you do have ovulatory pain, which some people do have, it's called middle schmerts, because it happens in the middle of the cycle. It's specifically pain around the time of ovulation from the big follicle. You should take Tylenol for that because it's not an anti-inflammatory medication.

Speaker 3:
[48:47] Interesting.

Speaker 4:
[48:48] Very interesting.

Speaker 3:
[48:49] Similar to how you don't want to take NSAIDs or anti-inflammatory medications around like your workouts.

Speaker 4:
[48:54] Exactly.

Speaker 3:
[48:55] Like part of that inflammatory stimulus is what causes your body to adapt.

Speaker 4:
[48:57] To heal and build the muscle. Exactly. So inflammation itself is not bad. It's not a medication we want to take just to treat it. What we want to do is really be combating the excess inflammation that we're exposed to and lowering that so our immune system can work the way it's supposed to. Yeah.

Speaker 3:
[49:15] I love that nuance that it's really ultimately, it comes down to what your baseline diet is. It's like if the ultra-processed treat foods that you pick up every time you run to Trader Joe's, if that's your norm and you're eating those foods around the clock all day long, that's a problem, but you can enjoy those foods. Just do so moderately.

Speaker 4:
[49:35] Yes. You've got to build your diet in a way that is more anti-inflammatory. Fruits and vegetables, lots of fiber. Almost every patient I see needs to increase the number of fruits and vegetables they're having in their diet. For optimal fertility, six servings a day. Fruits and vegetables, which many people are not getting that many. We live in a very meat and potato society. So you have to start incorporating more vegetables, more fruit. That's what has fiber, feeds your gut microbiome, decreases inflammation and insulin resistance. And then we have to start looking at the other things. Healthy fats are so important. Cholesterol is the backbone for steroid hormones. So you've got to, this is probably mostly women who still feel it's going for the low fat milk and the low fat yogurt, right? We grew up in that era. But your fats, you need healthy fats in dairy. You need healthy fats from olive oil, avocados, nuts. Like these are really healthy sources for you to get fat into your body. So we don't want to have this low fat, no fat life that is also not going to be conducive to optimal fertility. But the big harm is truly going to be from the ultra processed foods and the added sugars, right? So again, the idea, food is not neutral. Food can be helpful, food can be harmful. And we want to be making most of our choices most of the time in a way that's going to help fuel our body better.

Speaker 3:
[50:54] So true. Do you think that there's an ability for a high protein nutrient dense diet to support fertility? I mean, I like to say that we ought to get the bulk of our dietary fats from whole foods, like from foods that naturally contain fat. But I also think on the same side of the coin that it is worthwhile today to be mindful of your fat intake just because it's become so ubiquitous in the form of added oils. Added oils, fat extracts and things like that.

Speaker 4:
[51:26] That's absolutely a great point. I also think we have to meet somebody where they are. We know the worst dietary pattern is the standard American diet. So you can have a healthier diet and see improvement in a lot of parameters just because you've decreased ultra processed foods regardless of some of the other parameters we do. If we want to look through the lens of fertility specifically, we know that red meat is probably the most controversial on the table here.

Speaker 2:
[51:54] Not to me, but-

Speaker 4:
[51:55] I'm just saying, and the fertility data. Studies are only as good as how they set them up. Because red meat is a category of food and not all red meat is going to be created equal. I think you'll agree with me on that. Totally. But it's all grouped together. And so when they look at quartiles of exposure, so people eat the lowest amount of red meat versus the highest, those who took the highest amount had poor embryo development in IVF, lower pregnancy rates, they had lower sperm counts, they had higher rates of miscarriage, higher stage of endometriosis. Now, do we really think it's red meat specifically? It's probably also representative of an otherwise dietary pattern rate. Because a lot of that could be fast food hamburger gets looped in the same category as somebody's having a grass-fed steak. It's not, it's very hard to isolate any of the other animal food groups in nutritional literature. But it probably also brings to the point that a lot of people probably don't leverage plant protein at all, and we should leverage that some, right? Beans, lentils, tofu have a really great, helpful place. Soy itself can be protective against the endocrine disrupting chemicals we're talking about earlier. In a study called the Earth Study, looking at exposure of endocrine disrupting chemicals and people who are trying to get pregnant. Those who had higher levels of the endocrine disruptors that we started the conversation with, took them longer to get pregnant, worse outcomes with IVF. But soy and folic acid intake was protective. People who had more soy in their diet and more folic acid from food-based sources had lower levels of endocrine disrupting chemicals. Diet has that extra advantage of it can lower inflammation, can be nutritious, can protect you against endocrine disrupting chemicals, but you're not getting soy and folate from your ultra-processed foods. Right? No, it's a balance. So fruits, veggies, healthy fats, high-quality proteins, complex carbohydrates, and then really limiting the refined, the ultra-processed, the added sugars, that's the healthy dietary pattern. And then we all have to be our own in of one experiment, right? What, how you feel, if you feel inflamed, bloated, sluggish, after eating certain types of foods, you should listen to that because that's your body telling you how it's responding to different food groups.

