Is age 35 really a fertility cliff? Should everyone freeze their eggs? And why does your doctor speak in such vague terms when you ask about your chances?

In this episode, I sit down with Dr. Lucky Sekhon, a double board-certified reproductive endocrinologist in New York City and author of the bestselling book The Lucky Egg. Dr. Sekhon has spent years watching patients walk into her clinic overwhelmed by information that is not always true or grounded in science. This is what inspired her to write a book that could close the massive knowledge gap around fertility.

Dr. Sekhon gives the actual numbers most fertility doctors won't commit to and explains why doctors who speak in absolutes are a red flag.

How men have a biological clock too. Advanced paternal age can also bring on mutation risks and can affect pregnancy outcomes like preeclampsia.

We talk about how many women end up with unwanted pregnancies due to thinking they are not able to get pregnant anymore because their cycles are no longer consistent.

We also touch on vaginismus and how common it is in the South Asian community, where women often delay seeking help because of cultural stigma and family pressure. This is physical, not just psychological Dr. Sekhon will share something that confirms this is not in patients' heads.

And the shocking fact that one in four female physicians will struggle with infertility, and it's an independent risk factor beyond just delayed childbearing.

This is an episode you don't want to miss, especially if you're in the thick of making decisions around your fertility or you're a clinician in the field looking to better support your patients.

Highlights

• Egg freezing gives you a head start if you ever need IVF, not just an insurance policy.
• LGBTQ family building have more options than most people realize.
• Ovulation predictor can be helpful but aren't 100% accurate.
• Your fertility is individual you're not a statistic or an algorithm.
• How doctors can practice cultural humility.

If you're making decisions about egg freezing or navigating fertility challenges, make sure to pick Dr. Sekhon's book The Lucky Egg for the evidence-based information you need. Visit theluckyegg.com to use the egg freezing calculator and access more resources.

Make sure to subscribe to the podcast so you don't miss upcoming episodes.

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I love your book, man. This is good. Let's just wait and talk about it. Hey y'all, it's me, Dr. Smina Rahman, Gyno Girl. Welcome back to another episode of Gyno Girl Presents, Sex, Drugs and Hormones. I'm Dr. Smina Rahman. I'm your host, I'm your sexual medicine specialist and menopause expert in downtown Chicago. And today we are talking about something that sits at the center of so many conversations that surrounds confusion and anxiety and...

frankly, a lot of misunderstanding and that's fertility. And so joining me today is the amazing Dr. Lucky Sakan. She is a double board certified reproductive endocrinologist infertility specialist in New York City. She's on a mission to close the massive knowledge gap around fertility, reproductive health and evidence-based education with clear compassionate counseling. She's also the author of this bestselling book, The Lucky Egg. It's...

I will play on words there, but it's an incredibly accessible, practical guide to understanding fertility and ovulation and egg quality and IVF and all the myths around fertility. And really coming from an expert like her, this is like a next level book that we don't see that often. She wrote this book after many years of seeing patients come into your clinic with so much misinformation in the social media age, there's so much misinformation. So today we're going to really get into fertility myths and

yeah.

egg freezing and who should do it and how fertility intersects with perimenopause. We're going to talk on cultural experiences of fertility and women of color and see where else we can get into in terms of fertility journeys and today's political climate as well. Dr. Lucky, thank you so much for being on the show. Welcome.

Thank you for having me. I'm a big fan.

I'm big fan of yours as well. And he's like, oh, she's on another newscast. It's awesome. I love that you're spreading all this information. But obviously, I'm a gyno girl on Instagram. And so I love superheroes. And I love a good background story. What's your origin story? So tell us a little bit about what your origin story is in terms of choosing REI, choosing OB-GYN. How did you come up with choosing this?

Yeah

Hmm.

Yeah. Honestly, for as long as I can remember, this was the field that fascinated me the most. I stumbled upon it on a summer internship when I was an undergrad at McGill University, trying to just figure out what I wanted to do with my life. I always was very inclined towards the sciences and biology and how our bodies work, our physiology. was always so fascinated by it. And what's interesting is, is when I was doing, I mean, some of these basic science courses, I remember learning

now.

about neuroscience and the hypothalamus, the pituitary gland. And I was like, this is so fascinating. So hormones were always interesting to me. I just thought they were these cool messengers and these miracles happening inside of our bodies that most people weren't acutely aware of. And then I ended up doing a bunch of research at Cleveland Clinic with a room full of urologists. And that's where I first learned about IVF. That's where I learned about the option to freeze eggs. And this was all very,

like cutting edge and new and the success rates were nowhere near where they are today. So as I continued on to medical training, I just stayed fascinated because I was kind of staying abreast of all of the developments and updates in the field. And it just was so fascinating how it was moving so quickly and things were changing and improving for patients. I was very inspired by that. So that led me into my career in terms of

Now the double life I'm leading, which is obviously I care so much about my patients and I'm working full time as a clinician, helping people overcome infertility, diagnosing it, treating it. And also a large part of my practice is talking to young women about fertility preservation options. and helping with other forms of family building, which are traditionally not covered in the fertility guidebooks that have existed to date. So same sex family,

a couple family building, whether it be same sex female or male couples, they need help from the get go. And I have a lot of patients who are individual parents by choice, both male and female. so lots of different ways that building a family can look. And I have now become a huge advocate on social media and in the media in general. And that origin story is actually quite interesting because I had no intention as a doctor of doing these extracurricular things.

Right. I take no time, like no time at all.

It really is mission driven. No, no, but it's mission driven. And if it wasn't, if it was just a marketing tool or the means to an end to get people to read my book, it wouldn't work, right? Because it does take so much added effort and time and you really have to be passionate in order to be motivated to keep it up. And I've been doing it now for over five years. A huge push for me was COVID because I was 18 weeks pregnant.

Thank

And I recognize it was a, it was a epiphany light bulb moment for me as a physician to see how the power of social media was being used to disseminate information quickly, good information and bad information. And I was like, wow, this is a tool. This is a megaphone and I want to have a voice in this space. And so that's when I really started ramping up content creation and then used it to address all of the myths and misconceptions that are rampant in my field. And I'm so happy and I've never looked back and

information.

The book is just an extension of that passion because it's a way to in a 360 all encompassing way provide the necessary context in a way that I think is very effective to provide the health class 2.0 and fill the knowledge gap that we really need to fill.

