STOP Inflaming Your Body: The #1 Enemy to Egg Quality and Conception

Inflammation is hijacking your fertility. Do you think IVF is going to become the standard? Absolutely not. I think IVF is an incredible technology. And there's certainly people who would not be able to have children without IVF. The number one thing that I see that patients are not doing or they're putting in the bottom of the totem pole is... I was hoping you were not going to say that. My patients, they need to have more healthy muscle. Is there something similar in the realm of fertility? We've got sleep, stress, muscle, diet, and toxins. But sperm rates have dropped almost 50% in 50 years and they've dropped more rapidly, more recently. But we also see more women being diagnosed with low ovarian reserve. I see more premature menopause than ever before. So it's not solely just, oh, everything impacts the sperm. We're really seeing both men and women being impacted by a change in our environment and our life and what that means for our fertility. So you said that the vagina can contract? Yes. If you're not using it, you're going to notice that you're going to have higher likelihood of having vaginal strictures. You're going to have atrophy of your vagina. You have to explain to us what you mean. Dr. Natalie Crawford. I have to say, number one, your boots are amazing. Thank you. And number two, I have so many fertility questions for you. And you know why? Why? Because in our practice at Strong Medical, we are seeing more and more young women having fertility problems. Well, we are seeing an increase in fertility, but thank you so much for having me here and that we can hold space for this discussion, which is something that there's a lot of stigma behind as well because many people don't understand their body, their health, their hormones and they don't want to talk about their fertility. So by breaking down these discussions and hopefully we can help educate some people so they can understand what they should be doing or advocate for their health better. Do you think IVF is going to become the standard? Absolutely not. I think IVF is an incredible technology and there's certainly people who would not be able to have children without IVF. There are some genetic diseases or medical scenarios that we cannot overcome with any other technology, but I do not agree with that narrative because that IVF is going to be the way that all humans reproduce in a hundred years. But are you seeing it? Because I am seeing it more and more with younger patients and I'm talking about patients when I say younger, you know, 30s, early 30s. Yeah, absolutely. We are seeing an increased rate of infertility. So number one, when I first started as a fertility doctor almost 15 years ago, I would say one out of eight couples had infertility and now that number's one out of six and in the U.S., if you're trying to get pregnant for the first time, it's one out of five. One out of five couples. One out of five. So if you sit here and you say, I want to start a family, 20% chance that you're going to have difficulty doing so. And that's a really large number yet. I'll admit, I do not think the infertility field has caught up with what we should do, meaning this is a very reactive field. It exists within OBGYN because people had a problem. It's defined by failure. The disease itself, failure to get pregnant after 12 months, meaning right now women have to fail before they can see me get testing, even find out what's going on in their body. And as infertility rates rise, I really think we have to reframe how we look at fertility, how we think about it as a marker of our hormonal health, our longevity, our risk for future disease, and what that means about the life we're leading, but also what we can do more proactively to have an easier chance getting pregnant when we want to. Infertility is defined as the inability to conceive after 12 months. Correct. Correct. Are men or women become, which one is becoming more infertile? Both. We know that 50% of cases have a female factor and 50% of male factor. And of course, there's a large overlap where I see so many couples who, there's something going on with both persons. Now we know that sperm rates have declined immensely. Of course, this is very easy to check compared to some of the female factors, which are harder to ascertain. But sperm rates have dropped almost 50% in 50 years, and they've dropped more rapidly, more recently. And this is just such a direct correlation with the lifestyle we lead right now is so vastly different from what it was 50 years ago. The world is more inflammatory. There's more obesity, insulin resistance, environmental chemicals, and we're directly seeing that play out in sperm. But we also see more women being diagnosed with low ovarian reserve. I see more premature menopause than ever before. I see younger patients struggling to get pregnant, having higher rates of miscarriage. So it's not solely just, oh, everything impacts the sperm. We're really seeing both men and women being impacted by a change in our environment and our life and what that means for our fertility. So you've listed a handful of items. Do you think that the number one cause of infertility, is it fair to say that it's obesity? You know what I say? It is I say it's inflammation. Chapter one of my books is, Inflammations Hijacking Your Fertility. And this to me is many different things, but obesity is largely one of them. But I see a lot of patients who are not obese, but they have high levels of insulin resistance. They are doing behaviors they might think are healthy, but the nuts, some of all these choices are actually leading them to have a very inflammatory life. And if we think very segmentally, what's the role of an egg? What's the role of a sperm? It is supposed to capture, protect half of your chromosomes and then a sperm has to be able to swim and fertilize an egg. And the egg has the mitochondria. The mitochondria are going to get passed on to that embryo. So the competency in the metabolic capacity of an egg determines the competency of that embryo, meaning for cells to divide, for organs to form. All of that comes from the metabolic health of the egg. And so inflammation, insulin resistance directly impact both egg and sperm quality in addition to hormone function because of how inflammation can impact the brain. You know, we think a lot about in medicine so much is repairable. Is the quality of an egg and I've listened to you speak on other podcasts and we have all our eggs. Is that before we're born? Essentially, you have the highest number of eggs when you're a five month old baby inside your mom. You have six to seven million eggs, but only one to two million at birth. Now, after birth, can we change the quality of those eggs? Yes and no. And I want people to frame this because the older dogmas know, right, that tincture of time wears up and the chromosomes are going to break down and move around. And you'll often hear fertility doctors say age is the number one predictor of success. And yes, there's a huge age component because our eggs are in our body our whole life. Our chromosomes are held in metaphase of meiosis, which means they're all met in the middle in this perfect division. You have these proteins or these myotic spindles keeping everything in perfect place. And it is true the longer they are in your body, they are going to start to move around more because we know this proteins break down wear and tear of our life. But this metabolic health and this mitochondrial function is something we really need to pay more attention to than not enough people are. A recent study came out, it's getting a lot of present attention. And what the study showed was that mitochondrial DNA do not accumulate damage and change the same way that our nuclear DNA does. Now, some people are misinterpreting the same. Oh, doctors have been lying to us saying that our eggs don't accumulate DNA damage the same way. So I've been doing a lot of talking online saying, no, your chromosome DNA does actually accumulate wear and tear. But it's wonderful news that your mitochondrial DNA do not do that at the same rate because that means you have more of the ability to influence your mitochondrial health and the metabolic capacity of your eggs and to change it both positively or negatively. But as you