THE MILK
Welcome to The Milk- the podcast that pours it all out: the messy, the magical, & the mildly unhinged moments of motherhood and womanhood. Real talk, honest stories, and reminders that none of us really know exactly what we’re doing- and that’s kinda the best part! I’m Tayla- your host and mom of soon to be three. So let’s laugh, learn, and milk this season of life for all that it’s worth.
THE MILK
Dr. Sasha Hackman: What Every Woman Should Know About Her Fertility Before, During, and After Kids I Episode 9
Ladies, it's time we look at "fertility" as a life long discussion, not just one around the "trying to conceive" phase. Your period is a vital sign—and it’s time we treated it like one. So I invited double board‑certified reproductive endocrinologist Dr. Sasha Hackman on the pod this week to map the full arc of fertility and a women's reproductive health before thinking about kids, during the "trying" phase, & why it matters most even after having kids. We deep dive into what to track before "trying", when to seek fertility intervention if it's just not happening naturally, why freezing your eggs is an insurance plan if kids aren't in the near future, and why postpartum hormones can both help and hinder the path to baby number two or three (we talk secondary infertility too).
We trace fertility across a woman’s life with Dr. Sasha Hackman, from first period to postpartum, with clear steps to measure, plan, and protect your options. She shares real odds, practical testing, and how to choose treatments that fit your age, goals, and timeline.
MORE OF WHAT WE DISCUSS:
• reframing fertility as lifelong reproductive health
• IVF strategy, IUI limits and realistic success rates
• embryo banking to match bigger family goals
• postpartum hormone shifts and surprise conception
• secondary infertility drivers and endometriosis impact
• male factor basics and the three‑month sperm reset
• cycle tracking tools and luteal phase support
• why your period is a vital sign for long‑term health
• PCOS vs NCCAH and how pills can mask issues
More on Dr. Sasha Hackman:
Website: HERE
Instagram: HERE
Podcast: Trying To Conceive HERE
If you loved Sasha’s episode, would love for you to leave a comment or share this ep. with a friend. Ratings and reviews for the podcast are always greatly appreciated! xx Tayla
Follow The Milk Podcast on all platforms for weekly episodes that remind you you're not alone, you're not crazy, and you're doing way better than you think.
Follow & Subscribe For More:
YouTube: @TheMilkPodcast
Instagram: @TheMilkPodcast_@TaylaBurke
TikTok: @TheMilkPodcast @Tayla_Burke
Welcome to the Milk, the podcast that pours it all out, the messy, the magical, and the mildly unhinged moments of motherhood and womanhood. Real tough, honest stories, and reminders that none of us really know exactly what we're doing. That's kind of the best part. I'm Taylor, your host, and soon to be Mom of Three. So let's last learn and help the season of life for all that it's worth.
SPEAKER_01:Hi, ladies. Welcome back to another episode of The Milk. Today I'm joined by a very special guest. We have a topic of fertility today. And I I feel like we could go so many different directions when talking about fertility. So I invited an OPGYN and endocrinologist. I hope I am it's you're double certified though, right? You can give the whole spiel.
SPEAKER_03:Yeah, double board certified OBGYN and reproductive endocrinology and infertility specialist. So official.
SPEAKER_01:We have Dr. Sasha Hackman with us today. Thank you for joining us. Thank you for having me. So today I really wanted to hone in on just the overarching theme of fertility as like a lifelong discussion and not just when I used to think about fertility, it's like, oh, you're fertility for trying to get pregnant. And after speaking with so many doctors and professionals and just going through now three different pregnancies and all of my friends' journeys, I'm like, okay, fertility is something that impacts us before, during, and after kids. So I thought it would be fun to kind of like guide the conversation as fertility in different chapters of a woman's life. Um, before we dive into everything, do you want to give everyone a little spiel on like who you are, what you do, where you work. If anyone's listening who needs support in fertility, like what you offer and where they can find you if they're local?
SPEAKER_03:Yes, absolutely. So, like you introduced me, very nice introduction. Thank you. I'm Sasha Hackman. I am a double board certified OBGYN and reproductive endocrinology and infertility specialist, but I practice primarily infertility medicine. So when people say, Oh, do you deliver babies? I do not deliver babies anymore. I don't do any any general OBGYN, even though I really miss it.
SPEAKER_00:So you did use to deliver babies.
SPEAKER_03:So it is a prerequisite. You have to become a board-certified OBGYN to become a reproductive specialist.
SPEAKER_01:Interesting.
SPEAKER_03:And you do an extra three years of training after your four years of residency. And what people don't know is that there's only a handful of positions available in the whole country. And when I went into fellowship, there were only 35 positions in all of the United States to graduate reproductive endocrinologists. So as you can imagine, it's highly competitive. You have to be like pumping out really high-quality research. You have to have a spectacular CV, kind of have to be top of your class and residency in order to even be considered. And then you go around the country interviewing, you rank the programs in order of preference, and then they rank the candidates and you have to match.
SPEAKER_01:You look way too young to have been in school for so many years, first of all.
SPEAKER_03:Well, thank you. Yeah, it's a long process. It's from the moment you graduate high school, it's 15 years. Oh my gosh. And then another two years to become board certified in REI. So REI is short for reproductive endocrinology and fertility. And our specialty encompasses a lot. It's not just in fertility, it's pro reproductive endocrinology includes everything to do with your hormones. Everything. Okay, so we are the ultimate hormone experts, but most of us go into private practice. So I practice in a private practice at HRC in Beverly Hills right now. Um, though I do see patients part-time in the Valley and Encino. Um, I am also the host of a podcast called Trying to Conceive with Dr. Sasha Hackman. Everything to do with reproductive health and trying to conceive. Um and you can find me actually on my website is probably the easiest place at sashahackmanmd.com. But yeah, it's uh there there's a lot that we can do. We are ultimately the experts on hormonal contraceptives, we are the experts on menopause, we are the experts on disorders of sexual differentiation. So if you're born with ambiguous genitalia, if you're born with any sort of birth defect of the pelvic area, we are the people to help take care of that. Pediatric endocrinology is something we do a lot of. Though most of us start to sacrifice a lot of this because once we get into private practice, the massive, massive demands of people needing infertility services is just far greater than there are doctors available in this country at this time.
SPEAKER_01:So I'm sitting down with the right person next today.
SPEAKER_03:I can tell already.
SPEAKER_01:And you also are mom of two.
SPEAKER_03:Yes.
SPEAKER_01:And your kids are three and twenty months. Yes. I don't know how you balance all of that with being a mom. And you're someone who went through fertility treatment yourself. Correct. Yeah. And so that was what, four years ago?
SPEAKER_03:Yes.
SPEAKER_01:And it was IVF.
SPEAKER_03:It was IVF. So, well, if I backtrack, my journey was a little interesting because for years, so if I really rewind to my teenage years, I always had super irregular periods. Okay. I would sometimes go six months without a period and then bleed for two months. And so I knew that something was wrong. And um, I'm Canadian, so this was in Canada. My mom took me to a primary care physician because you can't go in and see an OBGYN. You don't get care by a gynecologist without a referral.
SPEAKER_01:Wow.
SPEAKER_03:So it's mostly primary care doctors who will take care of this, and not many of them are not well versed in this stuff at all. So my PCP, of course, put me on birth control pills, which as a physician, as a specialist, actually, it was the right call. Like it really was the right thing for me in my certain my situation. However, we didn't have a diagnosis. It was just the treatment, but not knowing why.
SPEAKER_01:It's the band-aid on the problem rather than like finding out the real cause.