No, and you do it so well, actually. think health information translation is a skill. It's something that some people don't do as well as others. So I think that yours is very clear, and I think people can really understand it. And so I think most of your viewers and listeners would really appreciate what you're doing. So thank you for that.

Thank you.

You know, you're talking about fertility and egg freezing. remember, because I'm older than you, but I remember being a resident, like an intern, I think. And we had, I want to say he was from Italy or something. And he was saying, we're doing all this egg freezing. And so, you know, like as a single, you know, OBGYN, you know, new intern or whatever, I remember hearing about egg freezing and how it was such a new technology, but the success rates weren't that great at that time. And so I felt at...

And I don't think many people were really accessing it. And so I never did it. And thankfully I never needed to. But tell me about what your thoughts on egg freezing are. Because obviously I have patients that come in all the time asking about egg freezing, requesting egg freezing. And I kind of navigate and tell them, you know what? You hope to never use it, but it can possibly be an insurance policy. It doesn't necessarily mean that you're going to get a live birth. But it's something.

where you can capture your younger eggs, which would potentially. Tell me, how do you counsel people? you think everyone should eggs? Who shouldn't freeze eggs?

Yeah.

Yeah, no, I think anytime you hear someone speak in absolutes, that's a red flag. So I'm not one of those fertility doctors that's like, you freeze your eggs, you freeze your eggs, right? I think the way I think about it actually is not necessarily a backup plan or insurance policy, but think of it as giving yourself a head start, if and should you ever need IVF for any reason. And of course we don't have a crystal ball and we don't have a way to predict.

Yeah.

who in their 20s is going to one day need IVF. It's a function of when are you ready to start building your family? How does the biological clock factor in? What is your future partner's sperm quality gonna be? There's all these things that are up in the air. But if you should ever need IVF for any reason, to have a larger cohort of eggs that are theoretically, most likely, healthier than what they would be five years down the road or 10 years down the road, that can be...

hugely advantageous because IVF is such a numbers game. When you think about human reproduction, it's so inefficient. Not every egg is capable of fertilizing, growing into an embryo and implanting as a healthy embryo. And that gets more difficult as we age because there's breakdowns in our eggs. And so a higher proportion of eggs would result in abnormal embryos. That's the number one driver of why in a given cycle an embryo doesn't implant, you don't get pregnant or it might implant for a bit and then stop growing. That's the number one cause of miscarriage in the first trimester. So,

If you have younger eggs to work with, their conversion rate of turning those eggs into healthy embryos is going to be higher than your older eggs. And so people who don't freeze their eggs and find themselves facing infertility have a variety of causes. if IVF, which is one of many tools in our toolkit, but it is one of the most effective, efficient treatment options, particularly if we have eggs to work with and we have good quality eggs. But even if you are facing some egg quality issues, can

turn those eggs into embryos and genetically test them and weed out the ones that wouldn't be helpful to you, right? And so it can streamline your path to pregnancy and lower your risk of miscarriage. But the rate limiting factor in success for so many people is being able to make those normal embryos. And so it's just easier with younger eggs. And you tend to have more eggs that you can get from one round of effort of taking the shots and having an egg retrieval the younger you are. So you may never need to use what you freeze. But I think for anyone who knows

with certainty, they most likely will find themselves in a situation where they're trying to build their family beyond age 35, maybe even closer to 40, or anyone who has a known gynecologic issue that compounds this, where they're like, okay, I also have an independent risk factor for maybe needing intervention from the get-go because I have PCOS and really irregular cycles. Yes, we can do things before IVF to help women with PCOS, like help them ovulate an egg each month in a regular fashion.

but it can get very old very quickly. You might do that for six months and if it's not working, you may have a sense of urgency of wanting to move past that and do something like IVF. So it's just thinking strategically and again, you may do it and not need it. And there are people that have no red flags and maybe they're in a relationship in their early 30s and thinking this is the person I'm gonna marry and I shouldn't have any problems because I'm starting at a younger age.

and they could run into fertility issues. So it's never a perfect equation that you can tell if something is gonna go wrong, but I don't think there's a major downside to doing it. There's a cost and effort associated with it, but especially if you have benefits, I'm like, it kind of takes that out of the equation and it can make sense for a lot of people.

Yeah, yeah, I know my office is very close to Google in downtown Chicago and I get a lot. I think some of them include it in their benefits. And so I have a lot of patients that come through from some of these tech companies that are including egg freezing because they don't really want to encourage pregnancy in their.

Mm-hmm. yeah. Yeah.

Yeah, whatever their motivations, I'm always like, just take the benefits.

Take the benefits exactly. So, all right. And so, and what is usually like, do you have any overall like live birth rates that you can quote in terms of, I guess it kind of depends on at what age you freeze up and all the quality and everything.

Yeah, yeah, but I talk about numbers. I think we shouldn't shy away from that. think a lot of times traditionally in my training, I remember seeing counseling conversations and just hearing about the types of conversations people would have. And it was all very tentative and vague. And even now, like people are always like, I can't find someone that will just commit to a number goal. And it's like, I think people are afraid because it's like, you don't know and we don't have that crystal ball.

But the best we can do is lean on our actual experience, our lived and shared experience. And I think for people who work maybe in large practices where they've had the opportunity to amass data like we have, like every week patients are coming back who have frozen their eggs previously and we're thawing eggs multiple times a week in multiple patients. And so now compared to 10 years ago, 15 years ago where people were always a little bit nervous when someone would come back to use their frozen eggs, cause you never knew what to expect.

