WEBVTT
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Hi everyone, we are Rena and Dara, and welcome to Fertility Ford.
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We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City.
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Our Fertility Ford podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
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Okay, we are so excited to welcome to Fertility Forward today, Dr.
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Carrie Dickin, who is one of our REIs at RMA of New York, Long Island.
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And on today's episode, we are going to be addressing the very hot topic of trying to conceive after 35.
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What you need to know.
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I feel like 35 needs to be followed by the law and order music because that's what people think about when they start to think about age, you know, this kind of doom.
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That is so true because so many women and patients that I see feel like at 35, some like magical switch is going to go off in their body, and all of a sudden, like it's impossible to get pregnant, or they're so high risk, or you know, things are drastically different than they were a month or two ago when they were still 34.
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And that's just not the case.
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I mean, certainly we begin to worry more as women get older, but everything is kind of a process and it's still gradual and it's not an instantaneous change at 35.
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I think part of my thing is I would think that around 35, isn't that typically when you're considered of advanced maternal age?
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Yes.
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But what's interesting, so there are a couple of reasons why 35 is this like cutoff age.
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One of them is kind of like like the history of it, and it's kind of outdated with how technology has changed.
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But historically, the risk of having an amniocentesis and complication from it, like miscarriage from amniocentesis, at age 35, the risk of a loss equals the risk of having a finding of Down syndrome, right?
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So that's kind of historically where that number came from.
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But then also with all of our data of how female reproduction changes with aging, more of the rapid changes tend to begin after 35.
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But there actually is a bigger decline, and I guess we'll get more into the topic of egg quantity and quality, but there's more of a rapid change from 37 to 39.
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But we just start to see more changes after 35.
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So there are a couple of reasons why 35 is this magical number.
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And I do also want to ask, we're not going to focus on this, but I mean, there's also a fertility age for men as well.
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I think there's this, you know, sort of misconception that men are totally fine until whatever age.
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And that's not the case.
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That is not the case.
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That's true, but the age is typically closer to 50 when we start worrying about age impact on sperm, whereas it's certainly much earlier in women.
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Sure.
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But there still is an age for the floor.
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Yes, age affects eggs and sperm.
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That is absolutely true.
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It's not all about the women.
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Yes.
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So I think it's just important to also have that in here.
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Yeah, yeah.
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Well, so I guess, okay, so back to women and age.
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Can you tell us so some of those changes that you're referencing that happen around 35?
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What are some of those changes specifically?
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So I think one thing that's really important for everybody to know is that men and women are so different when it comes to fertility because men make new sperm their entire life.
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Like every 70 days, they make new sperm.
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Women, as little girls, when we're born, we are born with our eggs.
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We never make any new eggs and we are constantly losing them.
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Even if you're like on a birth control pill for, you know, your 20s and you're not ovulating, you're still losing eggs.
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And so there is a constant, gradual decline in egg quantity with aging.
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And there is also a decline in quality of eggs.
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But the more rapid changes with both quantity and quality tend to be seen from 35 and beyond, right?
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So if you were to look at the changes in a woman's ovaries from age 25 to 35, very minimal changes.
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Things are still gradually declining, but the slope of that decline is not very steep.
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And that picks up after 35.
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So you're saying that both the quality and the quantity kind of intersect at that point where it's well, they are both always declining, but the rate at which the decline happens picks up after 35 for both the quantity and the quality.
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And so it's like this double whammy for women, right?
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Because quantity is important, but it's really important more so with like fertility treatment, right?
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Because if you're trying to conceive naturally, most women ovulate one egg every cycle.
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So whether you have a diminished reserve or not may not be that important if you're getting pregnant or trying to get pregnant naturally.
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But if you want to use fertility treatment, which really requires there to be other eggs to respond to the medication, quantity is very important.
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Quality is always gonna be the most important, right?
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If I get in a like an IVF cycle, if I get 20 eggs and I have those from a 30-year-old versus a 40-year-old, right?
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There's some women in 40 that can do that.
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I know that the percentage of eggs from that 40-year-old that are actually gonna create healthy embryos is so significantly less than that 30-year-old.
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Well, here's where I find such a disconnect in healthcare, because I would love Dr.
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Dickin to hear your ideas on my theory.
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Um as women, right, I think it just feels like just another thing we have to think about, right?
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I feel, you know, in an ideal world, right, that we, you know, we grow up.
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I mean, number one, that this is taught to us in school, right?
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Not just about how to not get pregnant, but how to preserve our fertility and to start to think about these things in terms of age and how we might use medical means necessary or available to us to preserve our fertility, which is egg freezing right now, but that it becomes a comprehensive care, right?
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So you're having these conversations with your OB, that it doesn't feel like another thing on your to-do list of, okay, you know, I turned 30 and let me just start checking my fertility, see how everything is, and then by the time I'm 35, freeze eggs if that's where I'm at in my life.
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Right, right.
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I think the decision of when to preserve fertility, it's a bit of a balancing act because the younger you are when you freeze your eggs, obviously the more likely those eggs are to be healthy and to be successful for you in the future.
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But the younger you are, I guess the lower the chance you may need them, right?
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When you're ready to start your family, you still may be very capable of getting pregnant.
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So it's a balancing act, especially because it can be such an expensive treatment.
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Thankfully, some insurance is starting to cover it, but a lot don't.
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So it's a real balancing act.
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But yeah, I agree with you.
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It's like one more thing on a woman's plate to think about, but at the end of the day, it's biology and we can't change it, and we can only use the technology that we have to try to help women to have these younger eggs to use in the future should they need them.
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But I feel like it should be another sort of quote unquote required checkup, right?
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Like, okay, a mammogram, right?
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That's on your checklist now at 40.
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That, okay, when I'm 40, that's what I need to do, right?
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That's what the recommendation is.
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Okay, you know, my doctor's gonna tell me to do it, I'm gonna do it.
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But at age 30, that, okay, checkup with an REI.
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I go, I just get checked.
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Is everything tracking?
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Okay, great.
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Then I go back the next year.
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Then, okay, if something's off, right, I'd have that information ahead of time instead of what we see all too often, right?
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Is patients that come in, they had no idea any of this.
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And then it's we're not in a situation where we're ahead of it.
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We saw that things were declining, we preserved fertility, right?
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That it's just not, that's not where the language and the care is yet.
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I I hear what you're saying, and I want to say I agree a hundred percent, but I think it's important that you fully understand what testing we are actually able to do before a woman tries to get pregnant.
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Because every test I can do objectively, sonogram, blood work, and we can talk about all of those things, does not tell me if a woman is going to have an easy or difficult time getting pregnant.
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We do not know that until somebody actually starts trying.
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So let's say, you know, everybody gets fixated on an AMH level.
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And what does AMH really mean?
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So AMH, just you know, for logistics, is anti-mularian hormone.
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It is a hormone that is made from the super early eggs in the ovaries that we are not able to see, right?
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So the more eggs a woman has, the more of this hormone will be found in her blood.
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So when we check this level, it is an excellent marker of egg quantity.
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Okay.
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So everybody feels really great when it comes back high and they think, oh, great, I don't have to worry about anything, but that's not necessarily the case because that doesn't tell me anything about the quality of the eggs.
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So can I say that I am reassured that a 30-year-old has a good AMH level?
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Well, yeah, because she's 30, I feel pretty good about that.
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But if somebody comes to me, let's say at 37 and says, listen, I'm about to get married, I'm not ready to have kids now, I want to check my AMH and just make sure I'm okay to wait a year or two, even if her AMH level is good, maybe even better than expected for age, her age is still predicting how easy or difficult it's going to be for her to get pregnant, not her AMH level.
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So it's very difficult, right?
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Mammogram is going to screen for breast cancer.
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AMH level does not predict fertility.
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It only tells us about egg quantity.
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But even having that discussion with your OBGYN, I don't know, if 25, 30, having a discussion of whether it may be useful to freeze eggs.
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Oh, absolutely.
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Yes, a hundred percent.
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And to go back to what we were saying earlier about not just learning when we're young in school how to prevent pregnancy.
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We should really learn female reproduction.
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How likely is it that you get pregnant each month that you're trying?
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How does that change as you're trying maybe in your late 20s and early 30s versus your late 30s and your early 40s?
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And what things can be done to stop the clock on some eggs if and when you feel like it's the right time to do that?
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I think education is so important, but I think that so many women get nervous.
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I even think a lot of gynecologists get nervous by the AMH level.
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What if it comes back low?
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I always tell this story to my patients when they get sent in to me with a low AMH level.
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I had a patient young, she must have been in her late 20s, had just had a baby, was not interested in having another child anytime soon.
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I don't remember why, but her doctor, her gynecologist checked an AMH level and it came back very low, like in a range I would have expected for a 40-year-old.
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And he told her right away if you want to ever have another child, you better do it now.
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Your AMH is too low.
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Again, she didn't want the child or a second child at that time, removed her IUD.
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The woman was pregnant within two months, right?
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So her age was much more important than her AMH level.
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And so again, AMH is important.
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I'm not saying it's not, it absolutely is, but it's not the end all.
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And there are so many other factors.
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And I do think it's important that women have information.
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And if they want to check their AMH levels at a younger age just to see that it's age appropriate, I think that's smart.
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If it comes back low, maybe that does prompt an earlier conversation of maybe you should preserve your fertility now because that AMH level may be the same in a few years, but it may not be, and we can't predict that.
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Right.
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So the information is important, but it has to be explained properly.