get older, women are more prone to have more abnormally shaped mitochondria, have less good functioning eggs. And this is why especially if you have infertility or you're trying to start your family at a later age, you know, you're older, that focusing on lifestyle factors to decrease inflammation and improve your egg quality. I don't really think that's optional. I think that's something we have to be talking about because you can change how your eggs are functioning. Well, first of all, that's good news. What is the number one? If you were to say, OK, this is the biggest factor. So for me, I know that my patients, they need to have more healthy muscle. Period. End of story. Is there something similar in the realm of fertility? I wish it was just one thing. To be honest, I always say it's the sum of many things, meaning if we look at what causes inflammation in our body that we can control, we've got sleep, stress, muscle, diet and toxins. And truly, we're all wired a little different. We all do different things and make different choices. But I think the number one thing that I see that patients are not doing or they're putting in the bottom of the totem pole is going to be sleep. And when it comes to your reproductive... I was hoping you were not going to say that. I'm so sorry. But I think it's because it's easiest to change in some way, right? Maybe, you know, you talk a ton about building muscle. I talk a lot about nutrition and these have huge deltas, meaning huge margins for change. But sometimes the barrier to entry feels really hard for somebody. So I say sleep should be the first thing because we know that this is when your body is going to naturally heal from inflammation. It's when your hormones get a reset. You're going to improve your insulin resistance. I heard you say you only got two hours last night, so I don't love it. I don't love it either. But what are you going to do when you've got parents that they're kids? We cannot get them out of our bed. Period. I mean, I think they're seasons in life, right? And sometimes we do the best we can in the circumstance we're in. But specifically, if we are trying to get pregnant, if we have infertility, if we're spending the emotional, physical energy, the money, the time on IVF, we've got to take a more proactive role in controlling those factors we can. And that might mean changing our sleep environment, you know, making our partner kind of get up and be a greater help at certain times, changing the time we go to bed, changing how cool the room is, dark it is, a sound machine. So it's not perfect. I know you were in a hotel room with little children. I don't recommend. So there's seasons of life, but if we're really trying to optimize hormonal health and decrease inflammation, we have to start to say that the foundation of our day, sleep, stress and exercise, they matter more than we give them credit to. If you listen every week and feel like we are in this together, which I believe that we are, learning, growing and building strength, then I created a way for us to get connected even more closely. It's called Forever Strong Insider, a premium community for listeners who want to go deeper. You'll get ad-free episodes, which I know you'll love. Bonus Q&As, where your questions shape the conversation behind the scene moments because let's face it, I'm hilarious from my daily life and written takeaways to keep at your fingertips. But more than that, you'll be supporting the show so that we can keep creating content that matters. If you've ever wanted to feel part of the inner circle, this is your invitation. Join us at ForeverStrong.SuperCasque.com or through the link in the show notes. Is that the same for men and women? Absolutely. So sleep matters just as much to men when it comes to sperm quality as sleep matters to, I'm not going to say egg quality, I'll say, shall I say mitochondrial health? Sure. Okay. Do we think that it's the same impact? Yeah, this is two sides of a coin. So you could say, well, women are born with all the eggs they're ever going to have, so it's even more important that they mitigate these factors they can because you can't control your age. On the other hand, sperm live 90 days. You have a completely new turnover of sperm. They're packaging DNA and creating new sperm. So you can make the biggest change can be in men. And yet I often see a female partner who starts to go to sleep on time. She's eating everything right. She's working out. She's taking the supplements. And yet her partner is doing whatever he wants. And when it comes to sleep, if you sleep in the same bed with somebody, you've got to make a decision together that you're going to make a decision together. That you're going to improve sleep because if he's coming in a few hours later, if he's watching TV in bed or scrolling his phone, that's going to not be the best environment for you to get the rest you need, nor for him. And he's half the equation. And I like that you said so women go through nine months of pregnancy and all he has to do is sleep a little bit better. Yeah. I, but I actually like that it impacts him. It seems like more because of the sperm turnover. And that's something simple that anyone and everybody could do. Absolutely. He can make a bigger change faster. It doesn't mean that it's any less important for women, but fertility is a team sport. We've got to stop this mentality that it's a female problem or that only women need to improve it. We really have got to bring both parties into the picture more and approach this together. How much sleep do you recommend? Seven to nine hours a night. Seven. Who has time for that? Oh, my God. Okay. You can do it. All right. Seven to nine hours. Do you care the time? Circadian rhythm is actually important. I always like to say your body's like a toddler. It really wants to know that you're going to give it what it needs. And so if you can be really predictable and reliable, it will start to depend on you and that means it'll have better stress, response and resilience because it knows you'll give it the sleep. So we know that circadian rhythm studies show less sleep variability. The hours you go to bed and you wake up, you're going to have improved hormonal health and hormonal health. Maybe that sounds like a buzzword, but when we think about it, the hypothalamus part of your brain is that central command station, it's interpreting signals from all over your body and then sending out hormonal signals to the pituitary gland. And this is going to control ovulation, estrogen production, progesterone production. And if you're not, you know, sleeping enough, you're having interference coming back to that brain, that's going to influence everything else you do. So we really want to be at a place where we're optimizing our hormonal health or how our body functions to the best of our ability. That actually makes a lot of sense. Now, we know that men need to get a certain amount of sleep during certain hours because of increase in testosterone. Do women have that same cycle? For example, we want women to sleep from 10 to 2 because we know that that's the time that they're, and I'm just making this up, they're estrogen peaks. Do we have kind of the same data? You know, when it's dark outside is when your body is naturally meant to sleep more and, you know, getting early morning sunlight can be extremely advantageous, but there is truth to the fact that your gonadotropins, which are FSH and LH, these are the hormones directly controlling egg growth and ovulation and progesterone production. They're made from the brain in pulses, but a lot of that strongest signal does come in the early morning hours. So really trying to get into that REM sleep, you know, not waiting and going to bed at midnight because then you're going to miss that optimal interval of time, which for most women is going to be, you know, before four o'clock in the morning. So really trying to get yourself to sleep a little bit earlier, not just getting in the bed, playing on your phone, but like truly trying to cultivate a good sleep environment is really crucial for how your hormones function. This is your first pillar that you think that it's something that has a huge impact that everybody can do. Agreed. Okay. What about this use of, I want to say supplements and here's why. Very early on in my career, I was