We have a lot more data now and I don't have that sense of nervousness. I'm like, yeah, we don't know until we actually thaw them out and see how things play out. And sometimes things can be unexpected for sure. And there can be sharper than expected drop-off, but many people kind of fall into the standard statistics, which are 85 to 90 % of eggs typically survived the thaw. And that's thanks to newer technology that we've been using now for well over a decade or 15 years now called vitrification. And this has allowed us to have

better thought survival rate, better pregnancy rates. Not every egg that survives the thought is destined to fertilize normally. And that's true whether you ovulate an egg and you're timing when to have sex or doing this in the lab with IVF. It's like 70 to 80 % of eggs typically on average will fertilize. Obviously that number can vary from case to case. And then the biggest drop off is turning a fertilized egg into an embryo. A lot is happening during the course of that week. And that single cell egg,

goes from having two cells as a fertilized egg to 100 to 200 cells a week later. It's turning on its own genes. It's no longer got the GPS of the egg and the sperm to rely on. And so a lot of them don't make it. And maybe half drop off. And 50 to 60 % will convert. And then once they get to the embryo stage, you can genetically test them. You could also say, I'm not going to do the genetic testing. I froze these eggs in my 20s. They have a really low rate of having errors in them. I'm OK with just putting

the fastest growing one in the uterus and freezing the rest. You could also just freeze them and keep them for later. mean, some patients do that because they're still not ready to be a parent, but they now are in a committed relationship and they wanna know, hey, what do I actually have frozen? So they can turn their eggs into embryos. That way, if God forbid there's a sharper than expected drop off, strategically, they're still at a younger age than when they're ready to get pregnant.

where there's recourse and they could do another round and create embryos up front if they need more for their family building goals. So, once you get to the embryo stage, the chance of an embryo being genetically normal or not comes down to your age. So roughly, if you're in your 20s, 20 to 25 % of embryos will be abnormal, the large majority normal. If you're in your early to mid 30s, about a third of embryos will be abnormal, two thirds normal. At 37, 38, 50, 50 chance like the flip of a coin.

And at 40, 70 % or so of embryos will be abnormal, 30 % normal. So I have in my book and on my website, theluckyegg.com, kind of this inverted pyramid diagram where you can look at these numbers. And I even have an egg freezing calculator based on this equation of this downward funnel or inverted pyramid. And you can put in your age and the number of mature eggs you froze. And it will give you an estimate of what we think you might end up with. So if you're 35,

right now.

It'd be great to have 20 eggs frozen that are mature because we think of it as a 10 to one ratio of mature eggs to a live birth of a baby, given all of the attrition that I just outlined.

That's great. Yeah, I've never, you don't hear too many people give that kind of detailed statistics. I appreciate that because I do think that's what patients ask all the time. And so I'm definitely going to have them refer to your book and your website for that. Because I think it's very important for people to understand that freezing eggs doesn't always mean a live birth, but these are the ways that you can try to increase your chances of it.

Yes, exactly. And if you don't get the number you need from one round, you do have the option to do it more than once if you want to be conservative or reach a certain goal.

Mm-hmm.

Okay, great. Yeah, and I love actually in your book that you do sort of a lot of myth busting, because I do think there's a lot of myths out there about fertility. I'm imagining that's one of the reasons that drove you to write the book, because of all the negative noise that you might hear out on social media, TikTok, or whatever the case may be. What are some of the myths that frustrate you the most around fertility?

Well, I hear a lot of bad advice, just to be frank. I was talking to someone earlier today who told me she was able to get pregnant at 40. She wasn't expecting it because she had gone to see a fertility doctor and they said, this will be very difficult for you and you will not be able to conceive without treatment. And that's what I mean by speaking in absolutes. Our fertility is not a cliff that you fall off of at age 35 or at age 40.

Sure.

Even at 40, even at 45, believe it or not, there are some normal eggs that you can ovulate. Should we bank on that? Should we bank on luck? No, of course not. But I think we need to keep the door open a crack for some hope and the fact that anything can happen. And there's no single fertility test that can tell you definitively you are going to need treatment unless it's something very obvious. Like, obviously, if someone has no fallopian tubes or they're completely blocked, I know you need IVF to conceive.

Or if there's like zero sperm in the sperm sample, we have to retrieve sperm from the partner. Those are extreme examples. But I see a lot of not extreme examples in terms of the cases and the patient stories where people are told crazy things like, you know, a 28 year old with a very, very low AMH level, a low egg count, but she still has ovarian function. She's still ovulating month after month, maybe told you're going to need donor egg. And it's like, we don't know that.

Yeah.

You know, your current snapshot of how many eggs you have does not tell me definitively when you're gonna go into menopause, when you're gonna run out of eggs and run solo that you stop ovulating. Sure, if and when that happens, then I can say definitively, you're no longer ovulating and it's not gonna be possible to get pregnant unless you sporadically ovulate, which everything's on a continuum. Same with menopause, which you talk a lot about. It's not like you wake up one day and all of a sudden your ovaries cease to function. It is a very gradual process.

I

So when you talk about perimenopausal women, they still get pregnant, even if they have irregularities in their cycle, because they can randomly ovulate a healthy egg from time to time. Now, is it something I would say, bank on this and don't go talk to an expert? Of course not, because fertility is time sensitive. But that's one of the reasons I called my book, The Lucky Egg. Of course, it's a play on my name. But more than anything, it's to illustrate the very honest fact and truth.

that while science is great and we can talk about numbers all day long and stats and averages, you are not a statistic. You are not an average. You are a human being with your own individual biology. And we have so many blind spots in our field that it is ludicrous to speak in such absolutes with so much certainty and to label people. We don't even have a direct way to test someone's egg quality. So how can you tell someone you're going to have no ability to get pregnant on your own just from ovulating? If you have ovarian function, there's a chance.

100%.

Yes.

I tell my perimenopausal woman this all the time, like, is your, what are you doing for birth control? And they're like, what? And I always give examples of patients that you see, like, I clearly remember, like, I had a 49-year-old, 50-year-old patient, you know, like five kids, and didn't think that she would get pregnant again. And she did, and she had a healthy pregnancy at like, and it was like that one lucky egg that she ovulated, right? And I always tell them, like, it only takes one, it only takes one good one, so.

hahaha

Mm-hmm.

Yeah. Yes.

You never know, you know? And so I think.

Yeah, yeah. I think one of the hardest things about women's health is that everyone's always trying to fit us into a box. They're always trying to say like, you have endo, so you are going to have infertility. You know, like, there's a lot of like, overreaching. And I think we are so much more complex than that. And you really have to step back and look at the whole context of a person and leave room for possibilities.

Just don't.

Yeah. I mean, I think that's one of the issues with, you know, you know, big centers and they make algorithms and everything is going to be algorithmic care. And most people don't fall into a pure algorithm. Right. And so people are always asking, well, what's your algorithm? And I'm like, it's very nuanced. Like I can give someone a patch and a pill and I can give someone else, you know, an oral medication and they do much better, you know, so it's like nothing is absolute. And that's why we call it precision medicine. Right. Because it's really based on that person.

