Ep. 577 “Infertility Is a Warning Sign” – The Shocking Truth About Hormones & Long-Term Health with Dr. Natalie Crawford

Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. Today I add the honor of connecting with friend and colleague, Dr. Natalie Crawford. She's a double board certified fertility doctor and author of the fertility formula. Unlike many physicians, Natalie has a whole body approach to medicine, fusing lifestyle and functional medicine with science-based facts to help people conceive and understand their bodies. And this particular conversation may be a little bit of a challenge This particular conversation may seem like it is not in 100% alignment with women in the perimenopause and menopause transition, but I really want you to listen to this with an open mind because a lot of what Natalie focuses in on really applies to all hormones. Today we spoke about fertility being a vital sign, the impact of infertility that impacts one in six women and the top reasons for why this occurs. We discussed ovarian reserve and the reality of aging, specific labs that can be helpful for determining your ovarian reserve and health, what DOR and POIR, the perimenopause fertility overlap and why our ovaries are a cranky toddler in perimenopause. The influence of the gut microbiome for not only estrogen metabolism, but also inflammation, IVF, egg freezing and modern options, the impact of lifestyle and last but not least, rapid fire questions that I know my community will know and love. This is the book that I wish I had over 20 years ago when my husband and I were going through infertility. There are so many valuable insights here and I love how Natalie synthesizes both an integrative and allopathic lens for her patients. Her book, The Fertility Formula, is a must read for not only women in midlife, but also younger women as well. Dr. Crawford, such a pleasure to be connected to you. I feel like we have so many friends in common that it just makes sense for us to connect on the podcast and get to know each other better. So welcome to Everyday Wellness. Cynthia, thank you so much for having me. I'm so excited to be here. What's interesting is I was reading your book last night. I was like, gosh, I wish I had this book 20 plus years ago because I was one of those people who assumed that my fertility and pregnancy journey was going to be easy and it wasn't. And so I think 20 plus years ago there just wasn't as much information. And I think what a gift your book is and your breath of experience to women, especially families that are facing infertility or facing indecision around pregnancies. Talk to me about how fertility is a vital sign. I think for a lot of women, they think that their fertility is something they just take for granted. And I don't know if that's just this perception of people that end up having unplanned pregnancies or just easily and readily seem to get pregnant so easily. And yet there's a whole subset of the population that doesn't find it to be that easy. And I think for me, I was shocked when my husband and I got married that it took us as long as it did to get pregnant. I'm grateful I now have two healthy boys, but I always look at it as, what a humbling process that is like as a woman when we take for granted that fertility and getting pregnant is an easy thing to do. You know, and it speaks to just how important this is, but how little we're taught about it at a time to even know what to expect. Because you and I are very similar as far as with the era when we tried to conceive, there was so much fear around that you could just get pregnant, right? Prevent, prevent. That then I realized even personally when it was time to start trying, like I was an OBGYN and there were basics about how do I track my cycle, this, that, all these questions that I didn't have the answers to and then when we had loss after loss, I started to really realize, like goodness if I'm not prepared for this, like how does a regular woman stand a chance if you start to fall into this group where it isn't just quickly, easily happening. The most startling data, and I say this as somebody who had infertility, is that your fertility as you said is a vital sign, it's a health marker. Meaning women who have infertility have a higher rate of having metabolic syndrome, cardiac disease, heart attack, stroke, cancer, even earlier death. And that is a mouthful and really scary to say out loud, but it should make us zoom out and really start thinking about fertility more holistically. And I like to say it's a lot more than just getting pregnant. It's really a representation of a good hormonal health between your body that everything's connecting appropriately, but even on a more finite level, it's representing your cellular and metabolic health. And if we view infertility, the inability to get pregnant as a symptom, as a red flag, then that could allow us to leverage learning more about our body and making changes so that we do not fall into that category where we have these later health risks, that we have an easier time getting pregnant, better outcomes with treatment, but also so that we're not the one who ends up having the stroke, the heart attack, the cancer. And there's a lot of disservice that the infertility community has done in my field specifically when it comes to the language we use. When we talk about just UIVF, nothing else matters, or when we tie fertility only to age, we start to take out the agency that an individual has to control their own health, their own cellular health, and therefore have such a big role in their own fertility and health journey. Well, and I think it's so important because I think that many people are not tying in mitochondrial health, metabolic health to this conversation, and yet we know inflammation is really at the basis for a lot of infertility issues. And as I was reading your book last night, I was like, oh my gosh, infertility impacts one in six. So for listeners that are here, I know that a lot of my community might be in perimenopause and menopause. Maybe some are done having children, but there are many women that are mid to late 30s, early 40s that are listeners to the podcast that are still wondering, do I still have an opportunity to get pregnant? And so the thought of infertility sometimes can feel daunting and scary, but I love how you kind of break it down, both looking at it from a traditional kind of allopathic lens, but also from a more integrated perspective that you're kind of alluding to, which I think ultimately probably makes the trajectory of the process a whole lot more comfortable than when I went through this 20 plus years ago where it was like, these are the diagnostics, these are the labs we do, if X, this is what we do, if not on the leading, we give you this. It was like a very kind of protocol, the regimen. Yep, very much an algorithm. And I remember feeling like overwhelmed. I used to tell my husband, everything hurt, like every little intervention. I was like, I just remember thinking like, I'm so grateful. I really like my reproductive endocrinologist, but my husband couldn't fully appreciate some of the things I was experiencing. And I think that is so much that common space. And I love that you're bringing to the forefront that women are invited to have conversations that don't feel like they need to be ashamed or feel like it needs to be secretive. You know, Cynthia, thank you for saying that. And it's so interesting because I, people will say, oh, you're fear mongering or you're blaming, which of course I don't agree with, because I think women are brilliant, resilient. They can handle anything thrown at them. But what's the scariest, most fearful thing is actually the unknown, like not knowing the road you're walking, not knowing what to expect, how do you know what's abnormal, if you don't know what's normal. And so really pulling back the curtain on this is what you should expect or this is what's happening on your body and trying to tie these pieces together because your whole body is connected. And it is so personal for me. I know you read this because I went through, you know, four