Speaker 3:
[54:13] Totally. I strive to be non-dogmatic, and I consume soy protein. Not, it's not the, it's not the base of my, of my diet, certainly, far from it, but I love natto. I eat edamame fairly regularly. I use tamari sauce on my sushi, which provides a meaningful amount of protein, actually. And, and I, I eat lentils all the time. I'm a fan of plant protein. There's no doubt about it. But it's hard for me to ignore the fact that like, you know, again, trying to be, striving to be as non-dogmatic as possible, red meat continually comes up at the top of, of pretty much every nutrient density chart I've ever seen. Like red meat's at the top, and iron deficiency anemia is still a real problem. And there's no more bioavailable source of iron than that on top of the protein, on top of the creatine, on top of the vitamin B12, on top of the, you know, all of the other nutrients, the carnasine, the carnitine. So I think, yeah, it's, I'm very skeptical of the epidemiology surrounding red meat, because as you said, I mean, it's like garbage in equals garbage out. You know, these studies are so confounded, and it's like people who eat the least amount of red meat might be, you know, maybe they're more health conscious because they're, you know, they've read on like a wellness blog somewhere.

Speaker 4:
[55:31] You just don't know. Are they eating a lot of, you know, fish? Are they pescatarian? They have other health. There's so much nuance in dietary data that we have to evaluate it as such. I mean, I was a nutrition major back in college, took a whole class on fats and carbohydrates. Like, so I'm fascinated by it, but you also see the flaws in the research. It doesn't mean the research is terrible. We take it from where it is. And like all scientific studies, it is only telling us one variable, and it's so influenced by how they set the study up. It doesn't mean studies are bad. We love to practice evidence-based medicine. But similarly, just because a study hasn't been done, doesn't mean something's not true. And just because a study has been done, we have to look at the context of how it was done and structured before we draw these sweeping conclusions across the board.

Speaker 3:
[56:15] Amen, yeah. And just get, like, do your labs, like follow up with your doc.

Speaker 4:
[56:18] Do your labs, see how you feel. And ultimately, if you're otherwise having healthy dietary patterns, this argument over this or that probably doesn't matter. The carnivore diet is probably not the healthiest. It's probably healthier than the standard American diet, than ultra processed foods only. But you're missing out on fiber, fruits, vegetables, antioxidants, nutrients, right? So we really just want to have a more balanced approach for the majority of people. And the hard thing is that's scary if that's not how you're eating. It can feel really intimidating. Food is so ingrained in our culture and how we are raised and how we feel comforted. Cooking can be a big challenge for a lot of people. So I think we really have to bring it down in an easy way and start saying, one simple change in what you're eating on your plate, whether it's adding a veggie, start with one thing at a time in this attempt to work on decreasing inflammation. That's where I work with my patients. One meal of the day, make sure that you have a vegetable source protein, figure out a plant-based protein. That's going to make a lot of people get out of their box because you have a really healthy diet pattern. But there's a lot of people who don't consume any soy, any legumes, right at all. They're fearful of it even. So we have to really just start to expand our horizon and be willing to try things and change our behavior. But your health is worth it.

Speaker 3:
[57:35] Totally. It's totally worth it. And there's so many people today on social media just fear-mongering. Like you'll find somebody on social media who's fear-mongering pretty much every food or any food rather. Like there's diet tribalism when it comes to nutrition to me is so frustrating.

Speaker 4:
[57:52] Well, there's a lot of ethical reasons why people may choose a diet or not to. Right? And so we're having a conversation from a health stance. And that's where these conversations should be framed. Ultimately, it goes to the same thing. You eat however you want to eat. We're just here to provide data about what we know, what we don't know, and let you start to structure your day and your life in the way that makes you feel most confident that you're making the decisions right for you.

