Fertility Optimization with Dr. Sasha Hakman
Today I'm speaking with Dr. Sasha Hakman, a fertility expert, on the Longevity Optimization Podcast. In this episode, we discuss the rising trends in infertility, the impact of environmental toxins, and the critical importance of lifestyle factors such as nutrition and exercise on fertility. Dr. Hakman shares insights into the role of hormones, particularly progesterone, and how thyroid and autoimmune conditions can affect fertility outcomes. The conversation emphasizes the need for awareness and proactive measures to optimize fertility.
Dr. Sasha Hakman is a renowned fertility specialist dedicated to helping individuals and couples navigate the complexities of reproductive health. Throughout our discussion, we explore the intricate relationship between thyroid health, nutrient deficiencies, and fertility, highlighting the importance of maintaining optimal TSH levels for women trying to conceive. We also delve into the role of various nutrients, particularly vitamin D, in enhancing fertility. The conversation covers the impact of alcohol on reproductive health, the aging of eggs, and how lifestyle changes can significantly improve fertility outcomes. Personal experiences in fertility treatments underscore the importance of individualized care and the need for supportive healthcare providers. Additionally, we discuss various aspects of fertility, including the impact of age on conception, the process and considerations of egg freezing, and the management of conditions like endometriosis and PCOS. The complexities of IVF, including success rates and challenges associated with egg retrieval and embryo transfer, are also addressed, emphasizing the importance of understanding one’s reproductive health and the implications of lifestyle choices on fertility outcomes.
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Timestamps
00:00 Introduction to Fertility and Infertility Trends
02:51 The Impact of Environmental Toxins on Fertility
06:08 Lifestyle Factors Affecting Fertility
11:48 The Role of Exercise and Nutrition in Fertility
17:51 Understanding Hormones: The Role of Progesterone
23:56 Thyroid and Autoimmune Conditions in Fertility
37:05 Understanding Thyroid Health and Fertility
41:39 The Role of Nutrients in Fertility
51:42 Alcohol and Its Impact on Fertility
55:56 Egg Quality and Aging: What You Need to Know
01:09:08 Personal Experiences in Fertility Treatments
01:13:25 Understanding Age and Fertility
01:20:04 The Journey of Egg Freezing
01:30:35 Navigating Fertility in Your 30s
01:39:01 Managing Endometriosis and PCOS
01:46:51 The Complexities of IVF and Egg Retrieval
Transcript
[00:00:00.330] - KAYLA BARNES-LENTZ
Welcome to the Longevity Optimization podcast, where we discuss longevity, optimal health, nutrition, peak performance, cognitive excellence, and so much more. Okay, today on the podcast, this is a really exciting episode, and I will say that I have interviewed so many different fertility doctors in order to find you because it's a field that not everyone is as up to date on the research as you are and not as nutrition and lifestyle-minded as well. So I'm so glad I found you.
[00:00:36.160] - DR. SASHA HAKMAN
Thank you. I'm so excited that we got to work together. It's been such a fun journey.
[00:00:41.360] - KAYLA BARNES-LENTZ
I know. So today we have Dr. Sasha Hakman on the podcast, who is a physician with dual board certifications in OB/GYN and gynecology and reproductive endocrinology and infertility. She practices at HRC Fertility in Beverly Hills, which is where I was at recently, but it's such a pleasure to have you on the podcast.
[00:01:03.170] - DR. SASHA HAKMAN
Thank you. It's such a pleasure to be here. I'm really excited to get into all things fertility.
[00:01:07.990] - KAYLA BARNES-LENTZ
Same. I mean, obviously, my community is like 90% women. This is a really big topic, and I just want to start with the foundation. We know that infertility is rising, right? It's incredibly sad. I know we don't have a lot of data, but just throwing out some hypothesis. What do you think? Why do you think this is happening?
[00:01:34.530] - DR. SASHA HAKMAN
Infertility, it's funny. When I started practicing at a fellowship, we used to quote, 1 in 10 couples suffered from infertility. And already within four years, it's changed to one in six. In a very short time frame, we have updated data that shows that infertility is on the rise at a very rapid rate. The question is, why? We know that on one hand, women are waiting longer to conceive, and so there is the age variable that very much plays a huge role. But even when you control for age, statistically speaking, we are still seeing a higher rate of infertility in younger women and in younger men. There's a lot of theories behind it. We know that there's growing research on environmental toxins as being really key players in unexplained infertility for one, but also possibly linked to other disorders like PCOS and endometriosis if you have a genetic predisposition. The biggest thing is we're talking about EDCs, which stands for endocrine disrupting chemicals. These are things in our environment, things that people don't really think about. It could be in your laundry detergent, your household products, your skincare products, your cosmetics, hair products, everywhere. They're endocrine disrupting because they bind to the receptor.
[00:03:07.690] - DR. SASHA HAKMAN
In endocrinology, this is the study of hormones. I'm a reproductive endocrinologist, so my focus is the study of hormones that have to do with reproduction, but they all are very closely linked and they affect one another. We definitely work closely with general endocrinologists. We know that in the field of reproductive endocrinology and just general endocrinology, that there is a huge issue with EDCs. These chemicals bind to the receptor, and a lot of hormones, the receptor, what it does, it turns on certain genes to elicit a function in the body. When these chemicals bind to the receptors, they can either block that function, turn on that function erroneously, or completely change the function altogether of the protein that gets transcribed and It does what it's supposed to do in specific tissue. What that causes long term is what we're seeing is chronic diseases, infertility, and even growing cancer rates.
[00:04:12.120] - KAYLA BARNES-LENTZ
What is the actual mechanism? Let's say you have a high toxic burden, environmental toxins, these endocrine disruptors. What is it? Is it doing something specific to the hormones and then thereby impacting fertility, or is it turning? Is it on the epigenetic level?
[00:04:30.340] - DR. SASHA HAKMAN
It's probably a combination of different things, and it really just depends on the specific toxin that you're looking at. If we're talking about BPAs, that's a little bit different than talking about phthalates. There's just so many different chemicals that we can go over. We're still lacking a lot of data, mind you, but there are some pretty good research out there in high-quality studies that look at specific things like BPAs and phthalates. This is why you hear about them a lot because it's got more data. We know, for instance, with BPAs, this can mimic estrogen. If something looks like estrogen, imagine when you think of a receptor and you think of a hormone, think of a key going into a lock. So a key in a lock. A key has a specific fit for a lock, and that way you can unlock the door or lock it back up. If something has With a very similar shape, it can fit into that lock and possibly unlock it, or it could just jam that lock and prevent it from working. That's the analogy I like to use for patients to make it a little bit easier to understand where this is how these chemicals can work.
[00:05:47.390] - DR. SASHA HAKMAN
There's also VOCs, which I know that you talk about this a lot, with volatile organic compounds. When we look at, for instance, IVF patients, in our Embryology lab, we're always telling patients, Absolutely no fragrances, do not wear deodorant, no fragrant or scented body lotions or perfume the day that you come in for your egg retrieval because they emit VOCs. In the Embryology lab, the staff is not allowed to wear anything fragrant whatsoever. Even their laundry detergent should not be fragrant when they're cleaning their scrubs. It should be as neutral as possible because the VOCs can actually halt the the replication of DNA and can stop the development of the embryo.
[00:06:35.970] - KAYLA BARNES-LENTZ
Well, I love to know that that's the standard operating procedure within the actual lab. But it's amazing to me. I mean, it's obviously becoming more widely It's not widely known. But it's amazing to me that it's not more widely known. I just did this super long video on fertility that's part of the whole series of what we did and then the podcast. I just don't feel like it's widely known for women that one of the first things that you might want to think about if you're intending on getting pregnant or want to think about fertility preservation or optimization would be looking at your exposure to these different toxins, right?
[00:07:13.140] - DR. SASHA HAKMAN
Right. It's actually clinically something we're not doing. I think the difficulty is in finding standardized labs, places to actually check these toxin levels and study them in patients. I think that it would be a really nice clinical trial to see what is the outcome of an IVF treatment in a patient with unexplained infertility based on these levels. If we're looking at BPAs, we're looking at phthalate exposure, we're always preaching reduce exposure, reduce exposure, but we actually don't have concrete data in our own patients on what is your level and what do I expect your IVF outcome to be. It's really interesting. I would love to look to that. I think more and more awareness has caused a lot of fertility doctors who really care about lifestyles such as myself and about all the things that we can try to control in our environment to improve outcomes. We're starting to send out patients where they're seemingly unsuccessful with IVF. We have no other explanation, we have no answers, or we say, You know what? Let's check your toxin levels and see, are there actionable items that you can do to improve this, and are we going to see a difference?
[00:08:35.050] - DR. SASHA HAKMAN
The jury is still out. I don't know the answer to that, but I would love to see more research on it.
[00:08:41.260] - KAYLA BARNES-LENTZ
Yeah, definitely. I came in with my own toxic burden test. It was part of my own protocol. It's actually quite difficult, especially given where you live. It was a little bit easier for me in Ohio, more in the Midwest, to control for exposures. It was a little bit more difficult, and I'm navigating that here in California. But at a bare minimum, and I'll just speak for what I have found to have a beneficial impact on my total toxic burden, at least, we don't know full fertility status yet because we haven't really started trying to get it conceived. But air purification, massive one, especially right now with the fires. But just in general, I was actually shocked by how many people didn't have air purification prior. Yeah, I know. I know. We got so many texts like, Hey, where are you getting I'm like, Oh, gosh. In general, the air quality in LA is not good. Something to be thinking about water quality, shower water quality. I really like a resource. It's called the EWG or the Environmental Working Group. They have something called the Skin a deep database, or you can just type in the product that you're using, like makeup or fragrance, personal care products, and it'll give it a score.
[00:09:53.010] - KAYLA BARNES-LENTZ
Then you can start to learn more about why does this have a poor score? Why is this in the red? Just as you can Starting to swap things that are in the red range for something in the green range might be beneficial. Again, we don't have this solid data to link these two exactly together, but also we were chatting about the link between environmental toxins and reducing the AMH. So that seems to be somewhat understood. Not that that's going to say if you're infertile or fertile, but if that's there, and then we have this other preliminary data, might make sense that if you want to optimize fertility to start to reduce that burden, don't you think?