pregnancy losses myself. I'm very dismissed by the medical system. And in that time period, which is well over a decade ago, I certainly got the narrative that it's just bad luck. There's nothing you can do. You should just do IVF and I couldn't do IVF yet because of my schedule and medical training. And I remember asking, well, what should I be doing to get ready then? Like, how do I, surely there's things I should do for my body to prepare for IVF. And the answer was none of it matters. And I just had a really hard time believing that, you know, especially I was a nutrition major back in college. I really felt like that wasn't the best advice. And in fellowship, we do a year and a half of research and a year and a half of clinical time. So my own pregnancy losses were happening at this time where you pick a lab project. And everybody at my fellowship did lab based work for their research, very standard because you have to publish a paper and write a thesis, defend it, and it's easier to defend a very finite project. And I still remember I was right after my fourth loss and I was like in the trenches of it. And I went into my fellowship program director's office and said, hey, I want to study fecundability. I want to study natural fertility. Why do some people get pregnant and some people do not? I want to look at ovarian reserve and the luteal phase and vitamin deficiencies and environmental chemicals. And I'm really lucky because he said, well, that's going to be really hard to defend. They're going to really come at you. You know, a lot of these people are going to have advanced degrees and research. So if you want to do that, I'll support you, but I want you to get a master's of clinical research. And I said, sign me up and sign me up. Like these are my questions. Surely they are other people's questions. And I was really fortunate to be able to dive into all these different projects. And along the way, what you said earlier, I noticed inflammation was in all of this literature. And now I love that we're talking about it so much, even though I'll admit there still are a lot of traditional medical providers who will say inflammation is a buzzword and that kills me. Because I started back then saying, gosh, these are all connected by this common pathway, right? We're looking at how these different things are impacting your ability to get pregnant or your egg count and really putting inflammation before the disease, right? As the causative factor. And at that time in medicine, as you know, we very much were thinking about inflammation coming from the disease, right? You get this disease and it causes inflammation, not this other way that inflammation can actually contribute to what you're experiencing. And that led me to be my own end of one experiment, really dive into this literature, change what we did and long story short, right? I ended up cutting out gluten and making many other changes and we got pregnant and stayed pregnant. And a decade after that, I got diagnosed with celiac disease. And I even told my doctor when I got diagnosed, I said, there's no way I have celiac. I actually went in, I'm getting way off subject, but here we go. But it's, you're here, this is exclusive, people don't know all this. I got diagnosed with celiac, which was after all these pregnancy losses I had my kids. I started having really bad peripheral neuropathy out of the blue. And obviously I used my hands, I was in my hands and my feet and that was severe enough. Finally, I get to go to a doctor. I started getting an MRI and it looked like I had degenerative changes in my bones and my spine, which my family doctor was, who is lovely, love my PCP. And she sent me down a rabbit hole to get a dexa and I had osteopenia. And she said, you're too young for this. What's going on? And luckily went down this, you know, maybe you're not absorbing well, which got me the celiac diagnosis. But just to say, it wasn't GI symptoms, right? It wasn't a very traditional, like what you might think of. My presentation was chronic inflammation, recurrent pregnancy loss, this low level of symptoms that I had just become so accustomed to, right? It's like the frog and the hot water, like the fatigue, the bloating. I just never felt 100% but kind of said, well, I'm getting older. And these are the things that happen after you have children. Instead of really going back to saying these aren't normal symptoms, especially this long or altogether and really having to get so like quote, sick to even get to the diagnosis that had been brewing for all this time. And so I just feel really passionate that we've got to change how women think about our bodies, how we can learn to listen to our own symptoms and trust that it's worth advocating for. And again, you can't, we just assume everybody else is like that and they just tolerate it better. And that's an underlying problem in women's health in general. But I am happy to admit, I will tell you that I've reversed my own osteopenia now and it can be done. But just showing, imagine how I got in that diagnosis back when I had my recurrent pregnancy losses, right? Imagine the difference my health trajectory could have had if the thing that was causing me to be in that circumstance could have been fixed. And I think just the greater narrative is sometimes it's hard to get to a diagnosis and we know that. But if we think about chronic inflammation and insulin resistance and metabolic health and mitochondrial health as kind of this big bucket, when we start to work to improve that, we're getting off that conveyor belt of like disease state and that itself is so important. Well, and you're really speaking to kind of optimizing health and I think that's an important distinction. And certainly I'm so glad that you got those answers and got that information. It's amazing to me how many women I see that are in their 40s and 50s that finally get that diagnosis of celiac. And yet they've been under nutrient absorbed for so many years that they have nutrient deficiencies, they have bone health issues. And they're like, oh my gosh, I just haven't been absorbing for years and years and years, not to mention previous autoimmune conditions can put us at risk for more as we get older. One of the things that I think is really interesting is that the whole concept of ovarian reserve and the reality of an aging biological cox. So our ovaries are the most mitochondrial dense organ in our bodies. And so many people are sometimes surprised to find that our ovaries are as old as we are. It's not like men where I think they replenish sperm every 72 hours. Let's talk about ovarian reserve because there's some testing that's available now that was not available 20 plus years ago that I'm sure you're using with your patients to get a sense of what is their ovarian reserve? What are the labs that actually matter and what do you think is overhyped for women that are trying to conceive? Okay, good question. You're right. Men actually make sperm every second of every day. They make 1500 sperm a second and the lifespan takes 72 days to then make a sperm and 18 days for that sperm to then get out the ejaculatory system. So we tend to think roughly three months. So men have this constant sperm factory where they're making it. Women are born with all the eggs that we're going to have and I like to use the analogy of imagining them inside of vault and your ovary. When we start to think about it this way, one of the most fascinating things for us is to understand that eggs come out of the vault every single month, no matter what, until the vault is empty. And when the vault is more full, more come out. And when the vault gets emptier, fewer come out. This puts in light some statistics that women may have heard at this time, meaning when you are a five month old little baby inside your mother's womb, you have the highest egg count you'll ever have at six to seven million eggs. But by the time you're born, you only have one to two million. Why such a big drop? Because when you have more, you lose more. Between there and puberty, you have your next biggest drop where you'll go from one to two