Rewriting Fertility - The truth about Age, Health and Hope. Samantha | Dr Nozer Sheriar

Today's episode is an episode that has been a long time coming. This is an episode that each one of us need really.

Each one of us who harbors a dream to be a mother someday. So today I have with me one of the most respected fertility experts Dr. Noah Sharia. I'm going to

like dive straight into it and ask you what is the connection between fertility and age? Is everything connected to your

and age? Is everything connected to your age? So there's no doubt that there is a

age? So there's no doubt that there is a connection between fertility and age.

But there's also no doubt that women don't need to be pushed by this kind of connection. And my take is no. Women

connection. And my take is no. Women

should have babies when they want to have babies, not when they have to have babies. And that's where science, the

babies. And that's where science, the profession and society has to step up to look after them. You know, probably the

only cell in a woman's body that is her age is her eggs. Every other cell in her body is actually replaced regularly

every few months. There's something

happening in the world which has brought down sperm counts dramatically.

So when we talk about fertility, men have also been impacted in a way by lifestyle. And if there's one thing

lifestyle. And if there's one thing that's impacting hormonal health, it is the plastics in our life and in the environment. Endocrine disruptors

environment. Endocrine disruptors basically are substances which act like hormones though they are not really hormones.

>> So just for all of us to have a more have better reproductive health some of the how does stress, obesity, junk food, how does this affect reproductive

health? So for someone who is not really

health? So for someone who is not really thinking about pregnancy right now, but will surely wake up one day wanting to

be a mother, how is there a way that you can tell how much time she has left?

>> Hi guys, welcome back to Take 20.

Today's episode is an episode that has been a long time coming. This is an episode that each one of us need really.

Each one of us who harbors a dream to be a mother someday. And I say this because everywhere I look around me, I see women hustling between jobs, family

expectations, societal norms, swiping through dating apps trying to find the one. If he's the one trying to put a

one. If he's the one trying to put a ring on it, if there's already a ring on it, trying to decide if now is the right time to have a baby, if not now, when?

Also because we're chasing dreams, paying bills, we are filtering red flags, we are fighting for equal pay, getting our 10,000 steps in, getting our vitamins in, looking after aging

parents, cutting calories, trying to stay young, taking out fertility killers that comes in our food, checking period apps, tracking ovulation, scheduling

sex. Some of us are doing everything

sex. Some of us are doing everything while others are waiting. Yet nothing

seems to be working. all this while we are constantly racing against a clock that just does not seem to stop ticking.

This is why this episode is so very important for you because when it comes to fertility, time and choice, there's so many things that we know, so many things that we don't know, so many

things that we wish we knew soon. So

today I have with me one of the most respected fertility experts, Dr. No Sharia. He's

had many years of experience in women's health and reproductive medicine. And

I'm so glad that he took the time today to be with us and answer so many of the questions that that we don't have too many people to discuss with. And I'm so

glad that he has decided to spend some time with us and answer the questions that we all have about is it too late?

What are our options? What's fact, and what's fear? Thank you, doctor, for

what's fear? Thank you, doctor, for being here today.

>> Thank you, Samantha. Thank you. I'm

going to like dive straight into it and ask you this.

What is the connection between fertility and age? Is everything connected to your

and age? Is everything connected to your age? Because across the ages, women have

age? Because across the ages, women have been told so many different things. You

know, our grandmothers, we they were married off in their early teens. They

had kids in their teens. Our mothers

were married off in their early 20s and they said two children before 25 definitely before 25 then came the red

flag 30 impossible to have kids after 30 and now in today's age even at 35 you don't there are so many of us who are not ready >> right

>> so what is the connection between fertility and age and you tell me like like straight from the horse's mouth I want to know at what age this fertility decline.