SPEAKER_03:And I think that understanding what the diagnosis is is really important just to take a little more control of your reproductive health. And so I love that you said, I want to think of fertility as not just right when you're trying to get pregnant, but before, during, and after. And so if we reframe it to talk about reproductive health instead of just fertility, we can rethink of it as this is something that tells us a lot about our overall health too.
SPEAKER_01:And our fertility. So focusing on the reproductive health kind of guides you through that path to correct optimizing your fertility.
SPEAKER_03:Correct. And optimizing a pregnancy. Yeah. Because it's not just about getting pregnant, it's about having the healthiest pregnancy you can have so that you have hopefully a relatively uncomplicated labor and delivery and postpartum recovery. Because we want to optimize health of mom and health of baby. So I think that sometimes, especially those dealing with infertility, we kind of get sidetracked with let's just get pregnant, let's just get pregnant. But it's not just about getting pregnant, it's about walking away with a baby and both of you being in good health.
SPEAKER_01:Yeah.
SPEAKER_03:So, um, so yeah, I I was put on the pill, but then once I was an Over GYN resident, I thought, you know, let me see what is happening with my body, because I had no idea. And I had already rotated through two fertility clinics, and I encountered a few women in their late 20s, early 30s who were diagnosed with a premature menopause. And they never knew they were on the pill, they got off, and that's when they discovered this. And it's not because the pill caused it at all, it's because it masked any problem. So they weren't aware that there was a problem. So that's that's the biggest limitation to oral contraceptives or any hormonal contraceptive. Is it's not bad for you, it's just that it masks if there is an issue. So if you're gonna be on it long term, you should at least check in and see what's happening to know that things are working and functioning if you were to stop. So I got off the pill just as a way of seeing what happens with my menstrual cycles. Um, and I I never got a period. I didn't get a withdrawal bleed. I never got a period after that for three months.
SPEAKER_01:So I was like, okay, and how long were you on it for?
SPEAKER_03:At that point, 15 years. Wow. Yeah, continuous for 15 years. So then I was like, oh my gosh, I'm in premature menopause. I like, you know, went down the rabbit hole and I spiraled a little bit. So I went to see one of my attendings in the clinic, and um, you know, she she did a workup, but looking back, it honestly wasn't even the right workup. And she was like, Yeah, I have no idea why you're not getting your peers. This is really weird. So I sort of did it. I I took charge and started looking into things myself, doing my own scans, trying to figure it out. And um, that's when it sort of dawned on me, okay, this may be PCOS, okay, which is this is an endocrine disorder that results in high androgen levels for some women, really high follicle count. It's kind of like a disconnect between the brain and ovaries where there's a hormone hormonal miscommunication, and you're never really able to recruit a follicle to release an egg. So um, once I was in fellowship and I did further testing and I really understood this stuff inside and out, I was like, okay, yeah, this is PCOS. But PCOS is a diagnosis of exclusion, and people often fail to realize this. You can't just have two out of three of the diagnostic criteria and then say you have PCOS. You have to make sure there's no thyroid dysfunction, other hormonal issues that could be presenting this way. And it wasn't until last year, okay, I was 37. So 37 years of my life, I didn't know this. I have a condition that mimics PCOS that is genetic, and it is due to an adrenal enzyme deficiency. It's called non-classical congenital adrenal hyperplasia. It's a mouthful or NCCAH for sure.
SPEAKER_01:Never heard of that before. Right, most people haven't, but it's not that uncommon. So you so you thought even before even after you had kids, you just assumed that you had PCOS, and only last year you figured out that it was something masking.
SPEAKER_03:Yeah, because my egg reserve dropped in half. So there's a way to test your ovarian reserve. Two ways we do it. One is through blood test. The test is called AMH antimalarian hormone. I think every woman should do this regularly because it allows you to identify problems sometimes. It doesn't tell you anything about your fertility. But a really, really high number can indicate PCOS and a really, really low number, you could be catching the window of perimenopause before it's too late and do something about it.
SPEAKER_01:Is this something that you recommend women doing even before trying to have kids or is it something? Totally. Yeah, okay.
SPEAKER_03:Totally. And you don't have to do anything with it, but just trend it, you know, year to year. What are things looking like? Female age is still the number one predictor of reproductive success at the end of the day. Um, and that's just biology. We can't change that. And for some women, it affects them more than others. Um, but there are pathologies that AMH can help us sort of sound the alarm for, which is really an a good thing to have. So I saw that mine dropped within one year in half. Okay. And so I was like, that's really weird. PCOS doesn't usually do that. And so I finally did more comprehensive testing, and it did come back that I had NCCAH, and I was like, wow, I can't believe it. And when I think back on my fertility treatments, when I was 32, I was in fellowship, and my husband and I were doing long distance. He was in residency, he's an ER doctor in Michigan, and I was doing my fellowship in Georgia. So it was so hard. Like I was flying every two weeks to see him, but and we really wanted to already start our family, but because of the distance, we decided to postpone. And I knew I wanted multiple kids, and that age may become a variable. So I didn't want to leave it up to chance, and we decided to create embryos and freeze them for the future as a backup. And so we were able to successfully do that when I was 32. Then at 34, we had just gotten married, and I was like, I've been wanting to have a kid for years now, like we need to just get started. So once we got started, I knew that I would have to get treatment because I don't ovulate. So we started with ovulation medications to help recruit eggs and release them. And then even as a fertility doctor, knowing that the highest chance of pregnancy in a given month is 20% at your peak, I still thought, just like every woman thinks, that I'm in good health, I'm gonna get pregnant right away. Like this is gonna happen for me. And I didn't get pregnant right away. And then we're just doing treatment cycle after treatment cycle. Now I start adding in intrauterine inseminations or IUIs because perk of the job is I could take my husband's sperm, take it to work, process it myself, and then have my nurse do it for me. That's amazing. It's great. Against his will if you want to. Against his will. I'd wake him up early and be like, I need a sperm sample, sir. Um you'd be like, Don't you think this is a little extra? I'm like, it's not extra. Because by six months, 80% of couples will have conceived. Yeah, and that ain't us. What is happening here? So um I would do the IUIs, I still wouldn't get pregnant. I would start upping my dose, recruiting multiple eggs, and even ovulate three to four eggs at a time, which is reckless at 34. And I never got pregnant. And so then eventually I was like, forget it. We're just doing an embryo transfer. We have these embryos, we might as well use them. So as I got ready for my embryo transfer, I was a little bit paranoid about maybe there's some underlying something that is contributing. So I put myself on steroids, which by the way, is the treatment for NCCAH if you want to get pregnant.
SPEAKER_01:Interesting.
SPEAKER_03:Steroids.
SPEAKER_01:Okay, before you I don't want to lose this thought because I feel like this might be really important for anyone listening that may have PCOS or know someone. How do you get that test done about the egg? Um, is it the egg count that you were talking about?
SPEAKER_03:So yeah.
SPEAKER_01:So Where do you get that done?
SPEAKER_03:So you can either get that done at an OBGYN office or even with primary care physician. The biggest limitation to doing it with many doctors who aren't specialists, though, is that you may not get the adequate counseling. And so that is the only thing that gives, you know, I I see a lot of patients who are like, yeah, my doctor did it and didn't tell me that I needed to do anything. And sometimes their AMH is like 0.1 and they should have been sent to us immediately.
SPEAKER_01:So it's something where you can use them to get the results and then taking the take the results to a certain specialist who can guide you the right way.
SPEAKER_03:Yes. Or you can see a specialist from the beginning.