[00:10:33.230] - DR. SASHA HAKMAN
Absolutely. I think that it's really hard in the beginning for those who are completely unaware of this, where all of a sudden you have a doctor telling you, Okay, you have infertility, and this is your treatment protocol. But in the meantime, I need you to stop using toxic pots and pans at home for your cooking, because if it says non-stick, then there are chemicals in that that are leaching into your food. Even if it says that it's non-toxic, it probably is. Things like stainless steel are the way to go. You always encourage the other things that I discussed previously. Anything with fragrances, you want to remove that. As much organic, wholefoods as possible, the less it's stored in plastic, the better. The less that you are having to read ingredients on a the better. It's really hard to implement these changes overnight if you've done none of this. I always just encourage stepwise fashion of reducing exposure because even a reduction in exposure can make a really big difference in your overall health. And even if you are the most knowledgeable person and you're doing all the things, there are still things beyond your control, just from going outside and going to the gym and just touching anything.
[00:12:00.120] - KAYLA BARNES-LENTZ
I mean, yeah, totally. And that's for me where the testing comes in because there will be some... Sometimes I'm like, How is that possible? When something will pop up and just living life, travel, jet fuel, Ceding out so many different things. Pesticide exposure, so many. But I love that you guys are taking an approach to just slowly give the information. The more you know, the better. And then you can start to... And I don't want people to get overwhelmed either. Because I've spent the past many years, almost decade, refining this and slowly swapping things out. You don't have to do overnight, but it will be helpful over time. Totally. What about other lifestyle practices? This is where it's been really hard to find someone like you, because I will say that quite a few fertility doctors, experts that I've spoken to, sometimes just say, there's absolutely nothing that your lifestyle... Your lifestyle doesn't impact fertility outcomes.
[00:13:03.070] - DR. SASHA HAKMAN
Oh, I mean, it totally does. What's your thoughts? Of course, it really depends on the patient, the specific scenario and situation. For instance, with you, you have a very healthy lifestyle. It's actually pretty hard to improve on whatever you're doing. In your case, you're doing it all, there's really nothing I would change. I have other patients, for instance, where in our intake forms for a new patient consult, it asks about exercise, nutrition, all these things. If someone's saying that they never exercise, that's a really important lifestyle change that needs to be implemented, especially before pregnancy. Because once you are pregnant, then the recommendation is you're not going to start now to stress the body in a way that it's never been conditioned to do before. That's not the time to really start to change things. It's a time to continue from where you left off. So you want to get a good foundation before pregnancy. In many cases, when we're dealing with infertility, lack of exercise isn't necessarily a cause for infertility. So I don't want anyone who's listening to this, who for whatever reason, they're not Really, your listeners are probably exercising. Probably, yes.
[00:14:19.330] - DR. SASHA HAKMAN
But if someone is reducing their exercise because life happens, it's important to get that back up. If you are You're dealing with infertility and your physician tells you during your treatment, you should not be exercising because that can negatively impact your treatment. There's actually no data to suggest that unless there are specific medical contraindications. If you have a cardiac condition that prevents you from being able to do certain exercises, that's a different scenario. That's an exception, and you have to follow your doctor's guidelines based on whatever circumstances you're dealing with. But for the most part, you should be doing resistance training Training in combination with some cardio, whether it's hit, walking, getting your steps in on a daily basis, you want to move your body, get that blood flowing. There is no data to suggest that it is going to negatively impact your treatments. So ideally, you're exercising before you start treatments. Whatever you're doing, you should be continuing throughout your treatment. Now, in many cases, you may have to pause for a week or two, say in the scenario of you're going through ovarian stimulation. So this is where we give the injections to help grow the follicles.
[00:15:37.350] - DR. SASHA HAKMAN
Each follicle contains an egg, and those are hormonally driven. And so by the time you get to an egg retrieval, your estrogen level is much higher than it would ever be in a natural menstrual cycle. In women who have really high ovarian reserve, who are pushed aggressively to get as many eggs as possible, then they may end up with ovarian hyperstimulation syndrome. You and I talked about this before during your treatment, too, where it's called OHSS for short. If you have severe OHSS, your ovaries are extremely enlarged, your estrogen is through the roof, you know how fluid in your abdomen, you may have fluid in lungs. It is not safe at that point to exercise, so you have to pause for a couple of weeks. Those are the exceptions of where a doctor might say, Okay, I need you to pause. This is where I'll tell my patients, Okay, you got fluid in the lungs, you have electrolyte abnormalities, We need to take you to the hospital. We need to correct this. You're obviously not going to be exercising at this point in time. Luckily, those situations are very rare, and those are women not only with high egg reserve who are also extremely high responders despite very low medication dosing.
[00:16:47.390] - DR. SASHA HAKMAN
But for the most part, even though we lack data, I think there's only one clinical trial that compared exercise versus no exercise during ovarian stimulation and looked at the risk of ovarian torsion. That's really the biggest fear of exercise during ovarian stimulation is that your ovaries get so big, you walk around, you lift weights, you do yoga, whatever you're doing, and the ovary twists on itself, cuts the blood supply, and that becomes a surgical emergency. In this clinical trial, they found that there were no cases of ovarian torsion between the exercise and no exercise group. However, and there was no change in outcome for the treatment either, but the patient satisfaction was so much higher in the exercise group, not surprisingly.
[00:17:32.610] - KAYLA BARNES-LENTZ
Yeah, that was one thing that I really appreciated from you because I came in a minute ago. I've been told that I can't exercise during this. For anyone listening, I have an entire fertility series, but We didn't make it clear in the beginning, prior to my husband and I starting to try naturally this year, I went through egg and embryo creation that we'll talk about a little bit more, egg freezing, embryo freezing with Dr. Sasha. When I I met you through mutual friend, and we decided to embark on this process together. I had said it. I was told that I couldn't exercise. For me, I need exercise, yes, because it's good for you, but also good for my mental health. And I was so excited that you brought up this study. Of course, you advise, don't do serious yoga and twisting and all of that, but I could still maintain walking and uphill and strength training at a reasonable cadence. So that was a really great thing to hear as well. The question, the answer to this might be no, but is there any correlation, either in the data, in the scientific literature, or even that you're seeing clinically, that supports that living a healthier lifestyle could lead to a better outcome?
[00:18:48.150] - DR. SASHA HAKMAN
Yes. I mean, we know that, for instance, with a higher BMI, even the American Society of Reproductive Medicine has a pretty long and drawn-out practice guideline for women who suffer from obesity and the clinical consequences of that in pregnancy and even trying to conceive. We know that if you have increased abdominal fat, it is hormonally active. It could interfere with ovulation and lead to ovulatory dysfunction. If you're not releasing an egg in a predictable way, it's a lot harder to get pregnant. But it's not just about releasing the egg, it's also the quality of the egg. There are some reports that suggest that there is increased rate of miscarriage as well. It's not just about the women, it's also about the men. A lot of the fault tends to be focused on the women and what they're doing, what their BMI is, their exercise routine. But we actually know that sperm is a huge contributor to the pregnancy outcome as well. For instance, if you look at studies that compared men who had a high BMI versus lean men, you know that those pregnancies are more likely to end in miscarriage as well or more likely to have some complication during the pregnancy, whether it's preterm birth or C-section or large for gestational age baby or small for gestational age baby.
[00:20:18.930] - DR. SASHA HAKMAN
There's all sorts of studies looking into that. The main reason for that, if you really think about it, is that the sperm contributes 50% of the genetic code. It's not just about the DNA itself. There's an important thing that you previously just mentioned epigenetics a little bit earlier. Epigenetics is the study of the genes that are turned on and turned off in response to our environment. If I'm in a warm climate, certain genes are going to be turned on, versus if I'm in a cold climate, it's going to completely change. If I'm really cold, I'm more likely to shiver to help keep my body warm. And the cells are turning certain things on to create that process versus I'm in a really warm climate and now I need to sweat to cool myself off. It's just one very simple example. Our environment totally changes what genes turn on and what genes turn off. That can start from the egg and the sperm and even when it comes together to create an embryo.
[00:21:19.970] - KAYLA BARNES-LENTZ
Yeah, so important. What about sleep?
[00:21:24.230] - DR. SASHA HAKMAN
Sleep is super important. Our circadian rhythm also controls our menstrual cycle, the way that our hormones are secreted, everything starts in the brain. If you think about the menstrual cycle, if you think about spermatogenesis in men, it all begins with the brain. It starts with the hypothalamus, which is the control center of the brain that then talks to the pituitary gland, which is connected to the hypothalamus. The pituitary secretes so many different hormones, endocrine hormones, that communicate with their target organ, and it's not just reproductive organs. The pituitary is important for your thyroid gland. It's important for the testes and the ovaries. It's important for the adrenaline gland, thinking about cortisol and stress. You're For sleep is oftentimes when a lot of these hormones are secreted in a pulsatal manner. When we think for women, since most of the listeners here are women, we're thinking about the first first part of the menstrual cycle, which is the follicular phase. It's called the follicular phase because it's all about the follicle. So early in your menstrual cycle, you have every woman's got a baseline number of follicles that are available to grow. And that number is really variable from person to person.
[00:22:46.080] - DR. SASHA HAKMAN
It's also variable throughout the menstrual cycle and from one cycle to the next. It changes all the time. This is where your ovarian reserve plays a role in determining if this is a high number or a low number. But that follicle count is waiting for some a stimulus to grow. The stimulus that it needs is called follicle stimulating hormone. The name of the hormone does exactly what it suggests. It's called FSH for short, and it's the pituitary gland that secretes FSH. But what controls the release of FSH versus LH, which is the hormone responsible for the actual process of ovulation? It's the hypothalamus. The hypothalamus releases a hormone first. This is the first signal called GnRH, which stands for gonadotropin releasing hormone. Gnrh is responsible for both FSH and LH release, but what determines which one gets released is the frequency and the amplitude of that release. Things like your sleep patterns, whether you're a night shift worker or your sleep habits are just all over the place, those can impact the pulsatility and the release of FSH. There are also other things that can affect it. We know that really high stress, which means high cortisol levels, can also impact the secretion and the pulsatility of GnRH.
[00:24:14.850] - DR. SASHA HAKMAN
Body habitus. Women who are really malnourished, for instance, very low BMI, this can negatively affect gene or age pulsatility. The other extreme of that, very high BMI, can also impact that, which is why you see ovulation disorders in both extremes of BMIs.
[00:24:33.210] - KAYLA BARNES-LENTZ
That is very informative. Thank you. Sorry if those- No, I love that. I love that because it makes so much sense. It's the concept of if you are in fight or flight, whether that be from lack of proper sleep or high stress or a nutrient deficiency or potentially way too high of a BMI, your body is not going to be in a place to procreate, right? Because you're going to prioritize living for you versus is having this optimal fertility cycle. So thank you for being among the first specialists in this area that I've heard really lean into. This is why you really need to have high quality sleep and high-quality nutrition and good just lifestyle habits, exercise, and so on, so forth.
