“Myth Busters, Fertility Style!” – 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 OBGYN 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, Lucky, welcome to the studio. Nice to see you in person. You’re wonderful.

Dr. Sekhon: Thank you for having me. I honestly love the opportunity to sit, chat with you. It’s been how many years now since residency?

Dr. Fox: I don’t know, too many.

Dr. Sekhon: Exactly. I feel like the last time we sat together like this was, like, journal club.

Dr. Fox: Crazy. Crazy. My how you’ve grown. Look at you. You know, a fancy doctor in Manhattan. You’re seeing patients. You’re getting people pregnant. You’re a social media sensation. It’s amazing. Good stuff. I’m really happy you agreed to do this.

Dr. Sekhon: Thank you. I’m excited. I’m excited about our topic today too.

Dr. Fox: Yeah. So we’re going to talk about fertility myths. I did a podcast with Melka on OBGYN myth busters and this is like a perfect sort of follow-up to that related to fertility myth busters. But before that, if you could tell our listeners who you are, like where are you from? How’d you get into medicine? You know, just give us a little background.

Dr. Sekhon: Okay. So my life story in a nutshell.

Dr. Fox: Pretty much.

Dr. Sekhon: So I am originally from Canada. I moved to New York to pursue my residency training in OBGYN at Mount Sinai. That’s where I met you and your team and I’ve loved working with you guys since. And then stayed on for fellowship at Mount Sinai, but specifically where I work now at RMA of New York. We’re a large fertility practice, mainly based in New York City. We do have multiple labs. So we kind of have our tentacles in all of the boroughs, Westchester, Brooklyn, Long Island. But I’m based in our SOHO office and I’ve been practicing now, graduated from fellowship, double board certified for, I’m actually on my sixth year now. And a lot of what I do in my practice is helping people build their families, but also helping people strategize and preserve their fertility for the future. So there’s a lot of different things that we do and we’re, like I said, a very large volume practice. So we do a lot of it and we’re really good at it. Outside of my day job, I spend a lot of time almost doing a second job, which is myth-busting pretty much, which is why I thought this was the perfect topic for us today. But I spend a lot of time on social media trying to just educate because you and I both know that women’s health is always the easiest target for misinformation and for people trying to grift, make money, you know, sell different things that maybe aren’t actually proven strategies or therapies for the different problems that we treat. So I love what you do and honestly, I think that you and I see eye to eye on so many different things and both kind of have a similar mission outside of our day job of treating patients. We want to make a difference and make a larger impact for even patients that aren’t seeing us.

Dr. Fox: Cool. How did you decide to go into medicine originally? Were you considering something else?

Dr. Sekhon: Yeah. I actually, you know, I grew up raised by my parents who had immigrated from India and I don’t know if I’m allowed to say this. This is politically incorrect and it’s a major…

Dr. Fox: In this podcast, say whatever the hell you want, it’s fine.

Dr. Sekhon: Okay. But basically…

Dr. Fox: This is an adult podcast.

Dr. Sekhon: I mean, in my culture, it’s just very much like, okay, everyone, they really want you to be a doctor. So I grew up kind of rebelling against that and I told my parents from a very young age, “I will not be going into medicine. And nor will I marry a doctor.” And they were like, “Okay, fine, that’s fine.” But then…

Dr. Fox: They were playing you like Jedi mind tricks.

Dr. Sekhon: Exactly.

Dr. Fox: Like, okay.

Dr. Sekhon: But then everything that I enjoyed and was passionate about in my education was like biology, physiology. And then I was really interested in women’s health because I think because I grew up in a matriarchal type household. So there were a lot of things, a lot of norms that were flouted in my household. You know, my mom worked and was very progressive and forward thinking and there were three girls in my family and we talked about women’s health topics at the dinner table. And it wasn’t as taboo as what you would think it would be. And I feel like I just felt really comfortable and I thought it was empowering to be involved in women’s health. And then I did an internship with a male urologist and learned about IVF and male infertility. And I thought that was really cool. I mean, to be part of a field where, you know, the inventors of this technology are walking amongst us and everything’s moving so quickly. And I also loved the idea about fertility preservation. It just seemed very empowering.

Dr. Fox: So are either of your parents doctors?

Dr. Sekhon: No.

Dr. Fox: No. So then your dad was cool with your sisters and your mom talking about your periods at dinner?

Dr. Sekhon: I mean, he kind of had to be. He’s like…

Dr. Fox: Okay, I’m surrounded by ovaries.

Dr. Sekhon: Yeah. He’s surrounded by ovaries. Exactly. There’s a lot of estrogen in that house. And I also had a lot of girl cousins. Like it just, it was the way we grew up and it was just a very natural thing that I tried to resist. But here I am.

Dr. Fox: Are either of your sisters doctors?

Dr. Sekhon: So one of them is, but she mainly does research. I’m the only clinician that’s practicing and the other one’s a lawyer.

Dr. Fox: Okay. Got it. So you won.

Dr. Sekhon: I don’t know.

Dr. Fox: You’re the winning child.

Dr. Sekhon: I feel like we needed the trifecta. One of them should have gone into software engineering, I married a software engineer so that’s okay.

Dr. Fox: Okay. Excellent. And then tell us about your social media presence. Like what’s your, I don’t know what they call them, handles or tags. I’m so old. It’s so sad. Who are you on social media?

Dr. Sekhon: You are the person that needs to be on there because you’re one of the funniest people I know.