>> So there's no doubt that there is a connection between fertility and age, but there's also no doubt that women don't need to be pushed by this kind of

connection. So if you really go back and

connection. So if you really go back and you said it historically, women started reproductive lives really early and they started very young and

they usually had their babies. And let's

face it, grandma, our grandmothers had many babies. a mother's day, but they

many babies. a mother's day, but they usually were done in the early 20s. Now

the world has changed. We've moved ahead and I can tell you from my personal experience that a large part of my practice of obstetrics is looking after

women who are having babies in their mid and late 30s. So there's a entire shift.

In fact, women got worried at 30 and I'm happy if I have a 30 year old. It's not

a not an issue.

>> So 30 year old is now a non-issue >> for me. It's for me it's a for me any number is a non-issue. If she wants something she's got to get it and there are many different ways of getting it.

So when a woman I always tell women you keep your eye on the goal and then we will find ways to get there and there is

no doubt that with with time fertility does decline with age fertility does decline but let's face it that's also a choice women are making so I we have

this discussion amongst our profession who look at all the numbers and say women should have have have their babies early because when they're fertile is good and my take is no women should have

babies when they want to have babies not when they have to have babies and that's where science the profession and society has to step up to look after them so to

give you numbers if you were looking at probably the highest fertility is in the mid20s >> don't you think that feels like an unfair hand that nature has given us >> no no but that that's okay that's okay

because I'll explain that as well it then starts going down and starts going down significantly in the mid30s.

So if I was to give you a number and if a couple was trying for a pregnancy in say 25 to 30 or 35 then their chance of

conceiving in any one given cycle would be around 15%. In one cycle doesn't seem a lot but we are 8 billion people on planet earth.

When she comes to her 30s and mid30s, this probably goes down to 10 to 12%.

Per cycle that she tries. And I'm

assuming that she's otherwise normal as a normal partner and they having sex frequently enough at the right time. And

when she comes into the 40s, this drops down to 5%.

Now, you can look at these numbers two different ways. Five seems low, but I

different ways. Five seems low, but I think five is still good enough. So

telling a 40-year-old that she just has to do something and she can't have a pregnancy on her own is unfair because many of them will conceive on their own.

But obviously now the tolerance of weight is a lot less. What is

infertility? Infertility is a definition and the definition of infertility is if a normal couple has tried for 12 months and they haven't conceived and the

otherwise normal they having sex at the right times unprotected sex for 12 months and they haven't conceived infertility. If it's she's 35 let's

infertility. If it's she's 35 let's bring this down to 6 months but you have to give her an opportunity and a time.

So you're saying so you're saying age has most has everything to do with it. So

then where does health come in? Is

health a metric to decide fertility or not? Is that even a metric?

not? Is that even a metric?

>> So there are two things that influence what happens. The first is the sites in

what happens. The first is the sites in her ovaries. That's a number. She's so

her ovaries. That's a number. She's so

interestingly a girl child is born with almost 2 million eggs 2 million.

>> Exactly.

>> Once she gets into puberty and she starts menstruating this has dropped down to 3 to 400,000.

>> So what is the point of that dog? Please

tell me the logic. God is just being extremely unfair.

What is a young girl, a teenager going, she doesn't need it, right? she she

shouldn't need it.

>> Of the 300 or 400,000, a woman will probably ovulate maybe 400 eggs in her entire life. The others go unused.

So one is the number. Now fertility

depends upon many things. So if if you said health is a big thing and I have always said that give me a healthy 40year-old better than an unhealthy 30-year-old any day and I have a large

number of women in their 40s. Give me a healthy 40year-old any day over an unhealthy 30-year-old. And I'm talking

unhealthy 30-year-old. And I'm talking about pregnancies in women. And I'm

talking from an experience of probably more than 240 plus pregnancies who thankfully have mainly done well. We can

discuss later how they got pregnant and what they had to do to get >> 40 pregnancies in >> I've had more than 200 pregnancies in women who are over the age of 40 between

40 and 50 and 52. So, so you know I wrote a book on the permenopause and the actual story I've told in the book is a woman who had twins at the age of 51 and a half.

>> Okay.

