“Mailbag #11: Fertility Questions” – with Dr. Lucky Sekhon

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, I’m joined again by Dr. Lucky Sekhon. Lucky, my friend, my colleague, fertility specialist to the stars, thank you so much for coming back to talk to me and to us and to answer our listener questions from the Mailbag.

Dr. Sekhon: I love a good Q&A. Thank you for having me.

Dr. Fox: This is great. We’re gonna do rapid fire here. I’m just gonna throw these at you like 100 miles an hour, and we’re gonna see, you know, how you do. And I’ll pepper you maybe with some follow-up questions. So our first question comes from Masha.

“Hi. Thank you so much for your most amazing and informative podcast.” That was for me, by the way, Lucky, not for you. “I have a question that you can hopefully answer in the next Mailbag podcast. My friends and I wanted to know if there’s any research between alcohol use and negative fertility outcomes when a woman is not yet planning pregnancy but may try to conceive in the coming months. Does drinking alcohol in safe amounts affect a woman’s fertility?”

Dr. Sekhon: Yes, this is a great question, and I get asked this often, whether people are trying on their own or navigating treatment. You know, I always say, we don’t have to be extreme about anything. I do think that it is okay to have a drink here or there, but really, when you look at the large collection of studies which have tried to relate certain lifestyle patterns and behaviors to fertility outcomes, the suggestion is to keep your intake less than four drinks in a given week. So when I ask patients, you know, their history and, you know, about their habits and their lifestyle, it’s funny because everyone has a different definition of what’s a lot of drinking or what’s an acceptable or moderate amount.

So I think saying four drinks in a given week is, you know, kind of the guidance that I give, and it’s based on evidence. I always tell patients it’s a hard thing to study because a lot of behaviors go together. You know, people that drink 20 drinks a week might also be more prone to be also people that smoke. So it’s hard to kinda tease apart and set in a vacuum, but that’s my guidance.

Dr. Fox: All right, I like that, four drinks a week. Good stuff. All right, our next question is actually the same question from two listeners. I’m gonna read them both. The first is from Bria, and the second is from an anonymous listener.

From Bria, “My husband and I tried to conceive for two years without any pregnancies before doing a round of IVF. Our first embryo transfer was successful, but sadly, we lost the pregnancy at eight weeks. After my hCG levels returned to near zero, we started casually trying again while we waited for a follow-up appointment with our fertility clinic. To our shock, a month after our miscarriage, I was pregnant naturally. After two years of trying without success, we thought we had pretty slim chances of ever getting pregnant naturally. Lots of people say that women are very fertile after a miscarriage. Is this just a myth, or is there any truth to it?”

And the second question, which is very similar, “Hi. I’m obsessed with this podcast. I’m a nurse who is hoping to work in women’s health one day so I find all these topics fascinating. I was wondering if you’d be able to speak on getting pregnant naturally after going through fertility treatment. I struggle to get pregnant and have been through two failed IUIs and ends up going through IVF. Thank God I had a baby almost four months ago, and my OB told me that my odds of getting pregnant naturally are much higher postpartum. Am I technically more fertile now? Can you shed some light on the data and how it works? Thanks so much.”

So, basically, are you more fertile after a miscarriage? Are you more fertile after a birth, and particularly for people who had trouble getting pregnant, for those kinds of pregnancies?

Dr. Sekhon: Yes, I get asked this all the time. I guess the question or the assumption here is that there’s some sort of priming, like, being pregnant, the act of carrying the pregnancy, even if it results in a miscarriage or whether you had a live birth, that it changes your body somehow, like, sets your uterus up for success. And I think there is some sort of association there, but it’s different than what a lot of people are assuming or thinking. It’s not so much, I think, that the pregnancy is priming you to be more fertile in the next attempt. I think, statistically, anyone who’s had a miscarriage, something that I tell them to encourage them is that, statistically, I think of them as being in a different category than someone…

Dr. Fox: Because they got pregnant.

Dr. Sekhon: …who’s never been able to get pregnant. Right. It shows me that the machinery did work to a point, right? Your tubes were open. There was a way for the sperm and the egg to meet. There was a way for that embryo to implant. Why it stopped growing and didn’t progress to a live birth could be a completely unrelated issue, but at least we know a lot of it works. So when we look at our data, we see that women who’ve had prior miscarriages tend to have a higher overall fertility rate, but I think it’s just because you are looking at a different population versus someone who’s been trying years on end and has never once had a pregnancy. Those are kind of two different populations.