Dr. Fox: So we’re on social media, but thank God I have someone, Emily, who does that part for me cause I would, I’m not horrible. Like I can do it. I’m just not savvy is what I would say. So where, where are you? How do people find you?

Dr. Sekhon: So I am mainly on Instagram. I have a TikTok account as well, but I’m trying to figure that out. I hear all the young people are on TikTok. So that’s the next wave if it was like a band, but that’s another story. My handle for Instagram is at @lucky.sekhon. S-E-K-H-O-N. And I also have a blog called “The Lucky Egg”. And that’s where you get a lot more detailed information and links to articles and things I think are really essential.

Dr. Fox: And last I checked, you have like four billion people who follow you or something like that. It’s some crazy number.

Dr. Sekhon: I think it’s closer to like 60,000. But I have a lot of engagement. It’s really, if you look at who my followers are, 98% are women.

Dr. Fox: Yeah, of course.

Dr. Sekhon: And the majority of them are in New York. So it’s a weird thing because it’s not a huge following if you compare it to other people. But it’s very concentrated. Everyone is there for a reason.

Dr. Fox: Yeah. No, we have, I mean, we have the same sort of demographic obviously. And so when we look at who listens to our podcast, it’s bigger than I ever thought it would be. But it’s not like crazy huge, but it’s like everybody is like basically female age 18 to 50.

Dr. Sekhon: And they’re there for a reason.

Dr. Fox: And highly engaged.

Dr. Sekhon: Yes.

Dr. Fox: Right. And so, which is nice. I mean, it’s what you want from your listeners.

Dr. Sekhon: It’s so gratifying. You don’t want to be screaming into a void.

Dr. Fox: Yeah.

Dr. Sekhon: So it is nice. As much as people are like follower count and your likes and your views don’t matter, it does matter because it’s a living organism. You can kind of see what’s resonating, what are the messages people are craving and looking for guidance on. And you can kind of follow that path and figure out what your next step should be. So you kind of evolve and grow with it. But you have to be equally as engaged. And I would be embarrassed if you made me show, you know, my weekly report for my screen time because I am on the app a lot, but a lot of its creation, not consumption.

Dr. Fox: Yeah. You’re not just scrolling and looking at videos of cute dogs.

Dr. Sekhon: Yeah. I mean, there’s some of that. But yeah, I’m on it now. And honestly, I’m using it for a couple of different things. I use it to, I think, humanize doctors and IVF clinics because I think people feel very afraid when they step into a doctor’s office. And when you’re afraid, you’re anxious and you’re not able to retain information and ask the proper questions. So I think for patients who come and find me after because they followed me on social, they’re always more at ease because they almost feel like we have some rapport and they know a little bit about me. I think the biggest thing is sharing information because it’s so hard to navigate when you just are Googling things. There’s so many different messages and conflicting pieces of information. And then also for levity and a sense of community. It’s a plate… Like if you go to the comment section of any of my posts, it’s like a support group. And people are kind of bouncing ideas off of each other and helping each other.

Dr. Fox: Yeah. I don’t have so much of the latter part just because I just don’t engage as much on the social media just because, again, I probably, I guess I could, but I can’t. I don’t know.

Dr. Sekhon: You have to make a bit of an effort.

Dr. Fox: It’s more than an effort. I’ll need an education than an effort. But either way, it’s, but the first two for sure, I mean, I find that it’s nice people come in and they feel like they’ve met me before I meet them. They’re like, “I feel like I know you.” I get that all the time. “I hear you all the time and I’ve heard you speak and I like what you say and this is part of the reason I’m coming.” And also for other doctors when they come on, it’s the same thing. “Oh, I heard you on the…” Like, you know their voice, you know their personality, you sort of, they’re not a stranger, which is really nice. And the second thing is in terms of information, that’s been the biggest plus to this that, you know, when you come to the doctor, it’s an uneven relationship, right? The doctor spent 20 years, you know, learning and training and practicing and you come in and you have just your symptoms or your problem or whatever it is. Maybe you’ve learned a little on Google. Some of it’s right. Some of it’s wrong. You have no idea. But if you’ve heard the person speak on it or if you read something, they wrote on it, you’re sort of starting, like instead of starting a kindergarten, you’re starting in high school.

Dr. Sekhon: You’re primed.

Dr. Fox: Yeah. And so you’re ready. Like, okay, I get it. Let’s talk about high-level stuff. Let’s talk about me. And it’s a much more productive conversation when they’ve sort of prepped for it with you already. It’s not even with somebody else. They’ve literally prepped with you which is great.

Dr. Sekhon: And when there’s a new language almost, like I always say, there’s so many acronyms. Like I could sound like a crazy person who’s never thought of IVF or fertility treatments because everything’s an acronym or some sort of form of jargon, which, you know, people who have gone through treatment or a few cycles, they’re like very, very adept. So the learning curve is sharp. And I think it’s just helpful for people to have some background knowledge. And also, even if they’re not trying right now, fertility, as we’re going to talk about is a time-sensitive issue. So you want to make sure that you’re equipped with the right information about how your body works, what you need to be aware of, because the narrative that society loves to remind us about over and over again of when you turn 35, you’re old when it comes to fertility, that’s not very nuanced and helpful. It’s breeding fear and anxiety, but it’s not giving people the tools that they need.