>> I suppose IVF >> of course IVF. So that's why I said when you want something you keep your eyes on the goal and we'll find some way to get you to have it. So that's so health

plays a role.

>> She had her own babies. She gave birth she to her own.

>> She carried the pregnancy. She gave

birth from a pregnancy which came from donor eggs which is fine.

>> That was her choice. She got married when she was 46.

So she hadn't found someone till that age. Now when I told you about the

age. Now when I told you about the usides there is another factor and that's the age of the usides. You know

probably the only cell in a woman's body that is her age is her eggs.

Every other cell in her body is actually replaced regularly every few months. So

the woman is generally all new but the eggs that she got the moment she was born stay with her. Nothing gets added to it and they age with her.

So one of the factors that impacts the successes that we said 15% to 20% 10 to

15% and 5% is because you also have to factor in the age of the usite or the egg and it's a no-brainer that is

something ages it's capacity or function is a little less again let me underline here I have patients in their 40s is who

do conceive on their own all the time.

So no woman after we've done some other evaluation and we will maybe talk out talk about that later should ever give up on

herself and say okay now I'm past the date I should be doing something if she wants something she goes for it see the reality of life is and this is something

I believe in there are many factors which you mentioned in your introduction and many reasons why a woman might wait till the

time she waits. And one thing I know for sure that when a woman does the pregnancy, when she's not ready for it personally and everyone else is,

everyone in her life is the only person who really makes a sacrifice is the woman herself.

She sacrifices education. She sacrifices

profession. And I don't see any reason why she should. She should have everything she wants including the pregnancy and everything else. So why

don't we just find ways to help her out whenever she decides she needs help while also preparing her and giving her the advice to pre prepare for this

weight in case she wants to wait because there are certain things that she could do earlier on which might kind of protect her when she makes a decision in

future. Yes, I know we live in a society

future. Yes, I know we live in a society that loves to tell us when we as especially as women when we should be doing things and what is our time frame

and what is our cut off limit and we hear that all the time. So it's really heartwarming and it almost brought tears

to my eyes to listen to very experienced doctors say that no let us do the work let science do the work and find ways

to get you pregnant when you want to become pregnant when you decide that mentally physically you are in the right place with the right person because I

can imagine how having a at the wrong time can be bad for not just for you but for the child as well and it's it's really heartwarming that

you said that. Coming back to the science behind it for a moment does it mean that any every girl who is menstruating

does that mean you're fertile?

>> So normally if you are menstruating what is menstruation? Menstruation

is menstruation? Menstruation is the reflection of the ovarian cycle on the lining of the uterus which is called the endometrium.

So generally if a woman is menstruating regularly and if a woman is within reproductive

years which is 15 to 45 then theoretically she is fertile. There

can be other reasons why she may not conceive but theoretically she's fertile. What it's telling me is that

fertile. What it's telling me is that every month she starts by selecting a few eggs. We call them sites. The egg

few eggs. We call them sites. The egg

grows. It ovulates in the midcycle. A

structure called the corpus lutium comes, secretes the second hormone progesterone. And at the end of the

progesterone. And at the end of the month, she's either pregnant and the period doesn't come and the progesterone continues or she's not pregnant and the

progesterone falls and she menrates. So

technically every time a woman menstruates she's prepared for a pregnancy and because the pregnancy didn't happen she menstruated. So this

is the simplistic way of looking at it.

Of course there are many other factors in fertility and again it depends upon so many other things. The usites the age of the usites the time in a life. So

just releasing a usite might not be enough to conceive. and how much they may fertilize does go down somewhat with

age. It's also important to understand

age. It's also important to understand that just because you're menstruating and you are fertile does not mean you will conceive

because and this is the important part most of the time the work we do in women at any age is just point them to the

right time in the menstrual cycle. H

>> ovulation is an event.

It is a flash. It is a momentary event.