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Of course.
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Well, and I'm so glad that you really did a comprehensive explanation of AMH because I think, you know, similar to what you see, that is such a fear-inducing number for women.
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And they, you know, if it's low, then they automatically think, nope.
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But I think it's it's exactly what you said.
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And I know, Dara, you and I have talked about this before.
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It's, you know, it's knowledge is power, and that if you go right at age, you know, anywhere, let's say 25 to 30, right?
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And it's like, oh, huh, my AMH should be X, right?
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But it's super low.
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Then you have that knowledge that if you do want to try to freeze eggs, right, or you at least know, like, okay, this is something just to kind of file away.
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Um of course we don't have a crystal ball, and there are so many other things that go into getting and staying pregnant, but it's to be able to use what we do have available to us, right, to put us in the best position to at least have an understanding or be able to be informed.
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Yeah, no, a hundred percent.
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Knowledge is power, agree, a hundred percent.
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And I think it's great that women check these levels at an earlier age, but I want to make sure they're fully aware of what it truly means.
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Well, maybe can you go into for our listeners sort of the difference between freezing eggs and freezing embryos?
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And that's different.
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So freezing what a woman would go through, the actual treatment process to get eggs to grow, to extract them, is the same whether the decision is to freeze eggs or to freeze embryos.
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The difference is when we fertilize the eggs.
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And so with an egg freezing treatment process, women use injectable medications to stimulate egg growth.
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It takes, you know, I would say 10 to 12 days of medication, and then we do a procedure to extract the eggs that have grown from the ovaries.
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Okay.
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So that is actually done with either egg or embryo freezing.
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When the eggs are extracted, if the plan is to freeze eggs, the eggs get assessed in the laboratory to see which are ready to fertilize, but instead of fertilizing them, they are frozen, right?
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So we're stopping the clock essentially on the IVF process.
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We're not fertilizing them right then.
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We are freezing those eggs so that in the future we can continue the IVF process.
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So I think that's important for people to know if they're going to freeze their eggs and they need to use them in the future, you're not thawing eggs and putting them back in your body and like having sex to get pregnant.
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You are thawing those eggs to complete IVF or in vitro fertilization.
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IVF is how you would create embryos to either use or freeze.
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So if you wanted to freeze embryos, what that means is the same medication and egg retrieval, but when those eggs are in the laboratory after the retrieval, they are fertilized immediately rather than frozen.
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So by fertilizing an egg, you create an embryo.
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The embryo then develops to a stage we call blastasis, which is what an embryo needs to form before it can implant in the uterus, but we're then stopping the process, right?
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So we're not allowing that embryo to create a pregnancy, we're freezing that embryo so that it can be used at a future date.
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And the difference between the two, I mean, how I explain this to patients that I see who want to preserve fertility, is it really depends on a couple of factors.
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Number one, and probably most important, is do you have a partner or do you have a sperm source that you want to use right now?
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So for example, if I had a single female patient who in the future would like a male partner and would like to have children with that male partner, it would be better for her to freeze her eggs because if she needs to use those eggs in the future with that partner, she can thaw the eggs and fertilize them with his sperm.
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If I have a couple that comes in, maybe they just got married, but they don't want to start a family yet, but they know they want two or three kids, and maybe they're gonna start at 35 or 36.
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Well, it makes a lot more sense for them to create the embryos, right?
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They know they want to have children together.
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They're gonna create the embryos and keep those frozen until they're ready to start a family.
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In a slightly different scenario, let's say you had a same-sex female couple that knows they're gonna use donor sperm, right?
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They don't want to have kids now, and maybe they're young enough that egg freezing is a great option, but they know they're using donor sperm.
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In general, you know, if you have a single frozen egg and a single frozen embryo, that embryo is way more likely to result in pregnancy and you can feel more confident having embryos frozen.
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You don't need as many embryos frozen to feel confident that you could get pregnant compared to eggs.
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And so they may want to consider creating embryos with donor sperm at that time rather than freezing eggs.
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Does that make sense?
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I know that's a lot of information at once.
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I think that's so clear, and which is wild.
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I don't think we've ever had an explanation like that for our listeners of really breaking it down.
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Just to clarify, you know, you mentioned that if you're able to get an embryo frozen, it's much more beneficial than getting the egg.
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Can you go into more detail of why the potential of the egg puts someone at higher risk of not having a successful pregnancy in the end?
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Yes.
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So in general, and I'm sure you've heard this before, human reproduction is not very efficient, meaning one egg does not mean one baby down the line.
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It typically we need many eggs.
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And for young women, right, women under 35, I would say, I usually tell my patients 12 to 15 eggs for us to feel very confident that you're gonna have one baby from those, right?
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So if I create an embryo, that embryo has already gone through the fertilization process and the embryo development, and it's at the stage where it's ready for implantation.
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So if I started, just for simplicity, let's say I started with 10 eggs from a young woman, those 10 eggs, even if I directly inject sperm into them, you know, you typically about eight, maybe nine fertilize.
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Maybe half of those form blastocysts, right?
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So let's say I get four blastocysts.
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That's the stage of the embryo that we want before implantation.
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So if I have four blastocysts frozen, that came from the 10 eggs, right?
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So I have more information about what's frozen and stored for the future.
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And I can tell you that an untested, right?
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We're not going to get into PGT at all that, but let's just say an untested, subjectively normal embryo from a woman under 35, probably, I would say between 40 to 50% chance of implantation, meaning positive pregnancy test.
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Single egg frozen, just one single egg, estimate, I'd say about 8% chance per egg of a positive pregnancy test, meaning not that it's not worthwhile to freeze eggs, it absolutely is, but when we freeze eggs, to make it worthwhile, we want to freeze a lot of eggs.
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And the number of eggs we want to freeze depends on the age of the ovaries where those eggs are coming from, because the number of eggs I need to try to achieve a successful pregnancy for a 30-year-old is way less than what I need for a 40-year-old.
00:21:32.160 --> 00:21:45.279
So with that, that's what my next question, my follow-up question would be for someone who's 35 or older, what typically is the number of eggs that we see being retrieved per cycle?
00:21:45.519 --> 00:21:48.559
And I know I'm I'm sure the answer is lower.
00:21:48.720 --> 00:21:57.119
So typically, how many, or not, I'm not sure if there is a typical number, of how many cycles do you often recommend with that number?
00:21:57.359 --> 00:21:57.839
Right.
00:21:58.079 --> 00:21:59.839
So this plays back to that AMA.
00:22:00.240 --> 00:22:00.400
Level.
00:22:00.480 --> 00:22:17.680
And this is where the AMH level is really important because the AMH level, as well as something called an angry follicle count, which is seeing the early follicles on sonogram, gives us a very good estimate of how many eggs we may yield per treatment cycle.
00:22:17.839 --> 00:22:24.240
So that doesn't mean that age is going to tell me exactly how many eggs I'm going to get.
00:22:24.400 --> 00:22:32.400
If I have a 38-year-old with a good AMH level, I may get a great number of eggs.
00:22:32.559 --> 00:22:36.240
Maybe I can get 15 or 20 eggs from a treatment cycle.
00:22:36.400 --> 00:22:41.119
So it's not her age that's telling me that, it's her ovarian reserve.
00:22:41.440 --> 00:22:49.920
So the AMH and the antropological count, regardless of a woman's age, is what's telling me how many eggs I may get per treatment cycle.
00:22:50.160 --> 00:23:03.200
But her age, which is the best predictor of egg quality, is what tells me roughly how many eggs I would like to have frozen in hopes that those eggs will be successful for her in the future.
00:23:03.440 --> 00:23:12.400
And I think what's so frustrating for me and patients alike is that I don't know the quality of eggs until I try to create embryos, right?
00:23:12.559 --> 00:23:14.880
So it's just numbers, right?
00:23:15.039 --> 00:23:25.759
I could say, yeah, if I have, for somebody under 35, if I have 10 to 15 eggs frozen, I'm pretty confident, maybe about an 80% chance you're going to get one, you know, successful pregnancy from that.
00:23:26.000 --> 00:23:29.440
But for someone who's older, I need more eggs.
00:23:29.599 --> 00:23:34.319
I wish I could say there is a specific number, and for sure, then you get your baby.
00:23:34.400 --> 00:23:35.279
There's not.
00:23:35.599 --> 00:23:41.680
But what I can say is as women get beyond 35, we want to freeze more eggs.
00:23:41.839 --> 00:24:00.799
And because egg quantity tends to decline with age as well, it often could be more than one round of egg retrieval to bank away enough eggs that we feel confident that yes, if you need to use these eggs in the future, they are going to work for you.
00:24:00.960 --> 00:24:07.599
Because if the quality is declining, what we also see is not as many eggs survive the freeze and thaw process, right?
00:24:07.680 --> 00:24:13.039
The survival rate is not the same for a 30-year-old egg as it is for a 39-year-old egg.
00:24:14.000 --> 00:24:16.240
And what about carrying also?
00:24:16.480 --> 00:24:20.480
Because I know that is a different number than 35.
00:24:20.559 --> 00:24:26.319
That the medical indications around retrieving eggs, right, and egg quality at 35.
00:24:26.480 --> 00:24:28.319
But what about carrying?
00:24:28.480 --> 00:24:36.079
Because that's so I mean the beautiful thing about the uterus is that it works very well regardless of age.
00:24:36.319 --> 00:24:39.359
So, in terms of getting pregnant, right?