million to about half a million. So these eggs come out of the vault no matter what. You're not ovulating yet and puberty is not the ovaries turning on. It's actually the brain turning on and the brain being able to send out the signals to get you to ovulate. So in your ovulatory years, one of those eggs that's outside the vault will ovulate. The rest will die. Constantly losing eggs. Ovarian reserve testing is the idea that I'm going to evaluate the eggs outside the vault. And this is going to be a representation of what is inside, which is on principle really good. We've only been able to do this test a little over 10 years, so still new. It's not perfect, but the most common and accessible test is a blood test called AMH, antimalarian hormone. AMH is made from the granulosa cells and granulosa cells surround each follicle. So I want women to think about a follicle is the house that an egg is inside. The egg is microscopic. Granulosa cells surround it. So if more eggs are inside the vault, more come out, more granulosa cells, more AMH. The opposite holds true. Important ideas here. We want to think about Ovarian reserve. The ovaries not perfect rate. If I say a 30 year old on average has 20 eggs out every month. It will not be 2020, 2020, right? There's going to be up to a 25 to 30% variation month to month. So we might have 20, 23, 16, 22. And if I checked in AMH each of those months, it would be slightly different. Add to that. AMH doesn't clear from your body super fast. So there's some cumulative effect of representing the past few months. So it's an imperfect test, but much better than we used to have. I like women to think about AMH as a category, not a point value. Because if we think about a point value, it's really easy to get obsessed and say, oh my gosh, it was 1.5 and now it's 1.1. And I'm going to do the math and in four more years, it'll be a zero. And that's not true, right? It wavers month to month, but we want to know what category we're in. So is it average? Is it above average? Is it below average? Or is it critically low? Now, importantly, this is not a test of egg quality, right? Egg quality is a little bit different and we'll come back to it. But egg quantity is this ovarian reserve testing. Everything I'm about to say is against medical recommendation by our societies, right? The American College of OBGYN recommends that you do not check AMH testing or any test of ovarian reserve in a woman who does not have infertility. So they say that you should try to get pregnant for a year, fail, then come see me, then I'll check your ovarian reserve. And I completely recommend the opposite. I don't agree with that advice. I think it's very paternalistic and doesn't represent what many women are trying to do in today's era. Yes, it's an imperfect test, but I believe women are smart enough to make decisions based off of that. And it's better than nothing because their argument is that it's not a test of infertility, meaning if I have 20 eggs outside the vault versus if you have five, if these two women are otherwise the exact same age, everything else the same, same disease state, they're both ovulating one egg, they have the same chances of getting pregnant. That's true in a bucket. However, the woman who has five eggs, why does she have five? And many of the things that cause low ovarian reserve are autoimmune disease, chronic inflammatory disease, exposures, these different factors that, yes, we'll use endometriosis as an example. Absolutely impacts fertility, makes it harder to get pregnant, and causes a low egg count. So that statement's not false, that a low AMH doesn't mean you can't get pregnant. But I view it as another one of those red flag warning signs about why is it low? So if you find out your AMH is low, one, there's an evaluation to be done. Maybe you'll get your autoimmune disease diagnosis at a younger age, because this is your first presenting symptom. Number two is if you have fewer eggs coming out of the vault every month, you will go into ovarian failure early. It is a test of ovarian lifespan. And if that is the case and you have less time to grow your family, you deserve to know that information. Third, I can only get the eggs outside the vault to grow when it comes to egg freezing to IVF. So if we think about my best, strongest treatments, you will have a harder time per cycle. Doesn't mean you can't have success, but the woman who had five eggs would have to do four cycles to get as many eggs as her friend would 20. She'd have to get five one month, then go get them once from the next month and the next. So it's not impossible, but it's a different journey and a different marathon. The reality, though, is this is data about your body. And I strongly believe that healthcare providers should not be the gatekeepers of data about somebody's body because I sit across from women who say, I'm not ready to get pregnant in zero circumstance. And then they find out they have a low AMH. And suddenly the world looks different because their world is different. And sometimes we do choose to get pregnant earlier. Sometimes we freeze eggs or embryos. Sometimes we get a diagnosis. Maybe we make lifestyle changes. We stop smoking since that's associated with a low AMH. Maybe we do nothing. But at the end of the day, that woman got to be a part of the decision, what she's going to do about data that she didn't cause, but it's real about her body so that she can have the outcome that hopefully she wants because time will make that decision for you. 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And so that she gave me, I think it was like four to six months and she said, at 34, I don't want you to wait. So we're going to refer you on to a specialist who she didn't make me wait. But I think for anyone that's listening, making a woman wait a year when she's feeling anxious, ashamed, bothered, stressed doesn't make it easier. Like delaying that contact with a specialist does not per se make it easier for her. What I think is really interesting, obviously I'm not on TikTok as much as some of my colleagues, but I find it interesting. And I have an 18 and 20 year old son. So I have two adult sons, which is still hard to wrap my head around. And they were saying to me, there's a lot of women on TikTok talking about they don't get their cycles anymore. And I had a conversation with them and I said, well, are they like middle-aged women like me? And they're like, no, they're young women. And I said, hey guys, you know, the conversation around your menstrual cycle is a vital sign and why it's so concerning. I would imagine you're seeing women that maybe they have DOR, let's define what that is, and or even POU, Supreme Mature, Avarian and sufficiency. You know, where do you kind of, if they're coming to you, obviously they're concerned about, you know, are they going to be able to have children? Do they have something that's reversible? But as an expert in this area, I'm sure you probably get even more concerned than I do when you hear that, you know, women's 27 and has not a menstrual cycle in many years and isn't on contraception that's preventing her from having a normal menstrual cycle. Absolutely. There's three main reasons why we see somebody without a cycle, contraception aside. One's going to be PCOS, one would be Hypothalamic Amenorrhea, and one would be Ovarian failure, premature Ovarian insufficiency is the name if you are under age 40 and you are out of eggs. Essentially, that's menopause, right? It's an early menopause is what's happening. So there's three different scenarios that you're falling into. Hypothalamic Amenorrhea and Ovarian failure are the most concerning because in those states your estrogen is critically low. In PCOS, part of the disease process, you do make some hormones. It's not exactly the same. It still has its own spectrum of problem. But when I explain it to people, I say these three things are all tangibly different in your ovary. PCOS, you have too many eggs, Hypothalamic Amenorrhea, the ovary is just not getting a signal to respond. And in Ovarian failure, the brain is trying, but the ovary is out of