I think, you know, for the second, the anonymous listener who asked the question, if she has frozen embryos from that original IVF cycle, then I don’t think it’s wrong to just say, “You know what, I’m ready for baby number two. I’m just gonna go ahead and use one of my frozen embryos because I struggled for this long, and I went through this process, and this is the purpose of why we froze them.” But it’s not wrong for her to try, you know. She could try for three to six months and then say, “Okay, backup plan, I’m gonna use one of my frozen embryos.” I think it depends on how many embryos she has. Because I would be concerned about the timeline, I’m always thinking about, you know, where are we landing in terms of the number of eggs you’re gonna have in case you need to do another retrieval and their egg quality in case you need to do another egg retrieval. So when I say try for years on end and then go back to use one or two embryos, no, I don’t think that’s a good strategy because I kinda wanna know sooner rather than later if those embryos are going to be useful and helpful to us.

Dr. Fox: Right. It’s so interesting because all of us, certainly, people just know people, and certainly, those of us who take care of pregnant people all the time, we all have had the story of someone with years and years of infertility, they do IVF, they have a baby, and we’re like, “Are you gonna do birth control afterwards?” It’s like, “No, are you crazy? I’m in infertile.” And then, like, three months later, they’re pregnant again. Like, what the hell?

And so there have always been, like, three theories. The first, you mentioned, which is that somehow, like, it changes your body. Like, physiologically, your uterus is better, whatever, something is better, which I don’t really understand, but okay. The second is what you said that, well, no, you are now a person who’s had a baby. It’s like a natural selection type of thing. You’re better. But the third that people talk about is this undiscovered sort of nebulous psychological factor. Like, somehow, people…

Dr. Sekhon: Interesting.

Dr. Fox: …you know, that there’s all this stress and commotion and fear and anger and anxiety. And now that you’ve had your baby, that sort of is all, like, released from your wah, you know.

Dr. Sekhon: You know what, I’ve never actually thought of that, and I’ve never heard someone say that before.

Dr. Fox: That’s so interesting because that was, like, the first thing that people would say to me, like…that people said, “Well, since I’ve had a baby, I no longer have…” you know, the part…

Dr. Sekhon: That major fear.

Dr. Fox: Right. The part of fertility that we don’t understand, right, which is somehow, again, whether you call this blaming the mother or whether it’s just something deep that we don’t get, that sort of that, you know, spiritual/psychological/emotional component to pregnancy that somehow your inner sense, you know, your being relaxes, and you get pregnant. So I was, like, I don’t know. I mean, maybe. Like, it’s not implausible, right, obviously, because, certainly, there can be a component of our mental health affects our physical health. But those are the three theories. So you’re more in line with theory two.

Dr. Sekhon: I’m more in line with theory two, although, I will say, this is an anecdotal case, but I did have a patient who had years and years of, from an eating disorder, not ovulating and had a super paper thin lining that just never got thick. And we ended up doing a transfer with a very thin lining, and it worked. And that was great. And then, when she came back for baby number two, her lining was beautifully thick and responded well. And that, to me, makes a little bit of sense…

Dr. Fox: Number one. Maybe number one, yeah.

Dr. Sekhon: …because maybe the uterus in that case did actually get primed. Because I think the reason it was thin was because of such long-term estrogen deprivation.

Dr. Fox: Right.

Dr. Sekhon: So I do think that, you know, there are times where maybe the priming thing makes sense. Also, you know, I feel like people don’t realize how illogical our reproductive system can be, because all of those explanations are logical, but when you think about what could have happened, especially, for example, when patients come to me and they’re like, “Listen, I’m 40. I’m going through infertility. Don’t understand because my mom had me at 43 so I thought I was gonna be super fertile,” and I explain to them, “I don’t know what cosmic forces lined up in the universe that your mom happened to ovulate a healthy egg where there was a lot of unhealthy eggs at that age, probably.” And everything lined up perfectly, but that can happen to anyone. Like, there’s that serendipity and chance element that’s not logical, and you can’t put your finger on it, but that’s also something that’s at play as well.

Dr. Fox: Yeah. I mean, it’s similar. If you go back, like, let’s say you have a couple that’s younger, why did they have two years of infertility? And so it could be, you know, unexplained infertility. We don’t know why. You tried this, tried that. It could have just been they’re the outliers who have really bad luck, right?

Dr. Sekhon: Exactly.

Dr. Fox: Someone’s gonna have really bad luck, right?

Dr. Sekhon: Exactly, yeah.

Dr. Fox: Someone’s gonna have really good luck, and someone’s gonna have really bad luck. And so it’s possible that there never was a “problem,” just the odds didn’t fall in their favor. They’re the ones that lost all the money in Blackjack, you know, and then you come back the next day and you win all the money.

Dr. Sekhon: Exactly.

Dr. Fox: There is such an element to that with fertility. It doesn’t mean you shouldn’t do workups and do the right tests. Like, obviously, you got to do it right, but some of it’s just that’s just all it is.