00:24:39.599 --> 00:24:47.359
We'll talk about carrying afterwards, but just getting pregnant, it really has more to do with the quality of the embryo going into the uterus.
00:24:47.440 --> 00:24:50.480
That's why donor egg IVF is so successful, right?
00:24:50.640 --> 00:25:02.720
A woman can be in her mid to late 40s and have the same odds of getting pregnant as a 25-year-old if the embryo was created from this young 25-year-old egg.
00:25:02.880 --> 00:25:12.880
Now, the woman getting pregnant, her age plays into potential risk and complication in pregnancy, right?
00:25:12.960 --> 00:25:30.319
As women get older and are pregnant, they may have higher risks for strong complications like high blood pressure in pregnancy, diabetes in pregnancy, potentially needing a C-section, maybe preterm birth, and then the subsequent impact on the developing fetus.
00:25:30.559 --> 00:25:42.240
So there's risk to pregnancy as women get older, but the likelihood of getting pregnant and basically uterine function is less dependent on age.
00:25:42.640 --> 00:25:44.240
I'm happy for that clarification.
00:25:44.559 --> 00:25:45.599
Does that make sense?
00:25:46.400 --> 00:25:46.799
Oh yeah.
00:25:47.039 --> 00:25:47.279
Right?
00:25:47.359 --> 00:25:50.640
I mean, I have had women who have been through menopause, right?
00:25:50.799 --> 00:26:00.400
Postmenopausal women who, for one reason or another, wanted to be pregnant and were able to have and carry a successful pregnancy.
00:26:00.559 --> 00:26:11.519
They require the hormones that their body doesn't make anymore to prepare the uterus and to maintain that pregnancy in the early part of the first trimester until the placenta kicks in, but then the pregnancy takes over.
00:26:11.599 --> 00:26:14.319
So the fact that their ovaries aren't working doesn't matter.
00:26:15.039 --> 00:26:16.160
It's really incredible.
00:26:16.400 --> 00:26:22.960
And the technology is amazing, but that's not to say that I want women to wait until they're menopausal to have children.
00:26:23.039 --> 00:26:33.440
I mean, there's risk, of course, in pregnancy and the stress on the body and the changes in physiology of the body when women are pregnant, that's a stress on their heart and their lung function.
00:26:33.519 --> 00:26:39.200
And so I don't think any doctor would advocate for women to wait that long to have a baby.
00:26:39.519 --> 00:26:44.720
But if the situation kind of requires that, it can be done.
00:26:45.039 --> 00:26:56.079
So with that, along the discussion of age, and I may be wrong, so you may have to correct me, but for someone who's trying to get pregnant, I believe under, is it 30 or 35?
00:26:56.240 --> 00:27:00.240
The recommendation is, you know, to wait a year before you see a reproductive endocrinologist.
00:27:00.319 --> 00:27:04.319
And I believe it's six months for 35 and older.
00:27:04.480 --> 00:27:05.680
What are your thoughts with that?
00:27:05.839 --> 00:27:09.839
Do you think that's a good amount of time to wait, or would you recommend them coming earlier?
00:27:10.160 --> 00:27:10.559
Yes.
00:27:10.799 --> 00:27:34.720
So what I would say is for women who are under 35, who have very regular menstrual cycles, who don't have underlying issues that could affect their fertility, like endometriosis or PCOS, PMOS now, but what we used to call PCOS, women having regular ovulation and predictable periods, under 35, yes.
00:27:34.799 --> 00:27:36.640
The recommendation is try for a year.
00:27:36.799 --> 00:27:42.400
And if you're not successfully pregnant, then to see a fertility doctor and start testing.
00:27:42.640 --> 00:27:51.200
Women over 35, the recommendation is six months, again, without underlying factors that could make it more difficult.
00:27:51.440 --> 00:27:54.400
But I think it also depends on how close you are to 35.
00:27:54.480 --> 00:28:08.000
If you are 35, 36, 37, I mean, in honesty, all honesty, if I were talking to like my younger friends, I would tell them, you know, three to six months.
00:28:08.160 --> 00:28:10.240
Like, I don't want you to wait too long.
00:28:10.319 --> 00:28:13.920
And there's no harm in at least doing some testing.
00:28:14.000 --> 00:28:29.759
Like at that time, check your AMH level, see if your ovarian reserve is consistent with your age, or if the quantity is low, well, maybe you want to think about treatment sooner rather than later because it's probably going to be lower, you know, six months from now.
00:28:29.920 --> 00:28:35.200
So I would say three to six months would be my personal recommendation for somebody over 35.
00:28:35.519 --> 00:28:39.680
I was thinking that too, but I was I'm curious from a doctor's perspective.
00:28:40.000 --> 00:28:51.839
But it's again, I always wonder, again, like with people who go to see their OBGON, hopefully if they go every single year for their annual, you know, I wish there was some consensus in these conversations.
00:28:52.160 --> 00:28:52.319
Yeah.
00:28:52.480 --> 00:28:52.720
Yeah.
00:28:52.799 --> 00:28:53.119
Yeah.
00:28:53.359 --> 00:29:03.599
The other thing I would say that I wish women knew or I wish a gynecologist were discussing is their ultimate family plan, right?
00:29:03.759 --> 00:29:31.359
If if you're 35 or 36 and you're just starting and they tell you, yeah, wait six months, but you know you want three kids, IVF is a great treatment, not just to help you to get pregnant, but maybe you create, going back to embryo freezing, maybe you create your embryos at 35 or 36, so that, you know, if you're 40 and wanting your third child, your odds of getting pregnant are based on when you created that embryo, not the age you are when you use it.
00:29:31.440 --> 00:29:45.359
So you could forever have the odds of being 35 in terms of getting pregnant and the risk of miscarriage and the risk of genetic abnormalities being 35, even if your chronologic age when you use the embryo is older.
00:29:45.680 --> 00:29:59.440
And especially now that you mentioned, which I didn't, I wasn't really sure of, of you know, especially if you say the foundation is less of the issue than the actual egg, then that actually makes total sense.
00:29:59.759 --> 00:30:00.160
Yes.
00:30:00.400 --> 00:30:07.119
Age is really most important for the eggs, much more so than the uterine function.
00:30:07.440 --> 00:30:08.559
It's so fascinating.
00:30:08.640 --> 00:30:10.720
I mean, it really is so nuanced.
00:30:10.880 --> 00:30:17.440
And I think unfortunately, unless you are in this, people just don't know.
00:30:17.759 --> 00:30:17.920
No.
00:30:18.160 --> 00:30:20.559
You know, I think it's just so easy.
00:30:20.880 --> 00:30:26.720
Yeah, I I think everybody thinks, you know, anytime I don't use birth control, I'm gonna get pregnant.
00:30:26.960 --> 00:30:32.799
And then you're either in the boat where you're relieved it didn't happen, or you're learning very quickly.
00:30:32.960 --> 00:30:37.599
You're on the steep learning curve of wow, it's not that easy to get pregnant.
00:30:37.839 --> 00:30:38.079
Right.
00:30:38.160 --> 00:30:42.880
And then you very quickly learn about everything you probably never learned when you were younger, right?
00:30:43.039 --> 00:30:45.200
How do I actually figure out when I'm ovulating?
00:30:45.279 --> 00:30:46.799
How do I time things properly?
00:30:46.880 --> 00:30:51.440
And then, you know, what should I be doing if I'm not getting pregnant?
00:30:51.599 --> 00:30:56.880
Yeah, I think it's a huge steep learning curve for patients when they first come in to see us.
00:30:57.119 --> 00:31:06.400
I mean, this makes me think of I briefly spoke to my daughters about like their sex ed at school, their high schoolers, and they do speak about IVF, which is phenomenal.
00:31:08.240 --> 00:31:09.440
I never learned.
00:31:09.680 --> 00:31:10.880
I never learned it either.
00:31:11.119 --> 00:31:15.759
But I want to go home tonight and actually ask them what did you discuss specifically?
00:31:15.920 --> 00:31:19.839
Did you talk about egg freezing, embryo freezing, all of that?
00:31:19.920 --> 00:31:28.240
And I have a feeling probably not, but I'm curious now to see if they really are now educating kids at a younger age and giving them information.
00:31:28.559 --> 00:31:29.119
Yeah, yeah.
00:31:29.279 --> 00:31:33.599
I mean, going back to what we were first talking about, that information is power, right?
00:31:33.759 --> 00:31:42.480
It doesn't mean that you you need to use the technology that we have, but at least know that it's out there and understand how the female body works.
00:31:42.559 --> 00:31:50.559
So you're not in a situation when you want to have kids and you're struggling and you're like, oh, I wish I had done this five or 10 years ago.
00:31:50.880 --> 00:31:51.519
Exactly.
00:31:51.759 --> 00:31:56.720
You know, I think knowledge is power, and the more informed, the better.
00:31:57.039 --> 00:31:58.240
Yeah, definitely.
00:31:58.480 --> 00:31:59.039
Definitely.
00:31:59.200 --> 00:32:00.319
And it doesn't hurt.
00:32:00.480 --> 00:32:04.720
I mean, to check your AMH level or to do a sonogram is not invasive.
00:32:04.880 --> 00:32:33.279
It's a blood draw, it's a sonogram, it's not, you know, it's so easy to get information, but I think you need to make sure that information comes from the right person who can explain what it means, you know, because I don't want women to get numbers that seem abnormal and then think, well, oh my God, I'm going into menopause or I'm never gonna get pregnant, because that's really not what our testing is telling us.