Absolutely.

Yeah.

Right.

And I think that's what frustrates me a little bit when it comes to, cause I've done a lot of deep dives into AI and I feel like because there's so many OBGYN counties in the South and other areas that are missing OBGYNs right now, know, look, they're sending a robotic arm to, you know, Alabama because they can't find enough OBGYNs to do ultrasounds. All this radical stuff they're trying to replace these things with.

Mm-hmm.

automated care, like you're literally going to be automating racism and automating because it's like these algorithms are based on who makes them right and it's like it's and so I

Absolutely, yeah. Representation matters so much. And I do think, you know, women's healthcare research has been chronically underfunded. And we all know we're not little men. You know, our physiology is so different. And even one woman to the next, your physiology is different. So a lab value or just saying based on your age is not gonna work.

Yes.

because your fertility, your overall health outcomes are the culmination of your genetics, timing, how your biology changes with time and your environmental exposures. And even something like when people talk about different protocols that we use and responses that some women have to medications, how well do their ovaries respond, even that is an individual data point. And two people with the exact same age and numbers,

could respond very, very differently.

Yeah, and that's, and I think that's so important for people to take that into consideration because, you know, if you're getting so much of an automated system, then, you know, you're not, you're not, you're not treating that patient, you're treating her disease process or whatever, right? Like, and so there's so much more to it. And that's why I think, you know, the language around that matters and all the things we talked about.

Mm-hmm.

Absolutely.

Well, I mean, we're talking a little bit about perimenopause already, you know, because this is where I think fertility and the menopausal movements sort of that's happening right now are really at the forefront of discussion for women's health. I do feel that, you know, the idea that, you know, these patients are coming in and they're just a lot of them requesting menopausal hormone therapy without considering whether or not, you know, they're still ovulating and the possibility of pregnancy.

And then you have those patients who are getting pregnant in their 40s. And my friend Shiva calls it the peri-postpartum, peri-postpartum perimenopause, or something. She calls it like peri-postpartum, peri-postpartum, I forget what she called it. But it's basically like postpartum. Yeah, it's like postpartum into perimenopause, know? Or it's like you go from postpartum. And I think so many of my patients that I'm seeing have like two or three-year-olds at home. And they're like, I've just never been the same. And then they're like 48. And I'm like, yeah, well, like they're in

Hahaha

It's a tongue twister.

Yeah, yeah.

perimenopause, like you just continued on in. Can we talk about what rates are for women that are in perimenopause and, you know, like pregnancy rates around that? Because I, you always hear the statistic that like over 50 % of unintended pregnancies happen in this transition. And so

Hmm. Yeah, and I believe it. I actually believe that statistic so much because I think there is, people are lulled into complacency and also they don't want to quote unquote mess with their hormones because they feel like maybe they're all over the map and they're worried about now what's going to happen if I go on the pill or I use an IUD. You know, they kind of just want to not mess with anything because they feel like everything is already all over the place.

All

And I often explain like that fear is not really based in reality. In fact, for many of my patients that I've seen kind of enter this phase, because there are a fair number of patients that have come back for baby number two or three or they froze eggs and now they're back. So I'm seeing them longitudinally. I often tell them, listen, hormones can be your friend because this might help to regulate some of this annoying irregularity in the cycle where you never know when your period is coming because

Yeah.

What a lot of people don't realize is your period is very much kind of like the fifth vital sign. And for someone who has a regular clockwork-like cycle, let's say it's every 20 days, even though we know many people have varying lengths in their cycle, it doesn't have to be exactly 28 days, right? But let's say it is. What we typically see, what I see in a lot of my patients who are coming to me to talk about fertility is they often will say to me, I have a period every 21 days now, every 24 days. So it first starts coming on

quicker and it's because your FSH levels from your brain rise and you have a tendency to recruit and ovulate an egg faster and faster and faster. And so these get these short cycles where I'm not being dramatic. You might have a period like every two and a half weeks. That is super disruptive and annoying for people. And if they're not trying to get pregnant, I'm like, why don't we just avoid this? You know, let's just prevent your ovulation because this is annoying. Now, if you're trying to get pregnant, I mean, in some ways it can be a nice benefit because now you have more

Bye.

Yeah, yeah. Right.

shots on goal. The counter to that is that a lot of times this is happening in our 40s for many women, not always, but and so you also have a concurrent increase in egg quality issues. So it's interesting because there is this statistic that early in my career, I remember being like, that's so interesting that women who are getting pregnant in perimenopause, know, as their numbers are maybe lower, their FSH level is stronger.

And it can actually lead to a higher incidence of twins because you actually are more prone to ovulating multiple eggs. But I do think that that's balanced by more of those eggs sometimes being abnormal and not always both of them actually making it to the stage where you have a pregnancy. So, it's really variable and I don't have a specific rate for you, but I will say, I think it depends on if someone's still at the stage where they're ovulating regularly or even frequently, more frequently than usual.

Right.

Because eventually, once you get to a certain stage, a later stage of perimenopause, then the cycles start to space out and they start to become very infrequent. So if you're only getting two or three periods and ovulations in a year, yeah, it's gonna be harder to get pregnant, right? So it's the confluence of how often you're ovulating and how easy it is for you to predict in time that if you're intentionally wanting to be pregnant and what is your egg quality doing, which like I said, there's no test, but we can make a guess based on your age.

All right.

you.

Right. And I think that's the problem so much with perimenopause is that the chaos of like the hormone fluctuations. I feel like that's why so many women struggle not only with their like mental health and but their physical health as well. I feel like that's why I think so many of the symptoms come up because we always say it's not just the decline in estrogen. It's like the up and down of it and that Delta from high to low from one month to another when you get those loop cycle. Yeah.

Hmm. Yes.

and how your body reacts to fluctuations changes, right? So I've had patients who have gone through the process of preparing for, let's say, an embryo transfer. That's not necessarily relying on their ovarian function. I can create a fake menstrual cycle. I can give them estrogen pills and then mimic as if they ovulated and give them progesterone. We do that in a lot of cases, right? It's called the medicated frozen embryo transfer.

Your sense of duty.

I've had patients who previously had no issues come back four or five years later, and now they're kind of at that age where maybe they are in perimenopause and they have much more side effects and symptoms associated with starting or getting off of certain medications, hormonal medications. I think that your tolerance and your flexibility, your body's flexibility to deal with the fluctuations from day to day changes.

a person who never had menstrual migraines can develop them in their 40s. And so I do see this every day in my practice.