Dr. Sekhon: Yeah. Another example is, you know, a patient who, in her early 30s, came to me, ended up getting, like, 10 embryos from her IVF cycle, but only 1 was normal out of the 10. And we did specialized testing. I did karyotypes because I’m like, “Maybe they’ve got something going on.” Nothing came up, and they did another round, had a similar number of embryos, and, like, 8 out of 10 were normal. So what people, you know, who aren’t maybe familiar with biostatistics need to understand is that when you have a random collection of eggs, randomly recruited in that cycle, that’s not necessarily going to be representative of what’s going on with all of your eggs. And so there’s all of this randomness and skew of the statistics you are expecting, but eventually, when your numbers get high enough, we get something called regression to the mean, right? Eventually, things will start to make sense for most people.

Dr. Fox: Right. All right, great. Next question, from Michelle. “Hi. Yes, I also found you through ‘The Toast.’” Are you familiar with The Toast?

Dr. Sekhon: No.

Dr. Fox: Oh, my God. Because you’re not a millennial, right?

Dr. Sekhon: I don’t know what I am. Because I was born to immigrant parents, sometimes I feel like I’m a boomer. I have no idea what’s going on.

Dr. Fox: So our listeners know this. The Toast is a very popular podcast amongst the millennials.

Dr. Sekhon: Okay.

Dr. Fox: God bless them. And I delivered Jackie’s, one of the Toasters, babies, and so I was on that podcast.

Dr. Sekhon: Oh, cool.

Dr. Fox: And so, now, God bless, we love the Toasters, many of them jumped down to our train.

Dr. Sekhon: Amazing.

Dr. Fox: So when you hear this in the question, that’s what it is. See?

Dr. Sekhon: I’m gonna have to take a listen. And honestly, I’m trying to become very Gen Z because that’s where it’s at right now, so.

Dr. Fox: Yeah. You’ve already, in the last podcast, dropped a couple of, like, pop culture references. You mentioned the Kardashian. I don’t know which one you did, but whatever. So you would definitely be on board with this because they’re all pop culture, and they’re really, really funny. All right, here we go.

“Hi. Yes, I also found you through The Toast, and I’m so happy I did. Such an informative and easy podcast to listen to. Everything is talked about in such a common understanding way.” By the way, I only read this to, like, make me sound good. There’s nothing to do with…

Dr. Sekhon: I know. Like, where are my compliments?

Dr. Fox: Yeah, nothing to do with this. Well, they will. They’ll send another. All right, my question is, now that Naty’s done complimenting himself, “My question is I removed the Mirena IUD.” I actually hope you had a doctor remove it, Michelle. If you removed it yourself, then all of the power to you.

Dr. Sekhon: That’s talent.

Dr. Fox: But let’s assume that’s what you meant. All right. “I removed the Mirena IUD about six months ago, and I can tell my hormones are not fully back to a settled place. Example, spotting after period for days. I was told this happens because of uneven hormones. Would it be a mistake to try and conceive at this time? My OB had told me to wait six months to try to be safe. Thank you.”

So there’s two questions in here. One, is there a problem with “her hormones?” And two, is it a mistake to try to conceive after your IUD comes out?

Dr. Sekhon: Okay. So the IUD is an immediately reversible form of contraception. So when you pull the IUD, when you have someone else remove it…

Dr. Fox: Yeah, preferably a doctor, a midwife, or someone.

Dr. Sekhon: Exactly. Insert disclaimer here. You should assume that you’re going to be able to get pregnant right then and there. And I mention that because, a lot of times, people will say, “Maybe I need to stop this form of birth control and give myself, like, three to six months to warm up.”

Dr. Fox: Like a washout, yeah.

Dr. Sekhon: Expect that you might get pregnant right away. That could happen. And I don’t think it’s a problem.

Dr. Fox: Again, I don’t know who your OB is or whether they actually said this or meant to say this, but if they said it, that’s not typical. Typically, we don’t tell people to wait after…you know, “Go have sex tonight.” Like, whatever, if it works, it works. But there’s no danger to it in that sense.

Dr. Sekhon: Correct. I don’t think there’s necessarily something dangerous if you conceive while having this history of irregular spotting through your cycle. However, since you know about it and you’re noting it and you’re not pregnant yet, I think you should get it investigated. And it’s usually one of two things when I hear this type of history. The most common thing is there’s something going on inside your uterine lining, and the most common thing would be a polyp, which is essentially like a skin tag. You know, a lot of us get polyps, and they come and go, and they can break down with your period. Sometimes they’re bigger, and they’re gonna be more persistent. But they’re really vascular, they have a lot of blood flow, and they can cause a lot of pesky spotting throughout the cycle, especially after you ovulate because of the hormonal changes.