eggs, the vault is empty. We do see more women with POI and DLR than we have in the past. A lot of different hypotheses why, but certainly the world is more inflammatory. There's more toxins in the world. There's more toxic behaviors. And a lot of your Ovarian programming comes when you're a baby inside your mother's womb. And let's just like look at this generation of women whose moms were pregnant, you know, the 80s, 90s, wasn't the most environmentally friendly time just to be really nice. And so those aren't things we can go back and change, but they are factors that we need to understand because it is not good to not have a period unless you are on contraception. Right? If you're on hormonal contraception, it's a different ball game. But otherwise, your period is telling you important things about your body. And if you are in one of those low estrogen states, giving you estrogen back at high enough levels is crucial. It's interesting. I know you and I are living in this world of women's health, which we love seeing more women talking about hormone replacement and talking about estrogen and menopause hormone therapy. I've been passing on estrogen like candy for such a long time to these women with POI and hypothalamic amenorrhea because in those young years, not having estrogen changes their health dramatically. So I think the big hallmark here is it's actually not a hard diagnosis to get in those circumstances. It's easy blood work that we can do, which can reveal what is happening. But you need to be having a period. It needs to be regular and predictable and even more granular than that. Ovulation dysfunction is on a spectrum. Perfect periods. The first stage of ovulatory dysfunction is actually a short luteal phase. Then you get changes to your follicular phase and then you get into your classic irregular absent periods. But if you're going, you know, six weeks plus between cycles, that's also not normal, even if it is, quote, regular. So it's really important to start to learn like what is a normal period and not just say what I hear from young women all the time. And they sit in front of me and they say, well, I mean, who likes a period anyway? I'm fine that it doesn't come. I mean, which fair in some metric, but to understand that you're not making estrogen if you're not having a period and estrogen is so important for your health as a woman. And then also that you don't have to sort of off tinge of it. You don't have to wait for your annual exam to bring a problem up. If your periods, your regular absent, that's a visit within itself. Call your doctor. Go be seen. Same thing. You don't have to wait till you have quote, infertility, which is a time based definition to get an evaluation. That's the longest you should wait. But you can go anytime sooner and get an appointment and say, I want to have fertility testing done. I want to see how things are. And we can check your account, check a semen analysis, check your anatomy. It is your doctor should be pushing you if you're one year in and you haven't, but you should not be forced to wait that amount of time. I really think, you know, my big gold dream with the book is, yes, that we empower more women. They know more about their bodies. They optimize their health. But also we change how we approach fertility and we start to view it as something that's important enough to have earlier discussions and earlier testing and be more proactive about instead of being so reactive still. Yeah. And I think, again, as I was reading the book, I kept thinking, oh my gosh, if I had had this book, when I was going through this journey, there would have been so many more things that made sense to me, even as a clinician myself. Although at that point in my career, I was in cardiology and you can imagine we didn't, you didn't like dealing with anyone that was trying to conceive or pregnant. It just made us nervous. I think for a lot of women and certainly my generation of women, some of my friends got married in their 20s. Some got married in their 30s. Some got married in their 40s. I think there's tremendous concern that if we don't have babies by the time we're 35, that somehow we're not going to be able to get pregnant. In your experience, do you feel like women can still get pregnant on their own in perimenopause? If they are conscientious about, as you said, we're using our menstrual cycle as a report card, having a sense of whether or not it's regular, irregular. But women come to you because perimenopause can start in our mid to late 30s. And that's where I think many women kind of take for granted. Oh, I'm really healthy. I'm 42. I should be able to get pregnant and it doesn't always work that way. Okay. I have a lot to say on this one. So I'll try to be concise. The idea of your egg quality plays a role. Many women think I'll be out of eggs and that will be what stops me from getting pregnant as I get older. What makes it harder for the most part is the quality of your eggs. And this is twofold. Quality is one part genetic normalcy. It's another part cellular function, which is a lot about mitochondrial health and what we call the competency of the egg to do its job. Now, I like to think about genetics real quick because your eggs are inside your body. They're inside that vault your whole life. Let's imagine your chromosomes, which are perfectly lined up in metaphase of meiosis where chromosomes meet in the middle, held apart by proteins called the myotic spindles. They don't separate and get into what we think about as that 23x until you ovulate. So they've not been holding as long when you're 20 as compared to when you are 40. And just wear and tear of time. What we see is that inflammation normal daily life does add up. And I use the analogy of a line of kindergartners in alphabetical order. The longer I ask them to stand there, people will get out of line. Chronic inflammation does accelerate that process to double down on it because then we'll say, oh, that's like bringing puppies and kitties in the room. Suddenly everybody's getting out of line. And we also see a double hit with that chronic inflammation because we see a change in mitochondrial function. We see that the embryo is not going to function as well because the mitochondria goes from the egg to the embryo. The egg is not going to accept sperm as easy. The zone of pollucid in the shell on the outside is going to get harder and harder for sperm to penetrate. So we see many changes in the context of poor metabolic health. And if I generalize on the population, as you get older, you tend to get more metabolically unhealthy. So you suffer from tincture of time, but also inflammatory changes. But that's one that we can influence by our choices every single day. And in fact, the earlier we start to pay attention, likely the better it will be. Perimenopause, having a moment. Essentially, it is, perimenopause is diminished ovarian reserve. It is when your egg counts start to get past a certain level in your vault where we no longer can expect quite as much predictability from the old. There becomes both a level of sensitivity and stubbornness. It's like that, you know, we child getting to the toddler stage. No, I'm not going to do it. I'm not going to do it. Then it just doesn't really loud, right? That's what starts to happen inside the ovary. But the hormonal changes start to happen. The AMH gets lower. You have fewer eggs. Overy is becoming more stubborn. Before you might even really recognize it within your cycle, especially if you're not tracking your ovulation specifically. So if diminished ovarian reserve is perimenopause, in general, that's the five to 10 year period before the vault is totally empty or an ovarian failure. That can happen at a variety of ages. If the average age of menopause is 52, yes, for the most part perimenopause then will be happening in your 40s. But as I said, we see more DOR. We're seeing earlier age in certain groups of women. So we are shifting that earlier for a lot of people. The youngest girl I've diagnosed with ovarian failure was 15. I definitely have patients in their 20s who come off their contraceptive and