Speaker 3:
[58:17] Amen. I did want to ask you about GLP-1 drugs, which so many people are taking these days, and you're hearing reports about people being taken by surprise with completely surprised pregnancies, people that were having fertility problems, they go on these drugs to lose weight, and suddenly they're knocked up.

Speaker 4:
[58:34] There's two main groups where this is happening. So probably first and foremost is going to be patients with PCOS. Women with PCOS, because of what we talked about earlier, many of them are not ovulating. So there's many reasons why a GLP-1 can help them get pregnant. First is if you are PCOS and you're overweight, fat cells make estrogen, they confuse the brain even more because it's obviously not ovulatory estrogen. So simply by losing fat cells, your baseline estrogen will lower, your brain will notice that change and will start to ovulate again. Losing very little amount of weight, only five to 10 pounds can restore ovulation in somebody who's overweight. So weight loss itself can be advantageous. But we know the GLP ones are hugely impactful when it comes to improving metabolic health, fighting insulin resistance, decreasing inflammation. And because all of those play a role in patients with PCOS, like we talked about, regardless of their weight benefits, we see a metabolic benefit to helping the ovaries respond because we're changing that insulin-rich environment to be one that can respond and ovulate. So most of the surprise pregnancies are going to be people who weren't ovulating, therefore it's very hard to get pregnant, probably got frustrated by tracking their cycles, and then lost weight, improved metabolic health on the GLP one, and got pregnant. We should say that the medical recommendation right now is to not try to get pregnant if you're on a GLP one. We recommend a two-month washout period before getting pregnant due to fear that's unknown of fetal risk, right? We don't want to impact the fetal pancreas, things that we don't know. And of course, we're highly conservative in pregnancy, where there have been terrible, right? Think about the litamide babies and things we've had in the past. So we really need to be really careful when we're on a medication and we're actively getting pregnant. I think there's a lot of power for GLP ones and autoimmune disease and inflammation. Patients like endometriosis patients have had immense benefit going on very low doses, so not really looking at it for weight loss, but looking at it from an inflammatory benefit. Or some patients of mine who've had outcomes that don't match how they look on paper. Let's say that unexplained infertility patient or the young couple who's just not getting any embryos or not having success with transfer. I'll sometimes say, hey, we've got to change something, right? And so this can be one way to try to change the metabolic environment before we do this again. It's frustrating because it takes time. It's like you're going to do this for three months, you have to have two months wait. So we're adding a lot of time to a process that's highly time-sensitive, so it's not an easy answer. I think the emerging data on how it impacts inflammation is going to be very impactful for how we manage a lot of the diseases that impact fertility. But we know it's impactful in PCOS and in women who are overweight. So I think that it also makes it more attainable. Where I've sat across from people to say, oh, if we lost some weight, it could help this process have better birth outcomes, more successful pregnancy, better recovery. But the time it could take you to lose 50 pounds feels so long, especially if you've already been trying to get pregnant for a year or two. The idea now that we do see people able to achieve more substantial weight loss and a faster time frame can be very meaningful in the setting of infertility when time is such an important variable.

Speaker 5:
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Speaker 3:
[62:23] Hasn't metformin been historically used in the setting of PCOS?

Speaker 4:
[62:26] It is. Metformin is one of the standards of care we use. We also, inositol is commonly used as well. Metformin alone can even improve ovulation without anything else. Now, it's not standard of care. If you're truly trying to ovulate, then medications like Letrozole or Clomid do a better job. These medications work differently, but they essentially lower your estrogen level. So your body sees less estrogen, sends out more FSH. Hopefully that's a stronger FSH signal, so it's not as dilute with as many follicles. So those are oral medications that are relatively low risk, that we do very often to help women with PCOS get pregnant. But metformin, because of how it can help with the cellular metabolic health and insulin resistance, metformin alone can restore ovulation in a good number of patients with PCOS. Wow. And if you co-use it, like I often will put patients on it, we can see better outcomes when we do ovulation induction or we do IVF when we continue metformin. So a lot of times there's not a one-size-fits-all approach or I always like to think about all the tools in my toolbox. We want to talk about how do we have access to all of them, which tools make sense. Sometimes we want multiple tools for the same job and that's fine. We want them all available.

Speaker 3:
[63:33] And do you see diet and lifestyle working like as a first line? Like if somebody can adhere to it?