and still am interested in integrative medicine, but you know what it's like starting out as a physician. We get very excited about a lot of things in the beginning of my career. I was very interested in again, these younger girls that were having period irregularity and there was a lot of discussion about the use of chase tree berry. Right. And we use that early on and now 10 years later, I still see people using it and I don't know where the evidence is. So what I'm getting at is are there supplements that actually impact hormone regulation and subsequent fertility? Look, there's two different ways to look at this, right? So in the perfect world, you would get all the nutrients you need from your diet, right? And so a lot of supplements that I do recommend are ones that are, you know, micronutrients that maybe you're not getting enough of. They can actually support your cellular health. Part of what you're asking though is about like herbal supplements. And this is something that's been around well before you and I existed, right? Where people were trying to leverage improving certain problems with certain herbs that have some medicinal properties. And although this might not be wrong, we've got to think about the life stage you're in and what these are doing. So you mentioned chase tree berry or Vitex chase tree berry named chase tree because monks used to take it to suppress their sexual desire. So we want to talk about a hormone that's profoundly impacting how your brain is interpreting and sending out hormonal signals. If you want to get pregnant, does that sound like that's the right thing to be doing? No, it lowers your prolactin levels. It changes your brain's interpretation and how it sends out different hormones and it can influence progesterone production, which we know for conception. Progesterone opens and closes the implantation window. It's hugely important. So this is something that I do not recommend taking if you're trying to get pregnant or you're pregnant. Now, that doesn't mean that it doesn't hold some properties. Certainly in people who might have terrible PMS or period irregularities, they might notice certain benefits or changes to their menstrual cycle if they're using this, but nothing's without a tradeoff. So understanding that it's probably influencing endometrial receptivity. It is influencing how your hormones are interpreted and secreted. And if you're wanting to get pregnant, that's not a state we want you to be in. So it's not wrong if you use it and you're loving a benefit from it. But to me, why do you need it in the first place? Why are your hormones wrong? It's a band-aid, right? We really need to think about what's the underlying mechanism causing the irregular cycle or causing the spotting or whatever problem you might be having. And we really need to get back to that history taking the diagnostic skills of medicine and not just slapping any medicine as a band-aid, including herbal preparations. Yeah, that makes sense. Early on, roughly about, I would say, 10 years ago, we were using it for menstrual irregularities. But we spend more time in practice. You want to see randomized controlled trials. We want to understand what is the mechanism of action and why is this happening real root cause medicine? Because there's the herbal supplementation and then there's medicine. And then we have to ask, what's the difference? Yes, one is perhaps FDA approved and pretty rigorous. And then the other is maybe still having an impact, but it is unregulated. Well, and also, you know, if let's pretend your prolactin is high and you have irregular periods, this is a hormone made from the pituitary gland. What if you have an adenoma that's causing that? We never get to that root cause because you're using an herb to self-treat instead of actually getting to what's really going on. So I agree completely. And I'm glad to hear you say that. Are there supplements aside from micronutrients that you recommend just in general? Like herbal supplements? Yeah. I don't recommend any herbal preparation if you're trying to get pregnant largely because they're unregulated, different dosing in each one. And most of them do influence your hormonal system and we're trying to get your body in hormone balance. And I know hormone balance is a big trigger word, but what is it? Because I think it's a real thing. It means your brain is able to interpret the signals your body is giving you and respond appropriately. So why do I want you to take anything that's going to interfere with that process? I think that's good because people are very confused. And we see a lot of hormone support and frankly it is concerning. Well, let's just think about it. Right. Maka is very popular. Has a lot of estrogen like properties. We see a ton of adrenal supplements for people who might have adrenal fatigue. And I always say adrenal fatigue is a category of symptoms. There's largely something else going on. A lot of people have a really hard time getting to the true diagnosis, but that adrenal support supplement you might buy is literally ground up endocrine glands from animals. And it doesn't just contain adrenal glands. It contains thyroid hormones, prolactin, progesterone, estrogen, so many different hormones that you're now ingesting into your body that's going to influence your own ability to interpret what's going on. And to be fair, we probably don't want to do that. I do think that there are supplements that are warranted are good, especially for deficiencies. Oh, for sure. But it does concern me when people are using glandulars and items like that because it doesn't fix it. It doesn't fix it. It actually can make things worse and introduce new problems. And I get it. A lot of people are trying to get help. Sometimes there's providers recommending these and it's not, you know, people self-treating. But I think there's certain red flags that we should always have if we're, you know, a consumer. And to me, that is one of them. When somebody says, take this pig adrenal gland because your own are not working. We are going to take away the ability for your adrenal glands to actually start working if we're not getting to what's underlying the problem or changing what your real problem is. Oh, oh, sorry. It's time to record an ad for the show. Thank you to one of the sponsors of the show Timeline and listen, my kids still sleep with me. 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And they have just launched their low sugar vegan non GMO gluten free gummies, which by the way, I am eating by the handfuls, which I shouldn't, but they taste delicious. Timeline is offering our community 20% off your first order. Go to timelinenutrition.com slash Dr. Lion and use the code Dr. Lion to get 20% off. I recommend trying their starter pack with all three different formats. And of course, their gummies, which are incredible. What about the role of alcohol? Do people ask you this alcohol in cannabis? Oh, absolutely. And people want me to bless their ability, you know, to drink alcohol. I think we both know if I sit here and say inflammation is the top thing, you know, contributing to the rise of infertility that we see alcohol is absolutely inflammatory. Besides being a carcinogen and bad for your health. Otherwise, it takes a huge load for your body to clear alcohol out of your system. And what we want is it to be able to focus on making hormones, ovulating appropriately. You have to convince your body when you're trying to get pregnant that you're in a good place to handle the rigors of pregnancy because pregnancy is not health neutral. So drinking. What do you mean by that? Pregnancy is not how it is not health neutral. It's a huge load on a woman to be pregnant. There are certain risks to your own health that exist only in pregnancy that are very rare outside of pregnancy. And what are those? So things like developing blood clots, strain on your heart and your lungs, strain on your entire muscular system, how your ligaments and tendons and everything changes in pregnancy. And so we want to think about the fact that your body, as we said earlier, is like a toddler wants predictability. It wants to know we can handle that rigor. And if you are constantly challenging it by adding additional inflammation, right? There's inflammation in the world every day, the air we breathe, the water we