never get a period again. Find out they were in ovarian failure. It wasn't the contraceptive that caused it, but they lost that period change that would have been the warning sign for them to be aware of it. And I have many women in their 30s who have a low egg count who are in perimenopause. And it's important for us to realize that language is really the same. If you're not out of eggs, you absolutely can still get pregnant. In fact, because of this toddler behavior of the ovary, natural 20 is actually higher in perimenopause when you get pregnant than at any other age period. Because the brain is having to send out more FSH to get an egg to respond to the ovary stubborn, not listening, more FSH. So then fine, it listens and you get two eggs growing instead of just one. So you absolutely still can get pregnant. That is important for women to know who do not want to be pregnant. One, right? That just because you're like, oh, I'm in perimenopause, I can't get pregnant now. Not true. On the other hand, if you do have a lower egg count, regardless of your age, but especially if your age is older, it is even more important that you have a very proactive plan to getting pregnant because it is possible. But understanding certain things are working against you when it comes to how long your eggs have just been in your body, the genetic normalcy of them. So controlling that inflammation piece is even more important. Learning to track your ovulation so you can time in her course key. Earlier evaluation of all these fertility factors, especially your partner having a semen analysis, there's nothing more frustrating than seeing somebody who's 40 been trying to get pregnant doing everything comes in. Her partner has no sperm because that was time that was really important and valuable to her. And now we have to figure out why he has no sperm. Is this something that we can give him medication and wait three to six months and see if sperm adagenesis resolves? Does he need procedures? And now we're just adding more time to the bucket. So as we get older, we've got to control the factors that we can even more, right? We don't want to just rely on luck. So what can we control? We can control anti-inflammatory lifestyle, which is generalized good health. We can control understanding the data about our body, right? Getting earlier testing. We can understand, you know, our own recycle if we're trying naturally the doctor we have having somebody that we trust. And if we're going down a treatment pathway because sometimes we want to accelerate things, then we want to make sure that we understand what we're doing, why we're doing it, and that we're actively playing a role instead of just hoping it works out because that game plan just doesn't make sense to something that is as important to so many people as a person. So we're just having a family. I love that proactive approach and I will never think of our ovaries in the same way again as cranky toddlers because that explains so much. I mean, how many women that I have in my practice that I've worked with that just say, perimenopause, I feel like I am not myself, some cycles and it's because you can get this, you know, the brain is screaming at the ovaries. They can sometimes get this 20 to 30% increase in estradiol. And estradiol is as wonderful as hormone as it can be when things are not as, you know, hormones are a symphony when they're not balanced the right way. We can sometimes not feel like ourselves. Now, I have to tell you as I was reading the book and I stumbled upon you talking about the gut microbiome that warmed my heart because not only were you talking about it through the lens of fertility, it was really helping women understand. There are aspects of the microbiome that when they are healthy will optimize fertility and for, you know, like my patient population, optimizes how they respond to HRT, how they respond to lifestyle measures. Talk to us about the role of the astrobalome or as a podcast host said to me last week, the astrobalomy, every time I say that word now, I really have to struggle not to say that because it made me chuckle the role of inflammation and how it can impact how the astrobalome actually is functioning. For too long, I mean, you'd feel this way too, and we'll just kind of dive into it, but for too long we've really acted like our different organisms are so disconnected from each other. And I will say one of the greatest gifts of writing the book at this time and connecting with so many people is how even if we're looking at medicine as a slightly different piece of the puzzle, right? I talked to some of you looking at osteoporosis or looking at menopause or looking at, you know, just the gut, GI docs, we're all starting to come to this similar conclusion about what these important pieces of the puzzle are and how do you mitigate inflammation in a variety of ways. And one thing that is not discussed about in the fertility picture as much. And just to say, right, fertility and perimenopause and menopause, they are all in the same spectrum, right? It's not that I need to do this one thing here and it's going to be a totally separate thing here. We're really recommending the same things. We're just presenting you the data for maybe what's important to you right now so that you can understand. Your gut is really one of your biggest and first lines of defense against the outside world that goes inside your body. And we know how important food is for nutrients. They're the building blocks for your entire day, for every single cell and everything that you do. And especially in times of wanting to get pregnant, you need to have enough nutrients to be able to have the building blocks to grow a child to make steroid hormones. That's a variant nutrient dense process. The gut has this living microbiome, right? Which has a different bacteria in it that are supposed to be in certain proportions to do different functions. And the esterblom, the idea here is that beta glucuronidase is really important in metabolizing estrogen. And if we're not metabolizing estrogen and conjugating it, we're not clearing it. It's almost like getting a false signal of how much estrogen you have and it feeds back improperly. So when I talk to patients and I say, look, your brain and ovaries do not know what's happening, right? It is like you're in two parts of the building, you have a walkie-talkie and they're talking to each other. And they communicate with hormones, right? The brain sends out some, it's waiting to hear estrogen coming back. And when we have things like chronic inflammation, it's like static interference on the radio, right? If we have excess estrogen that we're not clearing, how is the brain going to be able to interpret that estrogen is low and that it's time to grow a new egg? And so we start to understand that there's certain things that we do or body states that are interfering with our brain ovary communication. The brain's not getting a pure signal, so it's not responding appropriately. We can start to really clearly see how in smaller data points, oh, having an abnormal gut microbiome impacts my ovulation. Even if I'm still having a period, I might not be ovulating when my egg is the most mature. It might predispose me to a luteal phase issue. Oh, having an abnormal gut microbiome impacts my egg quality because I have more inflammation inside my body and the ovaries ate, right? The cells in the ovary ate a double the rate of any other cell. So that means, unfortunately, they are very sensitive to the world around you. And so when we start to view it that way, I think we can start to understand that the gut microbiome is not just doing its own little thing. The byproducts from what they're trying to do really regulate hormone signaling and cell-to-cell signaling throughout your entire body, in addition to keeping the integrity of the gut, right? That permeability, keeping the bad stuff out from getting in and helping you absorb the nutrients that you need. And the number one way that we feed our gut microbiome is through fiber. And, you know, diet is always a hot topic for anybody, I think, because