[00:25:21.080] - DR. SASHA HAKMAN
It goes beyond fertility, right? It goes to the pregnancy, the health of the fetus, the health of the mother, and then getting to a point where you are having an optimal delivery and postpartum recovery. Oftentimes when we're in the fertility journey, especially if you're dealing with infertility, you're so focused on, I just want to get pregnant. I just want to get pregnant. Then you forget that, Oh my gosh, once you're pregnant, now you really have to continue to take care. Getting into these habits ahead of time can really change the whole experience of the pregnancy postpartum.
[00:26:00.960] - KAYLA BARNES-LENTZ
Yeah, such a good point. I am excited to... I haven't thought through all my protocols during pregnancy. I have an idea of diet and exercise and all of that. But once I get there or shortly before, I'm going to try to post what I intend on doing, just my end-of-one stuff. But hopefully I'll have... My mom had really easy pregnancy, so I spoke to her about that. I don't know. Is that an indicator at all? I've heard it. I don't know if that's true.
[00:26:28.920] - DR. SASHA HAKMAN
It really isn't Honestly, for instance, my mom had the best pregnancy. She loved being pregnant so much that she would be sad when it was over. I didn't have bad pregnancies, but it certainly wasn't as much of a pleasant experience for me. I will say my IVF pregnancy was a lot harder on me physically than my natural pregnancy. My first baby was through IVF after many failed treatment cycles. Then at nine months postpartum, I spontaneously conceived. I didn't think that it would happen, but it did. But it was a drastically different experience, to be honest. It's also probably because of the medication protocol that I was on for my embryo transfer, which the way it was done for me, I do very differently for patients. I had what's called a programmed FET, and this is where you're essentially on pretty high hormones, lots of injectable complications pretty much through the first trimester until the placenta is fully developed. Whereas I really like, especially in the right candidates, which is a lot of patients, you can do either a completely natural cycle for an embryo transfer or what's called a modified natural FET, where we give some pills to induce ovulation in a more predictable way.
[00:27:53.670] - DR. SASHA HAKMAN
You do a trigger shot to reinforce that ovulation and you get progesterone suppository. It's a lot... And these progesterones are actually, I know some people care about this, but they are bioidentical hormones. It tends to be a lot easier on the body. Patients who've had both protocols have given me feedback, and this is very anecdotal, of course. But they've given me the feedback that the natural FET was a much easier pregnancy than the program cycle.
[00:28:23.330] - KAYLA BARNES-LENTZ
It makes a lot of sense just doing... I'm so used to injecting things because I've been doing peptides for so long. Of different exogenous prescriptions. But yeah, it wasn't super fun going through injections all the time. Yeah, that makes a lot of sense. Sticking on progesterone Real quick. What role does that play? Because it was only a few years ago when I learned that women, and please correct me if I'm saying anything wrong, but I had a first-sitting experience with a friend who had really low progesterone and actually ended up having a miscarriage. But the next time, they actually were at my clinic and they were able to be prescribed progesterone, and then the pregnancy stayed. Can you explain that, mechanism a little bit and what's going on there?
[00:29:15.200] - DR. SASHA HAKMAN
If we just start by explaining the role of progesterone to support a pregnancy. If you think of the name progesterone, it's progestation. Gestation is pregnancy. It's a pro-pregnancy hormone. You need it to support the pregnancy. In fact, your progesterone from the moment you become pregnant rises continuously until the very end of pregnancy when you deliver. It's extremely high at the time of delivery. Now, where does progesterone come from? The follicle that grew in the follicular phase that after the LH surge, released the egg, it reseals and becomes a corpus luteum. Now you have entered the luteal phase. This is your post ovulatory phase, where if you have sex at the correct time, hopefully that egg fertilized, the dividing egg travels down the fallopian tube into the uterus for implantation about 5-6 days later. At that point, progesterone should be peaking from that corpuslutium. If there is a pregnancy, the pregnancy is releasing HCG, the pregnancy hormone, and that actually keeps the corpuslutium alive. It helps sustain it to continue production of progesterone to support the pregnancy. If you were to remove the corpusludium, aka remove the source of progesterone, you would miscarry. Sadly, we know this from studies, very unethical studies from I don't even know how long ago.
[00:30:53.930] - DR. SASHA HAKMAN
I mean, very, very long time ago. This is very old school, where they did laparoscopic procedures. They They've drained the cyst or they removed the cyst to see what happens in its role, and these women all miscarried. We determine the role of the corpus luteum being essential in supporting pregnancy. Now, in a small subset of women, they may have something called a luteal phase defect. Now, it's controversial how to define it. What is a luteal phase defect? Most people will use less than 11 days of the luteal phase. If it's a luteal phase, that's considered a luteal phase defect, meaning there isn't enough progesterone produced by the corpuslutium to support the pregnancy, and therefore, they need supplementation. Oftentimes, it's hard to really know how long your luteal phase is if you're only relying on the calendar method or basal body temperature. Even ovulation predictor kits, they're very good. It's a very good tool to help predict the likelihood of you ovulating, especially if you have regular menstrual cycles. But unless you really do monitoring with ultrasound in a practice with blood levels of your hormones, it's hard to say with certainty how long your luteal phase is.
[00:32:17.140] - DR. SASHA HAKMAN
In a fertility clinic, we have that data because we do such close monitoring with blood work. We send out labs, we do ultrasound, we know the day you ovulated based on these two things, and then I know from there how long your luteal phase is. Now, most of the time I can theorize a luteal phase defect. I'm not usually diagnosing it because if patients are coming to the point of treatment, we're usually just supplementing with progesterone unless somebody specifically says they don't want to. But the large majority of patients want to supplement because they don't want to take any chances. At that point, it's hard to say how much we're really improving the pregnancy and life birth rates because of progesterone supplementation. We know in IVF, specifically, you absolutely need progesterone supplementation without it. The success of IVF really goes down tremendously.
[00:33:18.210] - KAYLA BARNES-LENTZ
For a woman that maybe has experienced miscarriages in the past and maybe has had even more than one, would this be something that you would recommend looking into?
[00:33:29.500] - DR. SASHA HAKMAN
It would be part of the conversation, but it would be a small piece of an entire workup. If someone's had two or more pregnancy losses, then usually the best next step is to do a whole recurrent pregnancy loss panel. That looks at all of the causes of miscarriage, whether it's endocrine causes. It could be due to prediabetes, for instance, that increases the risk of pregnancy loss. High prolactin levels, and prolactin is a hormone that's responsible for milk production during and after pregnancy so that you can breastfeed. In some women, they may have elevated prolactin levels for different reasons, but one of the common reasons is a benign tumor that secretes prolactin, and that can increase the risk for miscarriage. Other endocrine causes are thyroid abnormalities, whether it's autoimmune or not. We think of anatomic causes, so the shape of the uterus. Some women are born with an abnormal shape of the There's something called a uterine septum that can increase the risk of miscarriage by 60%, so it's pretty significant, and that needs to be surgically corrected. It could also be fibroids or polyps. These are just benign growth inside the cavity of the uterus that could cause miscarriage.
[00:34:48.260] - DR. SASHA HAKMAN
Other anatomic causes that need to be evaluated as well. The most common cause of miscarriage ultimately is genetic. Mostly from random chromosome error. It's totally random. This is why miscarriage rates are very, very high. It's not necessarily due to our environment. It's more so that it's just nature. I know that people don't like to hear that answer because you have no control over that, but it's like rolling a dice. Our eggs are not all chromosomally normal, and then depending on female age, that will determine the percentage that are chromosomally normal versus not. But then there's also your own DNA. We have our sets of chromosomes, but sometimes in a very small percentage of couples, one person will have something called a translocation, where you have two pieces of the chromosome that will swap places. So you have the full complement of your DNA. But when your egg goes to split the chromosomes in half in order to accept a copy from sperm or vice versa with the sperm, when it divides its chromosomes in half, it can be an abnormal segregation because of the translocation. These are all causes that could be identified through testing and should be done earlier than later.
[00:36:11.380] - DR. SASHA HAKMAN
Unfortunately, even with recurrent miscarriages, you're only going to find a cause in 50% of cases. I didn't even get into all of the immune-related things, the autoimmune causes for a miscarriage, because that's another series of tests. But there's a lot of testing we can do, but in many cases, we will never find a cause, which is really frustrating for a lot of couples.
[00:36:32.600] - KAYLA BARNES-LENTZ
Yeah, absolutely. What impact does, for example, thyroid conditions or autoimmune have? What is the mechanism of why it makes it more difficult to get pregnant or sustain a pregnancy?
[00:36:44.840] - DR. SASHA HAKMAN
Well, we know that the thyroid hormone is responsible for so many different processes in our bodies, including our metabolism, and our metabolic needs change in pregnancy. If, for instance, you are not producing enough thyroid hormone, then it's really hard to sustain the metabolic demands of a pregnancy, and oftentimes the body will just shut it down and terminate that pregnancy. In many cases, when you have, for instance, hypothyroidism, that being the most common in women. If we look at the autoimmune cause of that, that's called Hashimotos. That's not the only reason for hypothyroidism, though. You really need to keep your TSH TSH levels below 2. 5. Now, we used to think that we need to keep TSH levels below 2. 5 for anyone trying to conceive whether they have hypothyroidism or not. If it's above 2. 5, then that falls under the category of subclinical hypothyroidism. Even though you're making enough thyroid hormone itself, the signaling hormone TSH, which is thyroid stimulating hormone, that is released from the and that communicates to the thyroid gland to make thyroid hormone. If it's higher than 2. 5, there's got to be something wrong that the brain feels that it needs to release more.
[00:38:12.110] - DR. SASHA HAKMAN
But newer studies are showing that that may not really be accurate. If your TSH level is still within the lab's normal range, which usually goes to 4 or 4. 5, depending on the lab, that should be okay as long as you don't have positive five antibodies that are associated with Hashimotos, for instance, like anti-TPO antibodies. If those are positive, then it's probably better to bring that TSH level down a little bit lower, even if your thyroid hormones are at a normal range.
[00:38:44.780] - KAYLA BARNES-LENTZ
Got I know. Okay. Yeah. Very interesting.
[00:38:48.240] - DR. SASHA HAKMAN
I know. It's all very complex, all these hormones. It's drawing all these different labs, putting pieces of a puzzle together, which is the fun part of my job, I would Yeah, definitely.
[00:39:01.930] - KAYLA BARNES-LENTZ
I love investigative work, right? Where is it coming from? There's also a super interesting link between gut health and autoimmune conditions. Yeah. So that's a whole nother podcast. Yeah, it is super interesting. Quick question. So I track, obviously, ovulation through natural cycles and then aura ring. So we know that once you ovulate, you see a consistent rise in the body temperature. If you don't ovulate, do you still have a rise in the body temperature or where you see no change?