When the usite is released, it happens one day somewhere during your whole cycle. That egg hangs around for 24

cycle. That egg hangs around for 24 hours. You use it up in 24 hours or it's

hours. You use it up in 24 hours or it's gone. The sperms hang around for 48

gone. The sperms hang around for 48 hours. So if you maybe had sex one or

hours. So if you maybe had sex one or two days before you could conceive. So

in every month of 28 days or 30 days, there are like 48 to 72 hours in which you can conceive.

Now that means it's about 30 to 36 days a year.

>> And given our lives and given the life you described in the introduction, >> I can tell you that sometimes the most common reason for a couple not

conceiving is >> they just don't have sex at the right time. So I always joke that we had a lot

time. So I always joke that we had a lot of pregnancies happening during pandemic.

People were locked down and I said you were you suddenly happened to be in the same room at the same time in the same city and pregnancies just happened >> or did you see a surge in pregnancies

during >> initially? No. People kind of became

>> initially? No. People kind of became nervous but then finally yes.

>> So it kind of just it just picked up. So

this is where the menstrual cycle is.

Now when menstrual cycles get disturbed there are two possibilities. One you're

not ovulating and how can you conceive if you don't ovulate. So one of the most common causes of infertility today is something called anovvulation women not

ovulating. And one of the most common

ovulating. And one of the most common causes of anovvulation is everyone talks about PCOS the polycystic ovarian syndrome and that

can lead to delayed cycles in which either the woman is not ovulating or she's ovulating very late. Now how does a couple So a couple who's had a woman

who's had a 28 day cycle is fertile around the 14th day. It's always 14 days >> before the next period. Now that's the tough one. If the next period is after

tough one. If the next period is after 32 days, it's not going to be the 14th day, it's going to be the 18th day.

Okay. So, so if it's all over the place, that's a problem. Again, when

>> Now there are apps, right? There are

many apps.

>> So, apps work when menstrual cycles are reasonably regular. Reasonably regular.

reasonably regular. Reasonably regular.

Otherwise, see, your app is only as good as what you put in. There are other ways of doing it. And you know, you've got something called an ovulation test kit.

But that again needs some kind of regularity. You can't go on using a kit

regularity. You can't go on using a kit for one week or two weeks to know when ovulation is happening. If you've got a kind of very small range, it makes more sense.

>> So the easiest way to know when >> So first of all, first of all, if your periods are regular, you can go by time and the app or what we used to call the

calendar method. Very simple. So 12th to

calendar method. Very simple. So 12th to the 16th day is probably where you are most likely to be fertile. And if a couple basically has sex on alternate days, their chances of conceiving are

what I told you earlier, 15%, 10%, whatever. If we wanted to be more

whatever. If we wanted to be more accurate, most parts of the world where access to medicine is not as easy as it's in our country, then you have the ovulation

test kits. Now, interestingly, a lot of

test kits. Now, interestingly, a lot of people misunderstand the kit. The kit

will give you a positive the day before you are at your most fertile.

>> So the people say, "Oh my god, I'm positive today. I have to have sex

positive today. I have to have sex today." Yes, that will work. But

today." Yes, that will work. But

tomorrow and day after are probably your best days. So don't forget to also also

best days. So don't forget to also also take advantage over those two days. So

that's the ovulation kit. A very simple scientific way of doing it but that comes in when you are medicalizing the process is to do an ultrasound and do something called as a follicular study.

>> Okay.

>> Where you do ultrasound over 3 or 4 days depending upon you actually see the egg growing you see the follicle growing and you see it being released. So you can actually say tomorrow and day after that

accurate but that usually means when you've gone to a doctor and and stuff like that. So it comes in its own time

like that. So it comes in its own time and my advice to couples is remember the defic definition of infertility. If

you've tried reasonably well for a year or 6 months if you're over 35, I think you should seek medical help. In fact, I think you should seek medical help even before you start trying because it's

nice to have a conversation and prepare for something this important in your life without expecting it to be a problem. Personally, I feel every woman

problem. Personally, I feel every woman should be evaluated and advised before she even gets on with planning a pregnancy so she's better prepared

healthwise and every wise for that. Now,

if the cycle is totally irregular and she's not ovulating, then we've got medications relatively simple, very safe. We've had

them for decades now and you can use those medications to induce ovulation.

oral medications most of the time.