it feels so personal. There's a lot about how we were raised and what we believe and the choices that we make. And there's so much poly-teching when it comes to food. But what we can't disagree on is the fact that the gut microbiome are fed by fiber. Fruits, vegetables, and plant-based protein sources, they have fiber that the gut microbiome likes and needs. I do get concerned when somebody's on a carnivore diet that they're not getting enough fiber for their gut microbiome. And we will see a hormonal impact of this and a change to their fertility. And fertility studies support that, right? For every serving of meat that we're having, when we replace meat with a plant-based protein, we see improvements in fertility outcomes. Yes, not all meat's created equal. That doesn't mean all animal meat is inherently bad. I think it's speaking to this underlying factor that feeding the gut microbiome, which are that first line of defense, really is important to what's going to happen downstream in our body. If you're in your 40s and 50s and feel like your body suddenly stopped responding the way that it used to, you're not imagining it. Bloating, waking, sleep disruptions, food sensitivities, and unpredictable energy are incredibly common in perimenopause and menopause. And here's what most people aren't told. Your gut microbiome is changing right alongside your hormones. And those changes can influence everything from how you store fat to how well you sleep to how your body processes estrogen. That's exactly why I wrote my new book, The Menopause Gut. In this book, I walk you through the science of how the microbiome, metabolism, immune system, and hormones are all connected during midlife. But most importantly, I give you practical, realistic strategies you can start using right away without extreme diets or complicated protocols. You'll learn why the same diet that worked in your 30s may not work now, how your gut influences hot flashes, mood, and weight, the truth about fiber, protein, and blood sugar in midlife, and the daily habits that help your body feel safe, stable, and resilient again. If you're tired of blaming yourself for changes that are actually biological, this book will help you understand what's really happening and what to do about it. You can pre-order The Menopause Gut wherever books are sold, and when you do, be sure to check out the special pre-order bonuses I've put together for you. Again, you can go to www.CynthiaTherlo.com. You'll click on the banner. It'll take you to multiple options for where you can order The Menopause Gut in pre-sale. If you're in perimenopause or menopause and are feeling more fatigued, dizzy, lightheaded, struggling with headaches, or noticing your workouts feel harder than they used to, electrolytes may be part of the missing piece. As estrogen declines, we lose some of the fluid regulating and vascular protective effects that hormones once provided. That means blood pressure regulation can shift, cortisol can run higher, and many women become more sensitive to dehydration, especially if you're strength training, walking more, intermittent fasting, or reducing processed foods. That's why I love Element. It is my favorite electrolyte formulation, and I've exclusively used their products for the past six years. Element contains a science-backed ratio of sodium, potassium, and magnesium without sugar, artificial ingredients, or unnecessary fillers. It supports hydration at a cellular level, helps reduce muscle cramps, improves energy, as well as recovery, and can even support better stress resilience. This is particularly helpful in midlife when we're prioritizing metabolic health and muscle preservation. I personally use Element throughout the day, and it's become a staple in my routine as well as my household. If you'd like to try it, go to drinkelement.com slash Cynthia to receive a free sample pack with any purchase. Stay hydrated, stay strong, especially in midlife. Yeah, and it's so interesting. I was interviewing a microbiome expert researcher last week, and at the very end of our conversation, we were done recording. I just looked at this paper, and it was talking about what happens in the absence of fiber if you're just doing a carnivore diet. She said, in the absence of fiber, your body will try to ferment protein. She said, you can imagine what that does to the microbiome. She was identifying that it's so, so important to find a source of fiber that you can tolerate. When patients tell me that they do not tolerate any plant-based materials at all, I'm automatically wondering what's going on in the microbiome. I had a lengthy hospitalization in 2019. I got a lot of antibiotics. It took me nine to 18 months to tolerate any fiber, but I knew my gut was decimated because of antibiotics. That made sense. It was interesting. I think it was Karen Rajan presented a paper a couple of days ago on social media, and he's just talking about one round of antibiotics. I love him. One round of antibiotics. It can alter the microbiome for up to eight years. I share this not to frighten anyone, but just to give you greater awareness of why it's so important that we're continuing to give the microbiome the constituents that it needs to be able to maintain not only gut integrity, but be able to produce these very important signaling molecules. For everyone who tells me women do not need fiber, I'm like, if you understood what's happening with the decline of hormones, you'd realize the alterations in short-chain fatty acid production starts a decline of estrogen. I kind of reinforce saying it doesn't mean that we all need the same amount of fiber. It just means we need to be conscientious about it. I think it really does make a big difference. I totally agree. Cosine completely. I think the other thing about diet specifically is that we're all a little bit different and that's okay. It makes it hard for, we'll say, the consumer on the other end hearing this different information, and especially when we're in this fertility lens where women are willing to do anything that they need to get pregnant. But we have to really learn back to the beginning to how do you listen to your body and understand how different things are impacting you and giving yourself grace as if I have these building blocks, if I have lots of fiber, if I have healthy fats, if I have the complex carbohydrates, these are the building blocks. If I'm avoiding the ultra-processed foods and the things that are only inflammatory, then hopefully I'm cultivating a life where my inflammatory burden will be lower, especially when I tack in getting enough sleep and managing stress and building muscle so that when I am exposed to certain things, I have that resilience to overcome it because the body is so beautiful and meant to have this different resilience. But when we're constantly challenged, when our inflammation is always high, when our system is always activated, then we have lost that resilience. And this is where we see the compounding effect of these little decisions and inflammatory changes that can really put us on a cycle that's hard to break. Absolutely. And if someone's listening and they're curious about the kind of modern options for either egg freezing or IUI or IVF, who are the people that should consider, in your opinion, should consider egg freezing versus IUI versus IVF. And I'm sure for listeners, there's many people that probably have had one or more of those. Talk to us about our options beyond what we've already discussed. So I think a huge misconception is people come to my office thinking, I have this biggest toolkit of all the treatments and therapeutics that we can do. And to be honest, the things that we can offer is obviously we can offer testing, we can do surgery, we can help you ovulate, we can do an IUI, which is Intruder Insemination, putting the sperm further, and we can do egg freezing and IVF, which are two parts of the same process. Egg freezing and IVF, egg freezing is just the first part of IVF, right? I'm trying to get one month's group of eggs all to grow, taking them out of the body. Freeze them as eggs for egg freezing versus