Speaker 4:
[63:38] I mean, absolutely. Clinically, I see patients who've been trying for so long already that we are in a place where we're always doing diet and lifestyle in addition to something else, right? But if we go back to how we started the conversation, even if you need IVF for X, Y, Z reason, I can only work with the eggs and sperm that we're getting. Sperm, three month life cycle. Eggs are in your body your whole life. But they start to become more sensitive to the world around you in the 60 days before they ovulate, okay? So that means, and we'll say two to three months time period, you can make a meaningful change to your egg and sperm quality. Doesn't mean you can reverse age or you can undo everything, but it means that's worth paying attention to even if you're doing other treatment. In the perfect world, I always say, why read the book? I want people to start doing this way earlier, because I do think you're right. If we start focusing on diet and lifestyle at an earlier time period before we have infertility, we're going to see a different trajectory for the majority of these people.

Speaker 3:
[64:39] Well, certainly anybody who's tuned into this episode is interested in their fertility. What are three things that anybody listening to this should begin doing today to batten down the hatches and improve their odds?

Speaker 4:
[64:50] Okay, immediately we want you to sleep at least seven and a half or eight hours a night. It's probably, as I said earlier, number one thing most people are not doing that I want them to do. Number two, especially for women, I want them to pick up weights and lift weights three times a week, right? Building, using that skeletal muscle, that is a powerful tool to combat insulin resistance and inflammation. And then number three is going to be stop cannabis. It's probably the most prevalent thing I see in my clinical practice, impacting sperm quality, pregnancy rates and egg quality with IVF.

Speaker 3:
[65:20] Wow. And does it matter the route of administration?

Speaker 4:
[65:23] That's a good question. I'm going to say truly from a clinical standpoint, I don't think it matters, meaning-

Speaker 3:
[65:30] Edibles, vapes.

Speaker 4:
[65:31] I mean, edibles have such a high concentration of THC. I mean, I'm seeing it from all ends because we're in Austin and people think it's healthier than drinking, so like cannabis everywhere. But we're really seeing, not disclosed, a really bad outcome in IVF, changing that one single variable and completely different outcomes. So it's one of the things I say, if you're on your let's get pregnant journey, just cut it out.

Speaker 3:
[65:55] Wow. For men and women?

Speaker 4:
[65:57] Men and women.

Speaker 3:
[65:58] Fascinating. Yeah, I have a, I don't like personally cannabis. I mean, I enjoy it a little bit sometimes before bed, but I don't like it like while I'm conscious, if that makes sense. Like to me, it's very useful in like micro dose form to help me get to sleep, to like turn off my brain. But yeah, it's something that I could easily give up. Do you see a lot of people using it regular? Like is it?

Speaker 4:
[66:19] I do. I see a lot of people using it like you are. It's like they're especially high performing men, high stressful jobs. It's their sleep aid, like a little bit just at night. They're highly hesitant to get rid of it. They really don't acknowledge it. They say, it's not a problem. It just helps me sleep. But they really, it impacts their sperm in a profound way and not always detected on a semen analysis, right? So we want to remember that a semen analysis is telling us about how many sperm are made, how the sperm move and the shape of the sperm. It's not telling us about the DNA inside the sperm's head, which is done with a different test called a DNA sperm fragmentation, not run on a standard semen analysis. And we know that yes, cannabis can suppress the brain and impact sperm count. The inflammation from it can impact motility and morphology or shape, but probably the most profound impact is how it damages the DNA inside the head of the sperm. And that's why I think men getting this problem is like, well, my semen analysis was fine, so it's not a big deal that I'm doing this. And it's a lot of times because they don't understand that the test we're doing is not truly looking at the quality of their sperm.

Speaker 3:
[67:22] Hmm. I can't imagine that there's data on the proportion of pregnancies that are surprise versus those that are intentional. But if somebody is trying to get pregnant, I mean, at what point do you recommend that they go in for a workup, like a semen analysis?