Sometimes we supplement them with a few injections but by now you're under a under a doctor and you're taking treatment. It is not something you

treatment. It is not something you should do yourself or you can do yourself and it's got to be monitored and again once this happens then I think we are kind of on the time for me this

is notional for me so as you don't rush yourself too much if you're doing something under medical supervision say you are having planned relations with

ultrasound 4 months if that doesn't work out unexplained infertility there is a procedure called IUI 4 months and if that hasn't work we talk IVF. So, it's

got to be a step-wise kind of a process.

In the past, couples just went on forever. I mean, this just hap it took

forever. I mean, this just hap it took away five and six years of their lives and it shouldn't. If you want something and you're ready for it, at that time, you should go for it in a very structured supervised manner. It also

has to be structured because sometimes I find couples getting pushed into advanced treatments when they don't really require them. So you also have to give yourself enough time and if it hasn't happened in 2 months and you then

rush in for advanced medical care, I think you're not being fair to yourself.

You have to give yourself time.

>> Yeah, I do see people around me, you know, they don't think about pregnancy at all and then one fine day they wake up and say, I want to get pregnant and they expect it to happen, you know, the

very next day or the next month. It's I

think people are taking this aspect for granted especially in today's world when a lot of focus is on achievements and

you know at work and you know status and wealth you know this seems to be taking a back seat. So for someone who is not really thinking about pregnancy right

now but will surely wake up one day wanting to be a mother, how is there a way that you can tell how much time she has left?

>> Yeah. So first of all, there's absolutely nothing wrong with her working to status and fame and achievement and she should but sometimes and this is what I do with

my patients. I do this kind of a mental

my patients. I do this kind of a mental game and say are you going to have a child? Do you want a pregnancy? And I

child? Do you want a pregnancy? And I

make it, let's make it a yes or a no answer. Some of them will say maybe. And

answer. Some of them will say maybe. And

then I challenge them and say by what age do you think you would want to have that child?

And initially, you know, they've never really thought about this. Nobody's ever

kind of >> made them. Let me ask you that question, Doc. Like people think about, okay, by

Doc. Like people think about, okay, by by 30 I want to have a house. by 32 I want to have this car and I want to buy an you know another house or like I want

to go on this vacation. There's planning

for everything but why is >> why when it comes to having a child why is it not really >> because she's they've never really thought about it that way. It's like

I'll get I'll get round to it someday.

And when you change the whole way that she thinks and that's and whatever she decides >> whatever she decides is fine. I mean she can say so I will say do you want it

let's say 26 20 20 28 you tell me you give me a number and she says I'd like to do this 3 years from now I say now let's start counting backwards and if

you're counting backwards 9 months to make a baby so you subtract 9 months and for a

normal couple and a relatively younger couple in 6 months 50% will conceive. So

you subtract another 6 months. So I say you will start trying for your pregnancy 15 months before that date you now set for yourself.

>> I think this is something that you should vehemently emphasize on.

>> So this is very much like your house and your car. You've set yourself a date.

your car. You've set yourself a date.

Now now there is one other thing to remember that if you are in your 20s and early 30s, this is fine. But suppose

you're now at an age where waiting 3 years may have implications. This is

when you can have a conversation with her and say listen you can have that baby later if you want. But you better start preparing now and you do something

for yourself which will then take the pressure off you completely.

And today technology allows a woman to freeze her usides and if she is doing it on her own or to

freeze her embryos if she has a dependable partner.

>> Okay? Or sometimes I play devil's advocate with my patients and I say do both.

And the reason why I say do both is usites and embryos because sometimes relationships don't work out.

And if you're stuck with embryos, then you're giving someone control on your life. So why not do both?

life. So why not do both?