[00:39:36.670] - DR. SASHA HAKMAN
So you can see no change most of the time, but sometimes you might see it for other reasons, and that's what we would call a false positive Most of the time that rise is pretty indicative. Basal body temperature is really great for helping to confirm ovulation, not in the most solid way. It's not like getting blood tests, for instance, that's really the best way you're going to get it. It's a great test for really over time tracking and understanding your cycles. But for those who use it to help predict ovulation, it is not a prediction test. It is confirming you've ovulated. So by the time your body temperature rises, if that's when you're going to start having sex, it's too late. No. Your fertile window is before you ovulate, not after. In fact, you're the most fertile 2-3 days before you ovulate.
[00:40:31.820] - KAYLA BARNES-LENTZ
I think I'll probably do like those. Do you like the little strips for ovulation? Yeah. I mean, I've been lucky. Well, I don't know if it necessarily was luck, but I've had very regular cycles, so I think I have a good idea. But yeah, I might use those too, just to confirm once we're ready to start trying.
[00:40:52.510] - DR. SASHA HAKMAN
Yeah. I mean, the test strips are really helpful. If you have really regular cycles and they're predictable and your OPKs is what I call it for short. So ovulation predictor kits. If your OPK shows that it's positive, you get the two lines, you're surging, chances are you are ovulating. It's really unlikely for you to not have an ovulatory cycle at that point. Is it possible? Yes, but very unlikely.
[00:41:20.540] - KAYLA BARNES-LENTZ
Thank you for that. I want to talk about nutrients next. So I do this test called the NutriEval, which this is at the very intense side. Yeah, very high level. Very high level, right? It's not necessary to do, but it's been helpful because I understand where I need to supplement, right? I don't prefer to just guess on my supplementation, although we do both like the same brand of prenatals, wenatal. What role could nutrient deficiencies potentially play in fertility? It's important to optimize nutrient status.
[00:41:57.150] - DR. SASHA HAKMAN
Yeah. I mean, it's really important We probably don't study it enough. I would say the nurse's health studies are probably the best ones in terms of us understanding nutrition as a whole when it comes to macronutrients. We still don't know enough about the effects of particular micronutrients on fertility. There's a lot of different things that we encourage our patients to take to improve egg quality, for instance. But those are heavily focused on antioxidants like CoQ10, more research on NAC and NAD plus, and all these different things that you can improve for egg quality. But in terms of overall fertility and micronutrients, obviously, we know that micronutrients are super important. I would say one of the most commonly studied things is vitamin D. So vitamin D is really heavily researched in its role on the endometrium, so the uterus and implantation. And so It's become very common. I wouldn't say necessarily evidence-based because once again, one of the most common problems we have is really high-quality data. Usually, this is due to a lack of funding for research, which is a whole other area we can get into, but I won't get into. But vitamin D, heavily researched.
[00:43:22.040] - DR. SASHA HAKMAN
A lot of fertility practices are universally testing all patients for vitamin D levels. I would say that the large majority of my patients come back vitamin D deficient and are told to supplement. Based on their levels, that's where we determine the dose of supplementation. Usually, it will not be enough in a prenatal vitamin. Even the best prenatals, you cannot pack that many nutrients into one or two pills. It's just too much. At that point, you just need a separate vitamin D supplement, especially for those who need 5,000 units a day or even more in many cases. So vitamin D is a really big one. There's more popularity on vitamin E, lots of talk about Zinc. And so There's growing body of evidence. They're just not high-quality data yet. But generally speaking, I would say that every single fertility doctor on the planet, I would hope, is telling their patients that you got to be on a prenatal. It's got to contain a little bit of everything that you need. The men should be on supplementations too, because they're probably, even if you have the best nutrition, you're probably missing some micronutrients in the food that you're eating.
[00:44:47.080] - KAYLA BARNES-LENTZ
What do you like to see vitamin D levels at?
[00:44:51.050] - DR. SASHA HAKMAN
Minimum 30 nanograms per ml. I don't expect anyone to understand the units, but at least 30 when we're drawing it. That That would be the bare minimum.
[00:45:02.010] - KAYLA BARNES-LENTZ
Yeah. I mean, to me, that feels so low. I keep mine at 70.
[00:45:07.220] - DR. SASHA HAKMAN
Yeah, that's a great level. That's a great level. Yeah, 30 is bare minimum.
[00:45:14.900] - KAYLA BARNES-LENTZ
I'd say- It's wild that you have a lot of people coming in under that.
[00:45:17.610] - DR. SASHA HAKMAN
Yeah, very, very common. Some as low as 12, 13. It's every day that I'm catching that. And I see it's not just important for your fertility, it's your bones, it's your overall health. It's your immunity, it's all of it. We got to get your vitamin D out.
[00:45:36.210] - KAYLA BARNES-LENTZ
Gosh, yeah. Okay, so that's another big takeaway, is vitamin D. We have the importance of exercise and sleep, and it's so fun to go through this through the lens of fertility. It's super exciting. Now we've talked about nutrient statuses. What are just some of your favorite, just clinically or what you recommend to patients in terms of nutrients for... You mentioned a few. You mentioned coQ10. These are mostly egg quality, right? Coq10, I see there is some I saw you share today on Instagram, and this is like something I've been exploring is NED or NMN or NR precursors. I'm excited to see where that literature goes. But I think if you have the means and you really want to fully optimize. I mean, I would probably put a high-quality one in there.
[00:46:18.260] - DR. SASHA HAKMAN
What else do you like to see? So for women who have PCOS, I really like enoxetol, but it's not just any enoxetol. So the research that has been shown to be helpful is myo-anazotol to dechyro-anazotol at a ratio of 40 to 1. Now, there isn't any evidence-based dosing in particular, but I would say that a lot of the high-quality supplements, they are using what's out there in the literature. The literature does vary tremendously, and the dose that you should be on really depends on your particular case, and that's something to discuss with your fertility doctor. But with PC PCOS or with insulin resistance, whether or not you're on metformin or some insulin sensitizer, it's really helpful to add that on. In some cases, you can even try that first with lifestyle optimization before starting any pharmacotherapy like metformin or insulin or now GLP-1 agonist, which that's a little bit harder for us to use because if you're actively trying to conceive, you can't be on GLP-1 agonist even if someone's a really great candidate. So at that point, the conversation is, do you delay childbearing and fertility treatments to be on these GLP-1s until we get you at a metabolically better place?
[00:47:44.470] - DR. SASHA HAKMAN
Which I always recommend doing that first. But in many instances, women are getting older and they're like, Well, I don't have the time. I'm getting older. I want a baby yesterday, so let's just start the treatment. So at that point, I say, All right, well, we'll start metformin, we'll do a nazotol, Here's exercise, nutrition, all the lifestyle things to optimize you as much as possible as you're going through the journey simultaneously.
[00:48:09.590] - KAYLA BARNES-LENTZ
What about for men? What do you like men to be on?
[00:48:13.100] - DR. SASHA HAKMAN
For men, it's a little bit controversial. Many fertility specialists will start supplementation for men. The data isn't really there yet. Some studies have actually shown it to It's really harmful to supplement with Zinc and CoQ10, but that wasn't statistically significant. Other studies have shown that it could be helpful. Anything that's controversial is just a big fat question mark for me. I usually just say you need to be on at least a men's multivitamin. This is why I like Weedle. It's because they do that for the men, and it's a two-in-one packaging for the women, for the men. You're doing this thing together. You feel like a team as you're going through this fertility journey. I really like that it puts it on the men as well to take their health seriously as they're helping to hopefully achieve a pregnancy because they are still contributing 50% of the genetic material. I do usually, like WeMiddle is really on my recommended list, if that is cost prohibitive, then I recommend just being on any multivitamin. Also, really stress for the men that resistance training really is a must. We know that for men, resistance training helps improve testosterone levels.
[00:49:44.210] - DR. SASHA HAKMAN
It helps improve sperm parameters. There are good studies on this. They need to improve their sleep hygiene, their nutrition. Same thing as for women. Wholefoods, really increasing plant intake. There's just not enough veggies people's diets these days, preferably some of it being raw. Obviously, you want to wash it very thoroughly because of possible pesticides. Being a doctor in Southern California, we're really privileged here where I say, We have year-round farmer's markets. We have access to reasonably affordable non-pesticide-sprayed produce. So always prioritize that. And so that's just part of my counseling.
[00:50:35.650] - KAYLA BARNES-LENTZ
Yeah, I love that. Give us one quick break because I want to make sure I want to go through some of this, and then we're going to talk about my stuff, and then we're going to answer these questions. Okay. Do you have a lot of thoughts on the gut microbiome infertility?
[00:51:00.720] - DR. SASHA HAKMAN
It's so early in its infancy, unexplored, and also not my expertise either. There's probably some researchers out there, but yeah.
[00:51:11.350] - KAYLA BARNES-LENTZ
Yeah, I feel like we haven't talked about that a lot. Okay, so we've covered really a lot of core foundational health practices as they relate to fertility. I do want to talk a little bit about alcohol. I'm so excited that we now... I feel like as a health, The health industry as a whole for so long, we tried to make alcohol healthy somehow in moderation because of Rastafetraal and whatnot. But I think it's pretty clear now that alcohol is not healthy for you. It's not a health beverage. So what are your thoughts on alcohol and for either trying to optimize your fertility or getting pregnant?
[00:51:51.830] - DR. SASHA HAKMAN
If you're going to follow the American College of OB/GYN recommendations, the American Society The Society of Reproductive Medicine, the Society of Maternal Fetal Medicine, all of the societies, there is no healthy level of alcohol when trying to conceive or in pregnancy. Now, are there moments where patients are like, Is it okay if I have a glass of wine during my egg freezing cycle. I'm like, Yeah, go for it. That being said, at that point, I say, Got to really limit it. We know that it could affect egg quality, it affects sperm quality, And anything lifestyle-wise as an added tip for people to know when it comes to sperm quality, men are so lucky that they are continuously making sperm because they can clean up their act. And in three months, you have a whole new batch of sperm. It's not just the DNA, it's not just the semen or the sperm parameters in terms of the concentration of sperm that goes up, the motility of sperm, so So the percentage of swimmers, the morphology, the shape of normal sperm, which is suggestive of possibly its DNA, but it's also the epigenetics, as we spoke about before.