SPEAKER_01:Is it covered by insurance?
SPEAKER_03:Some oftentimes it is, especially if it's through your primary care. Okay. You can also do at-home tests like um modern fertility. You it's an at-home kit, you send it out. Um, so it's not always as accurate as going to Quest or Lab Core to get your blood drawn, but it's a really great tool to have in order to just get a general idea. And I did it myself, and it was honestly spot on with my blood tests. So um I I find it as a really good tool just to have a general sense of where you stand. And um, you should, if you're doing the test, you should absolutely do your research to find out is this a concerning number? Because if your AMH is under one, then you are in the category of diminished ovarian reserve. But if it's exceptionally low, that's when you really need to do something about it.
SPEAKER_01:And I think I learned this through Dr. Natalie Crawford. You can't enhance your ovarian reserve, right? It's it it only goes down.
SPEAKER_03:It only goes down. Okay. Sometimes I will see a jump back up years later in some patients. Interesting. Um, and it's really there, there's more to it that we just don't understand yet. It's overall a downward trend in your life, but sometimes you'll get a little jump in it and it'll go up. And I've even seen this in family members where even in their early 40s, it just jumps up. Very unusual. Um, but in most of those cases, they have PCOS.
SPEAKER_01:Got it. Okay. Um, okay, back to your story on your IVF. So you're about to do the transfer.
SPEAKER_03:So I'm about to do the transfer. I put myself on steroids, and um, I remember some of my colleagues being like, You're crazy, dude. Like, that's so unnecessary. You don't need to be on it. Um, and I got pregnant, and that's how I had my first child, Remy, who's three, almost three and a half. So first round of IVF. First um, embryo transfer. So I always think of IVF different from the embryo transfer. IVF is when you're creating the embryos, and then an embryo transfer is when you transfer them. So we did IVF when I was 32. Now I'm 34 and I'm doing an embryo transfer, and it was successful. Um, and funny enough, after having REMI, I was breastfeeding for several months, I think seven months. At the seven-month mark, I started weaning, but I was also during that time having a lot of weird allergic reaction to things and kept putting myself on steroids. And I conceived naturally. Crazy. Yeah.
SPEAKER_01:So that could have been treating your mouth full of a diagnosis.
SPEAKER_03:Exactly. Exactly. Without even knowing it yet. Yeah. And I conceived, and I couldn't believe that my first ovulatory cycle in my life, I conceived on my own.
SPEAKER_01:Okay. And you gave me the percentage of this happening before you was it 16 to 20 percent?
SPEAKER_03:16 to 26 percent of patients who conceive through IVF can conceive spontaneously naturally on their own after their first baby, depending on which study you're quoting. Yeah. Yeah.
SPEAKER_01:Incredible.
SPEAKER_03:There's almost a one in four chance that you can get pregnant on your own afterwards, depending on how old you were when you started.
SPEAKER_01:Yeah. And is that because are you like more fertile after your first pregnant or your your pregnancy because your hormones are, I don't know, maybe enhanced or all over the place, or why is that a thing?
SPEAKER_03:So it can definitely improve things for two main categories of people. If you have PCOS, hormonal suppression really helps in the first few cycles afterwards, once you reverse that suppression. What's suppression? Breastfeeding. Breastfeeding keeps your estrogen and progesterone levels very low.
SPEAKER_01:Which is why you don't get a period.
SPEAKER_03:Which is why usually you're not ovulating and you don't get a period. Now, some people can, but for many women, myself included, I never had a single period while breastfeeding during those seven months. Um, and so it works really well at doing what it's supposed to do. But then when you reverse that suppression, which is removing the stimulus, which is breastfeeding, and your prolactin levels go down, prolactin is the hormone responsible for creating breast milk, then you will start to ovulate in those first few months before things go out of whack. That makes sense. So you have a little bit of a grace period.
SPEAKER_01:Yeah.
SPEAKER_03:And that's when you're more likely to be fertile.
SPEAKER_01:I think I fell victim to that. I think I uh like you, I started weaning, I think around seven months. I got my first period, and then but I it was like so small of a period. I just didn't know where I was in my cycle. Yeah. And then two weeks after that, I got pregnant, and this was like pull-out method used, everything. Wow. Yeah, yeah. One time. Wow. One time. I mean, you know, when you're in the thick of like baby phase, and we know it was we were testing out a product from my business migral wellness, where we came out with the sexual health line, and it was broad daylight, sober, did the deed, pulled out, took a pregnancy test two weeks later, and I was pregnant. I'm like, that's insane. How is that possible? Wow.
SPEAKER_03:Yeah. This was very much on purpose because I actually had a very different experience than most women, I think, where the first baby I thought was so easy.
unknown:Yeah.
SPEAKER_03:First, my first. Like, yeah, with Remy, I was like, this is so easy. I don't know what everyone's talking about. Did the second one trick you? Oh my god. I I don't I was really in a bad place.
SPEAKER_01:I feel like it's either or like you either get shook with uh like the first one, the first one. I had a colicky baby. I had I was just shook by motherhood in general, where I was like, I don't even know if I can have another kid. And then the second one was an angel, but then there's some like you where you have like an angel baby first. Like, this is incredible. Give me 700, so predictable. Yeah.
SPEAKER_03:I mean, only cried when he was hungry or tired, but he was a great sleeper, so easy to sleep train. It took two nights, that was it. And and it I did like the whole gentle sleep training, like constantly going in his room but not picking him up. And um, and he did great. He was just so chill, he was easy. I mean, it was fantastic. And so I was like, I I mean, if these are the kind of babies that I make, then this is great. And then, you know, with Rocky, our second, he was very colicky, and my husband was working more than ever. And so I was solo parenting most of the time and working full-time. So I just felt like I was drowning and I had no help. And so, like, I would come home from work to relieve the nanny and take over, but then it was me with an 18-month-old and a and a baby and just feeling it over my head. Oh my gosh. Um, and both having extreme needs at that point because you know, once your easy baby turns into a toddler, then it's not easy anymore.
SPEAKER_01:Well, two under two, like you have two babies at the same time, but they have completely different needs because they're like one's on milk, one's doing solids, they have different nap times. They correct. It's just such a whirlwind. Yeah. And like we're so blessed to have help when we work, but then like people are like, Oh, you're so lucky you have help. But then it's like when you're working, you have help, but then when you the help is off, you're working again with your children. Yeah, it's like you don't get a break by having that help.
SPEAKER_03:No, yeah. And sometimes you're completely neglected, like no food, no shower, no nothing. And and then you just all you're doing, and with my line of work, all I do is take care of people, right? Yeah. So I felt like at one point, all I do 24-7 is take care of everyone except for me. Um, and so I I reached a breaking point where I told my husband, I'm like, you need to work less. Like, I don't know what else to do.
SPEAKER_01:You just need to work less. I want you home more. And now are you done at two, or are you thinking of another one in the free in the future?
SPEAKER_03:I desperately want number three. And I've been ready for number three. Um, and so this has been, and I shared this on Instagram before, but I'm like, I'm ready for another transfer, and my husband is so not for it. So we ended up doing another IVF cycle last February because I'm 38 now, and I said, you know, I I don't have the time for us to figure this out.
SPEAKER_01:Yeah.
SPEAKER_03:We're gonna put our embryos on ice and we're just gonna wait until we come to a point where we are in agreement.