So an easy test that you can do is a saline sonogram or just even start with a basic sonogram. But the best thing to do is a saline sonogram because you really have this collapsed cavity. That’s what the uterus is, and it’s, like, imagine, you know, two edges of a shag rug against each other. It’s easy for things to hide in there. So you wanna inflate the uterine cavity with fluid. In a saline sonogram, you’re gonna be able to see whether the cavity has a nice smooth contour, or do you have things jutting into it, like a polyp or even a fibroid? And if you have those, it makes sense, I think, to get them removed in a really simple procedure called hysteroscopy because it’s gonna create a better environment for an embryo to implant, and you know, the uterus doesn’t like blood, so it’s just better to not have that as a factor.

Now, if you do the tests and everything is normal structurally, it is true there are certain hormonal changes or imbalances that can make you predispose to your progesterone level fluctuating after you ovulate and that causing this irregular spotting. That’s less common. The things to look out for are thyroid function, so get your thyroid checked, and a hormone called prolactin. All of that can interfere with the signals that your brains are sending to your ovary.

Dr. Fox: If she has one of those, it was not because she had the Mirena IUD.

Dr. Sekhon: Correct.

Dr. Fox: Right. It’s just, coincidentally, right.

Dr. Sekhon: Well, the Mirena usually stops you from bleeding.

Dr. Fox: Right, exactly.

Dr. Sekhon: So that’s, like, one of the treatments for what we call dysfunctional uterine bleeding. And so, if anything, it was probably keeping these symptoms at bay.

Dr. Fox: Right. We talked about this in the last podcast specific to pills, but it’s the same with the Mirena. If someone gets their Mirena out and then they have irregular bleeding, it’s very unlikely because they had the Mirena in. It’s just this would have happened otherwise, but the Mirena was sort of preventing it from happening in a therapeutic way. Okay, good stuff.

All right, next question is gonna be from Brielle. All right. “Hi, Dr. Fox. I came across your show not too long ago, and I genuinely enjoy each episode I listen to. I apologize…” See, Lucky, see how I do this? “I apologize in advance for the lengthy question.” Hey, do not apologize for lengthy questions. I could always edit them.

“I suffered an ectopic pregnancy that was treated with two doses of methotrexate. This was my second pregnancy. My first was totally healthy and uncomplicated and resulted in the birth of my daughter who’s now 21 months old. I was told I need to wait three to six months post-methotrexate to conceive again. It seems that this advice varies from doctor to doctor, and I cannot find any evidence to support such a long wait when methotrexate is used in such small doses for the treatment of an ectopic pregnancy. I would be inclined to wait the full recommended time, however, my husband has now had two vasectomy reversals as he is prone to scarring, long story, is why that was necessary, which I won’t go into. I am worried that if I wait another two months, we will be dealing with male-factor infertility and have no choice but to do IVF. Would you recommend waiting despite my complicated circumstances?” And then the second part, “In hindsight, I wish I had just done surgery, but as you know, these decisions are often made quickly, as waiting a day to think things through isn’t really an option. I appreciate your insights.”

So I’m gonna break that down for you. Question number one is related to, in general, should someone wait that long after methotrexate before conceiving? Hard to get very specific into Brielle’s own circumstances because we don’t exactly know the male factor here. And then question two is, okay, when you’re seeing someone with an ectopic and you’re counseling them about methotrexate versus surgery, how do you take into account future fertility with that decision? Obviously, there’s pluses and minuses to surgery versus medication at work. You have surgery. We got a podcast on that but specific to fertility.

So first question, how long do you tell people to wait after methotrexate?

Dr. Sekhon: Three months.

Dr. Fox: Yeah. And it’s a pretty hard line on that because…

Dr. Sekhon: I’ve never said six months.

Dr. Fox: Yeah. I mean, the fear is that methotrexate really causes birth defects. It’s not like one of the medications that might, maybe. Like, it’s bad, right? You do not want to be on methotrexate when you conceive. And how long does it take to get out of your system? It’s probably at least a month, and so we put a buffer on that and so two to, like, three months. And so it’s a pretty standard recommendation. So I would not recommend trying to get pregnant within three months of methotrexate. That doesn’t mean there will be a problem if you do get pregnant on your own or whatever, but I would not intend to get pregnant after methotrexate.

Dr. Sekhon: A lot of fertility clinics allow patients to start preparing for an embryo transfer, maybe, you know, three weeks into that three-month wait, at the tail end, as long as they know the transfer is happening outside of that 90-day wait.

Dr. Fox: Yeah, yeah. Okay. So the second question which I think is the bigger one, so obviously, you see people with ectopic pregnancies.

Dr. Sekhon: Yeah.

Dr. Fox: And you’re deciding giving methotrexate versus doing the salpingectomy to remove the tube surgically.

Dr. Sekhon: Yes.

Dr. Fox: Aside from the general medical/surgical risk-benefit, how much do you get into the fertility aspect of it?