00:32:33.599 --> 00:32:34.480
Exactly.
00:32:34.720 --> 00:32:41.119
So, and I think would you agree with just going to get a consult with a reproductive endocrinologist?
00:32:41.279 --> 00:32:43.039
That is just established care.
00:32:43.119 --> 00:32:48.240
You can go, you don't have to go to an RE because you want to freeze your eggs or conceive.
00:32:48.400 --> 00:32:51.119
You can go to an RE just to say, I want to do a consult.
00:32:51.279 --> 00:32:54.079
I just want to check, is anything getting flagged?
00:32:54.240 --> 00:32:54.880
That's it.
00:32:55.200 --> 00:32:55.599
100%.
00:32:56.000 --> 00:32:58.640
I have women who come who say, I just want information.
00:32:58.799 --> 00:33:01.839
I want information about the treatment processes that are available.
00:33:02.000 --> 00:33:06.000
I want information about my own hormones and what my body's doing right now.
00:33:06.240 --> 00:33:08.880
And then they make decisions for what they want to do.
00:33:08.960 --> 00:33:20.319
And at least they know, okay, well, I understand what my body is doing right now at this age, and I understand what I can do, and maybe I will consider doing that in six months or a year, right?
00:33:20.400 --> 00:33:23.920
Coming to see a fertility doctor doesn't mean we're starting you in treatment right away.
00:33:24.160 --> 00:33:24.559
Exactly.
00:33:24.960 --> 00:33:26.400
Good for our listeners to hear.
00:33:26.559 --> 00:33:26.720
Yeah.
00:33:26.960 --> 00:33:30.400
I think this was really, I learned so much from this discussion.
00:33:30.640 --> 00:33:49.839
And I really like Rena and I were, you know, before we started recording, like, pretty in awe that like after all these years of this podcast, we actually haven't really broken things down and really explained to our listeners about these basics AMH, antropolical level, egg freezing, embryo freezing.
00:33:49.920 --> 00:33:51.279
So I I really appreciate Dr.
00:33:51.359 --> 00:33:54.960
Dickin that you took the time to educate us and our listeners.
00:33:55.279 --> 00:33:56.400
Oh, it's my pleasure.
00:33:56.559 --> 00:33:57.599
I love talking about this.
00:33:57.680 --> 00:33:59.680
I can talk about it all day.
00:34:00.240 --> 00:34:02.400
Thank you so much for coming on.
00:34:02.720 --> 00:34:05.839
And we could talk about it all day too.
00:34:06.720 --> 00:34:11.199
The way we like to wrap is by saying something we are grateful for.
00:34:11.519 --> 00:34:15.119
So any gratitude or gratitude that you have.
00:34:15.440 --> 00:34:22.159
Well, I am really grateful to be able to be on your podcast and talk about this and hopefully get the information out to women.
00:34:22.320 --> 00:34:32.960
And hopefully it'll reach, I hope, many women, but even if it's just a handful, so that they hear this and they can go get information about their bodies themselves and understand their fertility.
00:34:33.280 --> 00:34:34.079
I love that.
00:34:34.400 --> 00:34:35.679
Sarah, what about you?
00:34:36.000 --> 00:34:37.519
Well, lots of things I'm grateful for today.
00:34:38.000 --> 00:34:39.119
Meeting new friends.
00:34:39.280 --> 00:34:44.320
I had uh a really nice lunch yesterday with some new friends that really excited me.
00:34:44.400 --> 00:34:58.000
And also, I think getting older and with age really does, at least for me, has come with a lot, I don't know, more reassurance, more I feel like I'm more at ease the older I get.
00:34:58.239 --> 00:35:02.719
And I think as women, sometimes we look at getting older as something negative.
00:35:02.960 --> 00:35:06.880
And I don't know, I'm learning to love it bit by bit.
00:35:07.840 --> 00:35:08.880
What about learning?
00:35:09.679 --> 00:35:10.480
Let's see.
00:35:10.800 --> 00:35:23.840
I am grateful for being able to do this work and being able to talk about this and share this knowledge and be a trusted provider for patients.
00:35:24.000 --> 00:35:25.599
So super grateful for that.
00:35:26.000 --> 00:35:26.480
Nice.
00:35:26.800 --> 00:35:27.519
That's so nice.
00:35:27.679 --> 00:35:29.360
Thanks so much again for being on.
00:35:29.840 --> 00:35:30.960
I I love doing this.
00:35:31.119 --> 00:35:32.320
Happy to come back anytime.
00:35:33.039 --> 00:35:33.760
Amazing.
00:35:34.400 --> 00:35:36.400
Thank you so much for listening today.
00:35:36.559 --> 00:35:45.199
And always remember, practice gratitude, give a little love to someone else and yourself, and remember you are not alone.
00:35:45.440 --> 00:35:49.360
Find us on Instagram at fertility underscore forward.
00:35:49.519 --> 00:35:59.199
And if you're looking for more support, visit us at www.rmany.com and tune in next week for more fertility forward.
00:00:13.919 --> 00:00:17.839
Hi everyone, we are Rena and Dara, and welcome to Fertility Ford.
00:00:18.000 --> 00:00:24.480
We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City.
00:00:24.640 --> 00:00:36.320
Our Fertility Ford podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
00:00:36.880 --> 00:00:42.640
Okay, we are so excited to welcome to Fertility Forward today, Dr.
00:00:42.799 --> 00:00:48.960
Carrie Dickin, who is one of our REIs at RMA of New York, Long Island.
00:00:49.359 --> 00:00:59.359
And on today's episode, we are going to be addressing the very hot topic of trying to conceive after 35.
00:01:00.960 --> 00:01:02.079
What you need to know.
00:01:02.240 --> 00:01:12.560
I feel like 35 needs to be followed by the law and order music because that's what people think about when they start to think about age, you know, this kind of doom.
00:01:14.319 --> 00:01:36.640
That is so true because so many women and patients that I see feel like at 35, some like magical switch is going to go off in their body, and all of a sudden, like it's impossible to get pregnant, or they're so high risk, or you know, things are drastically different than they were a month or two ago when they were still 34.
00:01:36.799 --> 00:01:38.640
And that's just not the case.
00:01:38.879 --> 00:01:52.159
I mean, certainly we begin to worry more as women get older, but everything is kind of a process and it's still gradual and it's not an instantaneous change at 35.
00:01:52.560 --> 00:02:01.519
I think part of my thing is I would think that around 35, isn't that typically when you're considered of advanced maternal age?
00:02:01.920 --> 00:02:02.239
Yes.
00:02:02.400 --> 00:02:08.719
But what's interesting, so there are a couple of reasons why 35 is this like cutoff age.
00:02:08.960 --> 00:02:16.000
One of them is kind of like like the history of it, and it's kind of outdated with how technology has changed.
00:02:16.319 --> 00:02:35.039
But historically, the risk of having an amniocentesis and complication from it, like miscarriage from amniocentesis, at age 35, the risk of a loss equals the risk of having a finding of Down syndrome, right?
00:02:35.199 --> 00:02:38.639
So that's kind of historically where that number came from.
00:02:38.800 --> 00:02:52.560
But then also with all of our data of how female reproduction changes with aging, more of the rapid changes tend to begin after 35.
00:02:53.280 --> 00:03:03.199
But there actually is a bigger decline, and I guess we'll get more into the topic of egg quantity and quality, but there's more of a rapid change from 37 to 39.
00:03:03.280 --> 00:03:06.400
But we just start to see more changes after 35.
00:03:06.479 --> 00:03:10.800
So there are a couple of reasons why 35 is this magical number.
00:03:11.199 --> 00:03:18.240
And I do also want to ask, we're not going to focus on this, but I mean, there's also a fertility age for men as well.
00:03:18.400 --> 00:03:24.479
I think there's this, you know, sort of misconception that men are totally fine until whatever age.
00:03:24.560 --> 00:03:25.599
And that's not the case.
00:03:26.000 --> 00:03:26.960
That is not the case.
00:03:27.120 --> 00:03:37.919
That's true, but the age is typically closer to 50 when we start worrying about age impact on sperm, whereas it's certainly much earlier in women.
00:03:38.159 --> 00:03:38.479
Sure.
00:03:38.639 --> 00:03:42.240
But there still is an age for the floor.
00:03:42.400 --> 00:03:44.960
Yes, age affects eggs and sperm.
00:03:45.120 --> 00:03:46.159
That is absolutely true.
00:03:46.319 --> 00:03:47.680
It's not all about the women.
00:03:47.919 --> 00:03:48.159
Yes.
00:03:48.319 --> 00:03:51.520
So I think it's just important to also have that in here.
00:03:51.759 --> 00:03:52.400
Yeah, yeah.
00:03:52.800 --> 00:03:56.080
Well, so I guess, okay, so back to women and age.
00:03:56.240 --> 00:04:01.360
Can you tell us so some of those changes that you're referencing that happen around 35?
00:04:01.520 --> 00:04:03.840
What are some of those changes specifically?
00:04:04.080 --> 00:04:15.919
So I think one thing that's really important for everybody to know is that men and women are so different when it comes to fertility because men make new sperm their entire life.
00:04:16.079 --> 00:04:18.800
Like every 70 days, they make new sperm.
00:04:19.040 --> 00:04:22.800
Women, as little girls, when we're born, we are born with our eggs.
00:04:22.959 --> 00:04:27.759
We never make any new eggs and we are constantly losing them.