fertilize with sperm and make them into embryos. Penceps will only do genetic testing, save the embryos, transfer them later. IVF is the only thing that's ever going to exceed natural fertility rates. So everything else, IUI, ovulation induction surgery, I'm trying to get you back to what you should be based on your age, so we are not, not because we have fallen off the curve. So that decision may look different at different ages. So a 30-year-old, you know, might have a monthly rate of getting pregnant around 20%. Okay, but if we get older now, we're 38, that monthly rate might be closer to 5%. So you have usually a tendency to see recommendations tringe towards more aggressive as we get older. There was a study looking at women who were 38 and older who had unexplained infertility, so all their testing came back normal. And the two treatment options that we usually present in that case is one of what I call more eggs, more sperm. Trying to get you to ovulate more than one egg, I use a bad, like, you're kicking a field goal. So if I have two field goals down in one end, and then putting, doing an IUI, putting your players further down the field, so you get to get closer, higher odds that you're going to make it. But if there's an underlying problem, we're really not treating anything here. We're just really trying to line up the shot. Whereas IVF is the other option, trying to get the eggs out, make fertilization happen to love, grow the embryos in a non-inflammatory environment. We can control more in IVF, therefore, success rates are higher. Across all ages, when we have a genetically normal embryo, we tend to see a success rate around 65% per embryo. Still not 100, right? So this other idea of, like, IVF is just going to work. We're going to wait and do IVF later. That will be fine. The big asterisk is it becomes harder to find a genetically normal embryo as we get older. Few are eggs to work with, more that are genetically abnormal. The metabolic health also plays a role in egg and sperm quality as well. So a lot of a confusing picture, and what this means is that it really should be a personalized approach. I think it's really unfortunate that so many people go in to places, and they're just told, okay, well, we just do six IUIs here, and then if you fail, you do IVF, or you kind of get on that conveyor belt. Because there's some patients who are a great candidate for that, and some who are not. In general, you know, if you're under age 35, if we know you're not ovulating, let's help you ovulate. If there are some minor issues to the sperm, let's put the sperm closer to where it needs to be. Many patients have both of those, so the combined approach can be really helpful. If you're 35 and older, we really have to have a discussion on how many kids you want. There are people who may not need IVF right this second to get pregnant, but because of their ovarian reserve or their desired family time, might choose to freeze eggs or freeze embryos because it's going to help them catch up. And I really dreamed of four kids, but I met my partner later. We can overcome that by putting some in the freezer. For egg freezing, cost-effectiveness studies, which are not everything, but they look at probability of needing the eggs versus the money you spent to use them, tend to show that if you want to have kids one day and you are not ready to start trying by 32-33, this is the optimal time to consider egg freezing because you're still in general going to get a good number, quality will be high, and there's a greater chance you're going to need to use them if you're not ready to start down that pathway, but that depends on your total family size and when you will start. I always say you don't know what you don't know. So if you're starting to be curious about it, schedule an appointment and say, I want to learn about egg freezing, you'll automatically get your ovarian reserve checked because guess what? If it's low, the recommendation is different. You might now really want to do it, right? Because you don't have that time money in your brain you thought waiting to 35 was okay, but now you know you have a low egg count and your shift has to look different. If you are having these questions, like fertility doctors are nice, we're not going to force you to do IVF, we are going to do an evaluation. The general approach should be really long consultation with history, collection of data about your body, and then a follow-up visit to go over all of it and come up with a game plan. And this is because it should be a personalized approach. Absolutely. And do you find that most insurance companies are now covering evaluation or are most of these technologies still kind of out of pocket expenses? You know, it's really going to depend on the state that you live in. There are some states that have true fertility coverage. I'm in Texas, so in Texas, most evaluations that we call testing is typically covered by standard insurance, but treatment is not. We do see a lot of tech companies coming into Austin and they do have some fertility benefits, so that's really nice. If you work at a company, you have a benefit or your daughter has one, like use it. It is quote, free money to just freeze your eggs now because you probably will be at some really cool startup that doesn't have that benefit later and like get the benefits from your employers while you have them if you want to potentially just keep the door open. And that's how I view egg freezing. Egg freezing is an opportunity. It is not a guarantee. It's not an insurance policy, but it's an investment, and it's an investment in you, your future, your potential dreams, and keeping something on the table. That time will eventually shut that door. Well, and I think it's important to have options. I think so many women, and I kind of listened to like what my community says and women share with us online. You know, some people are like, I didn't meet that right person at 30 or 35. I met them later. I have a college roommate who didn't get married until her 40s, and they did years and years and years of infertility and didn't actually ever successfully become pregnant. And she was having a conversation with me and she was like, I'm just going to be everyone's auntie. And yet by the same token, she said, I wish I had met my partner earlier because it would have probably worked out in our favor, just understanding as you stated, for a lot of women, if they're already in a state of significant ovarian decline, makes it a lot harder. And I think she and her husband were not interested in egg donations, and that was something that had been suggested. So when we're talking about actionable takeaways, there are definitely some things that you've mentioned multiple times. Obviously nutrition is really important. Talk to me about sleep quality and sleep hygiene and how that impacts both sleep and stress, and then go hand in hand. In your experience, how do women that are super stressed and not sleeping, how successful are they at conceiving and actually maintaining a pregnancy? I think the hardest thing for us is we see these different people who do all these different things and still get pregnant because there is no hard, fast line. So this person sleeps five hours and they were fine, this part, right? So we see all of that in clouds of our own judgment. Have we want to look at the science? For every hour sleep less a woman gets, she gets fewer eggs with an egotriple cycle, right? It is impacting your ovarian response and your ovarian reserve. For every hour less a sleep a man gets, he has lower testosterone and lower sperm counts. We also know that for women, sleep is when your body, I like to say, clears up inflammation, improves that insulin sensitivity, but also your gonadotropins, the hormones from your brain, are released in the early morning hours after you slept a certain amount of time. So if you're not sleeping enough, you're preventing your brain from having the ability to send out the hormones it needs to make estrogen, progesterone, and to ovulate. So let's just like zoom out and say it's not just a luxury, it's a necessity and