drink, but the stress levels we take on, the foods that we eat. And alcohol is one that is only straining your body with absolutely no benefit to you in addition to being a poor, you know, stress coping mechanism and straining your body more. Cannabis too, and cannabis more directly has even more literature showing such harm. For men and women? For men and women. Dramatically for men, again, sperm quality is easier to test than egg quality. So we have to understand the limitations. I can have a man ejaculate in a cup and I can check his sperm quite easily. For women to evaluate their eggs, I've got to go through a procedure and take him out of your body. So we just have more literature on men, but we know that cannabis can downregulate the brain. So you start to send out less FSH and LH. Same hormones in men control sperm and testosterone production. So men suddenly are having lower testosterone with cannabis, lower sperm production, decreased motility of sperm and increase in abnormal shapes. And a fascinating study even showed that men who use cannabis, even if their partner does not, their partner has a higher rate of miscarriage. Which I wanted to ask you, what are some of the risks of miscarriage? You mean some of the risk factors for having miscarriage? I'm somebody who had four miscarriages myself. So I say this from a place of it's a terrible thing to go through and nothing makes you doubt your own body, like getting pregnant and losing a pregnancy or not being able to continue a pregnancy. It makes you re-question and look at everything that you're doing. Yeah, it's very, it's devastating. It's devastating. So there's some things that you might have no control over that are risk factors. So there's certain genetic scenarios, you know, your chromosomes, you can inherit what's called a translocation, which predisposes to a high risk. You can have a uterine birth defect, a uterine septum is one of them. Where if you have a septum or this birth defect, uterus is fascinating. It's actually formed in two different pieces and then it fuses together and the midline portion reabsorbs. And if that midline portion fails to reabsorb the entire way, you can have a piece of a vascular tissue almost dangling inside the uterus. And women who have a uterine septum have up to an 80% chance of a pregnancy loss. So what do they do? It's, it's, if it's diagnosed, it's easily correctable. We can go to surgery and take it out and they have a normalized rate of loss. But many women don't know that they have this until we do an evaluation for repetitive pregnancy loss. But so there's genetic factors, there's uterine birth defect factors, there's clotting disorders. But a lot of the true risk factors, as we know, autoimmune disease. Meaning thyroid. Thyroid, diabetes, insulin resistance, iseliac disease, which I did not know during my own infertility journey. PCOS, a lot of these things though, increase the miscarriage rate through that same inflammatory mechanism. And we have to remember that inflammation is so nuanced when it comes to conception. Because acute inflammation, or the body's ability to heal itself, is really important in ovulation. A follicle grows an egg, it ruptures, allows the egg out and then has to reform. Inflammation is so crucial to ovulation that if you take NSAIDs or anti-inflammatory medication like Motrinolive and Apoxyn, you can actually prevent the follicle from rupturing, prevent the egg from being released. And then inflammation is also really important for implantation when a pregnancy is trying to invade. And your immune system is modified based on estrogen and progesterone. But we know that chronic inflammation is really detrimental. And especially to that side of the process where an embryo is highly sensitive. So that's going to be early embryo growth and before the placenta is fully grown in around nine weeks. And so that's when your environment does really matter. And we have to start understanding that we can't control everything. And I never sit here and say that I caused my miscarriages. But I certainly didn't know everything that I could have known. And I wasn't making choices from a place of knowledge where I could say, I know that I'm optimizing my health and having the best environment that I can for a pregnancy. Purely because I didn't know about it and we didn't talk about it. And when you treat, say, ciliac. So for those listening, ciliac is someone who cannot tolerate gluten. It creates a cascade of inflammation to say the least terrible. Once you treat that so you remove gluten and anything that would be seen as some kind of cross contaminant or antigen. Is an individual able to then overcome that milieu of miscarriage? Yes, because you have treated what the underlying cause of the inflammation was. And this is another place where we have to. Even if, sorry to interrupt, even if ciliac disease. So for example, individual with ciliac, it never goes away. So it never goes away. And there's many other chronic inflammatory disorders too. And so some of them you can, you have to treat the disease to the best you can. But even more important in some ways is to make sure that you're not adding to your inflammatory burden. Meaning I'm going to have more baseline inflammation than somebody like me who doesn't have ciliac disease. That's how my body is wired. I have an autoimmune disease. So I need to be extra cautious that I am getting enough sleep. Cautious about the food I put in my body, not just from a gluten standpoint, but from an inflammation standpoint, because I have more baseline inflammation and I'm more prone to it. And my body's more sensitive. But it's rare that you're going to be able to fully get rid of any inflammation in any one individual. So we have to understand how do we mitigate risk by lowering this, lowering our inflammatory burden as much as possible. Acknowledge is the way to do it. Yeah, acknowledge this is what we're doing. And my story is so interesting because I got diagnosed with ciliac 10 years after I have my losses. And during the time when I had pregnancy loss, I was told the very classic, just keep trying. You're just stressed. You're in residency and fellowship. And all my testing came back normal. I feel like I knew something was wrong. You get that feeling that things aren't right and a very classic female experience to feel gaslit by the providers that you're going to see. And at the same time, I was doing my fellowship research, which in reproductive endocrinology fellowship, we do a year and a half of research and a year and a half of clinical work. And most fellows do IVF research. They do the lab. It's a very controlled environment, a great project to go sit for your oral boards. And I went up to my mentor's said, I want to study natural fertility. I want answers to the questions that I have. I want to know what influences our ability to get pregnant and stay pregnant. Those are the questions my patients have. And they said, well, no fellows as a project like that. It's too hard to defend. Epidemiology is too complicated. I was very stubborn. They said, well, you'll have to get a master's in clinical research. And I said, sign me up. Right. Sign me up. I want to learn all about it. And that's when I started diving in to the world of natural fertility and fecundability and saw this common thread of inflammation so often in the literature. But in medical school, we learned about inflammation only in a disease process. Right. Oh, inflammation contributes to infertility because of endometriosis. Right. Never as this almost stand alone. What is contributing to some of our underlying body function or health optimization. Thank you to Bonchage for sponsoring this episode of the show. And if you've been following me for a while, you know that I take light exposure seriously. Why? Because it impacts your sleep, your hormones, your mood, your ability to recover and focus. It doesn't just affect you, but it also affects your kids. And that's why I use Bonchage. They've created science back tools that help balance our modern industrialized lives from harsh indoor lighting to too much screen time. Their blue light blocking glasses are a nightly ritual for me and my kids barrel mine. They help calm my nervous system, protect my circadian rhythm, especially if I just happened to look at my screen, which we all know that