00:04:27.920 --> 00:04:34.959
Even if you're like on a birth control pill for, you know, your 20s and you're not ovulating, you're still losing eggs.
00:04:35.199 --> 00:04:42.639
And so there is a constant, gradual decline in egg quantity with aging.
00:04:42.800 --> 00:04:47.600
And there is also a decline in quality of eggs.
00:04:47.839 --> 00:04:57.920
But the more rapid changes with both quantity and quality tend to be seen from 35 and beyond, right?
00:04:58.000 --> 00:05:05.680
So if you were to look at the changes in a woman's ovaries from age 25 to 35, very minimal changes.
00:05:06.079 --> 00:05:12.240
Things are still gradually declining, but the slope of that decline is not very steep.
00:05:12.399 --> 00:05:14.879
And that picks up after 35.
00:05:15.279 --> 00:05:33.360
So you're saying that both the quality and the quantity kind of intersect at that point where it's well, they are both always declining, but the rate at which the decline happens picks up after 35 for both the quantity and the quality.
00:05:33.759 --> 00:05:36.480
And so it's like this double whammy for women, right?
00:05:36.639 --> 00:05:43.439
Because quantity is important, but it's really important more so with like fertility treatment, right?
00:05:43.519 --> 00:05:47.759
Because if you're trying to conceive naturally, most women ovulate one egg every cycle.
00:05:47.839 --> 00:05:54.720
So whether you have a diminished reserve or not may not be that important if you're getting pregnant or trying to get pregnant naturally.
00:05:54.800 --> 00:06:03.920
But if you want to use fertility treatment, which really requires there to be other eggs to respond to the medication, quantity is very important.
00:06:04.160 --> 00:06:08.560
Quality is always gonna be the most important, right?
00:06:08.720 --> 00:06:15.839
If I get in a like an IVF cycle, if I get 20 eggs and I have those from a 30-year-old versus a 40-year-old, right?
00:06:15.920 --> 00:06:17.920
There's some women in 40 that can do that.
00:06:18.160 --> 00:06:26.480
I know that the percentage of eggs from that 40-year-old that are actually gonna create healthy embryos is so significantly less than that 30-year-old.
00:06:26.800 --> 00:06:31.439
Well, here's where I find such a disconnect in healthcare, because I would love Dr.
00:06:31.519 --> 00:06:34.959
Dickin to hear your ideas on my theory.
00:06:35.199 --> 00:06:42.879
Um as women, right, I think it just feels like just another thing we have to think about, right?
00:06:42.959 --> 00:06:46.480
I feel, you know, in an ideal world, right, that we, you know, we grow up.
00:06:46.560 --> 00:06:49.439
I mean, number one, that this is taught to us in school, right?
00:06:49.600 --> 00:07:08.000
Not just about how to not get pregnant, but how to preserve our fertility and to start to think about these things in terms of age and how we might use medical means necessary or available to us to preserve our fertility, which is egg freezing right now, but that it becomes a comprehensive care, right?
00:07:08.079 --> 00:07:26.720
So you're having these conversations with your OB, that it doesn't feel like another thing on your to-do list of, okay, you know, I turned 30 and let me just start checking my fertility, see how everything is, and then by the time I'm 35, freeze eggs if that's where I'm at in my life.
00:07:27.040 --> 00:07:27.759
Right, right.
00:07:28.000 --> 00:07:45.199
I think the decision of when to preserve fertility, it's a bit of a balancing act because the younger you are when you freeze your eggs, obviously the more likely those eggs are to be healthy and to be successful for you in the future.
00:07:45.519 --> 00:07:51.439
But the younger you are, I guess the lower the chance you may need them, right?
00:07:51.519 --> 00:07:56.079
When you're ready to start your family, you still may be very capable of getting pregnant.
00:07:56.319 --> 00:08:00.560
So it's a balancing act, especially because it can be such an expensive treatment.
00:08:00.720 --> 00:08:03.920
Thankfully, some insurance is starting to cover it, but a lot don't.
00:08:04.079 --> 00:08:06.240
So it's a real balancing act.
00:08:06.399 --> 00:08:07.839
But yeah, I agree with you.
00:08:07.920 --> 00:08:30.240
It's like one more thing on a woman's plate to think about, but at the end of the day, it's biology and we can't change it, and we can only use the technology that we have to try to help women to have these younger eggs to use in the future should they need them.
00:08:30.720 --> 00:08:36.720
But I feel like it should be another sort of quote unquote required checkup, right?
00:08:36.799 --> 00:08:38.399
Like, okay, a mammogram, right?
00:08:38.480 --> 00:08:41.039
That's on your checklist now at 40.
00:08:41.120 --> 00:08:43.919
That, okay, when I'm 40, that's what I need to do, right?
00:08:44.000 --> 00:08:45.840
That's what the recommendation is.
00:08:46.000 --> 00:08:49.679
Okay, you know, my doctor's gonna tell me to do it, I'm gonna do it.
00:08:49.840 --> 00:08:53.679
But at age 30, that, okay, checkup with an REI.
00:08:53.759 --> 00:08:55.360
I go, I just get checked.
00:08:55.440 --> 00:08:56.559
Is everything tracking?
00:08:56.799 --> 00:08:57.360
Okay, great.
00:08:57.519 --> 00:08:59.120
Then I go back the next year.
00:08:59.360 --> 00:09:07.679
Then, okay, if something's off, right, I'd have that information ahead of time instead of what we see all too often, right?
00:09:07.759 --> 00:09:11.679
Is patients that come in, they had no idea any of this.
00:09:11.919 --> 00:09:15.440
And then it's we're not in a situation where we're ahead of it.
00:09:15.519 --> 00:09:19.279
We saw that things were declining, we preserved fertility, right?
00:09:19.360 --> 00:09:24.080
That it's just not, that's not where the language and the care is yet.
00:09:24.320 --> 00:09:40.000
I I hear what you're saying, and I want to say I agree a hundred percent, but I think it's important that you fully understand what testing we are actually able to do before a woman tries to get pregnant.
00:09:40.159 --> 00:09:49.919
Because every test I can do objectively, sonogram, blood work, and we can talk about all of those things, does not tell me if a woman is going to have an easy or difficult time getting pregnant.
00:09:50.159 --> 00:09:54.399
We do not know that until somebody actually starts trying.
00:09:54.480 --> 00:09:57.360
So let's say, you know, everybody gets fixated on an AMH level.
00:09:57.440 --> 00:09:59.759
And what does AMH really mean?
00:10:00.080 --> 00:10:05.200
So AMH, just you know, for logistics, is anti-mularian hormone.
00:10:05.360 --> 00:10:12.799
It is a hormone that is made from the super early eggs in the ovaries that we are not able to see, right?
00:10:12.879 --> 00:10:19.120
So the more eggs a woman has, the more of this hormone will be found in her blood.
00:10:19.279 --> 00:10:25.679
So when we check this level, it is an excellent marker of egg quantity.
00:10:25.919 --> 00:10:26.240
Okay.
00:10:26.480 --> 00:10:35.919
So everybody feels really great when it comes back high and they think, oh, great, I don't have to worry about anything, but that's not necessarily the case because that doesn't tell me anything about the quality of the eggs.
00:10:36.240 --> 00:10:43.279
So can I say that I am reassured that a 30-year-old has a good AMH level?
00:10:43.440 --> 00:10:46.480
Well, yeah, because she's 30, I feel pretty good about that.
00:10:46.639 --> 00:11:09.919
But if somebody comes to me, let's say at 37 and says, listen, I'm about to get married, I'm not ready to have kids now, I want to check my AMH and just make sure I'm okay to wait a year or two, even if her AMH level is good, maybe even better than expected for age, her age is still predicting how easy or difficult it's going to be for her to get pregnant, not her AMH level.
00:11:10.080 --> 00:11:11.360
So it's very difficult, right?
00:11:11.519 --> 00:11:13.759
Mammogram is going to screen for breast cancer.
00:11:14.000 --> 00:11:16.799
AMH level does not predict fertility.
00:11:16.960 --> 00:11:19.840
It only tells us about egg quantity.
00:11:20.399 --> 00:11:32.480
But even having that discussion with your OBGYN, I don't know, if 25, 30, having a discussion of whether it may be useful to freeze eggs.
00:11:33.200 --> 00:11:34.240
Oh, absolutely.
00:11:34.480 --> 00:11:36.000
Yes, a hundred percent.
00:11:36.080 --> 00:11:42.399
And to go back to what we were saying earlier about not just learning when we're young in school how to prevent pregnancy.
00:11:42.559 --> 00:11:45.120
We should really learn female reproduction.
00:11:45.360 --> 00:11:49.200
How likely is it that you get pregnant each month that you're trying?
00:11:49.440 --> 00:11:56.159
How does that change as you're trying maybe in your late 20s and early 30s versus your late 30s and your early 40s?
00:11:56.399 --> 00:12:05.840
And what things can be done to stop the clock on some eggs if and when you feel like it's the right time to do that?
00:12:06.000 --> 00:12:12.000
I think education is so important, but I think that so many women get nervous.
00:12:12.159 --> 00:12:16.080
I even think a lot of gynecologists get nervous by the AMH level.
00:12:16.240 --> 00:12:17.759
What if it comes back low?
00:12:18.080 --> 00:12:22.559
I always tell this story to my patients when they get sent in to me with a low AMH level.