>> On the topic of how much time a woman has left, I remember you asking me to check my AMH levels. What is an AMH

level? Okay. So, basically when a woman

level? Okay. So, basically when a woman comes to you, one of the questions she has is what's my fertility time frame?

Now, we have this measurement which we started doing maybe like maybe 15 years ago when this test became available called the AMH or the antimarian

hormone. Now the antimarian hormone

hormone. Now the antimarian hormone basically is an assessment of ovarian reserve.

We talked about how many sites you have at the start, how many uses you have at puberty and then you keep using your sites up till you reach the menopause.

AMH basically signifies your ovarian reserve and it's complemented by one or two other tests. One test is called an antal follicle count. It's an ultrasound

which you do very early in your menstrual cycle. It gives you a fairly

menstrual cycle. It gives you a fairly good idea of ovarian function and it correlates with the AMH. So we now have two tests to tell us what the fertility

reserve is. It's called the antentral

reserve is. It's called the antentral follicle count. It basically looks at

follicle count. It basically looks at the prim the follicles when they first come up early in the cycle.

>> Okay. Now, but you have to put these two in context because too much panic is created when these tests are done. I

would add one more test to this and this is particularly for a woman who's in her late 30s or in her 40s and that is a test to assess maybe what her time to

menopause is likely to be. That's

important. Yes,

>> part of it is is suggested by a mother's history cuz that correlates pretty well and part of it is done by this test called FSH which is a hormone secreted

by the pituitary gland and which controls the ovaries and if the FSH is high it tells you ovarian function has started depleting. So there these three

started depleting. So there these three tests AMH and folic count and in the older woman the FSH. Now we seeing all

kinds of AMHs. I'm seeing low AMHs in younger women today and I'm seeing decent AMHs in slightly older women. So

for each woman it's different. When this

test first came there was panic. Women

were told you need to go for an IVF >> and you need to do a donor egg.

>> Oh wow.

>> Okay. And I remember back then I started keeping a record of my patients and very quickly I had a 150 patients who conceived on their own with really low

AMHes with minimal treatment which is now kind of accepted that you don't have to rush but your AMH is kind of telling you that maybe it's time to look at

things a little differently. So if I was to give an analogy for AMH, my analogy is it's the fuel gauge in your car.

>> Mhm.

>> You are now inching towards reserve.

That does not mean your car will stop.

It does not mean your car will not function. It just means that you know

function. It just means that you know you maybe need to find a gas station.

>> Now with your ovaries for your ovaries you can't refuel but you need to get whatever you want done in that much time. But what you can however do is and

time. But what you can however do is and if there's no plans in the immediate future, you can use this number to plan

a procedure where you put aside what you need for a later date.

>> Right?

>> Okay. So that's the significance of AMH.

Please read it in context. Do not panic with a low AMH. Though a low AMH is telling you something, so listen to it.

But I have had patients of mine conceiving with EMHs. You won't even believe, >> right?

>> So I always say that we do witness but I would not let a woman just maybe don't I'll tell you you could conceive but

please be prepared with other options as well. Okay. So so there is no doubt that

well. Okay. So so there is no doubt that in men too with age fertility will decline. Having said that, unlike women

decline. Having said that, unlike women who start off with a finite number of uses at the start of their life, men are

manufacturing millions of sperms every day and every week. No, but they they they are in trouble. I can tell you that. So, so I always anecdotally, Sir

that. So, so I always anecdotally, Sir Charles Chaplain had his child I think when he was in his 70s with his own sperm.

So men do stay fertile longer than women. But if there is one thing that

women. But if there is one thing that has changed, it is male infertility has gone up in leaps and bounds in the last one or two decades.

>> Why?

>> Than female infertility. So I can tell you >> as a student 30 35 years ago, male infertility was responsible for like 25%

of couples not conceiving. Today it's

50%. So do not let the guy and stop doing that. Now I'll tell you another

doing that. Now I'll tell you another very interesting fact. When I was a student, the WH said a normal sperm count needs at least 60 million sperms

per amen. Today the WH has brought it

per amen. Today the WH has brought it down to 20 million sperms because if they kept the 60 million sperms today, most men would flunk. Right now,

interestingly, this is something that's true across animal species. There's

something happening in the world which has brought down sperm counts dramatically.