Dr. Fox: A hundred percent. All right. So let’s get into it. So you sent me some of the great myths that you’ve seen over your career, and we’re going to go through them one by one. I’ll mention the myth and you’re going to tell me the truth. And then I’ll pepper you with some questions because, you know, this isn’t my specialty, so good. All right. First one, myth number one. There are tests that can definitively tell you that you are fertile before you start trying.

Dr. Sekhon: Yeah. So this is the most frustrating one for doctors and patients alike. The best way to know whether or not you are fertile or whether you’re going to have fertility issues is to try. And that’s frustrating to people because a lot of people have anxiety about if they’re going to have problems either because of their age or their family history or things that they were told by their GYN a long time ago. And so they want to come to me for a “fertility checkup”.

Dr. Fox: Right. Like an inspection.

Dr. Sekhon: Yeah. I just want to know, yeah, exactly. Like, can you look under the hood, tell me if everything’s all good, then like, you know, my partner and I feel like we can hold off for another two years or maybe I don’t have to freeze my eggs after all. And then it’s kind of like breaking that down and re-educating and explaining that there is no direct way to test for really critical things like egg quality. We have to go based off of assumptions. And a lot of people are confused. They think, well, there is this test that tells you about your egg count. So, you know, then I should know if I’m good or not. And so I have to kind of break it down and say, you really, even if I test everything that there is to test, like I test that your fallopian tubes are open, that your partner has sperm, those things are subject to change. So those tests are not really relevant and meaningful to do right now when you’re not actively trying. But if you’re actively trying and it’s not happening after a certain amount of time, then let’s talk about that. If you’re under 35, we say it could make sense to try for up to a year. If you’re over 35, we say because this is a time-sensitive issue, don’t wait longer than six months before getting an evaluation and treatment. And if you’re in your 40s, we say you should have a very low threshold, about three months of trying. The reason for that is that fertility, trying to conceive is extremely inefficient. Human reproduction is inefficient. I want to put that on a t-shirt and sell it as merch because everyone should know this. If you’re even in your 20s, which is considered…

Dr. Fox: Because we don’t have we don’t have litters.

Dr. Sekhon: Right. Exactly. We’re very different.

Dr. Fox: But not anymore. We did in the ’80s.

Dr. Sekhon: Right. Yeah. Yeah. That was a different situation. But I think people don’t realize that there’s only like a 20% chance each month. If you ovulate every month, that is, and you time it perfectly in your 20s. And when you approach 35, that’s probably like 15% right each month. So it makes sense that you need to try. Don’t be devastated if the first month that you’re trying, it doesn’t happen. And to get your cumulative probability to an acceptable rate, you may need to try month after month after month, but you need to know when to call it and then say clearly things haven’t lined up. And I know that they wouldn’t necessarily need to line up within one cycle, but I’ve given it enough time now that there is an issue. And even the testing that we can do testing, you know, your reproductive tract, testing the sperm, testing your egg count, those high-level tests will not necessarily reveal the underlying cause. About 15% of cases are called “unexplained”. It doesn’t mean there isn’t an explanation. It means that the testing we have at our disposal is not going to point to the cause. But a lot of times the actual cause in these situations are things like endometriosis. You know, there could be sperm-egg interactions. There’s things that you can’t directly look at. So there isn’t a catch-all fertility test that just tells me yes or no, you’re going to struggle and have issues or it’s going to be easy for you. A lot of it’s almost like a lottery because every month you ovulate a random egg. And all of us have some abnormal eggs. I’m sorry to break it to anyone who’s listening who thought their eggs were perfect. Even in your 20s, you’re going to have some abnormal eggs. And so even just that alone, you know, adds this variability and unknown to the mix where people get frustrated because they really want to be able to just define everything and test for everything.

Dr. Fox: Yeah. The way I sort of always thought of it from a simplistic standpoint, and you can tell me if I’m wrong, by the way, you’re welcome to, is like, if someone said to me, “How do I know if I’m going to have a hard time conceiving?” And I could ask them two questions. I would really just say like, how old are you? Do you get regular periods? If the answer is I’m young and I get regular periods, you’re very likely to do okay. Not always. Obviously, anyone could have infertility or fertility issues. And if you’re, the older you are, and the less regular your periods are, the harder it’s going to be to conceive.

Dr. Sekhon: And that’s a great point. You know, all of those thresholds that I talked about waiting for a year, waiting for six months, none of that applies if you have irregular or absent periods. Because if you’re not ovulating, which is, you know, the number one way to tell that is the regularity of your periods. If you’re not ovulating, you’re not in the game. So you’ve got to get in the game.

Dr. Fox: Yeah. And then try.

Dr. Sekhon: Yeah, exactly.

Dr. Fox: All right. So the next myth is related to the first myth, which I get this all the time. Someone comes in, they’ve never tried to have kids, they’re young, and they say, “Here’s my AMH value. This means I’m good to go or this means I’m screwed,” right? So, which is a myth. So tell me about AMH and why that’s not true or why that might be true or when it’s true, when it’s false.