Dr. Sekhon: Well, I pride myself on being very proactive and on top of ectopics. We always say, at our clinic, it’s seldom that you’ll ever have a patient with a ruptured ectopic in the middle of the night because we pick them up early from doing diagnostic imaging, sometimes sending them your way for diagnostic imaging, and follow their hCG or pregnancy hormone levels. So we can kind of see from a very early stage, this is a pregnancy that’s suspicious. We can’t see where it is, but it’s behaving like an ectopic pregnancy would with, you know, an oscillating hCG level.

So sometimes the choice is not available because we don’t actually see it, right? And I’ll explain what I mean when I say that. Let’s say I have someone with an abnormally rising hCG level, and I know this is not a normal pregnancy. At this point, we’ve given it multiple data points, and we know that it’s not tracking normally. I don’t reflect simply to say, like, “Let’s just give you methotrexate because I think this could be an ectopic.” A lot of times, I will do things like a very gentle D&C where we bring them in, we sedate the patient with similar sedation to what’s given during an egg retrieval, takes about 5 to 10 minutes, and we just basically will kind of disrupt the linings.

If the lining is thick, you know, a lot of these are early abnormal pregnancies inside the uterus, so I might disrupt the lining a little bit, and that way, the thought is if there’s an early abnormal pregnancy inside the uterus, it’s not in the tubes, it’s not an ectopic, and the hCG level goes down tomorrow because I’ve disrupted that process that was happening in the uterus, because it’s kinda like trying to persist, but it’s not doing so successfully, then I know that this patient doesn’t need methotrexate.

Let’s say the levels continue to rise the next day. Well, that’s a situation where I would offer them methotrexate because I would say I’ve now proven that even despite disrupting anything going on in the uterine cavity, something is continuing to grow. And where else could it be? It’s an ectopic. So in those situations, I’m not gonna offer surgery to the patient because I wouldn’t know what to take out, right? I can’t tell. Is it in the left tube? Is it in the right tube? Where is this? So the only option at that point if you’re trying to nip it in the bud is let’s give methotrexate. And studies have shown, if you give methotrexate earlier, it has a better chance of working, right?

So those are situations where the choice is obvious, and what I tell patients is they need to wait three months, and it’s not from time of resolution where the levels are now negative but from the time that the methotrexate was administered. And we monitor for that first week. We check, you know, four days later, seven days later. And as long as there’s at least a 15% drop in that level between day 4 and day 7, then you’re considered treated. Otherwise, you’re giving another dose sometimes, as this listener had to have. And then you’re just kind of keeping track of the levels every one to two weeks once you’re successfully treated, making sure it resolves completely. Patients can still have a ruptured tube even though they got the methotrexate. So that’s something I always tell patients.

I might be giving you this 90-day wait that you’ve now bought into, and you might still end up needing surgery, so you have to be okay with that. And let’s say you do see it on the ultrasound. Now, this is when I talk to patients about, “You have the option of doing the methotrexate, or we can surgically remove the tube.” Now, obviously, I don’t take surgery lightly, but the surgery that’s done for, especially in a nonemergent setting where the person is not bleeding…

Dr. Fox: Right, it’s pretty low risk.

Dr. Sekhon: It’s very low risk, and you know, if they have a sense of urgency, it might be nice to just take care of this definitively, and that way, they can just kinda get back on the path to fertility treatment right away. Obviously, there’s gonna be a little bit of downtime, but it’s a minimally invasive approach, and you know, sometimes, having this ectopic, it’s damaging to the tube so that this thing about just removing the tube is, now, it’s no longer communicating with the uterine cavity, because having tubal damage can actually interfere with the uterine cavity environment and make an embryo less likely to implant or more likely to miscarry.

So after I’ve treated someone with methotrexate successfully, I usually send them for an HSG because I want to examine the tube. And a lot of times, it’s great, you know. The methotrexate did a good job. It dissolved the ectopic, and there isn’t any residual scarring or issues. But once in a while, I’ll find that there is a tubal issue, and maybe that was the underlying risk factor for why this happened, and it just wasn’t picked up previously.

So those are kind of the different things I think about. It really depends on the situation, and I don’t think three months is that detrimental to someone’s fertility, and that’s something important. Obviously, she has a different situation with the vasectomy. And maybe as a side note, I would consider whether he should freeze a few vials of sperm. So, that way, you have other options as well.

Dr. Fox: Yeah. I agree that when it’s very early, there really isn’t an option for surgery because you don’t know what you’re taking out. It comes up when we see the ectopic and we’re trying to decide, it sounds like, “Well, if I remove the tube, won’t that reduce my fertility?” And what I always tell people, sort of, again, as not a layperson but not as a fertility specialist, I say, “Potentially, obviously, you’d rather have two tubes than one tube.” But the question is you had an ectopic in this tube. So number one, why? It could have been from an underlying tubal problem, in which case, we can fix it, but maybe you’ll get another ectopic there, or like you said, it could be toxic. And number two, the ectopic itself could have damaged the tube.