So, when we talk about fertility, there is always all the medical things that can happen. But men have also been

can happen. But men have also been impacted in a way by lifestyle >> which is something lifestyle related.

>> But besides lifestyle, it is definitely the polluted world we live in. And one

of the things that we are sometimes either not aware of or we are in denial for is the environment plays a very important role in our lives. And if

there's one thing that's impacting hormonal health, it is the plastics in our life and in in the environment.

Now plastics and byproducts of plastics that get into everything. You know today we are talking about microlastics and all kinds of stuff. We found it in women's breast milk and everything

>> work like an estrogen which is a female hormone and imagine giving estrogen to a man. You're going to bring his sperm

man. You're going to bring his sperm counts down and they also have reproductive implications. Then there's

reproductive implications. Then there's other stuff like one of the things that came up recently was uh smoking has always been something that impacts fertility and I always tell my couples

that there's no doubt that when you're not in peak health your fertility will be compromised. So look at it and look

be compromised. So look at it and look at it differently. Vaping was thought to be safer. In fact, vaping probably has

be safer. In fact, vaping probably has more hormonal implications because of the flavors and things they add to them are synthetic and they could

impact your hormones as well. So, we we need to start thinking of things differently. You're absolutely right in

differently. You're absolutely right in saying that it's always been the woman's responsibility and burden and that's so unfair.

I would never and I have never I refuse to start anything unless I have both partners doing that.

>> I was just going to ask you that question because it's always the woman who shows up at the clinic.

>> I would refuse to start anything because it is a partnership issue.

It is two people who are equally going to do it together. It's not one person to blame and one person to be responsible. And society has very

responsible. And society has very conveniently always found fault with this and did have and I'm I'm saying that has changed at least in our

practice. We did have a time where where

practice. We did have a time where where the husband wouldn't even or the partner wouldn't even oblige as they doing as though they are doing us a favor with the semen analysis and I would refuse to

do anything until he did. And

interestingly, so often you'd find that the issue is is maybe his than hers. And

I never make it a his or her thing. It's

a partnership. Two people have to do it together. And sometimes one compensates

together. And sometimes one compensates for the other with fertility.

>> So male infertility is a fact.

>> Is this something that you would want to change and you would wish for change in the societ in society in the mindset of the society that both partners are equally?

>> It should be. It should be. I don't know if I should be letting this out to your viewers and listeners, but I will always find some m something the matter with

the sperm count and the semen anises report because it keeps them engaged and well behaved because because it's nice it's nice for both people to be in it

together whatever they are doing >> in your years of practice Dr. And you know this is very disheartening to hear that sperm count is reducing and you're

saying in all it's like a >> across mamian species >> a mamillian species and that's disturbing facts and according to you

some of the most common reasons that you find that you have found to be >> so >> causing this infertility >> they are called endocrine disruptors.

Endocrine disruptors everywhere.

everywhere.

>> Endocrine disruptors basically are substances which act like hormones though they are not really hormones. So today when women

are exposed to endocrine disruptors, imagine a pregnant woman being exposed to an endocrine disruptor, we see certain changes in a female fetus when

the child is born because she has been exposed to an endocrine disruptor. So at

least the first thing you can start doing is audit your life wherever possible. Particularly when it comes to

possible. Particularly when it comes to your your home and your kitchen. Try and

see if we can minimize the use of plastics. We go back to good old glass

plastics. We go back to good old glass and steel and again you know >> and fragrances >> everywhere you have it. And of course, everyone should be a champion and

advocate for the fact that we need society and we need our leaders to make sure that we are more environmentally responsible.

>> So just for all of us to have a more have better reproductive health some of the how does stress obesity junk food how does this affect reproductive health?