Dr. Sekhon: Yes. So fertility doctors have a love-hate relationship with the AMH test. AMH is anti-mullerian hormone. It’s a hormone that is produced by all the little cells that line each of the follicles or the bubbles of fluid that contain one egg. So every month, you need to know how your body works to understand the answer to this question. We’re born with all of the eggs that we’re ever going to have, right? Like two to three million. And by the time we get into menopause, the average age of which is about early 50s in this country, that’s when you have a critical threshold. You’re below that critical threshold of 1000 eggs. And that’s when your cycles start to space out. You stop being able to release an egg, right? You stop being able to ovulate. And a lot of the women who come to me who are reproductive age are between those two time points. And we can kind of get a sense of where you’re at in a relative way, you know, by testing your AMH level or doing an ultrasound and counting the number of follicles or bubbles of fluid that are visible in both ovaries. And both of those things are just telling us about your egg quantity. Every month, you’re able to release a few of the eggs that are stored up, and they kind of escape to the surface of the ovaries. They’re recruited, so to speak. And it’s a very limited subset. And those are the ones that we can see. We can’t see the other ones, the millions or the hundreds of thousands that you have buried deep inside. And so both your AMH level, which is a blood test, and your egg count on the ultrasound, are just telling us how many eggs are available if and should you go through an egg retrieval, right?

What’s happening naturally in your body, if you’re someone who ovulates and gets a regular period, is that your brain would send a signal to the ovaries and like a lottery would randomly select one of those bubbles of fluid containing an egg to be the lucky winner that gets to ovulate that month. The rest of those other recruited eggs get thrown away. They die off. And so we’re always recruiting and wasting a bunch of eggs. And so the number that you have recruited or your AMH level, which is going to indicate that as well, has nothing to do with the chance that the one lucky egg that you ovulated is actually going to turn into a pregnancy. It’s not really a numbers game. I always tell patients, “Listen, you’re 35, you have the exact same chance, at least statistically speaking, as a 35-year-old sitting next to you in the waiting room who has a really high egg count compared to your lower egg count,” right? You’re not really worried about egg count when it comes to ovulation because everyone is on a level playing field and ovulates one egg. What you do care about it for is if you’re going through the process of an egg retrieval, which might be because you’re doing fertility preservation, egg or embryo freezing, or we need to do an egg retrieval to help you overcome infertility as part of IVF, it tells me how easy it might be to get you to respond to the medications. The medications we give for that process are essentially that brain signal I was talking about, but at a higher level in an effort to select all of the recruited eggs because we want to select them and salvage them and extract them before your body would throw them away. And the more you have, the more we have to work with, and the better the chance of maybe getting what you need from one cycle because it’s more efficient if you have more eggs. Does that make sense?

Dr. Fox: Right. So basically, the AMH level, a higher level indicates the same thing as having more follicles seen in ultrasound.

Dr. Sekhon: Yeah. Yeah.

Dr. Fox: Lower is the same as fewer, not relevant if you’re not about to undergo fertility treatments.

Dr. Sekhon: Right. Exactly.

Dr. Fox: But quite relevant if you are about to undergo fertility treatments.

Dr. Sekhon: Yes. Yes. It helps me understand how much medication to give you, which protocol to use. And it helps me to also set your expectations of this is how many eggs we might get. And that’s important because not every egg will fertilize and grow into an embryo and not every embryo will be healthy. So it’s a numbers game. IVF is a numbers game. Yeah. But trying to conceive on your own isn’t.

Dr. Fox: Yeah. So just to like make it blunt. So someone comes to me and says, I went to a doctor to get a fertility check, which was myth number one. And that doctor sent an AMH. And it was low. And then the doctor said, because of that, “Oh my God, you’re screwed. You’re not going to get pregnant. You should see a fertility doctor.” That’s like false, false, false.

Dr. Sekhon: Correct.

Dr. Fox: Okay.

Dr. Sekhon: But I do care to know that it’s low. And a lot of times women who come to me in their 20s and especially their early 30s, where their AMH level is very, very low to the point where I’m like, this is an outlier. This is not what I typically see. And if you look at just the general population and there are some studies that have kind of documented what’s “normal”, and trust me, there’s a wide range, right? But I will do specialized testing.

Dr. Fox: Just to be sure.

Dr. Sekhon: Specialized testing, which I don’t see being done often, but to look for things like an underlying genetic predisposition that shows you may be prone to going into menopause early. AMH is not actually an accurate indicator of age of menopause, which is when you “run out of eggs”, in your early 50s for most people. But if you have a family history, a mom who went into early menopause, and we do this genetic test and it shows that you carry something called fragile X pre-mutation, that’s a valid known risk factor for going into menopause early. You might treat that patient a little bit differently. You might have more of an urgency to say, “You know what, let’s freeze whatever eggs we can get to and maybe we’ll do multiple cycles because once you go into menopause and you’re not ovulating, the only recourse you have is to use previously frozen eggs or maybe donor eggs.” So not everyone with a low AMH is going to continue to lose their eggs on that trajectory. It’s a snapshot assessment. Doesn’t tell me that this is going to continue to be an accelerated loss of eggs. You could stay at a low level for quite some time. And I think testing for things like autoimmune factors because some people can lose eggs at really fast rate because of autoimmune issues. So I will do specialized testing on some patients who have an incredibly low AMH for their age. It’s also important to realize sometimes being on long-term birth control pills, it’s definitely not harmful. We’re going to get to that myth, but sometimes that can falsely suppress the AMH.

Dr. Fox: That makes sense because you have fewer follicles.

Dr. Sekhon: Yeah. So, you know, that’s something to talk about with the doctor as well, but just know that AMH does not define you. If you’re someone who gets periods, that means you ovulate. If you ovulate, you’re in the game and I care more about your age and your potential egg quality than the number of eggs you have.

Dr. Fox: Amazing. All right, next one, next myth. IVF is a guarantee.