I call it one of the foundational principles of the day. Really at minimum we should be going for about seven and a half hours of sleep. So that's something that we've got to start to prioritize one. I'll say that's the number one thing most medications are just not doing. They think it's a bonus, not a need. Stress and exercise always go hand in hand when it comes to these. For exercise specifically, what we know is that building skeletal muscle and using it is going to help decrease inflammation and it's the best option for hormonal health. It doesn't mean other exercise types are bad, but it just means this is what most women are not doing enough, that they need to do more, especially in their reproductive years. This is because your skeletal muscle has a transporter, can leverage using glucose without needing insulin, and is one of the best ways to help improve insulin resistance once it's already kind of started to form. Outside, obviously a proactive approach of what you're eating. And stress goes the same way. Chronic stress causes insulin resistance because of what happens inside the body. Your body's trying to give you extra glucose so you can run away from the bear and survive. So it breaks down glucose and puts it in your bloodstream. But many people also cope with stress by stress eating, stress drinking. That constant cortisol is so inflammatory, it just creates such a terrible cycle. Stress is a hard one. It's one that I see dismissed by my peers too much, and they just tell patients, don't stress about being stressed, which is another one of those phrases I just despise. But I do think we have to think about stress in three buckets. The first is, yeah, you should, especially if you're going through IVF or you have infertility, take off your plate which can. So for the place that you can, whether it's friends who are triggering because they're pregnant, whether it's work assignments, whether it's these obligations that you don't really have to do, take off what you can. Number two is to give your body that cortisol release at least some time every day where your body can start to trust that it won't constantly have cortisol all the time. This is different for all of us, and it can look different every day. Touching grass, going on a walk, journaling, meditating, acupuncture, yoga, they're all good. There's not one superior to the other, but you should carve it out of your day because if we just put it to the end, it probably won't happen. And the third and the one that I think is so interesting is if we leverage how our bodies were met, right? Your survival from the bear should not depend on your last meal. Understanding that your body's going to freak glucose into your bloodstream when you do get that bad email or have that bad encounter or the bad doctor's appointment. And if you know glucose is inside your bloodstream, instead of stress eating or drinking, let's go activate that skeletal muscle and do 10 quick squats in place or go for a short walk. That is going to use up that glucose and bring you back down to normal and help break that insulin-resistant cycle that we know stress can cause. I love that approach. I think it's so important. I have some rapid-fire questions just kind of to tie up the conversation today. What is the most underrated fertility factor? Well, I think one of them I'm going to say is going to be men's health in general. Too often women take all the blame, but it's 50-50 women and men. And because sperm are made as we started the conversation every single second, they are much more influenced by the world around them. And men can make a huge change in their sperm count and quality by their lifestyle changes. Most overhyped test. Oh gosh, that's the Dutch test, I will say. Largely because it's interpreted incorrectly and it's not always done at the right time. But women often do sometimes feel like they can just have one test of all their hormones at one time. But hormones are dynamic. They have to be interpreted in light of each other. And somebody has to interpret it who knows what they're doing. And serum hormones are not that expensive. I do love living in the world of, maybe you can order your own hormones at labs now, right? So you do have more access. I feel like there was a time period where that wasn't the case. There was a lot more gatekeeping. It's interesting, I have a group program and they asked me about the Dutch today and I said, anyone that is ordering the Dutch and is not interpreted more than 100 should not be interpreted. But that's what's happening. And so it's not universally bad, but it is overhyped and overdone by people who don't understand it and then recommend the wrong thing. Yeah, absolutely. One thing women in their 40s misunderstand about fertility. I would say that they can just do IVF and that it will always work for them and not understanding that even with IVF, we can only work with the exasperm work given. And so playing that active role and controlling what you can is so important. Thoughts on birth control, masking, perimenopause. It does, right? It masks any hormonal state, whether that is PCOS or ovulatory dysfunction, low ovary reserve, perimenopause. That doesn't mean it's inherently bad, but you should know that's what's happening. If you're on a birth control, you're really happy on it. You might say, okay, this is not going to allow me to see those little early signs that perimenopause is happening, but I'm good right now. So I think the bigger part of the discussion where we've missed is educating women what's happening when they're on birth control. This even goes when they're younger, right? They get put on birth control for a medical problem. Maybe it is PCOS. They're never told that. Then when they stop and they have all the classic symptoms of PCOS, they might think it's the pills fault and they missed all of those years of learning about PCOS, how to manage it, what they could be doing about their metabolic health that the pill wasn't touching that entire time. So it will and can mask the symptoms of perimenopause to a degree. You'll get to a point, the estrogen in the pill is not the same type of estrogen that the ovaries make. So there will reach a critical threshold where you'll still start to say, I don't feel like myself. Believe yourself and listen to it and get help. I love that. Best first step for a woman concerned about declining fertility. Get an AMH test. Biggest mistake you see high achieving women make. Oh, blaming themselves and having fear or shame along the process and letting that delay them and getting help. The idea that getting fertility testing is an acknowledgement of failure instead of looking at it as simply as data about your body. I love that. And last but not least, if you could give every woman one piece of advice about her hormones and fertility, what would it be? Your hormones and your fertility is influenced by the world around you. So you deserve having your health in the best shape possible. Having healthy hormones is a piece of that puzzle regardless if you want to be pregnant one day, not now. If you're in the midst of trying or even if you're in perimenopause and beyond. But in today's world, nobody's going to tell you all this information. You're going to have to learn it for yourself and advocate for you. Well, I so enjoyed this conversation. Please let listeners know how to get access to your new book, which will be out very soon. How to learn more about your work or work with you directly if they themselves are in need of infertility support. Thank you, Cynthia. The book is the fertility formula and it is available everywhere that you buy books. The fertility formula is just years of work and I've divided into three different parts, kind of everything I want you to know about your body, how to really leverage your body and understand it and ask for tests and navigate trying to get pregnant. And then all of this lifestyle optimization and really looking through the lens of hormonal health. And then I'm online at Natalie Crawford MD and I practice in Austin, Texas at Fora Fertility. Awesome. Thank you again. Thank you so much.