00:12:22.720 --> 00:12:31.200
I had a patient young, she must have been in her late 20s, had just had a baby, was not interested in having another child anytime soon.
00:12:31.440 --> 00:12:40.320
I don't remember why, but her doctor, her gynecologist checked an AMH level and it came back very low, like in a range I would have expected for a 40-year-old.
00:12:40.559 --> 00:12:45.279
And he told her right away if you want to ever have another child, you better do it now.
00:12:45.360 --> 00:12:46.879
Your AMH is too low.
00:12:47.039 --> 00:12:52.480
Again, she didn't want the child or a second child at that time, removed her IUD.
00:12:52.879 --> 00:12:56.000
The woman was pregnant within two months, right?
00:12:56.159 --> 00:13:01.679
So her age was much more important than her AMH level.
00:13:01.919 --> 00:13:04.639
And so again, AMH is important.
00:13:04.799 --> 00:13:09.519
I'm not saying it's not, it absolutely is, but it's not the end all.
00:13:09.600 --> 00:13:11.679
And there are so many other factors.
00:13:12.000 --> 00:13:16.320
And I do think it's important that women have information.
00:13:16.399 --> 00:13:23.679
And if they want to check their AMH levels at a younger age just to see that it's age appropriate, I think that's smart.
00:13:23.840 --> 00:13:37.200
If it comes back low, maybe that does prompt an earlier conversation of maybe you should preserve your fertility now because that AMH level may be the same in a few years, but it may not be, and we can't predict that.
00:13:37.360 --> 00:13:37.600
Right.
00:13:37.759 --> 00:13:42.399
So the information is important, but it has to be explained properly.
00:13:42.799 --> 00:13:43.120
Of course.
00:13:43.279 --> 00:13:54.639
Well, and I'm so glad that you really did a comprehensive explanation of AMH because I think, you know, similar to what you see, that is such a fear-inducing number for women.
00:13:54.720 --> 00:13:59.120
And they, you know, if it's low, then they automatically think, nope.
00:13:59.279 --> 00:14:01.360
But I think it's it's exactly what you said.
00:14:01.440 --> 00:14:03.679
And I know, Dara, you and I have talked about this before.
00:14:03.840 --> 00:14:10.320
It's, you know, it's knowledge is power, and that if you go right at age, you know, anywhere, let's say 25 to 30, right?
00:14:10.399 --> 00:14:14.399
And it's like, oh, huh, my AMH should be X, right?
00:14:14.480 --> 00:14:15.840
But it's super low.
00:14:16.159 --> 00:14:26.879
Then you have that knowledge that if you do want to try to freeze eggs, right, or you at least know, like, okay, this is something just to kind of file away.
00:14:27.039 --> 00:14:45.679
Um of course we don't have a crystal ball, and there are so many other things that go into getting and staying pregnant, but it's to be able to use what we do have available to us, right, to put us in the best position to at least have an understanding or be able to be informed.
00:14:46.000 --> 00:14:47.360
Yeah, no, a hundred percent.
00:14:47.519 --> 00:14:50.480
Knowledge is power, agree, a hundred percent.
00:14:50.639 --> 00:15:03.120
And I think it's great that women check these levels at an earlier age, but I want to make sure they're fully aware of what it truly means.
00:15:03.840 --> 00:15:10.240
Well, maybe can you go into for our listeners sort of the difference between freezing eggs and freezing embryos?
00:15:10.480 --> 00:15:12.240
And that's different.
00:15:13.120 --> 00:15:26.240
So freezing what a woman would go through, the actual treatment process to get eggs to grow, to extract them, is the same whether the decision is to freeze eggs or to freeze embryos.
00:15:26.399 --> 00:15:29.519
The difference is when we fertilize the eggs.
00:15:29.759 --> 00:15:37.519
And so with an egg freezing treatment process, women use injectable medications to stimulate egg growth.
00:15:37.919 --> 00:15:46.960
It takes, you know, I would say 10 to 12 days of medication, and then we do a procedure to extract the eggs that have grown from the ovaries.
00:15:47.120 --> 00:15:47.440
Okay.
00:15:47.759 --> 00:15:52.159
So that is actually done with either egg or embryo freezing.
00:15:52.320 --> 00:16:06.080
When the eggs are extracted, if the plan is to freeze eggs, the eggs get assessed in the laboratory to see which are ready to fertilize, but instead of fertilizing them, they are frozen, right?
00:16:06.159 --> 00:16:09.600
So we're stopping the clock essentially on the IVF process.
00:16:09.679 --> 00:16:12.080
We're not fertilizing them right then.
00:16:12.320 --> 00:16:17.120
We are freezing those eggs so that in the future we can continue the IVF process.
00:16:17.279 --> 00:16:27.679
So I think that's important for people to know if they're going to freeze their eggs and they need to use them in the future, you're not thawing eggs and putting them back in your body and like having sex to get pregnant.
00:16:27.840 --> 00:16:33.279
You are thawing those eggs to complete IVF or in vitro fertilization.
00:16:33.679 --> 00:16:39.200
IVF is how you would create embryos to either use or freeze.
00:16:39.360 --> 00:16:53.600
So if you wanted to freeze embryos, what that means is the same medication and egg retrieval, but when those eggs are in the laboratory after the retrieval, they are fertilized immediately rather than frozen.
00:16:53.759 --> 00:16:56.799
So by fertilizing an egg, you create an embryo.
00:16:57.039 --> 00:17:06.799
The embryo then develops to a stage we call blastasis, which is what an embryo needs to form before it can implant in the uterus, but we're then stopping the process, right?
00:17:06.960 --> 00:17:14.559
So we're not allowing that embryo to create a pregnancy, we're freezing that embryo so that it can be used at a future date.
00:17:14.799 --> 00:17:24.400
And the difference between the two, I mean, how I explain this to patients that I see who want to preserve fertility, is it really depends on a couple of factors.
00:17:24.559 --> 00:17:34.400
Number one, and probably most important, is do you have a partner or do you have a sperm source that you want to use right now?
00:17:34.720 --> 00:17:56.640
So for example, if I had a single female patient who in the future would like a male partner and would like to have children with that male partner, it would be better for her to freeze her eggs because if she needs to use those eggs in the future with that partner, she can thaw the eggs and fertilize them with his sperm.
00:17:56.880 --> 00:18:07.119
If I have a couple that comes in, maybe they just got married, but they don't want to start a family yet, but they know they want two or three kids, and maybe they're gonna start at 35 or 36.
00:18:07.359 --> 00:18:11.359
Well, it makes a lot more sense for them to create the embryos, right?
00:18:11.440 --> 00:18:13.279
They know they want to have children together.
00:18:13.519 --> 00:18:19.920
They're gonna create the embryos and keep those frozen until they're ready to start a family.
00:18:20.240 --> 00:18:27.920
In a slightly different scenario, let's say you had a same-sex female couple that knows they're gonna use donor sperm, right?
00:18:28.000 --> 00:18:34.720
They don't want to have kids now, and maybe they're young enough that egg freezing is a great option, but they know they're using donor sperm.
00:18:35.039 --> 00:18:44.799
In general, you know, if you have a single frozen egg and a single frozen embryo, that embryo is way more likely to result in pregnancy and you can feel more confident having embryos frozen.
00:18:44.880 --> 00:18:50.799
You don't need as many embryos frozen to feel confident that you could get pregnant compared to eggs.
00:18:50.960 --> 00:18:58.160
And so they may want to consider creating embryos with donor sperm at that time rather than freezing eggs.
00:18:58.799 --> 00:18:59.440
Does that make sense?
00:19:00.000 --> 00:19:01.519
I know that's a lot of information at once.
00:19:01.839 --> 00:19:03.839
I think that's so clear, and which is wild.
00:19:03.920 --> 00:19:09.759
I don't think we've ever had an explanation like that for our listeners of really breaking it down.
00:19:10.000 --> 00:19:18.480
Just to clarify, you know, you mentioned that if you're able to get an embryo frozen, it's much more beneficial than getting the egg.
00:19:18.799 --> 00:19:27.920
Can you go into more detail of why the potential of the egg puts someone at higher risk of not having a successful pregnancy in the end?
00:19:28.160 --> 00:19:28.640
Yes.
00:19:28.960 --> 00:19:38.880
So in general, and I'm sure you've heard this before, human reproduction is not very efficient, meaning one egg does not mean one baby down the line.
00:19:39.119 --> 00:19:41.839
It typically we need many eggs.
00:19:41.920 --> 00:19:53.759
And for young women, right, women under 35, I would say, I usually tell my patients 12 to 15 eggs for us to feel very confident that you're gonna have one baby from those, right?
00:19:53.920 --> 00:20:06.559
So if I create an embryo, that embryo has already gone through the fertilization process and the embryo development, and it's at the stage where it's ready for implantation.
00:20:06.720 --> 00:20:20.799
So if I started, just for simplicity, let's say I started with 10 eggs from a young woman, those 10 eggs, even if I directly inject sperm into them, you know, you typically about eight, maybe nine fertilize.
00:20:21.039 --> 00:20:23.920
Maybe half of those form blastocysts, right?
00:20:24.000 --> 00:20:25.920
So let's say I get four blastocysts.
00:20:26.000 --> 00:20:29.119
That's the stage of the embryo that we want before implantation.
00:20:29.359 --> 00:20:35.039
So if I have four blastocysts frozen, that came from the 10 eggs, right?
00:20:35.119 --> 00:20:40.240
So I have more information about what's frozen and stored for the future.