Dr. Sekhon: Yes. So a lot of people think this, and I think it’s fueled sometimes by celebrity headlines. You know, Naomi Campbell had a baby in her fifties and, you know, so and so did this or that. People sometimes overestimate how far the science has gotten us, right? IVF is basically a treatment that’s trying to rectify how inefficient human reproduction is because ovulating one random egg every month or every cycle and hoping that all the things after that line up is really inefficient. So if you have now multiple eggs to work with because you did an egg retrieval cycle and now you’re just kind of seeing survival of the fittest, which one’s fertilized, which ones turned into embryos and then you can test the embryos, you can freeze them, pick the best one to transfer. That’s a lot more efficient, right?

But we’re still confined to working with this inefficiency because not everyone is gonna have access to a lot of eggs and that’s where things like AMH come in. And even if you have a lot of eggs, maybe there are major quality issues. So when you hear about people doing multiple cycles and not being successful, it’s usually either because they have a very low count and a hard time responding or because they have the eggs, but it’s really hard to get the eggs to grow into embryos. A lot of them stop growing before they even get to the embryo stage or they’re testing the embryos and the embryos are coming back abnormal genetically, which is something that is very much related to age. Or it could be a combination of the two issues. You see that a lot with women in their 40s especially.

So it’s not a guarantee. It is much more successful than other treatment options that we utilize like making you ovulate regularly or making you ovulate more than one egg and pairing that with inseminations, which is just getting more eggs and more sperm to interact, but that’s a lower tech treatment option. IVF is much higher tech. You’re taking control of every aspect of the process that you can, but it’s still not a guarantee. It’s contingent upon being able to access eggs and having some high-quality eggs to work with.

Dr. Fox: What do you quote people as a success rate of an IVF cycle? So someone’s coming five after you’re gonna do one cycle and the chance will end up with a baby. Obviously, it ranges, but what is the range?

Dr. Sekhon: So I think I like to work backwards because a lot of what we do now, and I don’t wanna say a hundred percent of the cycles, but a large majority of what we’re doing IVF involves genetically testing the embryos. So to me, the new benchmark has become what is the likelihood that you can make a normal embryo? Because if you talk about the chance of a genetically balanced 46-chromosome healthy embryo implanting and resulting in a life birth, in general, it’s around 60% to 70% now, which is extremely high, right? And so that means even if you only make one embryo, that’s genetically normal.

Dr. Fox: 60% to 70%. So if it’s genetically normal and you put in one, on average 60% to 70%.

Dr. Sekhon: Correct. Now the question is, what’s the likelihood that you’re gonna make a normal…

Dr. Fox: And that’s based on age, I assume, right?

Dr. Sekhon: Age and AMH. So it’s the interplay between the two. How many eggs do we have to work with? Because I’ve had patients with a very low AMH, but they’re in their early 30s at a time when the large majority of embryos coming from your eggs are gonna be healthy. And so I always encourage them and say, listen, I’ve had patients get two or three eggs at retrieval, which is a low number…

Dr. Fox: But they’re gonna be good.

Dr. Sekhon: Still make a normal embryo. There’s a higher conversion rate.

Dr. Fox: Okay, fine. So that’s fair. All right, so that’s good. 60% to 70% if you get a genetically normal embryo, which may or may not be easy to do.

Dr. Sekhon: Right. Which means it usually takes one, two, and at the most three transfers to get to a live birth.

Dr. Fox: Okay, cool. All right, next myth. Birth control pills cause infertility and or irreversibly stop ovulation.

Dr. Sekhon: Yes. This is the bane of my existence. I don’t know if you ever get this.

Dr. Fox: I find that birth control pills cause you not to get pregnant.

Dr. Sekhon: Yeah, exactly. They work well when you’re taking them. What I have seen a lot is that women will come to me after decades of contracepting, and they are getting a fake period, right? Because they’re giving themselves low dose hormone in the birth control pill that’s fooling their brain into thinking, “Hey, you don’t need to make anyone ovulate cause the hormones are there.” And then they go off of it and they’re like, “Okay, now I’m gonna do a 180. I’ve gone from preventing pregnancy, now, I am intending to get pregnant.” And their periods aren’t happening. They’re not getting a period. Or they are getting a period and they’re having all of these like horrible symptoms and things that are happening, like really bad cramps.

Dr. Fox: And they blame the birth control pill.

Dr. Sekhon: Correct.

Dr. Fox: Instead of their body.

Dr. Sekhon: Correct, exactly. And so things like PCOS, endometriosis, problems that can cause infertility come to light, and the automatic assumption, the human nature reaction is, “Well, this all happened because I was on the pill all these years.” And what I have to explain to them is, “No, the pill was masking those things.” And masking has such a negative connotation cause people feel almost betrayed by the birth control pill. They’re like, “I’ve gone all these years without knowing this about my body because I was on the pill.” And I’m like, “But the pill was actually kind of keeping things in balance and keeping things at bay. So don’t be mad at that.” And now that we know about this, like great, let’s tackle it. So if you go on social media, you don’t have to search very long to find tons of disparaging posts and misinformation about the pill and not to get political, but this is not what we need as a society right now. Right? Like a lot of people, like record numbers of women are saying, “I don’t wanna be on birth control at all, but I have no intention of getting pregnant.” And they live in places where, you know, that could be a major problem. Put them in, you know, a serious tough situation where they don’t have access to healthcare and options.