never happens. I also love their red light lamp. I turn them on as soon as it gets dark and I use the big panels 10 to 20 minutes each day. They are some of the best red light products I have ever used low EMF on the market. And right now Bonchage is having their holiday sale. So you can save a massive 25% off just head to bonchage.com and your 25% off code will automatically be added to your order. The sale will end on the 31st of December, 2025. So hurry and don't miss this chance to save on your favorite Bonchage products. So I did my own in a one experiment changing our whole life. The things in our kitchen, how we move, the sleep we got, the foods we ate, but what I really tell people, and I know you have this approach too, is you've got to leave space for rules and then what works for you. And learning to understand your body is probably one of the key tools that women are never really taught because we are dismissing gaslet. We don't learn how to lean into that. Something's wrong and I know it's wrong, right? Yeah. And so learning to say this causes me to feel worse. This causes inflammation in me and therefore I'm not going to be exposed to it. And when I got pregnant and stayed pregnant with my kids, I actually was avoiding gluten. Because I was really leveraging this, what makes me feel bad and what makes me feel good. And then 10 years later, got diagnosed with celiac. And now I think that if an individual is able to connect with the right provider, you can do a whole host of autoimmune. We do autoimmune panels. We're living in a different world right now, thankfully. And I will say this just on the topic of miscarriage before we move on that the guidelines have changed. You used to have three miscarriages before you would get an evaluation for recurrent pregnancy loss and now it is two. So if you are having multiple pregnancy losses and somebody dares to tell you, you must lose another pregnancy before we'll test you for anything. Go somewhere else. Yeah, that would be terrible. Yeah. What about thyroid? Yeah. Now, Hashimoto's is an autoimmune condition of a thyroid. And when we are talking about, you know, as I was thinking about this, the 12 month prep plan for getting pregnant for conceiving, we think about the biggest factors that we can move the needle on, which you had said, our sleep and mitochondrial health and obviously exercise avoiding toxins, which we're going to kind of circle back. But also addressing this inflammation, which you've really been talking about this for years. This is not, you know, we're talking about it because we're talking about it here and highlighting your book. But the reality is you have been studying and talking about it forever. And I do want to highlight that inflammation comes in many different forms. It does. Hashimoto's, which is autoimmune condition of the thyroid. I just want to touch on the impact of thyroid and fertility. I have a love affair with a thyroid. I'll just admit my bias here. I've written chapters and books about it. I've given Grand Round talks about it because I think it is. Such a prevalent disease and reproductive age women. And let's just step back for a minute for the vast majority of my patients. Infertility is the first medical problem that they have. They have only gone to the doctor for health preventive measures. They've talked maybe about birth control or contraception. This is the first moment where things are really going wrong. And I'll admit there's a big debate about do you screen for thyroid? Do you not? And I leverage what the endocrine society says and what I know in my own clinical practice is that your thyroid gland is meant to function in a state of perfect harmony. So the brain sends out a hormone called TSH, thyroid stimulating hormone. The thyroid gland sends out circulating thyroid hormones called T3 and T4. And those talk back to the brain. And one thing that I think is really important for people to understand is that we often screen thyroid disease with a very simple blood test, just TSH. Many physicians, that'll be the first thing that they check. And it's not giving you the full picture, but it's giving you a glimpse of the picture. TSH is an interpretation of your brain's ability to say, do I have enough or do I not have enough thyroid hormone? And you get this really big thyroid range for TSH. 0.5 to 4 is what most labs will say is normal. But if you're functioning at the high end of that range, meaning your brain is already feeling like it's trying to get your thyroid gland to make a little bit more thyroid hormone. And I tell you the moment you get pregnant, the moment HCG or the pregnancy hormone from the embryo starts circulating in your body, you need 30% more thyroid hormone made. Your brain is already telling me it's not going to be able to achieve that load. It doesn't have the capacity to do so. So I really view normal lab ranges are one thing and optimization of health is another. Thyroid issues can cause period problems, irregular cycles, luteal phase deficiency or low progesterone levels, miscarriages, infertility and decreased success rates with fertility outcomes. So I'm a big believer in screening the thyroid and treating the thyroid. Now, even more so than that, because the incidence of autoimmune disease is only rising in people and because Hashimoto's or autoimmune hypothyroidism is the leading cause of autoimmune disease in women, I screen my patients. Now my patients have infertility. I screen them with a thyroid panel. What I find is especially a lot of women with unexplained, all your normal tests. So your semen analysis is fine. Your uterus is normal. Your fallopian tubes are open. Come back normal and you're having a regular cycle. So you really get dismissed or put in this box of unexplained infertility. Unexplained infertility to me is just undiagnosed. It's hard to diagnose. So we're going to acknowledge the weaknesses here. You're in a unique category, but a lot of the things, almost all of the things in that category are inflammatory. So I tell my patients, Hey, this is chronic inflammation, autoimmune disease until proven otherwise. We're going to test what we can, which includes an autoimmune panel. And regardless of what it's showing us, we're going to look in the detail about how you ovulate because a lot of these women have ovulatory dysfunction, but they're still having regular cycles. They're just not optimal optimally ovulating and their luteal phases in as great. So to pause and kind of lay this out for individuals, they could still appear to be getting a regular period, which they are, but they're not releasing an egg. Is that right? Not releasing an egg or not releasing it at the optimal time or this luteal phase. So the first half of the cycle is called the follicular phase. The follicle is growing the egg. It's an estrogen dominant phase. Estrogen triggers the brain to ovulate. So the brain sends out LH or luteinizing hormone and then you'll ovulate. And that same follicle that ruptures, reforms becomes the corpus luteum that makes progesterone at the direction of the brain. So LH pulses continue to make progesterone pulses. And I think a big failure of my field is people say, Gabrielle, your period's regular. And you'll say, yes. And there's no more questions. That is it. Besides looking at, well, how long is your luteal phase? Where in the cycle are you ovulating? Are you having any spotting or abnormal bleeding in between? Are you having any pain with your periods? So very often we don't really learn how to track our cycles. We don't learn how to track our ovulation. All the apps that we have are just telling us, you know, they're using a calendar method and nothing about your actual body to determine when you're ovulating. But my nuance here with a thyroid is we'll see subtle changes in your period that if we learn to leverage that period as a vital sign, we can detect these abnormalities. And that can be something we can correct and help you get pregnant. And back to the topic of autoimmune thyroid disease or any autoimmune disease in general. Autoimmune disease means your body is attacking itself in some form or format. Right. And those are what antibodies are that we are testing. But a lot of the tests, you know, have to have your antibodies to a certain level to test positive. And there's something called the preclinical