SPEAKER_01:Yeah, and like take control of your timeline. I feel like that's so empowering. And for women nowadays, like we are getting married, having kids later in life, which is incredible. Like if women want to focus on their career more or they're still finding the person. Like we are women nowadays, like we have full control of um protecting our fertility and even future children by investing in if you can. I mean, IVF, it is it is expensive, the egg retrievals and everything, but I think it's so smart to do that as like an insurance policy. On, you know, you don't have to rush, you don't have to be under pressure of this ticking time clock. I have so many girlfriends that are still single in their early 30s, and it just takes the pressure out of any waiting game.
SPEAKER_03:Even dating. Yeah, because I think that a big part of dating in your early 30s, at the back of your mind, you're like, I need this to work. And some people settle because of the pressure.
SPEAKER_01:They're like, oh, this person's good enough because you know, I'm creeping up to my mid-30s and I want to have kids, and that's the worst thing you can do, especially when you involve kids.
SPEAKER_03:You don't want to, you always have to think of it. Is this someone I want to co-parent with? Yeah. If I have to? Like, is this the person I want in my life forever, regardless of what happens in our relationship? Because even if you break off or like you separate, then you still have to co-parent. Yeah. And that that could be really tricky if you don't agree and if it becomes a hostile situation and it affects your kid. And so I'm I'm all about never ever ever settling for the sake of having a baby. We love that. We have the technology for you to never be in a position of regretting the decision you made in like in the partner that you made. Of course, you never know where life is going to take you and things may not work out, but it's different going in saying, Well, I did all my research, I did my homework and I did not settle. Things came up later that were unexpected, and now we're not very compatible, but at least I know that I did everything in my power to make sure this was a good relationship at the time, versus feeling like I know that there were red flags and I just settled for the sake of having a baby. Yeah.
SPEAKER_01:No, preach. I love that. Um, okay, so a third is in your future, hopefully. I hope so, yes. So you'll be having an embryo transfer at 38, you said?
SPEAKER_03:That's my hope. Okay. That's my hope. I really would love to be done before 40. Amazing. So you can do it.
SPEAKER_01:I'm not saying at any age, but like in your late 30s, that's completely plausible.
SPEAKER_03:Oh, totally. I mean, you can even get pregnant naturally in your late 30s. Um, it for me, the the main reason of my timeline is, you know, we probably feel very similarly. You're already in it. Yeah. Just be in it. Because I think it's really hard to get completely out of the baby face and regain that level of freedom and now be back in that situation, which is such a beautiful chapter. And there's something nice about having it linger, but it's also the day-to-day, I mean, logistics are really challenging. And so going back to that logistical challenge, it's hard.
SPEAKER_01:Yeah.
SPEAKER_03:Um, and then the other thing I this is very personal to me, but something I always think about is I just want as many years as I can have with my kids. Like, I really felt that after my firstborn, where I was like, man, um a relatively older mom. I mean, you can definitely have kids much older than that, and it's still beautiful. But I just wish, and I talk about this with my girlfriends who had kids in their 40s, they all feel the same way.
SPEAKER_01:Like, I just wish I had more years with my kid. It's such a morbid but such a true thing to think about. There's this one saying where it's like, your parents you don't have long enough. Your kids you like meet not too late in life, but you want more time. And then there's like the siblings that you like met pretty much at the same time too. You're giving that to them as well, too, like giving them siblings that they'll have their entire life together. But yeah, it's like I think about it, I'm like, oh my gosh, like I wish I could just have you forever. Like, I want as many years of my life. Like it's like you have this like addiction to them as just like it's like this soulmate bond. Yeah. And you just want that to last as long as possible. So yeah, it's like, why not just knock them out all together and just have as many like good quality years with them as possible? Totally. I'm all for that. Yeah. Okay, so I want to go back to a little bit on fertility before having kids. Like when people come to you, what are the most common fertility issues that you see in your clients? That's my first question. And then also, like, where when do you typically see them? Like, when is the right time to come to you to seek help?
SPEAKER_03:Very good questions. Okay, so in LA, the most common problems I see are very different than other places I've practiced. So we moved to LA three years ago. Before that, I practiced in Scottsdale, Arizona, and before that I practiced in Detroit, Michigan. So I've kind of been all over.
SPEAKER_01:And what does this do to the difference in different environmental?
SPEAKER_03:Environmental, but also different populations, right? So for instance, when I practice in Michigan, um it's the Midwest, different culture means different sort of health problems, right? Food, and so food, movement, working out. And then also I had a pretty large uh black patient population. And so I dealt with a lot of fibroids, things that are more genetic to the black population. And so um it modifies a little bit of what you're experienced in and what you get really good at, right? So for me in Michigan, I dealt with, like I said, a lot of black women, but then also a lot of young women, and they all tend to have PCOS, ovulatory issues. I also did treat a lot of women in their 40s, um, but they, you know, the my bread and butter was really PCOS. That was what I was dealing with all day long. Wow. And so when it came to strategies for treatment and even all the way to IVF, very, very different strategy compared to if I compare my patient population here in LA, I would say that I am experiencing so many women with diminished ovarian reserve, really low egg reserve here. And is that because of environmental factors? That is my guess. My guess is there's environmental factors. There is definitely a cultural change where LA is very rat race, hustle. There is no slowing down here. Everyone is trying to do something for their career. It's the city of dreamers, right? Everyone is, it's it's the thing I love about LA, um, where people here are generally very health conscious. So it's really crazy to see that. Um but high stress. But high stress, high stress, and uh, you know, so it's a different strategy. If you have low egg reserve, what we're trying to do is very different than if you have PCOS, which is really high egg reserve. And then I also have a lot of patients in their 40s, a lot. Women here are waiting a long time, and I think there's been just a lot of trends online, social media, with the, especially with the wellness industry, sort of pushing the narrative that, well, if you control your hormones and your health, age is not a factor. And that is such a lie. Yeah, it's it's a harmful lie because then I have these women coming in saying, Well, I'm healthy and I believe in God and I believe that this is gonna happen. And what's really funny and tricky about this is that we all think we're the exception to the rule. And I said before, I even did that to myself when I was going through treatments. I know that the chance of an IUI working is only nine to ten percent in a given cycle. Why did I think I was gonna be that nine percent? I didn't think I was gonna be in that 90 to 91% group. And how many IUIs did you do again? I did three total. And they none of them worked.
SPEAKER_01:Yeah. Yeah.
SPEAKER_03:And so, yeah, the recommended number is three. If three doesn't work, then you move on to IVF.
SPEAKER_01:Okay.
SPEAKER_03:Um, some people will do more, some people will do less. It's really a personal choice.
SPEAKER_01:Do you always recommend starting with IUI before going to IVF, or is it like a case-by-case basis?
SPEAKER_03:Vary case by case, depending on how long someone's been trying to conceive, how old they are, what their ovarian reserve looks like, and what their family building goal is. That's probably the number one thing. If you're 38 and you tell me you want three kids, you should not be doing IUI. Because if you get pregnant with IUI and then you wait nine months, deliver, you want to breastfeed, you want a bond, you need to recover, you need to give it at least six months. Now we're dealing with trying to conceive at 40. And while that may happen, it is far more difficult to conceive at 40 than it is at 35. Like you might as well retrieve those eggs earlier. Yes. You might as well retrieve bank embryos for the future so that it's not as difficult to conceive. And you may not need them, but it's a really good backup plan because I mean, I see a lot of these women. They got pregnant the first time easily, now they're 40, and they're coming to me confused as to why they're not getting pregnant.
unknown:Yeah.