And so it’s not necessarily better to have an ectopic relieved by methotrexate than by surgery. It might be better. It might be worse. And it’s really hard to know for sure from a fertility perspective which way you’re better off. And again, if you pick them up very early, you’re going to do methotrexate because it’s before that even happens.

Dr. Sekhon: Yep. And your fallopian tubes do not produce hormones. They’re just a conduit, a place for the sperm and the egg to meet. And by the way, a lot of people think that you ovulate one month on the left, one month on the right. And so, automatically, this detracts your chances by 50%. That’s not true. You ovulate randomly. Sometimes it could be three times from one side and then two times from the other. And you can have what we call contralateral transfer of an egg to the opposite too.

Dr. Fox: Right, it flips over.

Dr. Sekhon: Because the tubes aren’t like what you see in a diagram. They’re not out like a T shape. They’re actually hanging out kind of dependent, like, down by both of the ovaries, which often are right next to each other behind the uterus. They kind of move around a little bit. So there is an ability to ovulate from one side where there isn’t a tube and for it to be picked up by the opposite side too.

Dr. Fox: We definitely see that because an ultrasound when someone’s pregnant, you can see which ovary the egg came from, typically, the corpus luteum. And sometimes we know someone had their left tube removed, for example, and we see that on the left side. You’re like, “Whoa, like, you got pregnant from, you know, the side that doesn’t have a tube.” And so, yeah, it absolutely does happen.

Dr. Sekhon: It will diminish your overall success by a little bit, but definitely not by 50%.

Dr. Fox: All right, cool. All right, next question is about fibroids. Coleen sent in this question. It’s a pretty long question, and it’s specific to her, but I want to sort of summarize it by basically saying the question as follows, Lucky. How do you counsel women about fibroids prior to pregnancy? Meaning, if you see…because these fibroids, a lot of women have them. They’re in a lot of different locations. Are there certain fibroids that you say, “This needs to be removed automatically?” Meaning, before even start trying. That’s sort of Category A. Category B is this is a fibroid that we’re going to watch. We’ll see how you do. And if you have problems conceiving or miscarrying, I’ll remove it. And category number three is under no circumstances are we removing this fibroid. That’s crazy talk. It has nothing to do with this.

Dr. Sekhon: Yes, right. So when you think of the uterus, it’s a big, thick muscle, right? And it has an inner lining. That’s the cavity where the embryo is gonna implant, and that’s what builds up and sheds every time you get a period. Then you have kind of the wall, which is all muscle, and then you have, like, the surface of that muscular layer. And so that’s, like, on the outskirts of the uterus. And so if you ever look up what fibroids look like in a diagram, you’ll see them labeled according to where they’re located in the cavity.

The ones that are in the inner lining that kind of jut into the cavity and they’re very obvious when you do tests like a saline sonogram, those are called submucosal fibroids. And in general, I would say they’re taking up valuable real estate, and even if they’re small, like 1 centimeter, I will, in general, recommend removal.

Dr. Fox: So they’re like the squatters in New York City, those fibroids. So you’re on the side of removal. All right, there we go.

Dr. Sekhon: Yes, because I feel like…

Dr. Fox: Politically, for fibroids, Lucky is, “Get the squatters out.”

Dr. Sekhon: Yes.

Dr. Fox: All right.

Dr. Sekhon: You know, I think that having said that, people will have these submucosal fibroids and be able to get pregnant.

Dr. Fox: Sure.

Dr. Sekhon: But there is a potential risk for miscarriage, right?

Dr. Fox: Sure.

Dr. Sekhon: Because sometimes that fibroid could encroach upon the space that that embryo, and eventual fetus, needs to grow and expand. And it can cause issues with even, like, the placenta and how it implants. So not to scare anyone, but definitely, it’s something that usually I will say to remove. If it’s intramural, meaning, it’s in that thick muscle wall. Let’s say you have, like, a 2-centimeter. It’s not jutting into the cavity. You didn’t even know you had it. Forty to 80%, which is a garbage statistic by the way, depends on which population you’re looking at, but 40% to 80% of women have fibroids. They’re super common. A lot of people listening on this right now have fibroids and have no idea about it. I can guarantee it. And if it’s not causing heavy periods or pain because they’re large enough that they’re pressing on your bladder or your bowel, then they’re not an issue. And you know, someone who had, like, a 2-, 3-centimeter fibroid that’s in the muscle wall of the uterus and it’s not bothering anyone, I would never say, “Go have surgery and have someone make an incision on your uterus to remove this.” It’s not affecting anything.