So I think it’s important for people to realize that the birth control pill has been around for a long time and it’s evolved and changed. And now we have lots of different forms of birth control, not just birth control pills. We even have non-hormonal forms of birth control, you know, like the copper IUD for example. And it’s important to make sure you’re talking to a doctor who’s going to explore all of these options with you and recognize that like any other medication, birth control can have side effects because that’s the other side of the coin. Beyond masking PCOS and then getting blamed for things like PCOS is, you know, well, it made my hair fall out or it gave me depression. Yeah, there can be side effects. I’m definitely not, you know, a biased person that’s gonna say, “No, birth control is perfect,” but that just might mean that you haven’t found the right thing for you. And I think if you really are not wanting an unplanned pregnancy and you’re sexually active, then you need a plan. And, you know, I think blindly just saying birth control is evil and I don’t want to put hormones in my body without actually understanding the science and the data is not great. A lot of people don’t realize that the risks that are on the back of the birth control pillbox about blood clots and things like that, pregnancy is more dangerous.

Dr. Fox: Right, much more.

Dr. Sekhon: Right. Exactly. You know, it’s endless battle.

Dr. Fox: Yeah. Well, all right, keep fighting the good fight. All right. Next myth. Miscarriages are preventable. Like if you take progesterone or go on bed rest.

Dr. Sekhon: Yes. So the number one thing that I observe and I’m sure you see this in your practice is self-blame. Right, I think everyone wants to feel like they have some element of control. And then the other side of that coin is that when things don’t happen the way we want them to happen, when pregnancies end in a miscarriage, women will think, well, I had the control to, I could have done something. I could have taken a supplement. Maybe if I was on progesterone. Maybe if I wasn’t so stressed and working so hard etc., etc. And we know that the number one cause of especially first trimester miscarriages are chromosomal errors. They’re essentially typos that you had no control over. You can’t control which egg you’re gonna ovulate and all of us have some abnormal eggs that are missing or have extra DNA. And some months, you know, you win some, some months you lose some. And you’re gonna release an egg that’s missing or has extra chromosomes and it could fertilize and result in an embryo that is imbalanced and has either too much or not enough DNA. And most of these do not implant and you don’t even know how close you came to getting pregnant with that embryo, but sometimes they will implant and maybe they’ll get up to 9 weeks, 11 weeks. It depends on what genes are out of balance that determines how far that pregnancy can go and then it eventually stops growing because it doesn’t have all the tools it needs to continue growth and development and then you have a miscarriage. And people will attribute it to so many other things when really we know that I’d say 90% or more of first-trimester miscarriages are because of this issue that you have no control over.

Dr. Fox: Yeah. It’s more than people’s nature to blame themselves, which is very strong. It’s the messaging and this is messaging that’s come from doctors, that’s come from social media, that’s come from society, that’s come from the lay press, you know. When someone has a miscarriage and then the doctor’s like, “Were you taking your prenatal,” right? That makes them think. “Oh, if I don’t take my prenatal it’ll cause a miscarriage.” Total baloney, like not true or, you know, “Oh, you’re having a little bit of spotting. You should go home and rest.”

Dr. Sekhon: Yeah.

Dr. Fox: Meaning, “Oh, does that mean that since I exercised last week I’m miscarrying?” And it’s not intentional. Like we don’t mean to be blaming women for this, but we have to be very careful when we tell people these things, that’s what they hear. Because people are primed to hear, what did I do or what did I not do? And so we have to be very cautious in what we say to them. And if you’re on the other end, you have to be very cautious what you read. Because it’s gonna make you feel like you did something wrong when, like, it’s not. I always tell people, be sad, don’t feel guilty. Like, you know, it is sad, but you should have no guilt whatsoever. You didn’t do anything. It’s crazy.

Dr. Sekhon: Exactly. And we know maybe, you know, not every single case is going to be caused by this and so this is the PSA that if you’ve had two or more and I count biochemical pregnancies in that as well, then you know see a specialist or talk to your OBGYN about getting a recurrent pregnancy loss workup. And this is looking for any potential underlying predisposition that could lead to future miscarriages. And. you know, this will be things like genetic testing for you and your partner, looking at the structure of your uterine cavity, and screening for, you know, swollen infected tubes which sometimes go unnoticed that can actually increase your risk of miscarriage. You know, I post about this a lot and there’s a very specific list of tests that the American Society of Reproductive Medicine says, like, this is the actual workup. And a lot of times when I see patients for second opinions, I’ll note that they didn’t have that workup. So that’s just something to be aware of to not just say, “Oh, well this is out of my control and, you know, it’s fine that I’m going through this a third time.” You should really take a pause and think about if there’s something that could be picked up on testing. And 50% of workups will be totally negative or normal, but at least then you know you’ve ruled out some of the other things that you should be thinking of.

Dr. Fox: All right. The next two I’m going to put together because they’re both related to egg freezing. So egg freezing has a low success rate. It depletes your egg reserve and it causes early menopause, meaning egg freezing is bad. So that’s the myth. Why is it a myth?

Dr. Sekhon: Well, I’ll start with the second part first because it kind of feeds into what we were just talking about. Remember, and this is why it’s so important to get into the nitty-gritty of how the ovaries work because a lot of people don’t understand what’s happening in the background that eggs are being recruited and being thrown away all the time and that not all of your eggs are available at one moment. I only know how to get to the recruited eggs. I wish I knew how to open the vault, but I don’t have the key. I wish I could access those other eggs because it would make IVF so much more successful if I could just summon more eggs to the surface.

Dr. Fox: Right. Get 100,000 eggs out do them all.