SPEAKER_03:Like there's nothing you can do once you're once the effects of age have happened. Now we're talking about you can totally get pregnant with your own eggs if you have them. Yeah, but if you don't, but you need far more eggs to get a normal embryo compared to before. So if I give specific numbers, like I recently got uh a 44-year-old patient pregnant, it took 150 eggs to get there. So seven retrievals. Because she had really high egg reserve, seven egg retrievals. So she had the advantage of high egg reserve, which is not usual in that age category. Most of the time in that age category, you're only getting a handful of eggs. Yeah. And so, um, and if you look at the data, it takes about 50 eggs to get one chromosomally normal embryo at age 43, versus it takes five if you're under 35. That's a natural baby.
SPEAKER_01:And that's determination on her part to go through seven egg retrievals because they are. I mean, I've a close girlfriend who's gone through it, and it's just what emotionally, physically taxing and exhausting.
SPEAKER_03:It is, but you can get through anything if your doctor set the right expectation.
SPEAKER_01:Yeah.
SPEAKER_03:So if I went in saying, okay, yeah, I think this is gonna work, you have good egg reserve, let's do this. But if I didn't say this is probably gonna take us a lot of cycles unless you just happen to get lucky.
SPEAKER_01:Yeah.
SPEAKER_03:Because there is there is luck that plays a huge role. We don't know which batch of eggs is going to have the egg that's gonna lead to that baby. We don't know. And and the egg with the sperm that's gonna lead to that baby, they have to coincide.
SPEAKER_01:I love what you said off camera before we started this about making sure that you find a doctor that sets the right expectations. And that's kind of like what how success is defined, right? Totally. So for anyone who is listening that's in need of potential fertility support, that's something for them to look out for, right?
SPEAKER_03:Yeah, just proper education. And it's not to be pessimistic, it's just setting like I know that some people will say, Well, the last doctor I said told me um that the likelihood of me conceiving at this age is less than 1%. And that's ridiculous because I feel deep in my soul that I'm going to be the exception. And then I say, honestly, everyone says that. Like almost everyone says that. Everyone thinks they're the exception, but we have, I'm not saying that you are just a data point, but we have hundreds of thousands of data points to let us know in a certain age category, what is the likelihood that you are gonna get pregnant?
SPEAKER_01:Yeah. So it's kind of like having credible honesty while still remaining optimistic. For sure. With a doctor. That's what you're kind of looking for. Someone who will like not sugarcoat it to make you feel like you're gonna get pregnant easily, but will also have a pathway of like if the first time doesn't work or the second time doesn't work, like this is where and even yeah, and even support what you want to do, right?
SPEAKER_03:Because there there are times where patients want to do things that that I disagree with, and I say, I don't think this is gonna work. But if you want to do this for closure, I'm all for it. But just know I don't think this is gonna work. I hope you proved me wrong. I really hope you proved me wrong.
SPEAKER_01:And how often do they prove you wrong versus being right?
SPEAKER_03:Yeah. Never, actually. I've never had once a situation where I was like, oh my god, I can't believe this happened. Yeah. Never. And I think it's just a balance, right? Because at the end of the day, I really do there are certain things where I'm like, believe women. They know their bodies best. So if you tell me something is wrong and I don't see anything as wrong, I'm gonna believe you.
SPEAKER_01:Yeah.
SPEAKER_03:I'm gonna believe you that you know something feels off for you. And we're gonna keep looking and trying to figure it out. But that's different than getting pregnant because that is like there are so many things that have to happen for an egg and a sperm to come together to continue to divide, develop into an embryo. That embryo eventually develops into a fetus. Um, and so many things can go wrong along the way, but also your personal medical history and your previous fertility history and your age and his age all play a factor. And so you have to take all of this information into consideration to really determine what your prognosis looks like and what is the best strategy to get you to where you want to be.
SPEAKER_01:Yeah. Okay, so for anyone before the trying phase of fertility, do you have like what are your highest recommendations, like maybe top three to five things that women can do that's like the biggest bang for their buck, or like the least amount of effort for the biggest results of like if it's is it lifestyle factors? Like, what do you tell them to do?
SPEAKER_03:So, my number one thing is if you are not on hormonal contraceptives, record your menstrual cycles. Do not skip the step. Understand it, record it, log everything, use an app like Natural Cycles, um, with or without your aura ring. Um, use ovulation predictor kits to check to see if your LH is rising. Because if you come to your doctor with zero data, how are we supposed to interpret anything? I'm I'm just taking your word for it that you ovulate regularly. But 83%, I think the statistic is something like 83% of women incorrectly track their periods and do not even know when their peak fertility is.
SPEAKER_01:Oh my gosh.
SPEAKER_03:People are tracking it wrong all the time. They have no idea. And most women don't even understand the menstrual cycle. So understand the menstrual cycle, track your menstrual cycles so that you can figure out if something is wrong and take it to your doctor with the data you have logged so they can use it and interpret it to understand what's happening with you.
SPEAKER_01:That makes so much sense because then you're not wasting time and like like you have data for the doctors to look at rather than like, okay, well, now we have to find the data to see what's going on with you. It's like you're you you're a step ahead in figuring out, getting to the bottom of anything your body's going through.
SPEAKER_03:Yeah. And this is where I love their at-home devices like Mira or Anito, where you could also track your hormones to really understand what's happening. Most people don't even know how to interpret it. Some women are really good at educating themselves and learning this. But if you take that to your doctor, especially a reproductive endocrinologist, we can look at that and be like, okay, oh, I I've had a patient do that recently where I'm like, you have a luteal phase defect. You need progesterone after you ovulate to support a pregnancy. And it took a few months, but we got her there. And so, and so that's the other myth. Seeing a fertility doctor does not mean any fertility treatments. All I did was give her progesterone, track her cycles, tell her when is the best time to have sex. They did that, they got pregnant on their own, and I just monitored her early pregnancy until she graduated.
SPEAKER_01:Wow. So knowledge really is power when it comes to this and being proactive before Yeah. You find it's almost like being proactive before you even discover any issues. Correct.
SPEAKER_03:Yeah, because then we can find something so easy to tweak. Yeah. Um that doesn't really require much on your part except for taking a progesterone suppository after you ovulate. Yeah. Um, so that that I would say is number one. Um the second thing is just going in to do sort of a fertility checkup with a fertility specialist. If something feels off and you go to see a fertility doctor and they're like, well, well, you should really consider doing IVF, and you're still early in the stage, you haven't even started trying, and you feel like it's being pushed on you, always get a second opinion. You're not tied to one particular physician. It's got to feel right. They have to be aligned with what you want to do and really just educate you. So I'm I would say those are like my top two things, but definitely tracking your menstrual cycle and keeping track of your AMH are really, really helpful things. Um, and then in terms of optimizing your reproductive health with lifestyle, nutrition exercise really, really helps to move the needle. So there's very little we can control in terms of what happens with the egg and the sperm, but you can optimize as best as you can nutrition-wise. I mean, that's a whole monster topic, but just to give a very quick, you know, idea of what you should be doing: whole foods as much as possible, ultra-processed foods as little as possible. It doesn't mean you can never have it, just means minimizing it, um, with you know, higher protein intake. And a lot of that protein should still come from vegetables and legumes because uh too much animal protein can also be detrimental to reproductive health. Is it because of the hormones? So it's it there are various theories behind why hormones is one of them. Um, but there's a lot of molecular things that are also happening and more inflammation that occurs in response to especially high red meat intake. Got it. And so for patients with endometriosis, for instance, um, we know that reducing dairy and red meat and even poultry is super beneficial. So it doesn't mean you have to go vegetarian or vegan, but I would say the ultimate diet is really a pescatarian, Mediterranean style diet. Interesting if if I were to just define it in one word.