Speaker 4:
[67:38] Oh, great question. Again, medically, people would say, if you ask your doctor, many doctors would say, let's just not worry about it unless you don't get pregnant. Right? Now, you can ask for testing, and this is where we have to become our own health advocate. I think everybody should get a semen analysis before they conceive. Some of the hardest cases I've seen are patients who've been trying one, two, three years, and he has no sperm. Wow. Zero sperm. One, because you feel like, wow, I was shooting blanks all that time, where you still have the same amount of ejaculate. You feel like every single one of those months, you had a zero percent chance of getting pregnant. It can take months and months to get sperm to return to the sample if it can at all. Sometimes it takes a surgical procedure, expensive medications, and we're way behind in getting to that place. It's a very easy test. You can go to a fertility doctor's office. You also can do a mail-in. There's a company called Fellow that does a CLIA-approved lab. They give you all the values on it. So you can collect it home, mail it in. So there's no reason not to do that. In my opinion, if you and your partner have any discussion, check sperm, number one. Number two, I think you should ask for an AMH test. Was it a test of ovarian reserve? So we talked about my vault analogy earlier. The eggs that come out of the vault, the cells that surround them make AMH, which is a hormone called antimalarian hormone. More eggs make more AMH, fewer eggs make lower. It's not perfect. It'll vary some month to month because the body's not sending out the exact same number of eggs. But if we think about it like a category, do you have a normal amount, high level, low level, critically low? If you find out you have a low egg count or a critically low, you might be in a position to make different decisions, especially if you want more than one child. In addition to the fact that we know you would get fewer eggs with IVF or egg freezing, the younger you are, the better the outcome. But also, why is it low? Do you have autoimmune disease? Do you have endometriosis? Have you been smoking cigarettes? Should you stop that? You would give people data about their bodies, they can make active decisions. I'll be really clear that's against current medical society recommendations. The American College of OBGYN says that you should not check an AMH level in people unless they have infertility. Their idea is that it's too stressful to find out if you don't have a high AMH value if you're not trying to get pregnant. But I think that's a really paternalistic view. They also argue that there's some data showing that doesn't have a lower rate of getting pregnant. And that's right in some ways, but not all. If we think about two women the same age, one has five eggs outside the vault, the other has 20. Well, for ovulating, we're both releasing one egg. So if everything else is the same, that's true. We have the same odds of getting pregnant. But what's not represented there is the, but why does this person only have five eggs? Because endometriosis, autoimmune disease, these things do contribute to a higher rate of infertility and might make different decisions along the way. Clinically, I see couples when the woman has a low AMH and they make decisions differently because now they're making it from a place of knowledge. Especially if you're like, this is my life partner. We're married, we're together, we want to have kids. We think we're going to wait a couple years. We'll now find out you don't have a couple years maybe to wait. Maybe you decide to try earlier. Maybe you freeze eggs or embryos. Maybe you do none of that. You just start trying to live your healthiest life. So you have the best egg and sperm quality. At the end of the day, all women will run out of eggs. Right? Fertility is finite. So if somebody's going to be making the decisions about your reproductive future, I think it should be you and not just letting time make them. We are all on a different time path. So this idea of don't check that till you have infertility, I don't think it serves anybody. So I would ask for an AMH test. Simple blood test costs like $79 if you don't have insurance. It's like not that expensive, right? So an AMH blood test, a semen analysis, and the middle ground is going to be to really learn to track your ovulation. Not just when your period is coming, but apps where you're marking when your period is coming and it's giving you a fertile window. I don't know if your girlfriend has one. They'll say, this is your ovulation day. That is only accurately predicting ovulation 20 percent of the time. Apps are wrong most of the time because they're using a calendar method presuming that the luteal phase, the second half of the cycle, is 14 days. But in fact, most women don't have a 14-day luteal phase. In fact, having a short luteal phase where it's less than 11 days is one of the first signs that you're not ovulating to the degree that you should be and that something is wrong. But if you don't know when you're ovulating, you're just going by your app, you're missing the clues, and you're not effectively timing in our course. So learning to track ovulation, this can be with cervical mucus. So cervical mucus is the barrier to the uterus. It becomes sticky, stretchy, like an egg white when you have your peak estrogen. So estrogen levels of 200 picograms or more causes the cervical mucus to come out of your body like an egg white. So if women learn to just kind of look, like wipe with toilet paper before they go to the bathroom, they'll say, oh, this is that sticky egg white stuff. The last day of type IV cervical mucus is ovulation day. So that's free. There's no tech or anything required. Second is going to be your basal body temperature. When your body makes progesterone after ovulation, core body temperature rises 0.4 degrees Fahrenheit. So if you're able to track your temperature, you can know when you ovulated. Ten years ago, this was so problematic. There was a special thermometer at the right time of the day and very influenced by the world around you. This is where tech's been incredible because now we have wearables, or a ring, Apple Watch, Natural Cycles has a wearable where it can highly accurately look at your temperature across multiple times of the day and know when your core body temperature is rising and predict your ovulation. So that's an easy way, if you don't want to think about it, where you can leverage technology in a way that can help you know this. And then another one is urinary hormone monitoring. So the brain sends out a surge of LH or luteinizing hormone to cause that follicle to rupture and release the egg. And if you detect when that is happening, you can know ovulation is eminent the day after. And so this can be with a simple LH based test called an ovulation predictor kit, or there's fancier ones now like Inito or Mira that can check many different hormones, but essentially it's like a pregnancy test. You pee, text with a stick, it's going to tell you when this is happening. So AMH, semen analysis, and then learning to track your ovulation. These are three things that you should do. And if your ovulation is irregular, if your luteal phase is shorter than 11 days, if your cycles are further than 35 days apart, these are signs where you should, don't pass go, go get an evaluation now, because there could be a thyroid problem, a prolactin problem, PCOS, there could be something underlying that you deserve to know right now before you're spending your time just trying and seeing what happens.