phase of autoimmune disease. And this is where things are not functioning normally, but you are an otherwise healthy person trying to make change to this and you're not sick enough to get a diagnosis yet. The earlier we can detect these changes, let's say your thyroid antibodies are a little bit elevated. They're not through the roof. This is where we really can leverage lifestyle changes as well to decrease inflammation because you now get to fall into the same camp with me, which is autoimmune disease. You're going to be more sensitive to inflammation in the last thing years. If antibodies are attacking your thyroid gland, that's a highly inflammatory process. Sometimes taking synthetic thyroid hormone can be helpful. The one that's going to give your body extra support to have extra circulating thyroid gland, because again, if you get pregnant, can the thyroid gland uptick that 30% if it's constantly being attacked? But also I see antibodies decrease when you're on thyroid hormone replacement. And the reason why is that suddenly these cells don't need to be as active to make thyroid hormone. We're kind of quieting them down because you're taking some thyroid hormone and the antibodies don't have as much to attack. So thyroid treatment with medication in addition to lifestyle changes, both are very important when it comes to thyroid management. I'm really happy to hear you say that because that has been our approach for years. Thank you to Noble for sponsoring today's episode. I travel a lot and I didn't realize how vulnerable most luggage is until someone showed me this. A ballpoint pen can pierce most luggage zippers in seconds and you can rezip it so it looks untouched. When you think about that, you think about your passport, your laptop or even medication. It's kind of unsettling. And that's one reason why I switched to Nobles all in one carry on. And if you're watching this video, I'm holding it up. It is completely wireless and locks with a latch and seals like a safe. I mean, listen, this is amazing. And Noble did not stop at security. They fixed everything that used to drive us all crazy about travel. There's a built in charging port. 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When I started, I was very interested in integrative medicine and people were coming on, coming into the practice on animal derived. You know what I'm talking about? Animal derived. Pig thyroid. Yeah. And it was making everything worse. Antibodies were going up. My patients didn't feel better regardless of what we were hearing kind of the hearsay. We took everybody off and put them on either tyrosine or some kind of synth and they responded so much better. It's definitely more controlled and more reliable. And I always acknowledge there's place for one offs, right? And we have an individualized response to medication, but just because your mom, sister, or friend really did well with this animal derived thyroid hormone replacement for the most part, it's also going to contain other things and be less reliable than a more regulated synthetic version. And that was the whole thing. Yeah. And synthetic hormones, we give synthetic a bad name, but really it's just structurally the same as your body would make. Synthetic hormones are also bioidentical hormones. Exactly. We've got to rebrand the synthetic thing. Yeah. That was a just to clarify. Synthetic hormones are still and can still be bioidentical hormones. It's a naming thing. It's actually usually tolerates them much better because it's structurally the same as the hormone that you would make. Just to be clear, are you recommending because we do that people screen for all we screen always for autoimmunity. We screen for celiacs. We screen for thyroid. You know, we typically do an autoimmune panel at least once. You know, this is against the classic recommendation. I know. For infertility, especially if you have unexplained infertility. I think that there is merit to checking for autoimmune disease, at least the ones that we can easily screen for. And you know, I know rheumatologists don't love an A and A level, but you can do a reflex if it comes back positive to so many different antibodies. But I screen all of those patients for autoimmune thyroid disease, celiac, and then do a reflex. And I, which makes me think about environmental exposures. Tell me about the impact of environmental toxins. I bet you 10 years ago, you started thinking about this, right? You know, I presented research probably 12 years ago about PFCs per fluorinated chemicals and their impact on ovarian reserve and fecundability at, you know, the American society of reproductive medicine. Before you tell me more, did people look at you like you were crazy? Oh, for sure. I had an oral presentation and it was, you know, looped in with all these other ones and people literally said, so you want me to get rid of things in my kitchen or you want me not to drink out of plastic that like I was a crazy human. Same, same. We're get some girl. Okay. Talk to me about these environmental toxins and Ocarin disruptors. You know, we actually threw out everything in our kitchen. So a couple of years ago, I was like, oh, nonstick. See you later. You did the same thing. Toodaloo Teflon, right? Yeah. Exactly. What we know. What is the evidence show and where do we think that that is going as it relates to infertility? You know, there is robust evidence that environmental toxins play a huge role in your fertility on multiple levels, right? So we have to just think about toxins are so pervasive, right? There's, there's 0% chance that you can avoid every toxin in the world. And we start focusing on this. It can feel so overwhelming that often patients want to do an ostrich approach, right? Head in the sand and I'm just going to change nothing because it feels too overwhelming. But this is where we have to start looking at how different toxins influence our health and it can be largely through endocrine disruptors by name and definition interfere with how your endocrine system functions. So if you want to be pregnant, you are pregnant. You want to influence the health of your unborn child. You want to have your ultimate egg supply and not going to menopause early. Thinking about the things that influence this hormonal system are really hugely important. We also have to think that a lot of endocrine disruptors are highly inflammatory to the gut as well, right? So they also can contribute to high levels of inflammation and insulin resistance. You get this double and what are they? If you were to say, okay, I'm going to go in your house. I'm going to throw out the Teflon. I'm going to throw out your stuff from plastic water bottles. There's a lot of different ones and that's what's so complicated, right? So we have, you know, BPA, perflornated chemicals, phthalates, and they get these big fancy names and they see very overwhelming. Here's what I tell people to start. The things that you're exposed to every single day is where you can leverage the most. So let's kind of go back to the foundation and the adding on the air you breathe, the water you drink, right? These are things that we need every single day. You can go to, you know, EPA.gov and you can look up the water quality in your own home and you can also look up what type of water filtration system is going to give you the best to filter out what is in your area. There's this nuance where people think, well, bottled water is better. And I always just want to say it's usually not. There have been studies showing it's not, especially bottled water that's packaged in plastic and we just have to think back. We know that plastics have a lot of different chemicals, even if they're labeled BPA free, they're now replaced with other plastics, which are also endocrine disruptors. And when plastic gets hot or really anything gets hot, that allows the chemical to leach into your food or your water or even more so. Think about a truck full of plastic water bottles being shipped across the country. I'm totally with you. Stored in storage building. So I always say, let's just start in our home. So do, where, how's the air where you live? Do you live in a city? So we always use air filter. Yeah, same. We always use air filtration systems. And, you know, there was data presented this year at the American Society of Reproductive Medicine looking