SPEAKER_01:Yeah. Okay, so let's get into the trying phase. Yeah. I feel like there's some not even just myths, just like things I've heard that I want to kind of debunk. Okay. When it comes to like mindset and best practices in like the trying phase, like what is the first one, like what is a normal range of how long it takes for a couple to get pregnant on their own?
SPEAKER_03:So by definition, infertility is 12 months of unprotected sex with regular intercourse if you're under 35. Okay. Six months if you're 35 and up. And really you should be getting an ASAP once you're 40. Okay. So you shouldn't delay. Yeah. Um but that being said, 80% of couples will have conceived by month six.
unknown:Okay.
SPEAKER_03:So if you're sort of like, I really just I don't like that this is taking this long. I want to know more. You don't have to wait in order to get a fertility evaluation. So you can really get it before you even start trying if you wanted to. No one's gonna tell you no to that. And if they do, then you should go to a different clinic.
SPEAKER_01:Yeah, that was another question I had because some doctors or some people that I've heard going to a doctor, they're like, oh, if you haven't been trying for six months, I'm not seeing you until Yeah, that's absurd.
SPEAKER_03:I mean, everyone should have the right to get a fertility evaluation even before they start trying. And that's what most fertility doctors do.
SPEAKER_01:Yeah.
SPEAKER_03:Most most of us didn't just start trying without understanding our reproductive health and doing a semen analysis and making sure that anatomy looked good. Most of us did it right off the bat.
SPEAKER_01:Okay, let's talk about the semen. Let's talk about the men. Yeah. What are your thoughts on a male's role in prepping their body for their part in getting pregnant? Like, what do they have to do? Are there things they have to cut out, like coffee or drinking? I've heard something about couples should stop drinking, is it three months before or really focus on their health for three months prior? So what do you tell your couples?
SPEAKER_03:Yeah. Looking at the the standard recommendation is for men to completely eliminate any form of smoking, drugs, alcohol, reducing endocrine disrupting chemicals just like the female partners, um, doing taking a multivitamin to ensure that they are completing all of the micronutrients they need that they may be missing from their diet. I mean, life is busy. We all are always on the go. It's really, really hard to ensure that you are getting all of your micronutrients from your nutrition. I mean, the best place to get is from your diet, but that's always not realistic. So taking a multivitamin is helpful. Making sure they're getting adequate sleep, proper exercise routine, so a combination of cardio resistance training on a regular basis, all of these things influence not only sperm quality, but there's emerging data showing that it influences the epigenetic of the sperm, just like the epigenetic of the egg is influenced in the whole body as babies developing once a pregnancy occurs. And so I it takes three months from the beginning of the production of sperm to when it comes out of the ejaculate. So if you do this for three months, then the sperm coming out three months later has been exposed to very little toxins.
SPEAKER_01:Interesting. Okay, another question when it comes to sperm. I've seen videos of like, I don't know if it's the it's doctors speaking on research or not, but that a sperm's quality can impact how sick a mother is going to be in the first trimester. If it like, does it impact first trimester sickness? Um, so there isn't enough data to this?
SPEAKER_03:Yes. Okay. There isn't enough data to really conclusively say that for things like morning sickness, there are paternal antigens in the sperm that can predict the likelihood of things like preclampsia, so pregnancy complications like that, which are obviously very severe. They're really serious. But um in terms of the uh morning sickness or nausea vomiting of pregnancy, jury's still out on that one. We love the male for that something we're going through. Um but I mean there may be truth to it. I just think that we need a lot more uh research. No, I just thought that was interesting.
SPEAKER_01:I'm like, can we can we blame the husbands if we're like, you did this, you did this, we're gonna be so better be at my bedside for whatever I need. Um so if there's anything in the trying phase, let's talk about that still. Um, what would you want to tell any couple that has probably been trying for outside of the six to 12 months that is looking for help? Like, what is one thing that you'd want them to know about seeking medical intervention and someone like you?
SPEAKER_03:I want them to know to not be afraid. I think that is the most common reason people delay going to see a fertility doctor. And I even get that a lot from patients saying, you know, I was afraid that I would come here and you would tell me IVF is what is needed. And I always try to rem remind patients that you have full autonomy on what you get to do for treatment. A doctor is going to help to find the diagnosis and then recommend treatment options based on that diagnosis. Um, but it's shared decision and don't be afraid of the possible diagnosis. I know it sounds scary that, you know, what if there's no sperm? What if something I'm told that my eggs are no good or something? Um but the reality is the sooner you get in, the more likely you're going to be able to do something about it. If you delay, then you may get to a point of no return. And if I give a very specific example of two patients that I'm currently treating, I had one who started dealing with very young, early 30s, hot flashes, hair loss, poor sleep, low libido, went to see her OBGYN, she got an AMH, saw that it was very, very low, immediately sent her to me. The patient made the appointment same week, and I, you know, we squeezed her in. And um, I told her, like, we are catching you in the beginning of perimenopause. And the way we know this is because there's a hormone called follicle stimulating hormone. It's the hormone responsible for recruiting an egg in a menstrual cycle to eventually release it. When you're on your period and you're cycle day three, so third day of your period, your FSH should still be below 10. If we see that it's way above that and that your EMH is really low, like 0.1, that tells me that your ovaries are literally running out of eggs and you are in the process of entering perimetopause. And the problem with menopause is it's a retrospective diagnosis. So if that was the last period, we don't know until a few months later, like that was the last period. We can't do anything now. But in her case, she went in right away, and I was like, okay, there's one follicle. Let's retrieve the egg. Let's see if we can make an embryo. And I'm even gonna go after the tiny little follicles where I don't think I'm gonna get anything, but we'll try and see if we can mature the eggs in the lab and go from there. And we were able to successfully do that. And in the end, I got her three embryos, which is insane given what her labs look like. Yeah, and they were chromosomally normal, which was really pregnant. So we're we haven't transferred anything yet. What I told her is you make great embryos, try naturally now. Okay, and that way, if you do get pregnant, and then after that you're in menopause, we have extra embryos for subsequent siblings. Wow. And now, like you have these as backup for more kids, and you can potentially grow the family size that you wanted originally, and now being in menopause is not going to be a factor. Whereas the other patient who was experiencing the same thing, her OBGYN drew her AMH, it was 0.01, very, very low, and did not send her to a fertility doctor. It wasn't until three years later that she came in to see me. And those three years, opportunity was lost. And now there's nothing. Like you could barely even see the ovaries because they're so small, they look like menopausal ovaries. And how old was she? 30. Oh my gosh. Very unusual.
SPEAKER_01:And is that like a genetic thing, or oftentimes it is.
SPEAKER_03:So if you know that your mom reached menopause really young, then that is your sign to get in ASAP to do something about it and to not delay. Um, yeah, it's it's a really tough situation where that happens. And I think right now there's this huge online trend going on. And it it's funny, I got eaten alive on threads the other day for saying there are so many doctors talking about how perimenopause starts at 35, and that is normal. It is not normal. You should not be reaching perimenopause in your mid-30s. That is unusual. That is pathology. So for women who still have regular menstrual cycles, um, don't freak out and thinking you're entering like menopause already. You can still get even pregnant in your late 30s, early 40s. Um, but once again, you just have to do your homework, do your labs, and see where you stand because you're not the same person as everybody else.
SPEAKER_01:So yeah, that's such an interesting statement because it's like some people are saying, Oh, yeah, you're you're completely fertile and healthy to get pregnant in your mid-30s. And then there's other people being like, perimenopause is normal at the same age. Right. Like that doesn't make sense.