[00:53:11.400] - DR. SASHA HAKMAN
You can have tremendously improved sperm within 3-6 months of completely changing lifestyle. Now, for women, this is a little bit more controversial because we're born with all the eggs that we're going to have in a lifetime. And so everything we do, our eggs have been exposed. Now, the extent The preventive exposure is the controversy because we know that most of our eggs, just as a little bit of a background, every egg is stored in its own container called a follicle. But most of the follicles are teeny tiny microscopic in a resting stage known as a primordial follicle. Eventually, it leaves that resting stage to become an enteral follicle, and the enteral follicle is what can then grow to then release that egg. The timeline from leaving the primordial stage to becoming an enteral follicle is believed to be around three months. There is that theory of, well, clean up your act for three months, and you're going to have improved egg quality through supplementation, nutrition, exercise, sleep, all those things that we previously mentioned. But I still like to stress to women that those eggs are still getting exposed. Obviously, whatever you've done in your past, I don't want that to be this huge burden and guilt that women feel like, Oh, my gosh, I have all this regret.
[00:54:34.890] - DR. SASHA HAKMAN
I wish I could take it back. Of course, you got to just look forward and change what you can now, and hopefully that can improve at quality. But in the same time, it's important to improve it now and not just three months before you want to start trying, because we do see, for instance, women who are heavy smokers or smoke cigarettes at all, for that matter, or who are heavy drinkers, they are more likely to have diminished ovarian reserve. Female smokers, on average, reach menopause earlier in life than nonsmokers. There are really big impacts on ovarian function, and it's not just related to fertility because menopause is important, too, because once you do hit menopause, the chance of all-risk mortality goes up because you don't have estrogen anymore. Estrogen is really vital for longevity and for your brain health, your cardiovascular health, your bone health, for so many other things, your gut health.
[00:55:39.040] - KAYLA BARNES-LENTZ
Totally. Yeah. Will you walk through how many eggs were born with versus when the main drop-ups are? Because I know that I got a lot of questions. We'll jump into questions here in a few for my female longevity community. But can you break that down for us?
[00:55:55.490] - DR. SASHA HAKMAN
Yeah. When you are a fetus in your mother's womb at around 20 in a week's gestation, you have 6-7 million eggs. By the time you're born, you're down to 1-2 million. You've had the most accelerated loss of eggs. We don't know why this happens, but it happens. Then when you go to hip puberty, you're down to about 300,000, maybe up to 500,000, depending on the woman. Then from there, once you start your menstrual cycles, on a monthly basis, you are losing about a thousand eggs every month. And there is nothing you can do to stop that. Some patients will ask me, Well, I was on birth control pills for 10 years. I was not ovulating. Did I save those eggs? You did not save those eggs because the process of the follicles leaving the primordial stage is happening no matter what you do, whether you're pregnant, no matter what you're doing to suppress ovulation. There is no stimulation to grow them because of either birth control pills or other contraceptives or pregnancy or breastfeeding, and they just disappear. They undergo a process known as atresia. This is physiologic. This is normal. We can't do anything to change that.
[00:57:14.170] - DR. SASHA HAKMAN
Where did they go? So the process of atresia is basically like programmed cell death. They just die and they're gone. Even when I see an antropholical, if there's no FSH to stimulate it, then it undergoes the same.
[00:57:36.780] - KAYLA BARNES-LENTZ
When it comes to, let's just say, fertility markers, I know it's so difficult because you can have a great AMH or a low AMH OMH. Just walk me through, if a woman is listening to this and she just wants to get some idea, let's say she's either 25 or 30 or even 35, as soon as you are aware of this and want to understand potential fertility, what are labs that you can have run and what might they tell us?
[00:58:04.080] - DR. SASHA HAKMAN
The main thing that you would have run is your ovarian reserve. Markers of ovarian reserve is a combination of primarily two things nowadays. There's other tests we can do, and I'll get into that in a bit. The most common two tests that you'll do is number one, a simple blood test for AMH, anti-mullerian hormone. This is a hormone that is secreted from the cells that surround the egg. These are called granulosa cells. It gives us an idea of the activity that is happening in the ovary within those follicles. Now, this number for AMH, it doesn't tell me how many eggs you have quantitatively, in a more specific way. It just gives me an idea of abundance. Do you have an abundance of eggs? Are you average or are you below average? Now, that number does not correlate to likelihood pregnancy. It does not give me an indication of quality, but there are some caveats to that. Now, entral follicle count is the process of doing the ultrasound, counting the entral follicle which are fluid-filled sacs in the ovaries, each sac containing one egg. These are the sacs that left the primordial stage. Like I said before, they became entral follicles.
[00:59:26.740] - DR. SASHA HAKMAN
They're ready for stimulation. The The number that's there gives me an idea of if I were to inject you with FSH, how many eggs could I potentially get all at once? For instance, I might see someone who has 30 plus follicles between both ovaries, and that's considered a very high egg reserve. It usually will correlate with AMH levels versus someone who may have 2-3 follicles total or per ovary. It just depends on the situation. Now, once again, doesn't correlate to quality. That being said, we do have theories that if you have critically low ovarian reserve at a young age, then it could be an indication of accelerated aging way beyond what we expect at this age. Perhaps the eggs that are remaining are of lower quality because usually, you will deplete the best eggs first. This is why when we talk about reproduction for women in their 40s, it's significantly harder to get pregnant in your 40s because your eggs have already aged. There's different components of ovarian aging, of egg aging. We often talk about the mitochondria, which is the energy source of the egg and is really important for its ability to become fertilized and become an embryo.
[01:00:59.130] - DR. SASHA HAKMAN
But there's the most important portion of it, which is the chromosomes. We have our pairs of chromosomes that are aligned along the equator of the egg, and they're held in place by these proteins called spindles. And spindles get weaker as we age, and so you get abnormal segregation and an abnormal chromosome number, which leads to abnormal eggs. For younger women who are exploring and they're like, Well, I just want to know where I sit, what's my average? This is really helpful to know where you stand for you as an individual. If you follow, for instance, the American College of OB/GYN, they say that you should not be testing this on an annual basis. Many of us fertility specialists are like, Well, I have a bone to pick with that because it's more information for this individual woman. It doesn't mean that because your AMH is one at the age of 25, you have to go and freeze your ex today. It just means that your AMH is just border mind normal. And maybe that's just normal for you, and it could stay that way for a very, very long time. Or you might redraw it next year and it dropped in half.
[01:02:11.890] - DR. SASHA HAKMAN
And you're like, wait a minute, I'm 26, and now it went down to Five, what's going on? Now, there are things in life that will drop your AMH that are less concerning. For instance, if you've been on birth control pills for a very long time, your AMH will drop, but this is reversible. The ovaries are smart. There's no stimulation to ovulate. So it says, Well, I don't really need to produce and secrete this hormone. And so the AMH goes down. And for women who come to me for egg freezing, who have really low AMH and have been on birth control pills, or they've been on some long-term hormonal contraceptive, except for the IUD, I say, You should probably stop that, and then we recheck in three months in order to get a better outcome for your egg freeze cycle, because we're going get a lower yield at an expensive cost. Let's not deny the fact that this is an expensive treatment. Oftentimes patients will do this and they'll get a much higher AMH, a much greater egg count as a result of that. But generally speaking, I am a big fan of testing it just so that you know where you're at.
[01:03:23.600] - DR. SASHA HAKMAN
If you're younger and your AMH is very low, we might be catching something as it's happening, which is called primary ovarian insufficiency. This is basically premature menopause or you're starting to enter that. If someone in their 20s comes to me with an AMH of 0. 2, 0. 3, I am concerned. Yes, they are young, and technically at that age, at quality, should be really great because of the age component. But this is where I would want to do additional testing. You want to check other things that might be affecting ovarian and causing an accelerated rate of aging. It could be genetic causes, like something called a fragile ex-premutation. It could be due to an abnormal chromosome, like something called Turner's mosaicism. Some women are missing an ex-chromosome but only in one cell line, so they have two cell lines in their bodies. Usually with full Turner syndrome, they will typically never have a period, and that's because they've essentially gone through menopause before they hit puberty. Oh, gosh, that's so sad. Yeah, and so they're born with this. There's other parts of that syndrome that makes it easier to tell and diagnose. But oftentimes, they're diagnosed around 14, 15.
[01:04:43.050] - DR. SASHA HAKMAN
They're like, I forgot a period, and I'm really short. But with churnus mosaicism, it's a lot less obvious because they're not that short. They might be. They've had fairly regular cycles, and then all of a sudden, their cycles are something shorter at a young age or you go to draw the AMH and it's really, really low. So it would require further evaluation.
[01:05:07.360] - KAYLA BARNES-LENTZ
Yeah. I definitely second your school thought. I would want to know. I think I got my first AMH. It was really like when I started to dive in and learn about it, maybe like 28 or something like that. Yeah, amazing. I wish I would have done it even earlier just to have, for me, tracking purposes and see some of these interventions that I've done. But yeah, I definitely think it can be helpful. What about LH and FSH? Do these really have much of an impact, or what do you think about them?
[01:05:35.610] - DR. SASHA HAKMAN
Yeah. Fsh is really helpful to draw on cycle day 2-5 of your menstrual cycle. Now, FSH can be a helpful marker of ovarian reserve in combination with estradiol if you have low AMH and low follicle counts, or sometimes I'll do an ultrasound for a follicle count, and I really don't see anything. Now, okay, AMH is low, I'm not seeing any follicles, I need to really investigate, are you entering menopause? This is where FSH could be a really helpful addition. If I draw FSH, let's say someone is still having regular menstrual cycles and we do ovarian reserve testing and things are not looking great. And FSH on cycle day 3 is above 10. That's telling me that the brain is working extra hard, extra early in the menstrual cycle to recruit eggs, and that's usually not a good sign. Same with estradiol levels. If your estrogen levels are above 70, 80 early in the cycle, that means that you've started the recruiting process probably at the end of the last menstrual cycle when you're in the luteal phase because there isn't much left. When I see high estradiol, high FSH with low ovarian reserve, I know that things are starting to approach an end, and you are in this perimenopause stage.
[01:07:10.550] - DR. SASHA HAKMAN
Now, if you're in your 40s, and I'm seeing that, that's physiologically normal. But if you're in your 20s and 30s, and I'm seeing this, then this is a situation of, We got to act fast. I don't know how much we're going to get, but we got to try and do something. Sometimes you can achieve retrieving eggs to freeze them, especially if you're not ready to have a kid and you don't have a partner. But other times there isn't much response at that point, and sometimes it's too late. There are associated autoimmune conditions with that, genetic conditions as I mentioned before, and even thyroid has some correlation with that.
[01:07:50.640] - KAYLA BARNES-LENTZ
Wow. There's essentially no test for egg quality, right? No. Is anyone working on one?
[01:07:57.910] - DR. SASHA HAKMAN
No, there's no test for egg quality It's really all about female age. You don't even know what the potential of an egg is until you go to fertilize it and watch them become embryos in the laboratory. Then once you have those embryos doing genetic testing of them. Although genetic testing is not the be-all-end-all, but it's really helpful.