No, it's I agree too, yeah. And it's very frustrating for people, I think. And it's frustrating for them to live through this sort of mental gymnastics of what's happening with their body and their brain. I feel like the mental health consequences of a pyramidopause are so understated, but are sometimes the first things we actually see in this transition. And actually speaking of that, I love how you address the mental health issues around fertility in this book. Like it's really so.

critical. And I don't think that enough people discuss the burden that it places on couples. When I was just talking to a patient yesterday who basically said, you know, for the five years that she was trying to get her IVF done, like they of course, they never had sex. So she was coming to me because she is in a sexless marriage. But it started at the onset of her five years of IVF that she went through to try to get her twins that she has now.

Yeah.

And so it was so interesting to think about, you know, the repercussions of even post fertility repercussions when it comes to mental health and sexual health. But I like that you address that so people can actually be aware of it and to have like a system in place, hopefully that they can kind of deal with.

Yeah, I think there's a lot of changes that happen even when you overcome infertility and you are pregnant, even if you've never had a fertility journey, I think just being pregnant, you almost feel like, this my body? There's such a change in identity, but I think with fertility, you feel like your body doesn't belong to you anymore because you're just being poked and prodded all the time. And I also think that there has to be this process of regaining trust. Like a lot of women

yeah. yeah.

Yeah.

You feel like this time.

lose trust in their own bodies and feel like their body is betraying them. And so it's hard to celebrate that and to feel like, you know, I think self-esteem takes a hit. I think different communication styles, you know, even in my own marriage, I know that my husband and I deal with stress differently. That can be a source of conflict for people because, you know, it can appear that the one partner is doing just fine and the other one is so affected, but meanwhile, both of them are in this together. And so I think...

I'm really addressing that and sharing what I have seen in treating so many, so many couples, thousands of couples and what works, what brings them together? What makes them more resilient as a unit? Because family building is a team sport. What tends to kind of drive a wedge between partners? And so I put together a whole mental health toolkit with prompts and guides that I think are ways to have healthy discussions and a reminder that your partner is going through this.

just as much as you are, even if you're the one shouldering most of the burden of the physical treatments or tests. I mean, you're in this together and it's, I think is a helpful guide for partners to know how to better show up for the person who's going through the bulk of the treatments.

Yeah, absolutely. And also just speaking of partners and how they're going through it together, some people don't address the male fertility as much. I feel like that's such an important aspect of this because women tend to blame themselves, this is my issue. And the reality is that's not the case for a large percentage of couples. So walk us through some of the myths around male fertility issues, because I think that's really important.

Yeah.

Mm-hmm.

my God, there's so many. There's so many. Yeah, and it makes sense. I totally get it. I don't fault society for this narrative that has existed for so long because we know that we don't make new eggs. We don't repair our eggs. Men are always making new sperm. So the assumption for a lot of people is like, this is just not a problem for men, right? But men and women both have a biological clock. It just ticks differently. And for men, it's not.

Right.

a standard agreed upon definition, what is advanced paternal age. But most studies say over 45 or over 50. So obviously that's different because for us changes in our egg quantity and quality tend to accelerate, not drop off a cliff, but accelerate at 35 and beyond. For them, they're still making new sperm all the time. So of course they can father children in their 60s, 70s and 80s, but should they? And if they do, they should be aware of the potential risks, right? And there are more and more

I wouldn't.

There's more and more mounting evidence that there are an accumulation of mutations that a man will accumulate throughout his lifetime as he ages, and those can be passed on to future children. Male health outcomes, chronic uncontrolled medical conditions, a sedentary lifestyle, obesity, smoking, heavy drinking, all of these things can influence the DNA in the sperm that can have an epigenetic effect on the future health of a child.

And it can also impact the way the placenta forms. And so there are certain risk factors in male behaviors and health patterns that relate to certain pregnancy outcomes, like the risk for preeclampsia, which is directly because of placental dysfunction, right? The placenta is not getting enough blood, nutrients, and oxygen to the baby. And so the mom's blood pressure goes up to try to compensate for that and get more blood flow to the baby. And that can be a really dangerous emergency that so many women experience. And so to find out

hey, this isn't just about my age and the wear and tear of my blood vessels and the factors affecting my health as a woman, but also the male health contribution cannot be understated and so should not be understated. So, I mean, it's a huge misconception because, you know, women are the ones carrying the pregnancy too. And so when we think about pregnancy complications, we're not thinking about the male health outcomes that influence that, but it's so important. And it's why I talk to every couple in my office at Syscrot's.

my desk from me about what they're doing currently and what we can be optimizing.

I think that's so important because you don't, I think when men have fertility issues, because I see couples a lot for their sexual dysfunction, because a lot of times they'll come in together. And it's just like 40 % of men, by the time they're 40, have erectile dysfunction. It's the same sort of scenario where you think a lot of the sexual issues are really.

you know, just, you the woman parts problem, but it's really, you know, a couple's issue. It's couple, and we call it couples pause, you know, like it really is something that's happening on both fronts. And we talk about shame and stigma and women all the time, but it's interesting the amount that they have as well. Like they're, and it's just so brocoded down that they don't want to talk about it at all, you know? And so.

Yeah.

Yeah.

Yeah, and I think a huge component is vascular. know that men with varicotile dysfunction can have cardiovascular risks that come along with that. It is thought to be like a cardiovascular red flag, but there's a huge component of it that's psychological too. And I think that, I feel bad for men actually. I think a lot of times it's like, I think a lot of times,

That is it.

We don't say that out loud because they have had traditionally so many advantages and a head start in so many ways. But, you know, as women are now on equal footing, I realize how advantageous it is that we are so much more open about our feelings and emotions. And you see these beautiful communities flourishing online, even in my comment sections, you know, on my corner of the Internet, on Instagram. It's like such a supportive community and an ability to be vulnerable and open.

that is culturally acceptable for women more than it is for men. I think male infertility, when a man has little to no sperm and he's looking for answers online, it's harder to find that community. Or even if you're experiencing infertility with your partner, even if you're physically not going through all the treatments, it can feel very hard to know how to show up for your partner, how to process things. And if you don't have male...

peers that you can talk to or go to about it, think that isolation can be really overwhelming.