SPEAKER_03:It doesn't make sense. And it's not normal because your ovarian reserve really starts to like the cliff is not at 35. I would argue the cliff is at 37. 37 is where things really start to change. And we see this by doing IVF over and over again. When I do IVF in 35 and 36-year-olds, I mean 36, I don't bat an eye for the majority of women. But once again, you have these exceptions of women who are in their early 30s entering perimenopause. They usually have symptoms. Um, but so if you're like, I'm having hot flashes and night sweats, what's happening? Just get evaluated. Your doctor might tell you you're totally fine, everything looks good, but then you might actually find something and you could do something about it before it's too late.
SPEAKER_01:Yeah, that's a great point. Okay, let's get into fertility after kids. Because I mean, we could go so many different directions with this, but I want to touch on first like the hormone shifts after having kids and how this can, well, we kind of talked about on sometimes how it can enhance your chances at getting pregnant again. But then there's also secondary infertility, which I think a lot of people are blindsided by because they're like, oh, I got pregnant so easily the first time. That's gonna happen for me again. What is the percentage of cases of, I guess, secondary infertility? Like how common is that?
SPEAKER_03:I mean, it's pretty common. I mean, right now, infertility as a whole, according to the CDC, it's now one in six couples. So that's a lot of people, right? Um, that's way more than before. It used to be, you know, 10% of couples dealt with infertility. We're looking more like 20% of couples will deal with infertility, which is quite high. And it doesn't discriminate against primary versus secondary. That being said, secondary is really common for two different reasons. Number one, depending on when you started building your family, you're now older. Things have changed. Egg quality and equantity have declined. Secondly, it's really, I'm not saying that stress causes infertility by any means, but we can't deny that high-level chronic stress does impact your reproductive health. It impacts every aspect of your health. Inflammation of our body. Totally. And so the reality is for some women and men, when you are extremely exhausted and depleted with your current kids, that can make things a lot harder. Yeah. Um, and so your your health is different, your anxiety level might be different.
SPEAKER_01:And so you're not eating the same, you're not eating, you're not focused on your nutrition. It's kind of like a uh what is like a slippery slope of like the perfect storm of total everything that comes after, especially after having a first kid. It's like your stress is higher, you're probably working harder, sleeping less, not eat, not prioritizing your meals. Correct.
SPEAKER_03:You're not taking care of yourself. You're your brain is telling you, I I'm things are not going well here. I cannot allocate resources to a baby. So that you know, cortisol levels being higher, more inflammation, poor sleep, poor nutrition, all those things can contribute. So um I would say those are the two main things happening. But then also sometimes disease like certain diseases progress, right? So for instance, with endometriosis, and I did forget to mention that when I was talking about two main categories who benefit for from pregnancy and are more likely to be fertile afterwards, it's PCOS and endo. Because endometriosis, when you suppress hormones, you tend to be more fertile. That being said, there are a lot of women with endometriosis who will have zero problems conceiving the first time, especially if they started young. But now, as they're getting older, especially if there's a big gap between siblings, their disease is progressing. And now it's impacting their fertility, whereas before it wasn't. And endometriosis, for anyone listening who doesn't understand what it is, it's having endometrial-like glands. So the endometrium is the cavity of the uterus where pregnancy takes place. Those cells, you can have those same cells or similar cells present outside of the uterus. And when we have a period, so a period happens when you don't get pregnant and you get a withdrawal of progesterone. Progesterone keeps the lining very stable. If you take progesterone away, you shed your lining. And in the new menstrual cycle, as your egg is growing and getting ready to be released, it's making estrogen, and estrogen very rapidly repairs the lining. But the lining is designed to undergo that kind of trauma on a monthly basis, and it does really well with it. It doesn't build scar tissue. But if that process is happening inside the abdomen, on other organs, on your peritoneum, which is like, think of it as saran wrap lining your organs, and it thickens and then it bleeds in response to all of the hormonal fluctuations. You can create so much inflammation, scar tissue, it affects anatomy, so it can cause blockage of your fallopian tubes. So a new anatomic abnormality that may not have existed before that. It can reduce ovarian reserve, so you have fewer eggs than before. It reduces egg quality, it reduces embryo development. Um, it also impacts implantation because it even affects the lining of the uterus, even though it's present outside of the lining. Um, and you also have higher risk during the pregnancy, preterm delivery, miscarriage, etc. So as time progresses, that disease gets worse and worse in your 30s, late 30s, early 40s. So now conceiving becomes much more difficult, whereas before it may not have been.
SPEAKER_01:Wow. Interesting. So it in some cases, PCOS and endo, um, they benefit from having a kid first when it comes to their fertility, but then in other cases, if they're older and have larger gaps, it can decrease.
SPEAKER_03:The disease progresses as you get older. That makes sense. And so now you've had this disease progression without even knowing it. And unfortunately, the average time of diagnosis for endo is at least 10 years. And the reason is because, of course, pain gets dismissed and people are told this is normal when it's not. But then there's also the fact that to the gold standard of diagnosing endometriosis is surgery.
SPEAKER_01:Yeah.
SPEAKER_03:It's surgical staging like cancer. It's insane. And so most of us don't want to routinely bring everyone back for surgery just to say they have endo when we try to manage it through medical management first, but it doesn't always work, and you don't really know that it's working because sometimes the pain really just does not correlate with severity of disease.
SPEAKER_01:Gosh, there's so much we can talk about within all of this, and especially after kids. So maybe for people that are done having kids, let's talk about like fertility and reproductive health. Why should we still focus on our reproductive health, even though we're done having kids?