[01:08:21.850] - KAYLA BARNES-LENTZ
Got it. Well, thank you for all of that. It was super helpful. To segue really quick, we mentioned it, but I just wanted to I want to point out a few things I really loved about working with you. We did this just prior for safety, for preservation, I guess, because we won't have so many babies. If we only wanted to have two kids, I'll be honest, I probably wouldn't have done any of this. It probably would have just started trying and had two or three children. But because we want more, significantly more than that, I think we're really excited that we now have a couple of embryos and we have frozen eggs. I'm glad that we made that decision to free some of the eggs and then do embryos with others. But because I do have a high AMH, it's about, I think, 5. 8, we thought that we might experience this ovarian overhyper stimulation syndrome. But a few things, you've been so incredibly hands-on and you were so attentive and adjusting the medications to ensure we didn't get that. I I think it was probably a team effort because as you said, I'm a very compliant patient.
[01:09:34.480] - KAYLA BARNES-LENTZ
Very. Yeah. So I did all the things that you told me, and a lot of them were actually already part of my lifestyle, like the high protein and just maintaining a healthy lifestyle. And then afterwards, we were so excited to see that it was like a week out. I had to retrieve them on a Monday, and then we came back on the next Monday. And I think you were surprised to see how quickly my ovaries had recovered. So I did a few end-of-one things. I'll put into a little protocol within my female community. Again, it's not medical advice, just what I did. Did a couple of sessions of hyperbaric oxygen, which we know can promote healing. They're used many times after different surgeries. Maybe that helped, maybe it didn't, but that's part of what I did. Then I did some red light therapy on the ovaries once a day for about 15 minutes a day. We're not sure which thing made it heal fast, but I was really excited because I was preparing for potentially a few weeks of not feeling well, and that didn't happen.
[01:10:35.720] - DR. SASHA HAKMAN
Right.
[01:10:36.370] - KAYLA BARNES-LENTZ
So excited about that. I know a huge part of that was everything you did. So it's important to find the whole purpose of me bringing this up. This is really important to find someone like you who's going to listen so much to the patient and be so conscientious. So thank you for doing that. My pleasure.
[01:10:56.100] - DR. SASHA HAKMAN
I totally agree with that. I mean, it's all about the patient goals, right? It'll look different for everybody, and so you have to accommodate what the patient is hoping to achieve.
[01:11:09.410] - KAYLA BARNES-LENTZ
Yeah. Well, I love that. If you are in LA, like I said, I put a lot of time and effort into finding you. I've done that for all of you women. If you're interested in either fertility preservation or you want to do IVF, I can't endorse you highly enough, doctor. Thank you so much. Oh my gosh. Thank you. Now we're just becoming such good friends. I love that. I love that, too. I know. Okay, so I want to jump into some of these questions. Yeah, let's do it. Let me pull this up. We might have a quick break here. Hi, guys. I'm going to interrupt this episode for a brief announcement. As you may or may not know, I started a community for females by females, and it's a female longevity optimization community. This is a place that you can connect with like-minded women. We are all here to support each other, and there's a variety of different benefits to being a member. You get a monthly Ask Me Anything, so submit your questions and I'll answer them directly. We also have an entire library of courses on all of the important components of longevity, such as labs, nutrition, exercise, sleep optimization, longevity optimization protocols that I'm doing, along with real-time updates to my personal protocols.
[01:12:26.310] - KAYLA BARNES-LENTZ
There are so many benefits of being a member of the community. We'll also be doing in-person live events here in California and virtual events for anyone that can't attend. But if you're interested in joining the community, I would absolutely love to see you there, and I will include a link in the show notes. All right, so we're going to do a little bit of, we'll call it rapid fire, but of course, take as long as you need to answer the questions. But yeah, these are from my female longevity community. If anyone's interested in joining, I will include some links in the show notes. But we just do AMAs. I post questions or a question box for my guests so that these women can ask really specific questions there beforehand. And I've gotten good feedback. So okay, one of the first questions, is it only are eggs that age and cause fertility issues, or does the uterus also age impacting the ability to carry a baby?
[01:13:19.240] - DR. SASHA HAKMAN
Very great question. The short answer is it's just the eggs that age. The uterus does not age. This is why if you use donor egg or embryo adoption, whatever that looks like, a 50-year-old woman can conceive.
[01:13:35.640] - KAYLA BARNES-LENTZ
Also why now we have these? Embryos. Yes.
[01:13:39.220] - DR. SASHA HAKMAN
Because I will add just a very quick nuance to this. If there is uterine factor in fertility, it does get worse with age. That is just a little caveat.
[01:13:51.380] - KAYLA BARNES-LENTZ
What? Like the misshaping?
[01:13:52.970] - DR. SASHA HAKMAN
Something like adenomyosis or endometriosis that affects the uterus and it affects its implantation or fibroids, things Things like that can get worse.
[01:14:01.600] - KAYLA BARNES-LENTZ
Okay, that makes sense. How does mental health affect the mother when pregnant?
[01:14:07.700] - DR. SASHA HAKMAN
Oh, okay. That goes hand in hand with when we talked about the epigenetics of the sperm, and that can affect the health of the fetus, the pregnancy itself, and then honestly, probably even the health of the child long term.
[01:14:21.010] - KAYLA BARNES-LENTZ
When is the latest time or age to have children in your opinion?
[01:14:29.480] - DR. SASHA HAKMAN
Okay. There's a bit of an ethical thing there. Well, there's my opinion, and then there's medically what is allowed. Most fertility practices are not going to do an embryo transfer past 54. The main reason for that is because of expected life expectancy and that child having a parent. It's just a very large age gap and concern for that child potentially not having parents or the emotional toll that it'll take for them to lose a parent at a relatively young age compared to their peers.
[01:15:08.740] - KAYLA BARNES-LENTZ
That makes sense. What about naturally?
[01:15:12.270] - DR. SASHA HAKMAN
Naturally is really just about how long your ovaries are working for. The majority of women are probably not going to be very successful in conceiving, usually past 42. It doesn't mean you can't get pregnant past 42. It just means It's that you're only seeing it about 4% to 5% of women.
[01:15:34.090] - KAYLA BARNES-LENTZ
Thank you for that. I have frozen. This is from a member. They have frozen their eggs. What can they do now to ensure her body is still fertile to bear a child at 43?
[01:15:48.910] - DR. SASHA HAKMAN
This is where you'd probably want to see a fertility specialist, get all the comprehensive testing, imaging, blood work to see how things are looking. In addition to that, just general overall health. You want your screening tests for PAP smears, mammograms, checking in with your PCP, looking at your blood sugar levels, cholesterol, just everything for overall health Because something oftentimes we forget about is that as we get older, the risk of metabolic and chronic diseases increases. Same with breast cancer, unfortunately, one in eight women. Ensuring that there are no issues that can negatively impact your health during your pregnancy is really important.
[01:16:35.520] - KAYLA BARNES-LENTZ
Absolutely. How does having high histamine levels impact an embryo transfer?
[01:16:41.780] - DR. SASHA HAKMAN
We don't really know. I mean, there are some studies, very old studies that have suggested that histamine is important for a process known as decidualization, which is, long story short, the way that the cells change in the lining of the uterus to accommodate implantation. There are some protocols for embryo transfers for prior failed transfers or suspected allergic or immune components to fail transfers where we might add an antihistamine. It's called an antihistamine protocol. But the studies have actually not been very convincing.
[01:17:20.570] - KAYLA BARNES-LENTZ
Interesting. How to do IVF as naturally as possible?
[01:17:25.720] - DR. SASHA HAKMAN
As naturally as possible will cost you a tremendous amount of time and money, which is a very old-school thing. Natural IVF is just letting your body ovulate one follicle at a time and then taking out that egg during the retrieval. That is really usually not recommended.
[01:17:46.390] - KAYLA BARNES-LENTZ
I asked about this early on, remember? Yes.
[01:17:49.130] - DR. SASHA HAKMAN
So you would probably have to do, gosh, so many retrievals back to back to back to back, which is early on the way it was done before all these medications were invented. But you could still do something called mini IVF. Still don't always recommend that unless you're looking to just spend a crazy, crazy amount of money on- Yeah, because you have to pay for each one of them. You have to pay for each one. It's very cost and effective.
[01:18:22.010] - KAYLA BARNES-LENTZ
Yeah. As someone who's very holistic-minded and very like, I just had to weigh the pros and cons of Yes, you take medications that are putting you at a super physiological dose. But it's for a very short period of time. And I'm of the mindset to, I don't even think there is anything to repair, but obviously, I was able to recover very quickly. Yeah, that made the most sense for me, and this was something that was on my mind. We talked through the potential of doing one each time, and that just didn't make the most sense. Right. What are long-term consequences of IVF on the mother?
[01:19:04.350] - DR. SASHA HAKMAN
There are none seemingly. That being said, the oldest IVF baby is 44. We don't have any longer term data than this. But we do know that, for instance, IVF medications do not increase the risk of gynecologic cancers, whether it's uterus, ovaries, does not increase the risk of breast cancer and even non-female-specific cancers as well. It is fairly safe. Even with my cancer patients that come to me for emergency consultations before they start chemo, and this includes breast cancer patients who are even ERPs PR-positive breast cancer, we will undergo ovarian stimulation. It does not increase or upstage their cancer. It does not increase the chance of recurrence. It's fairly safe to do.
[01:19:58.500] - KAYLA BARNES-LENTZ
Great answer. How long does the average couple take to get pregnant?
[01:20:04.840] - DR. SASHA HAKMAN
This is pretty much what has shaped the definition of infertility. For couples under the age of 35, 80% of couples should be conceiving within a year of trying, which means that if it's been a year and you have not gotten pregnant, it's really time to look into it. Now, if you're 35 and up, you only give yourself six months. Even though not 80% of couples will conceive at six months, when you're over the age of 35, it's more of the age-related factor that if it hasn't happened by six months, it's time to start to look into it because you don't really have time to waste, especially if you're wanting multiple kids.
[01:20:48.970] - KAYLA BARNES-LENTZ
Absolutely. What modalities to improve fertilities? We talked about, of course, diet, lifestyle, exercise. I like red light for a lot of different reasons, but what is your school thought on red light therapy?
[01:21:03.490] - DR. SASHA HAKMAN
I mean, if it's something you have access to, then go for it. But there isn't really data to say in any convincing way that it helps or harms or does anything. I doubt it harms. It probably helps, but we need good quality studies on that.
[01:21:21.700] - KAYLA BARNES-LENTZ
Yeah, there's the one, and it's obviously a small study, but there's the one in Japan that had pretty interesting result. That was more so with low-level laser therapy, which is more of a medical device than having it necessarily not home panel. But my thinking about it is we know that the oocytes have almost the highest density of mitochondria, right? Like the heart, So if you are having mitochondrial dysfunction, which we know so many people in the US right now have, and red light could potentially be beneficial to mitochondria, then not harmful may help. Yeah, Exactly. Exactly. Okay, great. What is the latest age that one could freeze their eggs? This person is 35. Would 37 be too late?