00:20:40.319 --> 00:20:42.799
And I can tell you that an untested, right?
00:20:42.880 --> 00:20:57.759
We're not going to get into PGT at all that, but let's just say an untested, subjectively normal embryo from a woman under 35, probably, I would say between 40 to 50% chance of implantation, meaning positive pregnancy test.
00:20:58.240 --> 00:21:17.200
Single egg frozen, just one single egg, estimate, I'd say about 8% chance per egg of a positive pregnancy test, meaning not that it's not worthwhile to freeze eggs, it absolutely is, but when we freeze eggs, to make it worthwhile, we want to freeze a lot of eggs.
00:21:17.359 --> 00:21:31.920
And the number of eggs we want to freeze depends on the age of the ovaries where those eggs are coming from, because the number of eggs I need to try to achieve a successful pregnancy for a 30-year-old is way less than what I need for a 40-year-old.
00:21:32.160 --> 00:21:45.279
So with that, that's what my next question, my follow-up question would be for someone who's 35 or older, what typically is the number of eggs that we see being retrieved per cycle?
00:21:45.519 --> 00:21:48.559
And I know I'm I'm sure the answer is lower.
00:21:48.720 --> 00:21:57.119
So typically, how many, or not, I'm not sure if there is a typical number, of how many cycles do you often recommend with that number?
00:21:57.359 --> 00:21:57.839
Right.
00:21:58.079 --> 00:21:59.839
So this plays back to that AMA.
00:22:00.240 --> 00:22:00.400
Level.
00:22:00.480 --> 00:22:17.680
And this is where the AMH level is really important because the AMH level, as well as something called an angry follicle count, which is seeing the early follicles on sonogram, gives us a very good estimate of how many eggs we may yield per treatment cycle.
00:22:17.839 --> 00:22:24.240
So that doesn't mean that age is going to tell me exactly how many eggs I'm going to get.
00:22:24.400 --> 00:22:32.400
If I have a 38-year-old with a good AMH level, I may get a great number of eggs.
00:22:32.559 --> 00:22:36.240
Maybe I can get 15 or 20 eggs from a treatment cycle.
00:22:36.400 --> 00:22:41.119
So it's not her age that's telling me that, it's her ovarian reserve.
00:22:41.440 --> 00:22:49.920
So the AMH and the antropological count, regardless of a woman's age, is what's telling me how many eggs I may get per treatment cycle.
00:22:50.160 --> 00:23:03.200
But her age, which is the best predictor of egg quality, is what tells me roughly how many eggs I would like to have frozen in hopes that those eggs will be successful for her in the future.
00:23:03.440 --> 00:23:12.400
And I think what's so frustrating for me and patients alike is that I don't know the quality of eggs until I try to create embryos, right?
00:23:12.559 --> 00:23:14.880
So it's just numbers, right?
00:23:15.039 --> 00:23:25.759
I could say, yeah, if I have, for somebody under 35, if I have 10 to 15 eggs frozen, I'm pretty confident, maybe about an 80% chance you're going to get one, you know, successful pregnancy from that.
00:23:26.000 --> 00:23:29.440
But for someone who's older, I need more eggs.
00:23:29.599 --> 00:23:34.319
I wish I could say there is a specific number, and for sure, then you get your baby.
00:23:34.400 --> 00:23:35.279
There's not.
00:23:35.599 --> 00:23:41.680
But what I can say is as women get beyond 35, we want to freeze more eggs.
00:23:41.839 --> 00:24:00.799
And because egg quantity tends to decline with age as well, it often could be more than one round of egg retrieval to bank away enough eggs that we feel confident that yes, if you need to use these eggs in the future, they are going to work for you.
00:24:00.960 --> 00:24:07.599
Because if the quality is declining, what we also see is not as many eggs survive the freeze and thaw process, right?
00:24:07.680 --> 00:24:13.039
The survival rate is not the same for a 30-year-old egg as it is for a 39-year-old egg.
00:24:14.000 --> 00:24:16.240
And what about carrying also?
00:24:16.480 --> 00:24:20.480
Because I know that is a different number than 35.
00:24:20.559 --> 00:24:26.319
That the medical indications around retrieving eggs, right, and egg quality at 35.
00:24:26.480 --> 00:24:28.319
But what about carrying?
00:24:28.480 --> 00:24:36.079
Because that's so I mean the beautiful thing about the uterus is that it works very well regardless of age.
00:24:36.319 --> 00:24:39.359
So, in terms of getting pregnant, right?
00:24:39.599 --> 00:24:47.359
We'll talk about carrying afterwards, but just getting pregnant, it really has more to do with the quality of the embryo going into the uterus.
00:24:47.440 --> 00:24:50.480
That's why donor egg IVF is so successful, right?
00:24:50.640 --> 00:25:02.720
A woman can be in her mid to late 40s and have the same odds of getting pregnant as a 25-year-old if the embryo was created from this young 25-year-old egg.
00:25:02.880 --> 00:25:12.880
Now, the woman getting pregnant, her age plays into potential risk and complication in pregnancy, right?
00:25:12.960 --> 00:25:30.319
As women get older and are pregnant, they may have higher risks for strong complications like high blood pressure in pregnancy, diabetes in pregnancy, potentially needing a C-section, maybe preterm birth, and then the subsequent impact on the developing fetus.
00:25:30.559 --> 00:25:42.240
So there's risk to pregnancy as women get older, but the likelihood of getting pregnant and basically uterine function is less dependent on age.
00:25:42.640 --> 00:25:44.240
I'm happy for that clarification.
00:25:44.559 --> 00:25:45.599
Does that make sense?
00:25:46.400 --> 00:25:46.799
Oh yeah.
00:25:47.039 --> 00:25:47.279
Right?
00:25:47.359 --> 00:25:50.640
I mean, I have had women who have been through menopause, right?
00:25:50.799 --> 00:26:00.400
Postmenopausal women who, for one reason or another, wanted to be pregnant and were able to have and carry a successful pregnancy.
00:26:00.559 --> 00:26:11.519
They require the hormones that their body doesn't make anymore to prepare the uterus and to maintain that pregnancy in the early part of the first trimester until the placenta kicks in, but then the pregnancy takes over.
00:26:11.599 --> 00:26:14.319
So the fact that their ovaries aren't working doesn't matter.
00:26:15.039 --> 00:26:16.160
It's really incredible.
00:26:16.400 --> 00:26:22.960
And the technology is amazing, but that's not to say that I want women to wait until they're menopausal to have children.
00:26:23.039 --> 00:26:33.440
I mean, there's risk, of course, in pregnancy and the stress on the body and the changes in physiology of the body when women are pregnant, that's a stress on their heart and their lung function.
00:26:33.519 --> 00:26:39.200
And so I don't think any doctor would advocate for women to wait that long to have a baby.
00:26:39.519 --> 00:26:44.720
But if the situation kind of requires that, it can be done.
00:26:45.039 --> 00:26:56.079
So with that, along the discussion of age, and I may be wrong, so you may have to correct me, but for someone who's trying to get pregnant, I believe under, is it 30 or 35?
00:26:56.240 --> 00:27:00.240
The recommendation is, you know, to wait a year before you see a reproductive endocrinologist.
00:27:00.319 --> 00:27:04.319
And I believe it's six months for 35 and older.
00:27:04.480 --> 00:27:05.680
What are your thoughts with that?
00:27:05.839 --> 00:27:09.839
Do you think that's a good amount of time to wait, or would you recommend them coming earlier?
00:27:10.160 --> 00:27:10.559
Yes.
00:27:10.799 --> 00:27:34.720
So what I would say is for women who are under 35, who have very regular menstrual cycles, who don't have underlying issues that could affect their fertility, like endometriosis or PCOS, PMOS now, but what we used to call PCOS, women having regular ovulation and predictable periods, under 35, yes.
00:27:34.799 --> 00:27:36.640
The recommendation is try for a year.
00:27:36.799 --> 00:27:42.400
And if you're not successfully pregnant, then to see a fertility doctor and start testing.
00:27:42.640 --> 00:27:51.200
Women over 35, the recommendation is six months, again, without underlying factors that could make it more difficult.
00:27:51.440 --> 00:27:54.400
But I think it also depends on how close you are to 35.
00:27:54.480 --> 00:28:08.000
If you are 35, 36, 37, I mean, in honesty, all honesty, if I were talking to like my younger friends, I would tell them, you know, three to six months.
00:28:08.160 --> 00:28:10.240
Like, I don't want you to wait too long.
00:28:10.319 --> 00:28:13.920
And there's no harm in at least doing some testing.
00:28:14.000 --> 00:28:29.759
Like at that time, check your AMH level, see if your ovarian reserve is consistent with your age, or if the quantity is low, well, maybe you want to think about treatment sooner rather than later because it's probably going to be lower, you know, six months from now.
00:28:29.920 --> 00:28:35.200
So I would say three to six months would be my personal recommendation for somebody over 35.
00:28:35.519 --> 00:28:39.680
I was thinking that too, but I was I'm curious from a doctor's perspective.
00:28:40.000 --> 00:28:51.839
But it's again, I always wonder, again, like with people who go to see their OBGON, hopefully if they go every single year for their annual, you know, I wish there was some consensus in these conversations.
00:28:52.160 --> 00:28:52.319
Yeah.
00:28:52.480 --> 00:28:52.720
Yeah.
00:28:52.799 --> 00:28:53.119
Yeah.