Dr. Sekhon: I would love that. I would love that. But unfortunately, that is not how the system works I can only get to what your body is gonna recruit and throw out anyway. So there’s no such thing as going through egg retrievals and taking multiple eggs out and that getting you to menopause faster, which is where you run out of eggs and get to that threshold of 1,000 eggs left total because I don’t know how to get to those other eggs, right? So that’s the number one thing to…

Dr. Fox: Right. You’re only getting the eggs that were coming out anyways, and they were gonna be thrown away.

Dr. Sekhon: It’s salvaging.

Dr. Fox: Yeah. You’re basically just taking the ones are gonna be tossed.

Dr. Sekhon: And by the way, they weren’t gonna be tossed because they were lesser quality. That’s another myth I should have added to the list. I’m giving you a bonus myth now, is that people…I think we give our bodies sometimes too much credit because people think, well, my brain is sending the signal to the ovary and it knows how to select the healthiest one. It’s natural selection. I hear that a lot and that’s a problematic concept because it’s not true. It’s been proven otherwise, no one would ever have miscarriages if our bodies knew how to select the best egg. But then a lot of people will talk about like use lower doses for IVF because then you’re not overriding natural selection and getting all the bad eggs and there is no such thing as that and lots of studies have disproven that.

But anyway going back to your first point about egg freezing, egg freezing gets a bad rep, right? What is egg freezing? It’s basically doing the egg retrieval freezing the eggs and knowing that you have that potential reproductive capability for the future to, if and should you ever need IVF to have a head start with a larger cohort of younger healthier eggs essentially. But we just talked about how IVF is not a guarantee, how even ovulating one egg is not a guarantee. A lot of eggs that we ovulate or extract for the purposes of IVF don’t have what it takes. So when you go to freeze eggs and then come back if you ever need to eventually thaw them out, of course, not all of them are going to be healthy and normal, right? But you’ll hear and read headlines like, okay, you know, Kourtney Kardashian froze seven eggs at age 39 and said she thawed them out and it didn’t work. And, you know, this egg freezing sucks. And then everyone’s very negative about her. The New York Times will highlight a study that shows you know suboptimal success rates. But what they don’t mention in the fine print is that this was in women who froze their eggs over the age of 38 and didn’t freeze enough eggs.

So you need to have a really detailed conversation with your doctor about what their thaw survival success rates are and what their typical drop-off rates are even just with general IVF, you know. And I think where you go to freeze your eggs matters You should always go to a center that does a lot of IVF and has fairly good success rates. Because eventually, the goal is you should be able to come back and use those eggs. So we have kind of goals depending on your age. If someone’s 35, I want them to freeze ideally a minimum of 15. I would love 20 because it’s almost like you need 10 eggs to get to that one live birth. That is the level of attrition and inefficiency we’re talking about.

Dr. Fox: Right. Next one is similar, that you can repair your old eggs using supplements. You can make your eggs better.

Dr. Sekhon: Yes, you know. And I think it’s confusing to people because we say it’s true. There are certain lifestyle patterns that are associated with better success rates with fertility treatment and just in general. But it’s hard to study in a vacuum, right? But we know that having less than four alcoholic beverages in a given week is considered to be associated with better success rates and pregnancy rates in general. If you look at the body of literature that’s available, we know that smoking is bad for fertility, right? It can accelerate how fast you lose your eggs and there are studies that suggest poor egg quality. So because of that, I think the natural assumption is, well, If I take a bunch of vitamins and, you know, I live a really healthy lifestyle that I can control the situation. And at the end of the day, age is the most important factor. That doesn’t go away even for the person who in their 40s is like, listen. I’m a yoga instructor and I eat so healthy and clean. It’s good that you’re doing those things. It’s good that you’re leading a healthy lifestyle. I always say as a guide, whatever’s good for your cardiovascular health is going to be better in terms of your fertility and setting you up for the healthiest pregnancy possible. Because then it’s easy for them to figure out, okay. Well, then, you know, diet, exercise, like all the common sense things, it is important. But is it necessarily going to turn back time, turn back the clock, and repair the wear and tear of aging that your eggs have incurred because you hold on to them for your whole life and we don’t have repair mechanisms? No.

But putting your best foot forward, you know, there is thoughts about like, a diet rich in antioxidants or taking supplements like coenzyme Q10. I have no problem with my patients taking that because there’s really no downside, And you know, there is something to be said about the fact that when you’re actually taking those injections of medication or that signal is being sent from your brain to mature and ovulate that one egg, the environment in which that’s happening is important because what’s actually happening when that egg is being matured and is ready to ovulate or be retrieved is it’s getting pushed through different stages of development and the genetic content of each egg is getting rearranged. So if you’re creating a healthier environment, in theory, you’re making it an environment that’s maybe less conducive to errors. But the errors that are gonna happen because of the wear and tear of aging are gonna happen, right? Does that make sense?

Dr. Fox: A hundred percent. All right. We got two more.

Dr. Sekhon: Okay, let’s do it.

Dr. Fox: All right. Second to last one. Fertility is a female problem.

Dr. Sekhon: Yeah. This one always gets me because it’s especially awkward if a couple is, you know, here for a consultation to see me and sometimes the male partner doesn’t want to get tested They think it’s not necessary and I have to tell them 40% of infertility is male factor. And that means sperm quality issues, sperm production issues. And it’s such an easy thing to test. We just really need you to provide a sample. And we look at it under the microscope and we look at sperm concentration, the percent of the sample that’s swimming in a forward direction that’s shaped normally. And there are things that you can do to improve your fertility on the male side. Unlike everything I just told you about limitations with trying to reverse egg quality changes with age, men are making new sperm every 72 days. And so we actually see…

Dr. Fox: 72 hours.