SPEAKER_03:Because your reproductive health is a marker of your overall health. Um estrogen, for instance, okay, and this really requires deep understanding of the menstrual cycle, which I would argue the majority of people, including women, don't even understand the menstrual cycle. So it so let's just start with a very quick description here so you understand what I'm saying. Okay. Hormonal fluctuation is totally normal. It is expected in a menstrual cycle. A normal menstrual cycle length is anywhere from 26 to 34 days. Okay. Um, if it's shorter, that's not normal. If it's longer, that's not normal. And shorter tends to happen as we get older and we're starting to phase towards perimenopause. Okay. Now, in a natural menstrual cycle, um, first day of your cycle, all of your hormone levels are really low. There's four main hormones at play. There's obviously way more hormones behind the scenes, but the four main hormones you have to think about two are coming from the brain, two are coming from the ovary. And the brain is talking to the ovary, telling it what to do. The hormones secreted from the ovary is then telling the uterus what to do. And the uterus is your sign of what is happening. Okay, so that's like the easiest way to know what's going on based on your period length and timing. In the first phase of your menstrual cycle, your brain sends a signal to then secrete a hormone called FSH, follicle stimulating hormone, a hormone that stimulates your follicles to grow. Follicles are basically containers for your eggs. And every month you have a group of them that rise to the surface of the ovary and they're in competition with one another. FSH is food for those follicles so that they can grow. But imagine having 10 people in a room who are starving, and you only give one plate, they have to hash it out, one person gets the food and the rest. Starve to death. That's what's happening with the follicles. One, we'll take that FSH, continue to grow, and we'll start to make your estrogen. So as the follicle grows and the egg within it is growing, it's making estrogen, which sends a signal back to the brain letting it know it's doing this, so the brain stops releasing FSH. As estrogen is rising, it's making the lining of the uterus thicken in hopes of preparing for a pregnancy. But something happens along the way once estrogen peaks, where the brain now knows the egg is ready. We still in science don't understand what that signal is. But somehow the brain knows the egg is ready and causes a spike in your LH. It's called the LH surge. That's that one big spike you see on the menstrual cycle chart. And that hormone, as it rises and comes back down, causes the follicle to rupture, release the egg, and then the egg is picked up by the fallopian tube, and that follicle will now reseal. And so that's ovulation. Once that follicle reseals, the follicle starts making progesterone, progestation, propregnancy. That is the hormone responsible for supporting a pregnancy. So as it's secreting progesterone, it peaks one week after ovulation, and that makes the lining nice and sticky, so that hopefully there's an embryo there that could attach an implant. And if there is no pregnancy, that follicle that became a corpus luteum will die off and you take away the progesterone supply. And I mentioned before a progesterone keeps the lining very stable. So if you take progesterone away, you shed your lining and restart the whole process all the way. So exactly. And so estrogen peaks right before ovulation, comes back down, and then goes up again in the luteal phase. And that's where you get your estrogen from. But it's not only important for thickening the lining of the uterus and for helping the egg to mature and eventually get released, it's also super important for all bodily function. Your bone health heavily depends on estrogen. So if you don't have enough estrogen in your body because you are not cycling, you are having anovulatory cycles, you end up with brittle bones when you're older. Not good for longevity. And what people don't realize is if you have brittle bones or osteoporosis, you are more likely to get a hip fracture. Once you have a hip fracture as an older woman, your five-year survival is extremely low. Your likelihood of dying in the next five years goes through the roof. So protect the estrogen to keep those hips healthy ladies. I've so improved that. This is why I check vitamin D on all of my patients because the low-hanging fruit. Oh, you're vitamin D deficient. We need to replace this for the sake of your bones. Oh, you're not having periods. I don't want to be on the pill. Like I have, like some women, for instance, who are athletes, they have they have hypothalamic ammonrhea or female bodybuilders. And gosh, I used to be part of that world. Like and I used to be a full-time athlete. When you stop getting your periods, that that is really, really dangerous for your longevity.
SPEAKER_01:So it's just as important to focus on your cycles after having kids as it is before or during.
SPEAKER_03:Yes. Unless you're on birth control pills. Yeah. Okay. Then that's different because you're getting those hormones. Yeah. And it gets a really bad rep right now. Um, but birth control pills are actually really great. It's not for everyone, of course, and not everyone does well on it. But for the people who do well on it, I mean, it's really fantastic for your overall health in in so many different ways, reducing risk of cancer, ensuring you have enough estrogen. Um, it's great. But if you are on nothing, then continuing to track your cycles to ensure that everything is functioning well is really good because if anything is off, that tells you that there's something else that could be off with other systems. What if you have a thyroid dysfunction, but you're not having traditional symptoms of anxiety, weight loss, or the opposite, easy weight gain, severe fatigue, hair loss, etc. Sometimes the very first sign is going to be your menstrual cycle's off. And now that is alerting the doctor that, okay, we need to check all the other hormones to see what's happening. It could be signaling that you are pre-diabetic or now you're diabetic, and that was the first sign to tell you that something is wrong.
SPEAKER_01:So what I'm hearing is that like a woman's menstrual cycle is like the biggest vital sign on their overall health and I guess future health too.
SPEAKER_03:Totally. I mean, it it can still be normal when there's other pathologies happening, but it's also very sensitive for most women. And once things are off and you are not cycling regularly, then that tells me there's something that was missed, and we need to figure out what's going on. Why are you so irregular?
SPEAKER_01:Yeah, gosh, you're a wealth of knowledge. I've learned so much today. I feel like we could be talking for like five, six hours and just never stop. Totally. Should we finish with a fun little game? Sure. Okay. I wrote down some questions, and it's called normal or worth checking. So I will give you a scenario and you say normal or worth checking. It's very like rapid fire. Okay, great. Okay. Exhaustion in a year postpartum. Oh.
SPEAKER_03:I I mean, I would argue worth checking. It's still a variation of normal, but could be worth checking.
SPEAKER_01:Okay. I like that. Periods that never return to normal after having kids. Worth checking. Low libido after childbirth. Normal.
SPEAKER_03:Yeah.
SPEAKER_01:For a while. If it stays that way, then worth checking. When does libido start to kind of kick back up after having a kid?
SPEAKER_03:I would say normal is once you start cycling again.
SPEAKER_01:Okay.
SPEAKER_03:Because your testosterone rises before ovulation, and that's where all the sex drive comes from.
SPEAKER_01:That testosterone. Okay, I'm going totally, I'm sidetracking here, but why do women are, I don't know, I'm in this phase. I my libido feels very high this pregnancy. Is that normal? That is a variation of normal.
SPEAKER_03:It could be higher or it could be lower. But you have higher androgen levels in pregnancy. So that can contribute to a higher libido.
SPEAKER_01:I'm like, I'm never this into sex. Why am I larger than charge, almost seven months pregnant, wanting sex for the first time? Isn't it funny how every pregnancy is just so different? Yeah. You'd think I'd have a boy inside me. I don't. Yeah, no. Um okay, rage or anxiety around ovulation or PMS?
SPEAKER_03:Not normal, worth checking, and there are great treatments for that.
SPEAKER_01:What are they?
SPEAKER_03:So you're not gonna love my answer, but if you, for instance, have really severe PMS or PMDD before your period comes on, then your options are really either antidepressants or anti-anxiety meds or birth control pills.
SPEAKER_01:Okay.
SPEAKER_03:Which are great. Good to know. If you don't have the if you don't have a period, you're not going to feel that because there's no fluctuation in hormones. Your hormones are sort of just even throughout.
SPEAKER_01:Hair loss, six to twelve months postpartum. Normal, unfortunately. Needing caffeine to function each day.
SPEAKER_03:Um variation of normal. If you're someone who's been doing caffeine for a long time, it is addicting. And so you go into withdrawal and you need it. But if uh if you really are extremely non-functional without it, then worth checking. Even if you're non-functional with it, definitely worth checking. Okay. Last one. Feeling off, but labs are normal. Keep pushing. Try and figure out what it is. Sometimes it takes a long time to get a diagnosis. Got it.
SPEAKER_01:Well, thank you. This was so fun. Oh, I hope you guys learned a lot. And oh my gosh. I need to go re-listen and like actually absorb even more of what we talked about because you just kept saying all of these mind-blowing things. And I'm like, oh my gosh, I need to remember this. I need to remember this. And I learned so much from you today, even with doing my own research. I'm like, I need to go listen to every episode of your podcast too.
SPEAKER_03:Yay, thank you. I'm I'm actually going to be launching more um YouTube episodes too for like just shorter clips of stuff like this. So it's more digestible because it's a lot of information.
SPEAKER_01:Yeah. Okay. So where can everyone find you across your social platforms? And then also if they're local in LA and might want to come see you.
SPEAKER_03:So you can find me on Instagram at Sasha Hackman M D. There's no C in Hackman. It's H A K M A N. Um, you can also find my podcast, Trying to Conceive Pod on Instagram, as well as on YouTube. And my website is sashahackmanmd.com, where I have basically everything you can find from where to find me in LA to all my socials and podcasts.
SPEAKER_01:Perfect. And I will also link all of those in the description of this episode. Thank you again. Thank you, everyone, for joining us today. And if you loved Sasha's episode, would love for you to leave a comment or message her with any questions you have, if that's okay. I'm totally amazing. Um, and if you would be so kind to leave a little rating and review for the podcast, I'd appreciate it so much. Until next week.