at the California wildfires and how it changed air quality and how it changed fertility, Agansperm quality. Oh man. Right. So that's of course an extreme example, but we can take those examples and studies and leverage it back to say, well, I need to control the environment inside my house, meaning of course no smoking cigarettes or cannabis or, you know, anything that's going to damage your own air quality, but also air filtration systems, water filtration and make sure that you're using something that's going to target what's in your area. That's really good advice. Then I want to look at our kitchen, right? And so looking at our kitchen, the things that you use frequently are going to be most important. So what are you drinking out of? What are you cooking on? And what are you eating from? And so we don't want plastics. We don't want Teflon or nonstick. We really want to be careful, especially about things that are getting heated. So I'll often hear this argument. Oh, I take this for work. So it's plastic and I put it in the microwave, get something glass. I mean, bro, that was 1980s. We don't do that. I'm already out. We have balls, right? You can easily get really great, you know, glass containers. If you do need to be able to heat it up at work or some other environment that are going to keep your food safer because it's not going to be able to leech those toxins and I want to make sure that I asked this because there's lots of parents there with this removal of quote, environmental toxins. There are always companies that pop up. Yeah. And they will say this is bamboo. It's reusable bamboo. It's BPA free, stainless steel. Are those okay? Are there certain materials that we feel comfortable with that are known to not be endocrine disruptors? Yeah, I can tell you what we use for, you know, my own kids, like stainless steel and glass tend to be what we're using largely. A bamboo does appear to be safe. And I think with everything you want to be mindful about how you're using it and in what environment, right? We still have and we had them from when the kids were young, all these stainless steel plates, right? And it's still their favorite thing to grab with stainless steel bowls. It's just easy to put snacks in, easy to clean. And it's something that's going to be good. Now you have to acknowledge where you are, right? So maybe you, your kids go to daycare and maybe you can't send glass bottles and you, and you have to send something in plastic, right? You have to control the exposures you can because you can't control everything. And so if let's say that's you and you're going to send your kids milk to school and bottles, you can say, okay, well, what can we do when we're not at school so that we can make sure we're lowering that burden with all environmental chemicals, studies are looking at total body burden. And so one off exposures, we should, we should free ourselves from saying, I can't control what happens at daycare. I have to play by the rules. I have to go to work. But also, you know, you don't know unless you ask. So can I send it in a glass bottle or can you heat it in a glass bottle and transfer it? You know, maybe the answer is no, but every school is built differently. And I think it's really important to leverage what you can for your children because we grew up in a more toxic world than our parents and our kids are growing up in a more toxic world than we did. And so we have to lower that burden wherever possible. And I do think the last tenant here, so we've got kitchen or while we're on kitchen, I think a big one I see right now is process foods. They come in packaging that have a lot of endocrine disruptors in them. Meaning the plastic or the wrapper, you know, the, the sealants on different things get into the food over time, but also take out. We're living in a world where I know, I mean, I door dash food, right? We're busy, but here's the key, right? They are going to put it in plastic or styrofoam or whatever. They're a restaurant. A lot of places are not putting their food into an hormone friendly container when it's being picked up by the delivery driver to your house. Just the length of time it sits in the container. So when you get this, don't ever eat out of that to go container. Transfer it to, you know, dishes right away. Let's say you're getting food and your kids are busy and you're not eating dinner yet, put it in glass or some other container. And then, you know, store it heated on warm in the oven in that. So really modifying when you're getting the food, because that's the moment you can, right? So make the difference where you can make the difference. You can't control everything. Yeah. And that's very practical. That is practical advice. I noticed that you didn't talk about makeup or skincare. Yes. That's the next thing that, cause I don't know if I want to hear it. I just want to be happy in my abyss, but look, the things you use every day are the things of biggest potential detriment. And a lot of this does come to us through fragrance and I, I love fragrances, but we really have to acknowledge that fragrance can be a huge endocrine disruptor and through other, through smelling or getting into your skin, usually things that you're putting on your skin, like rubbing it on your skin, you know, your shampoo. And so smelling it can be problematic, but things like the laundry detergent you're using, the soap that you're using on your hands, the perfume you're spraying around the products you use every day are the ones you need to pay most attention to. So if you have a special date night perfume that you love, you're not using that one enough to go obsess over it. You're like, honey, smell it and it's going to stay in the bottle and let's go out. But I think that the things that we are doing over and over again, you know, how we're washing our clothes and then we're wearing those clothes and we're letting that, you know, get into our skin. Your skin is an organ system as well, but it is not the largest organ. Nope. That's the muscle, but it is highly absorptive one. It is. Right. And we know that. And so we want to just leverage that to our benefit. And so this is a good place where if you run out of shampoo, maybe instead of just reflexively, cause we're all creatures of habit, we just buy the same shampoo. Maybe we say, Hey, how is this one? And there are different websites that we can, you know, look at to try to determine like, is this great? Is this not great? Think dirty is one or the environmental working group and you can search different products and learn about them. And then in the fertility formula, I do have a big chart where you have some ingredients because they're big names where you can look at and you can see. Okay. This one's harmful and this one is less so so that we can make mindful change on those products that we're using every day. And I think it's, it's simple to do that and to begin to switch things over from your kitchen to improving the water quality, to improving the air quality. And then over time, those don't seem like big deals. Right. It's incremental change. And the truth is, it's the sum of all these choices that really matter. So give yourself grace. If, you know, you were somewhere and you were exposed to something or you're not ready to change that yet. Say, okay, changing my moisturizer is going to be a really big deal. So I'm not ready. I'm not ready, but I'm going to pay more attention to my kitchen right now. That feels more attainable. So make the moves where you can and work towards that incremental change. The sum of these choices can be those that are helping your body and not harming it. As we talk about fertility, we cannot have a conversation about fertility without having a conversation about sex. Correct. How much sex do we need to have? Look, this is a great question and there's a few different ways to think about it. Number one, there is no reason to have less sex if you're trying to get pregnant. Meaning if you are in a relationship and you have sex every day or multiple times a day, great, just keep on going at it. One of the biggest mistakes I see is people trying to abstain and save up with this idea. I'm going to put more sperm there at the right time, but really that's not how the male body is made and frequent ejaculation actually can be more beneficial because sperm die. They