[01:22:10.280] - DR. SASHA HAKMAN
37 definitely wouldn't be too late. Thirty-five is obviously better than 37. What I usually tell patients is once you're in your 30s, the longer you wait past 35, the more cycles it's probably going to take you to get to a number of eggs that gives you a really solid chance at one live birth or two lives, two babies, depending on the number of kids you're hoping to have.
[01:22:35.520] - KAYLA BARNES-LENTZ
Yes, that makes a lot of sense. This is a really loaded question, how to reverse ovarian aging. I wish we knew that answer, but- We do not know that answer. We don't even actually know why the ovaries age is so much faster.
[01:22:50.730] - DR. SASHA HAKMAN
Yes, we don't know why. It really sucks, especially because we're living longer. Imagine living half your life in menopause. I mean, that's for a really long time. Thank God for hormone replacement therapy. Right.
[01:23:03.210] - KAYLA BARNES-LENTZ
Yeah. We'll keep this conversation. Your clinic might be a trial site for the rapamycin, something related.
[01:23:13.390] - DR. SASHA HAKMAN
Well, I'm hoping They're doing it at Columbia right now. I reached out. I'm hoping to bring it to HRC because I think that it's really important, number one, to have it in multiple different locations. I do think that geographic changes can change the the data and the information and outcome of the studies. I just think it's a really exciting aspect of our field to look into ways to delay menopause, ways to improve ovarian reserve. It's still an ongoing clinical trial. They stopped enrollment. We do not have any of the study outcomes yet. Of course, there was a lot of media attention with preliminary results looking to improve ovarian reserve by 26%, delaying the onset of menopause by possibly five years. It is something I really want to bring to our practice, but not just for delaying menopause, I really want to look into rapamycin as, can this improve live birth rates? For older women who are struggling to conceive, if we start them on rapamycin, are they more likely to achieve a pregnancy? I think that that would be a totally separate study, but another one that could be very interesting.
[01:24:34.670] - KAYLA BARNES-LENTZ
Absolutely. Well, as you know, I'm incorporating that for at least a short time in my protocol to see what happens. We'll keep everyone updated. All right, let's see. Labs for pre-pregnancy and during pregnancy. We did talk about pre-pregnancy labs. What in terms of while being pre-pregnant do you like to look at?
[01:25:01.920] - DR. SASHA HAKMAN
Well, actually, one pre-pregnancy thing I didn't mention before that I think is just so important is something called genetic carrier screening. This is testing you and your partner to see if you guys are carriers for the same mutation of diseases that can be passed on. A lot of these diseases can be very, very just heartbreaking for what the children have to go through, can also be fatal. Oftentimes, I'll catch a handful of cases before they ever start trying to conceive because they have infertility, where it's like, Okay, honestly, thank God you didn't get pregnant because you have a 25% chance of passing something like spinal muscular atrophy to your child. This is in the most severe mutation that could have caused them to become paralyzed as an infant and just really devastating. That should also be part of it. During pregnancy itself, there's a lot of different screening tools that are done with the obstetrician I don't really do a lot of anything past the first trimester anymore. Even though I'm a trained OB/GYN, I don't do deliveries or prenatal care once a patient has graduated from my clinic around 10 weeks gestation. Early in the pregnancy, even if you have done chromosomal testing of your embryos, for everybody, I like to do genetic testing of the baby just to confirm that baby is healthy.
[01:26:28.900] - DR. SASHA HAKMAN
Then Most of the early pregnancy testing is already done in a fertility clinic. Usually, later on, you're checking, again, to make sure that there isn't any gestational diabetes. You should be checking blood pressure all the time throughout the pregnancy, different urine parameters for UTIs or for protein in the urine that could start to be a signal for impending preeclampsia and things like that. Of course, if there's Is there any nutritional deficiencies, anything that someone has a particular history on, like previous bariatric surgery, significant weight loss, you need to look at these nutritional deficiencies and correct them. If someone is diabetic, checking on their A1C. So whatever disorder they have that needs to be checked in on throughout pregnancy, so it's optimized.
[01:27:23.370] - KAYLA BARNES-LENTZ
Nice. Well, I think I already told you this, but when I get pregnant, I'm going to do an insane amount of labs on the first one just to see because there's a lot of stuff we don't know. How does an AD levels change? What is your gut microbiome? What happens to it during pregnancy? And variety of other different labs, really in-depth labs just to see changes because I don't think that we have a super comprehensive data set.
[01:27:48.160] - DR. SASHA HAKMAN
No, we don't. We don't. And so I'm actually excited to see it through you.
[01:27:52.600] - KAYLA BARNES-LENTZ
Yeah, I know. It's going to be so fun. Any natural ways or cues to pick up whether you're feel fertile? So I'm assuming non-testing.
[01:28:03.200] - DR. SASHA HAKMAN
So this is where the menstrual cycle is a vital sign. So if your periods are irregular, so what does that mean? Your menstrual cycles are very short. If they're, say, 23 days apart, so the first day of one period to the day before the next period is only a 23-day interval, very short, go get checked out. If your menstrual cycles are very long, they're over 35 days long, go get checked out. If there's variability from cycle to cycle that's greater than a week, that's very unusual, go get checked out. So these are all reasons to check your different hormone levels, see what's going on. If periods are very painful that is not normal, and that should be evaluated. Might not only be endometriosis, could be something else. If your periods themselves are very long and drawn out or they're extremely heavy, that It will also be evaluated. This is where the menstrual cycle can tell you a lot about your reproduction just in its patterns.
[01:29:08.440] - KAYLA BARNES-LENTZ
Great. Thank you for that. What is the success rate after freezing your eggs at 20 versus 30?
[01:29:18.190] - DR. SASHA HAKMAN
It's probably pretty comparable. I mean, arguably the younger your eggs, the better to a certain extent. Actually, eggs tend to be a little bit better start not in teenage years. So eggs, when you're a teenager, are not that great. They actually have higher aneuploidy. We don't really know why. And then your fertility improves in your 20s. And then it really starts to decline in your mid when we talk about natural fertility and natural conception. That being said, all the data that we have on egg freezing, and this has shaped our egg freezing prediction calculator models that we use to counsel patients on, ideally based on their age, how many eggs that they should have frozen, based on the number of children that they want. It's probably roughly about the same if you compare a 25-year-old to a 33-year-old. Got it.
[01:30:15.300] - KAYLA BARNES-LENTZ
Makes sense. Age-related questions. What is the real impact or pointers for conceiving in mid to late 30s?
[01:30:27.350] - DR. SASHA HAKMAN
I would say my biggest pointer is is if you're in your mid to late 30s and you want more than one child, it's a really good idea to preserve your fertility. It is very common to conceive in your mid to late 30s, and usually these will be healthy pregnancies. I would say nowadays, we know that even though technically 35 is advanced maternal age, most 35 to 39-year-old pregnancies are doing great. I would even argue 40-year-olds are doing great in their pregnancies, especially if they're healthy. But oftentimes, your fertility might decline at a more rapid rate than you expect in your late 30s, and you got pregnant with your first child, and now it's exceptionally hard with the second, and you didn't expect that. This is where fertility preservation can really help to secure subsequent children if you're looking to have multiple kids.
[01:31:24.760] - KAYLA BARNES-LENTZ
Yeah, I agree, and that's what we did. Yeah, exactly. Can you your AMH or egg reserve?
[01:31:32.780] - DR. SASHA HAKMAN
There isn't anything that you can necessarily do to increase it. I sometimes do see fluctuations. I talked before about the fact that if you are on birth control pills for a long time, stopping that will help increase it. If there's been recent pelvic surgery, that will reduce AMH, usually temporarily, unless you've had a piece of your ovary removed or some ovarian cyst removed, then that will probably keep it low for quite some time. It might stay permanently that way. It might still bounce back. But in terms of lifestyle things to actually increase AMH, that really hasn't been looked into. I don't know if really significantly improving your lifestyle will improve AMH. It's really hard to gage that answer at this point in time.
[01:32:28.520] - KAYLA BARNES-LENTZ
Yeah, and we'll be interesting for the future, though, because we know that there's a link between environmental toxins potentially and lower AMH. I'm just not sure. Yeah, obviously we need the data to go back up, or is it just maybe better preserving? Exactly.
[01:32:42.650] - DR. SASHA HAKMAN
That's the ultimate question. Can we just keep it at a steady-state for longer, or are we actually going to be able to improve it? I don't know.
[01:32:51.560] - KAYLA BARNES-LENTZ
Interesting. But improving it would mean that you would be getting more eggs, right? Yeah. Which, I'm not sure.
[01:32:59.050] - DR. SASHA HAKMAN
I mean, Listen, I've seen weird things. I've seen EMH go up after a year, and it's probably variations in labs and assays. There is that variability, too. It's unlikely that ovarian reserve actually increased because it's only on the decline. It's probably that there's just more activity happening.
[01:33:25.820] - KAYLA BARNES-LENTZ
Got it. Okay, thank you. How to improve premature, diminished ovarian reserve from further fast decline?
[01:33:33.770] - DR. SASHA HAKMAN
This is where it's similar to what we just talked about. We don't really know how to, in an evidence-based fashion, really improve that. But in theory, and what I recommend to my patients is really just to reduce endocrine disrupting chemicals and environmental toxins, improving your nutrition as much as possible, wholefoods as much as possible, resistance training, Meditation, cardio, good sleep, all of these parameters could help to slow down that Dementiaeuterine reserve. That being said, if there's a pathologic process like endometriosis, if there's a family history of premature menopause, something genetic, then it's really hard to fight those things.
[01:34:19.360] - KAYLA BARNES-LENTZ
Well, the next question is actually in this line of thought, a bit vague, but what to do if you have endometriosis?
[01:34:26.610] - DR. SASHA HAKMAN
If you have endometriosis, the biggest thing is working with someone who will really help to shut it down. I know that there is growing popularity about not being on hormones, not being on hormonal contraception, things like that. Endometriosis is one of those things where aside from doing all the lifestyle things, you really do want hormonal suppression of your menstrual cycles because that could actually help save your fertility. The other added benefit of something like, and usually birth control pills are first-line, it's not the only treatment option, but it's usually the least invasive first-line option. If it works, that's great, is that women with endometriosis have a higher likelihood of ovarian cancer. They have a higher lifetime risk. The longer you're on birth control pills, especially a combination birth control pill or progesterone only, the more you're actually reducing your risk of ovarian cancer. For women who have been on birth control pills for 10 years, they're actually reducing that risk by 90%. So it's really huge. For endometriosis in particular, the more you are naturally cycling, the more you're actually increasing that inflammation because you have cells from the lining of your uterus outside of the uterus, and they are responding to the hormonal fluctuation.