But if it’s larger and there’s multiple, let’s say you have over 5-centimeter size fibroids and there’s many of them, and like, they’re kinda taking up a lot of the bulk of the uterus, which is that big, thick muscle, that could reroute blood flow from the inner lining. That can just create an overall environment that’s not as conducive to fertility, and it can cause problems, as you know, during pregnancy because there’s rapid growth of the uterus, and fibroids have a lot of blood supply, and the fibroid could outgrow its blood supply because of the changes that happen during pregnancy with the way the uterus grows. And people come in with pain. It’s almost like your fibroid is experiencing, like, a heart attack, and it can cause things like contractions, preterm labor.

So you know, if I think someone has enough fibroids that are large enough that they could be at risk of degeneration during pregnancy or that they are struggling and it’s hard for them to get pregnant, it might be something to consider. If they’re having really heavy periods and bulk symptoms where it’s, like, pushing on the bladder every time they’re having constipation when they’re trying to go to the bathroom, those are issues that I would rather you rectify before getting pregnant. Having a large uterus in the mix as well, right?

If it’s on the outskirts, it’s called a subserosal. It’s, like, on the surface of the uterus. I’m not so worried about those, but again, it depends. Are they so big that they’re pushing on other vital structures or organs? So you kinda have to look at the whole picture, but it’s really those submucosal ones or intramural, in the muscle wall, if there’s many of them and they’re kinda pushing on the cavity anyway even though they’re not inside the cavity, those are the ones that I usually recommend removing.

And I’ll add, if someone comes to me even for egg freezing, but I can’t get to their ovaries because the fibroid is in the way and I can’t even see an ovary on one side, how am I going to retrieve eggs from that ovary? I’ve had patients, because they’re like, “I am symptomatic anyway, now is the time to get the surgery, because after that I can have my egg retrieval.”

Dr. Fox: Right. Yeah, no, and listen, it’s a tough question because it’s so individualized, because, also, many times, when we do the surgery, not for the ones that jut into the cavity but the ones on the outside, if you do the surgery, take them out, they now need C-sections for their deliveries. And so, okay, it’s not the end of the world, but it’s a big deal, right? Now, your deliveries are gonna be different. And so it’s always sort of, again, unlike when we’re talking about ectopics where the surgery is very straightforward, when you take out fibroids, the surgery may or may not be straightforward, but it has more repercussions afterward. So it’s part of the equation, but it really has to be individualized in that sense.

All right, last question from Alyssa. “Hi, Dr. Fox. Firstly, a huge thank you for all that you have done in creating such a high-quality research for women’s health education.” But I didn’t make this up. People actually wrote this to me.

Dr. Sekhon: No, I listen to your podcast, so I second all of these compliments.

Dr. Fox: All right, God bless. It’s going to get better at the end. “It’s been immensely valuable to me and so many others. Now, for my question.” Like, why didn’t I cut out the beginning? Because I don’t want to. All right. “Now, for my question. I’m a 26-year-old woman who is planning on delaying pregnancy until about the age of 33 for career reasons.” It’s very precise.

Dr. Sekhon: I know.

Dr. Fox: I like that.

Dr. Sekhon: I like her personality.

Dr. Fox: That’s someone who had, like, one of those planners when I was in middle school. We call them…what are they called, Chandlers?

Dr. Sekhon: Agendas.

Dr. Fox: I don’t know what they’re called. Like, the little black books that had, like, every single day. This is pre-phones. All right, back to your question. “Is there anything I can do to evaluate my fertility now,” we talked a lot about this in the last podcast, “so I could perhaps pursue fertility preserving methods such as egg freezing? I’ve had chlamydia before so I’m concerned that my tubes may be blocked. If I would need to do IVF in the future anyways, my thought is that I may as well freeze eggs now. I’m also worried about diminished ovarian reserve/poor egg quality. Additionally, I have PCOS. Thank you again. You’re the GOAT.” Thank you for that.

So I guess the main questions are, you have someone who’s young and healthy, right, and she knows that she’s gonna be waiting X amount of years. At what point when you see them do you say, “You know what, it makes a lot of sense to freeze your eggs now versus let’s check on it again when you are closer to 33?” Like, how would you handle sort of that specific scenario?

Dr. Sekhon: I mean, this is clearly a forward-thinking individual who wants to plan everything out, right?

Dr. Fox: Great. We love it.

Dr. Sekhon: And I always say, there’s no downside to doing egg freezing for fertility preservation. My job is to be conservative, so I’m never gonna be the person that says, “Ah, you don’t need to do this,” right, especially if someone is going to find themselves in their mid-30s and beyond, trying to build their family. To me, then, the answer is always going to be, yes, I recommend freezing something just because of what we know about when egg quality starts to change a little bit more rapidly, right? Your fertility doesn’t fall off a cliff at age 35, but you do see a much higher rate of having eggs turn into admirable embryos that are missing or have extra DNA, right, that don’t have the ability to turn into a healthy pregnancy.