get a lot of debris and prolonged abstinence periods, meaning not ejaculating sooner than every four days, but especially more than seven really can be harmful to the ejaculate. Okay. So we have to pause. We did an episode. You know Tobias Kohler? Yes. Okay. So we had an episode with Tobias and he was talking about the penis can shrink if you don't use it. I mean, just like the vagina can contract as well. Yes. That was on my list. I don't think we're going to get to it today, but okay. Actually, now that you said that you have to explain to us what you mean. So you said that the vagina can contract. Yes. You know, your vaginal tissues and mucosa and it's highly estrogen sensitive, but also it has a lot of collagen in it and it stretches. It has great vascular blood supply, but if you're not bringing blood supply to it, if you're not using it, you're going to notice that you're going to have higher likelihood of having vaginal strictures. You're going to have atrophy of your vagina and it actually can then make intercourse more painful and this becomes a really circular process. How long does that take? It's going to be faster when we're in a state of low estrogen and a lot of us say, okay, well, that's menopause, right? So I'll worry about that in menopause. But what we forget is that sometimes we're in low estrogen states from postpartum, from prolonged breastfeeding, from the type of contraception that we are using. And we actually can see vaginal syndromes of birth control as well because the estrogen component in birth control is actually different than the estrogen that your ovaries are making and it can influence how your vagina feels, how it expands the collagen, the integrity of the vaginal tissue. But having sex can be a great way to counter that even regardless of your hormone state because it does keep that blood flow going and it stresses that vaginal tissue to a point that it's good in using that collagen. Tobias Kohler said that three months of no sex, just no erection, no sex. Shrinks the penis? Yeah, shrinks the penis, okay? It's a very specific, but... And I'm just curious, is that the same for the vagina or do we not know? You know, I don't know the answer there, but I do think that's an interesting question. Yeah, someone is going to definitely message me. But what you said before that, I mean, you dropped the bomb of vaginal stricter, so we had to go there. But men should ejaculate every seven days. Anything beyond seven days? Did I hear you right? I just wanted to make sure. Beyond four, we start to see changes in sperm perimeters and seven is definitely harmful. Meaning, if you're trying to get pregnant, first of all, if you're trying to get pregnant, sex is an important part of this, right? So more sex than merrier. There's no need to save up sperm. Sperm are meant to be created and to be ejaculated. I mean, simply if you're timing your ovulation, there's a lot of different nuance to help you get pregnant faster about trying to have sex the day you're ovulating the day before. How does someone know that? Because it's inconvenient to go to the lab to get a blood test, but there's got to be home lab testing that you recommend. There's a few different things. So the egg list for 24 hours, sperm can live for five days, so we want to get sperm before or then. What are the best ways to know that you're ovulating? These are called fertility awareness methods, and they're using your body's own physical signs and symptoms to detect ovulation. So here are my favorite three. First is cervical mucus, completely free. You don't have to spend a single dime on it. As your estrogen... Exactly what it sounds like. Yes, it is. When your estrogen rises, it changes the integrity of your cervical mucus. It is meant to protect the cervix as the opening of the uterus, so it's meant to prevent anything from getting inside the uterus except for sperm and only when you're ovulating. So peak estrogen levels, which trigger the brain to ovulate, also change the integrity of the cervical mucus, and they make it sticky, stretchy like an egg white. That's called type 4 cervical mucus. If you have intercourse with type 4 cervical mucus, you have a 32% chance of getting pregnant that month, which is much higher than on a day without type 4 cervical mucus. And that's sperm, so let's say you have sex when you have type 4 cervical mucus. That egg will last for 24 hours. So if you had sex anywhere within that span of, is it safe to say five days? Five days before the day of ovulation, so we consider the fertile window that's six day period. Gosh. But cervical mucus, I do want to say this, people kind of get a face when we talk about cervical mucus. You don't have to put any fingers inside or do anything. Man, it's going to be a lot worse once you deliver that kid. But truly, this is supposed to be an external evaluation. So just wipe with toilet paper, see what's there. I always say it's slimy, sticky, stretchy, and you know it when you have it. That's your target time. So type 4 cervical mucus is one way to know that you're ovulating. Second is going to be with ovulation predictor kits or urinary hormone measurements. OPKs are one that are just checking LH or that luteinizing hormone. Then the follicular phase is a naturally low LH time. And then when estrogen levels rise, that trigger the brain to release a surge of LH. Now then on LH will rise and fall. So we're really just trying to detect that first surge of LH. LH is released from the brain in the early morning hours. You urinate on these strips one time per day. I recommend between 10 a.m. to 2 p.m. And the day you get a positive is the day before you ovulate because you're detecting the surge. So target intercourse the day of the positive and the next day. If someone could do a blood spot test, would that be the same diagnostic as urine if they just happen to be able to get that? I'll check patients all the time right now. I live in a different world where I do an ultrasound, I check labs. You do it right then and then. Yeah, and I can see their LH is surging and I say, okay, great, you're going to ovulate tomorrow. So those urinary based systems are highly predictive of what serum is going to be. Amazing. And there are fancier ones that are checking FS, FSH, LH, estrogen progesterone. That can be really fascinating. It's definitely overkill. I don't want somebody to feel like they have to spend hundreds of dollars on a system to check all of these hormones to get pregnant. Now I'm a data nerd, so I love such things. We do too. Yeah, but you don't have to, right? So a simple urinary based LH strip only as soon as you get a positive, don't waste your money. You don't need to test anymore. You know that that's your ovulation. And then the last thing here is going to be basal body temperature. When your body makes progesterone. So after you ovulate, progesterone, as you know, completely changes your metabolism. And one thing that it does is raises your core body temperature by at least 0.4 degrees Fahrenheit. And so if we are checking and following our temperature, we can confirm when ovulation has happened. And we know now that your temperature actually drops as the follicle ruptures and then it's going to raise when progesterone is made. So if you're proactively looking, you can detect this shift. The start of my career, I used to say, do not do this. It causes more stress. I've spent hours of my own life when I was trying with a thermometer and graph paper and very difficult, but we have to acknowledge this is where technology has improved immensely because there's wearable methods that work with other apps that can detect your temperature over so many different time points that it's so sensitive and it's with an algorithm that can be much more predictive. So we've really seen a change where orenes, apple watches, whoops, natural cycles, there's so many different options now to proactively use your temperature and leverage that as an opportunity to get pregnant. Well, Dr. Natalie Crawford, I know that you've impacted so many people's fertility journey and I'm really grateful that you are able to share it with our audience and just it's just been so much fun chatting with you. Thank you. Well, thank you for having me and I feel like we could talk all day long. Yes, we could. And till next time, thank you so much. Thank you.