[01:35:58.270] - DR. SASHA HAKMAN
As your estrogen levels It's increased because you're getting ready to ovulate, the cells that, say, are present on your bowels, your bladder, your ovaries, your phalobian tubes, they're thickening. Then once you have that progesterone withdrawal because you didn't conceive, then it also sheds and bleeds. That's a very highly inflammatory process, which when it happens inside the uterus, it repairs itself beautifully because it's meant to do that. But outside the uterus, it's not meant to do that. It can cause scar tissue, it can It can completely obliterate pelvic anatomy. It could reduce both ovarian egg count and egg quality. It can block the fallopian tubes, which is the whole reason why IVF was invented in the first place, was blocked fallopian tubes secondary to endometriosis.
[01:36:46.960] - KAYLA BARNES-LENTZ
What is endometriosis?
[01:36:50.230] - DR. SASHA HAKMAN
This is where your endometrial cells, so this is the cells of the lining of the uterus, are present outside of the uterus. Now, if it's present inside the muscle of the uterus, because you have different layers of the uterus, you have the lining, the endometrium, then you have the myometrium, which is the muscle, and then the very outside is the serosa. If you have endometrial cells inside the myometrium, the muscle that contracts, that is adenomyosis. Also not normal, also can cause infertility, can cause very painful, heavy bleeds during your periods.
[01:37:30.620] - KAYLA BARNES-LENTZ
How can it be reversed?
[01:37:33.210] - DR. SASHA HAKMAN
It can't be reversed, and you can't get rid of it. So this is something that stays with you until menopause. The severity of endometriosis and adenomyosis is in terms of the pain, doesn't correlate to necessarily what we see during surgery. Endometriosis is technically the gold standard of diagnosing it is through laparoscopic surgery where you do a tissue biopsy and you send it out for pathology and it confirms endometriosis. There are other things we do. When I do an endometrial biopsy, there are certain markers, like something called BCL-6 that can indicate that somebody with infertility has endometriosis. There's no cure, and this is why hormonal suppression is really important. I'm a big fan of something called norethendron acetate for long-term suppression. It's a progesterone-only pill. The biggest thing I warn patients who I put on norethendron acetate to help suppress the endo is that because it's not a combination birth control pill, it's just a progesterone pill, if they don't take it at the exact same time every single day, they are very prone to ovulating and having an unintended pregnancy. If you need treatment, you're on this progesterone pill and you're not wanting to conceive, you need alternate forms of birth control, I would say.
[01:39:01.480] - KAYLA BARNES-LENTZ
Okay, thank you for that. Pco management tips, we talked about a lot of them, right? Mm-hmm. Anything else you would like to add there?
[01:39:12.380] - DR. SASHA HAKMAN
Pcos, God, I can't stress enough. The resistance training and the lifestyle measures. It can really be helpful. Even when you've perfected lifestyle with PCOS, even then you might not cycle regularly. For many women who who have overweight or obesity, they might find that all of a sudden their menstrual cycles are much improved. Their symptoms of hirsutism, which is hair growth on the face and body in a male pattern, might improve. But if it doesn't, then this is where pharmacology is important. It could be a combination of birth control pills or spironolactone to have that anti-androgen effect since the androgen levels are so high. Then more comprehensive things that would be discussed with your physician. It really just depends on what you're trying to target specifically for PCOS, but lifestyle is just so critical.
[01:40:11.460] - KAYLA BARNES-LENTZ
What is the best way to get ready for an embryo transfer?
[01:40:17.010] - DR. SASHA HAKMAN
Once again, a lot of it really comes down to the lifestyle things, because when it comes to an embryo transfer, there's really not much in your control. This is where if your suffering with anxiety, depression, any of the mental health aspects that we didn't really touch a lot on, but those things do play a huge role in the outcome of your treatment. If anxiety is really taking its toll, it's really important to manage that, whether it's talk therapy, medications. I know a lot of patients, they try to avoid the medications for concern of the effects on a growing embryo and fetus. In many cases, you'll still need it if it's really out of control because uncontrolled anxiety and depression could lead to far worse outcomes than being on treatment. But combinations of talk therapy or cognitive behavioral therapy are really, really important in those circumstances. Then aside from that, just really following your protocol to a T.
[01:41:23.400] - KAYLA BARNES-LENTZ
Yeah, absolutely. Does the sauna use impact mine or my husband's fertility?
[01:41:30.390] - DR. SASHA HAKMAN
It doesn't really impact female fertility because the ovaries are inside the body, and so the body is really good at controlling internal temperatures, no matter what the external temperatures are. Obviously, when you are pregnant, you should not be going into a sauna because that could affect neural development for the baby. But sauna for men, that can impact sperm, and that's because their testicles are sitting outside of the body in the scrotum. The scrotum does a really good job at bringing in and bringing out the testes based on the environment and the temperature outside. But when you're in a really really hot environment like a sauna, it can negatively affect sperm.
[01:42:19.020] - KAYLA BARNES-LENTZ
Yeah. That's why with the three months thing, my husband loves going into the hot tub, and I'm like, Try to limit that as much as possible. And so he's only going in for a few minutes. Yeah. A day, and then watching the sauna use as well. Is ureaplasma a cause of infertility that's not well known?
[01:42:42.990] - DR. SASHA HAKMAN
That's another controversial one where it's thought to maybe affect implantation or lead to pregnancy loss. The little data that's out there, some suggest that it doesn't affect it, some suggest it does. I do know a lot of doctors who will test for it prior to an embryo transfer, and it's even part of some panels. If we look at something called Emma and Alice, so this is when you do an embryo transfer, or sorry, an endometrial biopsy, you can test for all of these microorganisms that could potentially affect implantation. But your Ureaplasma testing, that's just like a vaginal swab, that's really still very controversial as to whether or not it will affect the success of a pregnancy.
[01:43:29.050] - KAYLA BARNES-LENTZ
How many How many rounds? We'll end on this question, so maybe it can be comprehensive, because I think the gist of a lot of these questions are, when should you freeze your eggs? How many rounds are you going to have to do? And what can you expect?
[01:43:45.150] - DR. SASHA HAKMAN
So the number of rounds of egg freezing depends on a few things. It depends on female age. So the younger you are, more likely the less cycles you have to do. The older you are usually the more cycles you have to do. It also depends on ovarian reserve. So this is where ovarian reserve can often be very falsely reassuring where, okay, I have an EMH of five, therefore I have all this time in the world to wait until I'm 40 to get pregnant. Well, number one, you don't know when your ovarian reserve is all of a sudden going to have a massive decline. I really thought that because I always had really high egg reserve, that it would just stay high. I recently turned 37. My ovarian Ovarian reserve dropped in half in the last year. I couldn't believe it. I'm like, Well, I'm doing all the lifestyle things. It is also possible that because I drew it shortly after giving birth, you know that after pregnancy, ovarian reserve does have a temporary decline, so I'm waiting to retest that. But still, a high ovarian reserve can be falsely reassuring because at the end of the day, female age is the number one predictor of fertility outcome in the likelihood of having chromosomes only normal embryos.
[01:45:06.490] - DR. SASHA HAKMAN
It's age, it's ovarian reserve, it's also the number of kids you're hoping to have. In your case, you want to have a lot of kids. Of course, you have to preserve your fertility because it takes time to not only get pregnant, but it's a whole nine months of pregnancy. Then if you choose to breastfeed, then however long that is, it might be a year. If you're breastfeeding and recovering, and then you stop breastfeeding waiting to start cycling naturally because a lot of women will have what's called lactating amenorrhia. If you're lactating, prolactin shuts down your periods. Not everyone is as sensitive to that, so that really varies. So it really depends. So I can't say how many cycles one individual will need until they come and see me and we look at all of their metrics their ovarian reserve. I look at their age. I talk about what their family building goals are.
[01:46:05.550] - KAYLA BARNES-LENTZ
Yeah, and I would say it's important, too, to know that there are drop offs, right? Say you have the egg retrieval and then only X number of those eggs are actually mature which then can move on to the next step, which is when the sperm and the egg actually come together, and then there's a drop off there, and then there's a drop off to get to day 6 to turn them to blast. So I think it's really a very individual process with your or your fertility doctor to figure out what makes sense for the amount of children that you want. Then there's also when then you go to implant them, also there's a potential drop off there.
[01:46:41.980] - DR. SASHA HAKMAN
If we talk about the averages here, this is to show you how ineffective and inefficient human reproduction really is, even when you are in peak fertility. This is why we need so many eggs for egg freezing, and especially based on age. If we look at averages, and this is based on tens of thousands of cycles, probably hundreds of thousands of cycles at this point, when we have, let's say, 10 eggs retrieved, you go to freeze those eggs, not all of the eggs are going to survive the thaw. The younger you are, the more likely they are to survive. Women under 37 will typically have a 95 % survival thaw rate, assuming they have a good embryology lab that they went to. And for those who are over 37, you expect an average of 85 % survival at the time of thaw. Now, when you go to fertilize those eggs, the average fertilization rate is about 70 %. So you're We're going to lose some eggs there. Of the eggs that then get normally fertilized, and that is an average, right? That means some people do better, but some people also do worse, even if egg and sperm look amazing.
[01:47:58.060] - DR. SASHA HAKMAN
We only expect about half of those fertilized eggs to become embryos. Then of those embryos, the percentage that we expect to be chromosomally normal depends on the age of the couple and especially female age. The older you are, the less likely they are to be chromosomally normal. If you're 35 and under, I expect around 50 to 60% to be chromosomally normal, so that's average. Then once you're in your later 30s, then it goes down from there. I expect probably about 40% to be chromosomally normal once you've entered your 30s. Now, once you hit 40, this is where the percentage really drops off every year. So 40 is not the same thing as 42 is not the same thing as 44. It just really gets exponentially harder after that.
[01:48:55.970] - KAYLA BARNES-LENTZ
Well, Sasha, this has been so informative, and it's been such a pleasure to chat with you. So thank you for coming on.
[01:49:03.160] - DR. SASHA HAKMAN
Thank you for having me here. And I really hope that a lot of women have learned things that they can take with them to empower themselves in their reproductive journeys.
[01:49:13.500] - KAYLA BARNES-LENTZ
I'm positive that they have. And yeah, it's been such a pleasure.
[01:49:17.380] - DR. SASHA HAKMAN
Thank you. Likewise.
[01:49:18.320] - KAYLA BARNES-LENTZ
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