Dr. Sekhon: Every 72 days.

Dr. Fox: Oh, 72 days, excuse me. Oh, okay.

Dr. Sekhon: Yeah. Yeah. Yeah. So you have new cells being regenerated. And then, you know, if you make changes to your lifestyle, we can actually see the results of that. Not to say that male fertility is anyone’s fault because there are things that are beyond people’s control. But, you know, 40% is a huge chunk. And a lot of times I see combined factors. So it’s very easy for a couple to say, “Oh, well, her cycles are irregular. She has PCOS, she has endometriosis. So we know it’s a female problem.” But we need to really be doing all the testing so that we’re not wasting time.

Dr. Fox: Yeah. That was a big revelation when we were being educated about fertility, like early in training, whether it’s medical school or residency I remember that it’s such a high proportion is for male factor. And people don’t think of it that way because she’s the one that typically goes to the doctor and she feels again, like there’s something wrong with her. And there may be an issue fertility-wise with her, but you got to check the couple. They’re both part of the reproductive process. So they both need to be checked out.

Dr. Sekhon: Exactly. And it’s so common sense, but for some reason, I think…

Dr. Fox: Well, you know, we’re a patriarchal society.

Dr. Sekhon: Well, I was just going to say, as a society…

Dr. Fox: Maybe more so here than Canada, but you know.

Dr. Sekhon: Maybe. I feel like definitely the burden of testing and treatment mostly falls on women when it comes to fertility medicine.

Dr. Fox: It’s a problem. And it’s sometimes actually a huge problem. Sometimes women undergo like painful, invasive tests and procedures before. And it’s like, what are you doing? Like, you know, it’s, yeah, good message really to, on our end, we’re working on this.

Dr. Sekhon: And men should know that they’re not immune to the effects of aging when it is reproduction. You know, extremes of age for men is like in their mid-40s, 50s, and beyond.

Dr. Fox: Thanks, Lucky.

Dr. Sekhon: I’m sorry, but I assume you’re done with your family.

Dr. Fox: I’m not trying to reproduce, but I like that I’m in the extremes of age category.

Dr. Sekhon: No, but you know that you can, but should you is the question. I’m just saying that there’s quality issues.

Dr. Fox: Wow. For all our listeners out there, Lucky just said, I’m in the extremes of age.

Dr. Sekhon: But you look great.

Dr. Fox: Thank you. Maybe you look great. You’re lucky to be alive. All right. That’s all good. All right. Last one. The amount of time your eggs or embryos are frozen matters. In other words, they could get freezer burn and not be good anymore.

Dr. Sekhon: Yes. So I think a lot of times I can simplify the matters for patients because they, you know, come to me for freezing eggs or they freeze embryos and they say, “Okay, well, when is a good time for me to come back? Like, I kind of need to know what the limits are.” And I explain to them, this is finally an uplifting fact that I can give you that’s not depressing. Unlike the graphs on age and fertility, I can tell you that your uterus, when it comes to fertility, doesn’t really age. Now you might be kind of grimacing behind your microphone there because obviously…

Dr. Fox: I’m not. This is great. This is great. I love it.

Dr. Sekhon: But yeah, obviously, you know, as we get older, we are more prone to high-risk pregnancy issues which you talk about all the time.

Dr. Fox: Hypertension, diabetes, but the uterus doesn’t give you hypertension or diabetes.

Dr. Sekhon: Right. So the ability for the embryo to implant and stay implanted, meaning your risk of miscarriage, none of that is going to be affected by your age if you’re using previously frozen eggs or embryos. And it’s true. The amount of time they’re frozen really has no bearing on the reproductive potential. That to me isn’t shocking because I know exactly what’s happening. All aging and metabolism is halted. They’re just kind of suspended in a glass-like state in liquid nitrogen. But I guess patients think about freezer burn and what happens to food in the freezer and they’re like, “Isn’t there like an expiration date?” There isn’t.

Dr. Fox: Yeah. No, this freezer is not like your, you know, your whirlpool at home that’s getting open and closed and this or that and gets frost on it and defrosted and the power goes out. This is like Captain America deep freeze, Austin Powers deep freeze. We’re talking, you know, frozen in time, literally. And I guess the limits haven’t been tested because this technology is only whatever 30, whatever plus years old.

Dr. Sekhon: They kind of have though. I mean…

Dr. Fox: Well, up to that point.

Dr. Sekhon: Yeah. But there are even people that have used donated embryos frozen 27 years ago and have had live births.

Dr. Fox: Right. Let me say, but that’s our limit as far as it’s been. We don’t have 200 years yet. But presumably, it would work. Yeah. Like in “Jurassic Park”.

Dr. Sekhon: Well, I thought about that when I was watching “Interstellar”, this is totally a tangent, but there was a scene where they had frozen embryos aboard like the spaceship. Because they were kind of depopulating Earth. And I thought that that’s an interesting concept. My husband was like, maybe we should send our extra embryos to space if we’re done with our family building.

Dr. Fox: Just have them orbiting around the planet. Wow. Awesome. Lucky, Dr. Sekhon, thank you for coming on the podcast. We’re having you on again, and we’re going to answer some listener questions. So thank you so much.

Dr. Sekhon: Thank you for having me.

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. It 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.