00:28:53.359 --> 00:29:03.599
The other thing I would say that I wish women knew or I wish a gynecologist were discussing is their ultimate family plan, right?
00:29:03.759 --> 00:29:31.359
If if you're 35 or 36 and you're just starting and they tell you, yeah, wait six months, but you know you want three kids, IVF is a great treatment, not just to help you to get pregnant, but maybe you create, going back to embryo freezing, maybe you create your embryos at 35 or 36, so that, you know, if you're 40 and wanting your third child, your odds of getting pregnant are based on when you created that embryo, not the age you are when you use it.
00:29:31.440 --> 00:29:45.359
So you could forever have the odds of being 35 in terms of getting pregnant and the risk of miscarriage and the risk of genetic abnormalities being 35, even if your chronologic age when you use the embryo is older.
00:29:45.680 --> 00:29:59.440
And especially now that you mentioned, which I didn't, I wasn't really sure of, of you know, especially if you say the foundation is less of the issue than the actual egg, then that actually makes total sense.
00:29:59.759 --> 00:30:00.160
Yes.
00:30:00.400 --> 00:30:07.119
Age is really most important for the eggs, much more so than the uterine function.
00:30:07.440 --> 00:30:08.559
It's so fascinating.
00:30:08.640 --> 00:30:10.720
I mean, it really is so nuanced.
00:30:10.880 --> 00:30:17.440
And I think unfortunately, unless you are in this, people just don't know.
00:30:17.759 --> 00:30:17.920
No.
00:30:18.160 --> 00:30:20.559
You know, I think it's just so easy.
00:30:20.880 --> 00:30:26.720
Yeah, I I think everybody thinks, you know, anytime I don't use birth control, I'm gonna get pregnant.
00:30:26.960 --> 00:30:32.799
And then you're either in the boat where you're relieved it didn't happen, or you're learning very quickly.
00:30:32.960 --> 00:30:37.599
You're on the steep learning curve of wow, it's not that easy to get pregnant.
00:30:37.839 --> 00:30:38.079
Right.
00:30:38.160 --> 00:30:42.880
And then you very quickly learn about everything you probably never learned when you were younger, right?
00:30:43.039 --> 00:30:45.200
How do I actually figure out when I'm ovulating?
00:30:45.279 --> 00:30:46.799
How do I time things properly?
00:30:46.880 --> 00:30:51.440
And then, you know, what should I be doing if I'm not getting pregnant?
00:30:51.599 --> 00:30:56.880
Yeah, I think it's a huge steep learning curve for patients when they first come in to see us.
00:30:57.119 --> 00:31:06.400
I mean, this makes me think of I briefly spoke to my daughters about like their sex ed at school, their high schoolers, and they do speak about IVF, which is phenomenal.
00:31:08.240 --> 00:31:09.440
I never learned.
00:31:09.680 --> 00:31:10.880
I never learned it either.
00:31:11.119 --> 00:31:15.759
But I want to go home tonight and actually ask them what did you discuss specifically?
00:31:15.920 --> 00:31:19.839
Did you talk about egg freezing, embryo freezing, all of that?
00:31:19.920 --> 00:31:28.240
And I have a feeling probably not, but I'm curious now to see if they really are now educating kids at a younger age and giving them information.
00:31:28.559 --> 00:31:29.119
Yeah, yeah.
00:31:29.279 --> 00:31:33.599
I mean, going back to what we were first talking about, that information is power, right?
00:31:33.759 --> 00:31:42.480
It doesn't mean that you you need to use the technology that we have, but at least know that it's out there and understand how the female body works.
00:31:42.559 --> 00:31:50.559
So you're not in a situation when you want to have kids and you're struggling and you're like, oh, I wish I had done this five or 10 years ago.
00:31:50.880 --> 00:31:51.519
Exactly.
00:31:51.759 --> 00:31:56.720
You know, I think knowledge is power, and the more informed, the better.
00:31:57.039 --> 00:31:58.240
Yeah, definitely.
00:31:58.480 --> 00:31:59.039
Definitely.
00:31:59.200 --> 00:32:00.319
And it doesn't hurt.
00:32:00.480 --> 00:32:04.720
I mean, to check your AMH level or to do a sonogram is not invasive.
00:32:04.880 --> 00:32:33.279
It's a blood draw, it's a sonogram, it's not, you know, it's so easy to get information, but I think you need to make sure that information comes from the right person who can explain what it means, you know, because I don't want women to get numbers that seem abnormal and then think, well, oh my God, I'm going into menopause or I'm never gonna get pregnant, because that's really not what our testing is telling us.
00:32:33.599 --> 00:32:34.480
Exactly.
00:32:34.720 --> 00:32:41.119
So, and I think would you agree with just going to get a consult with a reproductive endocrinologist?
00:32:41.279 --> 00:32:43.039
That is just established care.
00:32:43.119 --> 00:32:48.240
You can go, you don't have to go to an RE because you want to freeze your eggs or conceive.
00:32:48.400 --> 00:32:51.119
You can go to an RE just to say, I want to do a consult.
00:32:51.279 --> 00:32:54.079
I just want to check, is anything getting flagged?
00:32:54.240 --> 00:32:54.880
That's it.
00:32:55.200 --> 00:32:55.599
100%.
00:32:56.000 --> 00:32:58.640
I have women who come who say, I just want information.
00:32:58.799 --> 00:33:01.839
I want information about the treatment processes that are available.
00:33:02.000 --> 00:33:06.000
I want information about my own hormones and what my body's doing right now.
00:33:06.240 --> 00:33:08.880
And then they make decisions for what they want to do.
00:33:08.960 --> 00:33:20.319
And at least they know, okay, well, I understand what my body is doing right now at this age, and I understand what I can do, and maybe I will consider doing that in six months or a year, right?
00:33:20.400 --> 00:33:23.920
Coming to see a fertility doctor doesn't mean we're starting you in treatment right away.
00:33:24.160 --> 00:33:24.559
Exactly.
00:33:24.960 --> 00:33:26.400
Good for our listeners to hear.
00:33:26.559 --> 00:33:26.720
Yeah.
00:33:26.960 --> 00:33:30.400
I think this was really, I learned so much from this discussion.
00:33:30.640 --> 00:33:49.839
And I really like Rena and I were, you know, before we started recording, like, pretty in awe that like after all these years of this podcast, we actually haven't really broken things down and really explained to our listeners about these basics AMH, antropolical level, egg freezing, embryo freezing.
00:33:49.920 --> 00:33:51.279
So I I really appreciate Dr.
00:33:51.359 --> 00:33:54.960
Dickin that you took the time to educate us and our listeners.
00:33:55.279 --> 00:33:56.400
Oh, it's my pleasure.
00:33:56.559 --> 00:33:57.599
I love talking about this.
00:33:57.680 --> 00:33:59.680
I can talk about it all day.
00:34:00.240 --> 00:34:02.400
Thank you so much for coming on.
00:34:02.720 --> 00:34:05.839
And we could talk about it all day too.
00:34:06.720 --> 00:34:11.199
The way we like to wrap is by saying something we are grateful for.
00:34:11.519 --> 00:34:15.119
So any gratitude or gratitude that you have.
00:34:15.440 --> 00:34:22.159
Well, I am really grateful to be able to be on your podcast and talk about this and hopefully get the information out to women.
00:34:22.320 --> 00:34:32.960
And hopefully it'll reach, I hope, many women, but even if it's just a handful, so that they hear this and they can go get information about their bodies themselves and understand their fertility.
00:34:33.280 --> 00:34:34.079
I love that.
00:34:34.400 --> 00:34:35.679
Sarah, what about you?
00:34:36.000 --> 00:34:37.519
Well, lots of things I'm grateful for today.
00:34:38.000 --> 00:34:39.119
Meeting new friends.
00:34:39.280 --> 00:34:44.320
I had uh a really nice lunch yesterday with some new friends that really excited me.
00:34:44.400 --> 00:34:58.000
And also, I think getting older and with age really does, at least for me, has come with a lot, I don't know, more reassurance, more I feel like I'm more at ease the older I get.
00:34:58.239 --> 00:35:02.719
And I think as women, sometimes we look at getting older as something negative.
00:35:02.960 --> 00:35:06.880
And I don't know, I'm learning to love it bit by bit.
00:35:07.840 --> 00:35:08.880
What about learning?
00:35:09.679 --> 00:35:10.480
Let's see.
00:35:10.800 --> 00:35:23.840
I am grateful for being able to do this work and being able to talk about this and share this knowledge and be a trusted provider for patients.
00:35:24.000 --> 00:35:25.599
So super grateful for that.
00:35:26.000 --> 00:35:26.480
Nice.
00:35:26.800 --> 00:35:27.519
That's so nice.
00:35:27.679 --> 00:35:29.360
Thanks so much again for being on.
00:35:29.840 --> 00:35:30.960
I I love doing this.
00:35:31.119 --> 00:35:32.320
Happy to come back anytime.
00:35:33.039 --> 00:35:33.760
Amazing.
00:35:34.400 --> 00:35:36.400
Thank you so much for listening today.
00:35:36.559 --> 00:35:45.199
And always remember, practice gratitude, give a little love to someone else and yourself, and remember you are not alone.
00:35:45.440 --> 00:35:49.360
Find us on Instagram at fertility underscore forward.
00:35:49.519 --> 00:35:59.199
And if you're looking for more support, visit us at www.rmany.com and tune in next week for more fertility forward.