Totally. I do think there's probably pockets of it that are starting now, but it's just we don't see it as much. And I think that we need to start kind of normalizing that discussion just like we do when we just like how men are starting to get involved in sort of what's happening with their partner and perimenopause, like trying to talk about how they're supporting the person. And because it is sort of more of an overall arching issue that affects so many people, people at work, people.

No.

Yeah.

in couples and all the things. So I feel like it's very important. You also talk a lot about sort of navigating fertility within the LGBTQ community. Can you speak a little bit to some of the issues and myths around that? think that finding a surrogate and some of these things that have to be done can be challenging, difficult.

Yeah.

discuss. So can you talk to us about that?

Yes. Yeah, so for same-sex female couples, there's a lot of options, which can be a great thing, but it can also make it overwhelming. And so I always start when I'm sitting across from, you know, two female patients who are wanting to build their family, I kind of ask them, how much have you thought about this? are you coming in kind of with an idea? Because everyone's so individual and different, and some patients will be like, we have no idea.

where it even begin. And that's when I'll talk to them about, well, we have two uteruses or uteri, and we have two sets of ovaries. And I'm looking at your ages and I'm asking like what you're comfortable, what you envision, do you want to have two children? Is it important for both of you to carry? Is it important for both of you to be involved in terms of that pregnancy coming from your egg? Do you want, if you want to both be pregnant at some point and the goal is to have two children,

Do you want to use the same sperm donor? I've had patients with different ethnicities in the couple where they're like, actually, I want to use a donor that matches my partner's and then vice versa. So there's so many decisions. And so actually in my book, in my chapter on LGBTQ family building, I have a decision tree for same-sex female couples because I think there's just so many bifurcations that you need to visualize to really understand the lay of the land.

Even finding a sperm donor, is there someone that you have in mind? Is it important to use a friend or someone who's maybe related to your partner if you're the one who's going to be contributing your egg? Or do you want to go through a bank? And there are pros and cons to either approach on both a medical, medical legal, logistical, cost-wise, all of these things. And so I'm kind of

helping everyone to think 10 steps ahead as they navigate. Sometimes people come in and they're like, I already know, like for me, I don't want to carry, but my partner wants to carry. Some people have, you know, their gender identity is not congruent with carrying a pregnancy. And so it's like their partner is going to be carrying, but maybe they're willing to go through an egg retrieval and we can do something called reciprocal or co-IVF, where we take eggs from their ovaries in an egg retrieval procedure, which takes about two weeks.

And then we take the donor sperm and the eggs and put them together, create embryos. And then the embryo is actually transferred into their partner's uterus. There was a big study that came out recently that showed equivalent outcomes, whether you're doing reciprocal or co-IVF or just autologous IVF, meaning someone using an embryo from their own eggs and then having it transferred into their body, which makes sense, but it's nice to prove that because you never know, could there be some immune factors and things like that? So lots of options for male same-sex couples.

control.

Sure.

It's more about helping them find a donor for donating eggs or using previously frozen donor eggs and then helping match them to a surrogate. Surrogacy is such a personal journey. I mean, you're trusting someone with such an important thing, a task, and it's more than a task. It's a relationship. And I've seen some beautiful relationships form, but it's certainly complicated, not without certain risks and

There's a lot of lawyers and things involved. There's a lot of moving parts. We work with agencies. We work with the reproductive rights lawyers. And we help connect the patient. There's so much logistical coordination involved in all of this. So I think that is challenging from a cost perspective, from a timeline perspective, but it can be a really beautiful thing. And I have so many same sex male couples that I've helped build families for, and it's been really wonderful.

That's amazing. Yeah, I saw that decision tree. that was really cool. I haven't seen that before. When we talk about fertility in different communities, you know, I'm thinking of women of color and how, you know,

As a whole, think the medical community doesn't always address the issues with any kind of cultural humility when it comes to, you know, we're both South Asian women, it comes to, you know, Black women who seek fertility and sometimes don't get the care they need because of just underlying systemic racism and issues that are kind of harder to overcome.

Mm-hmm.

Yeah.

What do you see in your, like, you know, and there's so much stigma in communities, right? I think most Asian communities have stigma associated with it. And, you like the aunties asking you about, you know, when you're going to get pregnant and that's I know why you changed the auntie narrative. Anyway, I think that how do you sort of address some of these issues and what do you think as women of color, like?

Mm-hmm.

Those aunties. Someone's got to stop them.

How are there times that you feel like they should seek fertility help earlier? Because we know like one in four South Asians, I think, have PCOS and some of these other statistics around the metabolic dysfunctions that are carried in these communities, likely all still related to epigenetics and some of the systemic issues that we've to endure in our generations. And so do you think that

women of color, black women, South Asian women, Latino women, Native women, are they not getting the access that they need? Are they not coming to you soon enough? Where do you see this sort of intersection of culture and fertility?

Yeah. Well, I think that there's trends that we see in certain populations, like Black women are at a much higher risk of developing fibroids, and that can be a significant source of infertility for many of them, and often under-reported, under-recognized, delayed diagnoses, not being taken seriously when complaining about pain or heavy periods, which are hallmark symptoms.

And that delayed diagnosis can lead to discovering it at a time when it's harder to treat and more damaging to the uterus if they need to be removed. And so that's one aspect. For South Asian women specifically, we see a lot more PCOS and insulin resistance. And we see higher rates of endometriosis and tendency towards diminished ovarian reserve at earlier ages, probably something that's a concurrent risk along with endometriosis, right?

But that overarching theme is delayed presentation to seek care. And that is because of the cultural stigma, I believe. I think that there is this idea or this fear of being labeled with infertility or admitting that there's a problem. I think there's a lot of, know, the culture in most South Asian households is one where

intrusive questions are kind of like just part and parcel, right? Like it's like, everything's a family affair and your in-laws asking you about your family building plans and like what's going on. And, you know, that's kind of like more normalized in our cultures. So I think even going to see a fertility doctor, that can feel like a big step because it feels like everyone in your family is going to know about it. you know, and, and, and so they're less likely to exactly. And, and so

Yeah.

Yeah.

because fertility can be so time sensitive when people delay coming to me. And also I see like a resistance and almost like inertia when it comes to, okay, now you saw me, what are we doing now? And it might be like, they'll come in and then they'll go back and like be resistant to the idea of testing or treatment. Keep trying, keep trying, and then come back like months and months later. I see that a lot in my South Asian patients. Another thing that I see is a lot of sexual dysfunction.