Everyone still has normal eggs, you know, when they’re in their 40s, but it starts to become harder to ovulate that healthy egg naturally on your own. And even in your early 30s, I would say if I was to take all the eggs out of your ovaries and fertilize them with sperm and turn them into embryos, I would expect about a third of them to have those errors. And when it was as good as it gets in your 20s, it was like 20% to 25%. So no one makes perfect embryos from their eggs. That’s the first thing to know. And the rate at which you have eggs being released on a monthly basis that could give rise to an abnormal embryo increases much more sharply at 35. Like, by the time you get to 38, you’re looking at 50%, and by the time you get to 40, 70% of embryos test abnormal, 30% are normal.

So it almost increases just based on age alone. There’s an increased risk of needing a little bit of assistance. I’m not saying everyone is gonna need an IVF, but it just might take longer. It will be a little less efficient, right? And so having a store of eggs from when you are younger, especially in your late 20s, when the conversion rate to a healthy embryo is much higher and you’re probably gonna have access to a lot more in a given egg retrieval now versus what’s available later down the line, because the number that get recruited, it’s almost like a rationing, it’s gonna reflect how many you have stored up in the vault, in the ovary, right? So you’re just giving yourself a head start if and should you ever run into problems.

And I think it’s not just about age. Anyone who has any sort of gynecologic condition, she mentioned PCOS, that puts you at a slightly higher chance of needing a little bit of assistance or intervention. And it could mean, you know, getting you to ovulate regularly with medications and helping you track your cycle. But after a certain point, that’s gonna get old, and you might say after six months of doing that, “Okay, let’s just move on to IVF at this point,” right? That’s kinda like the next step or progression and the most effective and efficient treatment option that we have at our disposal right now.

So you’re essentially setting yourself up for future success if and should you ever need IVF. And to me, the main downside is the effort required, which is really, it’s a two-week process. It’s taking injectable medications. They’re subcutaneous injections, meaning they’re not scary long needles. It’s pretty user-friendly, and most of my patients are able to do them on their own without issues. And then you’re coming in for a procedure, which I wouldn’t even call a surgery. It’s a very minor procedure done vaginally while you’re sleeping for 5 to 10 minutes to take the eggs out. And the recovery and downtime is very, very minimal. It’s one day that you take off. I think the effort and the time and then also, of course, the cost, it’s expensive, that’s the downside. If to you that’s not a downside because the company you work for has fertility benefits and this would be covered, to me, it’s a no-brainer. You should do it.

I think if you’re paying out of pocket, unfortunately, like, you know, as a physician, I don’t want to be talking about money and costs, but we have to be practical on things. So if someone comes to me and they’re like, “I’m 30. Should I be freezing my eggs? But I’m in a relationship, and we’re going to start trying, you know, by the end of the summer, and we only want one child,” I’m like, “Well, then maybe just try and do that.” But if they’re like, “I wanna have three kids, and I’m not ready to start until I’m 33,” well, you’re inevitably going to be in that over 35 zone where there’s a higher chance of needing assistance. So why not have a backup plan?

Dr. Fox: Yeah, it always seemed to me that, again, the potential downside is time and effort, like you said, a few weeks, costs. And just so everyone knows, so much of the costs are the medications. It’s not like the doctors, right? Really, the medications are extremely expensive, and that’s just a pass-through from the pharmacy, essentially. But it is what it is. They are expensive. And I guess, potentially, some consternation later in life that I have these frozen eggs or frozen embryos and what do I do with them. Right, you know, okay. Like, there may be some I wish I didn’t have to make this “ethical decision,” if someone views it as an ethical decision or not, whatever. I’m adding that to the list for a lot of people to know the downside, but for some, it might be.

That’s it really. It’s not a particularly dangerous procedure, as you said, and you know, I guess it’s unpleasant from a physical standpoint, but as things go, it’s not quite as bad as other things we do in medicine to people.

Dr. Sekhon: Yeah. I mean, I guess I can say this and you don’t have to react, but I don’t think I’m the best patient. I’m known to be anxious, and you know, I’m very different as a patient than I am as a physician. And I went through the process, and I remember thinking to myself, “Wow, I actually am pleasantly surprised,” because I was expecting it to be worse for me. I hate needles. I hate being poked and prodded. It went by really quick. And obviously, you know, I had the benefit of doing it where I work, and so maybe I was just more familiar, and that made it easier. But I did feel like it was shockingly easy compared to a lot of how it’s portrayed and how people view it.

Dr. Fox: Yeah, cool. All right. Lucky, thank you so much for sticking around, doing podcast number two.

Dr. Sekhon: This was so fun.

Dr. Fox: Yeah, we’re definitely gonna have you back because you’re awesome, and this was great, and I learned a lot.

Dr. Sekhon: And then next, I’m gonna read the compliments about me.

Dr. Fox: Yeah, we’re gonna hang on to those because you are the GOAT. Awesome. All right.

Dr. Sekhon: Thank you so much.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.