Speaker 3:
[74:28] And should the doctor that couples seek out, should they be looking for reproductive endocrinologists?

Speaker 4:
[74:35] They can. So you can just call a fertility doctor and say, hey, I want fertility testing. And we will happily see you, do your testing, and I love this. And I'll tell patients, hey, if our worst case scenario is it's all good, then you can go on and we can decide based on your age or your goals, how long you try naturally. And then if you don't have success, what we might wanna do. I would say about a third of the time though, we're finding something where a couple of people are making a different decision. Whether it's let's freeze something, let's advance to care sooner, he's gonna go see a urologist, something other action is happening that otherwise would not have happened had they not had testing. Many OBGYNs will do initial testing too, so it just depends who you're in front of. But this is information I think you deserve to know, and it's stuff that you're gonna have to ask for. We sometimes grow up in this era, you go to the pediatrician and they're checking the boxes, and then suddenly you're an adult going to a grown up doctor, and we kind of wait for them to bring things up to us, and that's not how the medical system works. Your OB-GYN is gonna ask, are you trying to get pregnant? No, what birth control do you want? Because they want to help you not have a pregnancy if you don't want one. I tell my OB-GYN colleagues, the next question should be, do you want kids one day? Because if the answer is yes, we should talk about testing, timing, and an earlier evaluation so that people can make informed decisions.

Speaker 3:
[75:52] Wow. Dr. Natalie Crawford, so good, so illuminating, such a fascinating topic. I mean, I have not gone through this myself, but thank you for sharing your personal story and all of this wisdom with my audience. It's definitely, it all comes back to agency.

Speaker 4:
[76:08] It does. It's really about you making decisions from a place of knowledge and feeling confident and how you're structuring your day and your life.

Speaker 3:
[76:14] Exactly. Well, I've got one last question for you, but before we get to that, where can people pick up your book and where can my listeners connect with you on social media if they have follow-up questions?

Speaker 4:
[76:23] Wonderful. I'm on social media at Natalie Crawford MD and the book is The Fertility Formula. You can get it anywhere books are sold. It's going to go into much more detail over all the things that we covered today. I love it.

Speaker 3:
[76:33] It's a beautiful book as well. Congrats. What number book is this for you?

Speaker 4:
[76:36] This is my first.

Speaker 3:
[76:37] It's your first book.

Speaker 4:
[76:38] It's my debut.

Speaker 3:
[76:39] Wow. Mazel Tov. It's a big deal. Well, the last question that gets asked to everybody on the show, what does living a genius life mean to you?

Speaker 4:
[76:48] It's really what we talked about, meaning making decisions from a place of knowledge, like knowing the why behind the choices you make. That to me is what a genius life is.

Speaker 3:
[76:57] I love it.

Speaker 2:
[76:58] Cool.

Speaker 3:
[76:59] Thanks for coming out.

Speaker 2:
[76:59] Thanks for having me. I loved it.

Speaker 3:
[77:01] Yeah. Thank you guys. Thanks for listening. Share this episode with people in your life that may benefit from it. If this episode resonated with you, if this kind of content resonates with you, leave a rating and review on your podcast up of choice. Let me know or drop a comment in the video on YouTube and I will catch you on the next episode. Peace. Hey guys, thanks so much for listening to this episode of the show. If you enjoyed it, hit subscribe and leave a rating and review. It really does help. And don't forget to grab my free weekly newsletter at maxlugavere.com/newsletter for science backed insights, expert interviews and exclusive discounts. No spam, just good stuff. Catch you next time.