I see a lot more pelvic floor issues, a lot of vaginismus, and I don't know why. I mean, I'd be interested to hear your theories as to why that is. I think part of it is like, you're taught that sex is bad. You know, shouldn't explore that side of yourself. It's like our cultural upbringing, but a lot of women have difficulty then now that they are in a relationship.

with really enjoying sex. And it's like something that they actually are fearful of. And I've actually had patients who don't really have underlying infertility, it's the inability to have sex. And so I've helped them by doing things like inseminations because that is an easier thing for them to do. And I've even helped them take medication before the insemination to relax. And we've tried different techniques, but just getting them exposed to sperm reliably.

Right. No, think that's I always joke like I'm not a fertility doctor, but that's the one time I help people get pregnant is trying to overcome their unconsummated marriages and their dysfunction. And I think we do see it much more in the South Asian community. And that's one of the big issues I talked about in my book that's coming up. But also we see it in, you know, like, you know, orthodox Jewish relationships, Catholic relationships. I think it's an underlying sex shaming that people grow up with in certain religious communities.

Yeah.

Mm-hmm.

Um, and so, uh, we see it, think, uh, higher preponderance of it because I mean, if you look at the statistics, you know, in India, it's like 40 % of people that have like vaginism, it's pretty high. Um, and so, and then it's just not addressed either. Like, you know, I think people are just, I just like when the stress of fertility, um, kind of overcomes people, like they're just told to relax. that was historically the rhetoric around, you know, sexual dysfunction, like relax and have a glass of wine.

Yeah.

And so I feel like you're putting the issue on the patients that are trying to figure out what's the cause of their issue. a lot of it is pelvic floor dysfunction and that clenching and that, you know, the fear around it. And so there takes a lot of desensitization and therapy and Botox and Valium and all the things to help them overcome it. But I do think I have a lot of patients who just want to be like, the turkey baster done, you know, because like they've been trying and just like you said, like

Mm-hmm.

Yeah.

Sometimes I'll see a patient for a consult and I'm telling them, you know, got to get through PT. We got to do this Botox. We got to do all this stuff. And then they disappear for a while. And then they come back and you're like, okay, maybe I should really. So I think there is, you know, those issues that come up that we both, I think you probably know Ruhi Jelani in Chicago. She and I work together on a lot of patients and we send each other patients back and forth. I'm like, well, now she just wants to do this. So you take care of it.

Yeah. Yeah.

Yeah.

Yeah, yeah, it's a process.

But it's a process, yeah. And I think it takes a team to kind of get it done too. So I think that these are issues. I think by talking about it and educating women about it, it helps. But I think it's going to be a long time before so many different cultures overcome it because of the lack of discussion around it. So hopefully, the more we educate, the better.

And I think you probably hear this too, but I think representation does matter. And I've had several patients when I've discussed these types of issues with them, around South Asian fertility and like what the common themes tend to be. They tell me that it lands differently because they are talking to someone who looks like them and who actually understands the cultural experience, right? So there's something to be said for that. And I'm sure you help a lot of people just by being who you are and the background that you have.

Yes. Yeah.

All right.

because they feel seen and understood in a way that they otherwise wouldn't.

Right. And I think it speaks to sort of this implicit bias they experience in other offices. so patients will tell me, people are like, when people have a difficulty in OB deliveries and they can't get an exam, well, how did you get pregnant then? You accepted a penis. You can't get a baby out. Stuff that you think wouldn't happen.

Yeah.

you know, in fact, I talk about like one of the biggest things that happened to me in residency was when there was a pregnant woman who couldn't have a vaginal exam, she was South Asian. And my attending looked at me and like, what's the deal with your people? act like they've never had anything in their. I think that kind of that implicit bias exists. And so people experience it in other, places and they get told, you know, different things. And so then they don't feel comfortable even being in those offices. And so there's like, there's really a cultural humility, which is one thing that.

Hmm.

Yeah.

sort of I'm on a mission to really, you know, make people aware of because I think that among all the different races that we see, the implicit bias really impacts their delivery of care and people don't even realize they're the one.

Mm-hmm.

And I want people to know it's not in their head. Like I do egg retrievals on patients under IV sedation. They're fully asleep. And the vaginismus is still there when I insert the vaginal probe to do the retrieval. And they typically will require more sedation, you know, and to really, really truly relax their pelvic floor. So that goes to show you it's not in your head because you shouldn't be conscious of anything. You're not feeling anything.

They're exactly,

Right.

but it's kind of like your nerves learn to behave a certain way and that has to be retrained and that's the important role of pelvic floor PT and even things like talk therapy, which, you know, I think they go hand in hand, but there is a physical element to this that is not controlled by just mindset.

Mm-hmm.

Absolutely, And speaking of sort of our communities, there's also some data suggesting that doctors in general have higher rates of fertility. Do you see that and what is your thoughts? Yeah.

Yeah, absolutely. Yeah, one in four physicians, one in four female physicians will suffer with infertility. And we can't understand it because it's not just chalked up to, well, a lot of us are waiting longer because it takes long to train and maybe find the right partner in situation because they compared female physicians to other high-powered fields, other professionals like lawyers, engineers, whatnot.

Yes.

And they still found that it was an independent risk factor. So it's not clear if there's something about the culture of medicine, the deprioritization of your personal health and well-being that has something to do with this. Maybe it's the shift work, long hours. We don't know. But the physical demands of medicine might be obviously a unique risk factor that doesn't exist in other fields where you're sitting at a desk 10 hours a day or whatever.

Yeah.

I think it's interesting and it's something that we need to be talking to women about early in their medical training. And I think every residency program should have fertility benefits to offer things like egg freezing to their residents because it's a known occupational risk or hazard. And we have the data to back that up and prove it. So just like, you you see many residency programs having mental health, wellness days, things like that. It's like this should be part of that because this is

Right.

such a fundamental, important part of life. And the field of medicine is a noble pursuit, and people get into it most often for the right reasons, and they want to help other people. And so we really need to be helping each other as well as female physicians.

Yeah, listen up, whoever's listening in charge of the benefits of residence. This is really an important factor, I think. And I think that that should be something that we push for if we have any kind of union who would do this, guess, for sure. I want to be cognizant of the time, but I do want to ask you one other question around, you know, ovulation predictor kits and some AI-related things that are coming up on the market.

Yeah.

because I get asked this a lot by different patients. so do you find that, how do you counsel patients around using OPKs and the newest data that's coming out? And where do you see technology and AI meeting fertility?

Mm-hmm.

I think that we can't rely on it 100%, but I think layering it on top of being aware of the different symptoms and phases of the menstrual cycle and tracking with a calendar, whether you're using an app or just writing it in your agenda. I think layering multiple ways of cycle tracking on top of each other is going to improve accuracy. But I think if you only depend on one method or the other, that's where you might fall into certain

pitfalls where it's like, that was inaccurate. So I think using all the tools you have, but not overwhelming yourself, I don't think you need five different hormonal markers. I think really and truly you want to be understanding when are you getting an LH spike or surge. That might be confusing for some people. And if you aren't able to reliably get those readings and they're not lining up with the calendar or making sense, that's when it's time to talk to your OB-GYN and get expert help.

For people who have PCOS, you can often have difficulty with ovulation predictor kits because you might have false positives all over the place because a lot of women with PCOS, not all women, will have a tendency towards having high LH levels. And you might get these false readings that look like you're ovulating multiple times a month when you're not ovulating at all. So it might not be the best method for someone who has at baseline PCOS really irregular cycles.

and they're just not sure what's going on, it might be more helpful to get some objective cycle tracking done either with your OB-GYN or a fertility doctor in the form of blood work and or ultrasound. But it can work really well. And I think it's smart to incorporate these types of tools from the get-go so that you can really narrow your focus on trying during the most fertile window, which is really like, you know, the five days leading up to when you actually ovulate. And if you're really trying to concentrate,

your efforts to be as high yield as possible. It's that two to three day window before ovulation that you really want to focus on. So I think it is helpful. think when people are like, oh, I was trying and then I only started tracking, you know, eight months in, it's like you're potentially not timing it correctly. So being intentional if you want to be pregnant about when you're trying is very important.

Are there certain kits you like better than others or do you think the ones that just track LH tend to be?

I am not loyal to any particular brand. I think that at the beginning, if you want to splurge a little and spend more money on the type of ovulation predictor kit that first detects higher estrogen and then detects the LH surge, that can be helpful in terms of giving you the warning signal versus like a simple strip that you can buy online in bulk where it's just like one line or two lines. And if you have the two lines, then you know like your LH has surged.

That could be more confusing for someone who's never done this before. So I always say, if you're gonna spend more money on an expensive digital kit, you know, I'm just gonna throw out one brand I'm not sponsored, I promise, but like Clear Blue, for example, that's more expensive. Do you need to use it every single month if you're trying for a full year? No, and especially if you're trying to track, you know, with multiple measurements in one month, it might not be economical, but at the beginning, getting that additional data point of like, when is your estrogen level from a dominant follicle rising?

And then seeing the spike, can be very gratifying and like a sanity check of sorts.

Yeah, yeah, that's true too. And do you see any of these sort of AI related fertility? Like how is, do you see how AI might be coming into the picture when it comes to fertility in terms of assessing either quality of eggs or, you know, assessing how you're ovulating? Have you seen any new technologies in that capacity? I mean, sometimes I'll get random.

Not in that capacity in a way that I think is helpful. I think AI is helping people have more access to information, but it's not always good information. Sometimes they're made up resources, so you need to be cognizant of that. But I do think it's helping people feel little bit more in charge and informed. And at least right now at this current state in time, it's better than Googling because Googling is like all SEO and targeted ads.

Obviously that's subject to change and I think there are changes happening in the pipeline. So, you know, I think people do like it for now as this objective data gatherer for them, but I would caution against, you know, putting in your metrics and trying to get it to replace your REI or OBGYN because I've seen it get many things wrong. And I've had patients come in with, you know, things that they learned from their chat, JPT search where I'm like, no, no, no, this was actually wrong, but it can be good. A lot of the time it's just being able to discern.

fact from fiction in the cases where it gets things wrong, that's where it's tricky.

Yeah, sometimes it's like totally made up. like, what do you want to talk about? Yeah, that's crazy. Well, thank you so much, Dr. Liggett. So I do this one thing at the end. like my husband says the people that listen to me are vagilantes. So what's your vagilante verdict? What's your hot take that you want every listener to remember after this conversation?

Yeah, yeah, made up references. It's crazy.

Your biology is unique. You're an individual, you're a human being. You're not an algorithm to be fed into an ape I bought, right? And I think that it's important to advocate for yourself to make sure that you're getting individualized care. And I think anytime you hear someone speaking in absolutes, never always binning you into a category, kind of boxing you in just based on...

a number that's written on a piece of paper from a lab test done at one time, none of that is valid. And you should always be asking for more, getting second opinions, a third opinion, if you feel like you are being treated in that manner. Because our biology is beautiful and complex, and it deserves to be treated as such. Because if you take a simplistic, overly simplistic view of things and

and look at it through a black and white lens, you're often gonna miss the nuance and the things that might be very important to your individual case. So that would be my hot take and my best advice that I can offer when it comes to women's health.

Absolutely.

Absolutely, I love that. It's all about nuanced care and precision medicine. But thank you so much, Dr. Lekesikon. This is your book, The Lucky Egg. I love it. It's so beautiful. Thank you so much for being here today.

Thank you. As you can tell, it's my favorite color palette. This was a painting that was painted by one of my patients who froze eggs with me. And it really inspired my cover because her story is amazing. And all of the stories of my patients and everything I've learned from them has been infused into this book.

I love it.

Thank

Yeah, I love the little stories about each patient. good. And actually, it's really like, I think you called it a choose your own adventure, but it really is like you can just decide, you know, what do want to look up and even just look up things. You don't have to read it front to cover to back cover. But you can. But there's certain things you can just look up to. But it's a great book. I appreciate everything you do. You're wonderful. Keep doing what you're doing. Educating is so important.

Mm-hmm.

Thanks everyone for listening today. I'm Dr. Samina Rahman, Gyno Girl. Thanks for listening to Gyno Girl Presents Sex, Drugs, and Hormones. Remember, I'm here to educate so you can advocate for yourself. Please join me next week.

Thank you.