>> Yeah. Does it have any effect? If so,

>> definitely. So, first of all, today if there's one thing that has changed in populations is we've gone from scarcity to plenty.

>> Now, interestingly, there is a theory of something where you had women had a gene. We can call it the thrifty gene.

gene. We can call it the thrifty gene.

>> Yeah.

So this is something that maybe over centuries looked after women in times of scarcity and suddenly we are in a world of plenty.

>> Right?

>> If you go and look at adolescent girls today and you compared them to girls 20 years ago, there is a weight problem starting from adolescence itself.

Now that's contributed to by diets, lifestyle, less exercise, less activity and what we call as junk food.

uh well it's food it but it's it's not healthy in very large amounts. So so

when you have obesity and obesity is again linked with PCOS we spoke about that before 2/3s of patients or women or girls with PCOS will be overweight

one/ird won't and will start to conceive will have menstrual issues will have fertility issues and we'll have other

metabolic issues also. So obesity is not just going to be limited to menstruation and fertility but this these are women who in later life will have more hypertension more diabetes and just

imagine all of this can actually be reduced if we start right and we keep right. So that's obesity.

right. So that's obesity.

Stress impacts reproductive health and stress does it because stress works through the hypothalamus which is there

in the brain affecting the pituitary affecting the ovaries. Stress impacts

the secretion of cortisol from the adrenal glands and impacts reproduction indirectly. So there is no doubt that

indirectly. So there is no doubt that stress plays a role. Part of it is indirect, not direct like maybe obesity and hormonal issues would, but definitely needs to be something we

would address as we go along when it comes to fertility. In fact, there were there were very interesting studies done. See, any young girl knows that in

done. See, any young girl knows that in stressful periods, say during examinations, they often skip a period, >> right?

People said that in World War II when Europe was under the blitz and cities were being bombed, large number of women stopped menstruating

because stress does that to you through your hormones, your hypothalamus pituitary. It's called the HPO access,

pituitary. It's called the HPO access, your hypothalamus, pituitary ovarian access being impacted. So that's

something that you can probably look at.

These are factors which to an extent are something you can modulate.

Medicine traditionally has been practiced as let's fix a problem.

>> Yes.

>> And the ultimate goal of medicine should be let's prevent the problem.

>> Yes.

>> Okay. Prevention always is more of an effort. Takes more time. Takes more

effort. Takes more time. Takes more

counseling >> and it's individualized. It's it has to be individualized and let's face it when you're talking about a profession this constant refrain of we are too busy to

be doing this no no doctor can be too busy to be doing that >> so so I think that's been the shift and more and more doctors are acknowledging it and accepting it fortunately more and

more other health experts and providers have stepped in so where you had everything done with a doctor at one

point in time. Today, you've got so many other people from people who can help you with your nutrition to people who can help you with your exercise to

people who who kind of can give you great health advice and are health coaches to what you're doing and raising awareness for people. So, these are the

kind of things which are now available which maybe women didn't have a few years ago. Yeah, I remember the first time I heard a friend of mine say,

"I'm in a very happy marriage, but I choose to not have a baby." And it shocked me. Uh it was uh probably five,

shocked me. Uh it was uh probably five, six years ago, I think. I heard that for the first time. Now I hear couples say that all the time that we choose to not >> have a child. And I remember when I

heard it five six years ago, it really shocked me because uh I thought that people got married to have children and

I also meet people who have children and it has completely changed their lives.

It has given their lives purpose and it has given their lives something bigger than themselves and they turned out to be

fantastic parents and I see such joy and I want that for myself when I when I see such joy and happiness in their eyes and their hearts and you know your heart

almost it looks like it's becoming bigger to accommodate this this little being this uh you know well I have dogs and that's not does not come close. But

I I can imagine how it must feel to have a child. And I definitely love for

a child. And I definitely love for couples to, you know, every time I hear that we're going to have a child, I'm very very excited for them. And I I know that this I think what do you feel that

that >> so I think it's about choice >> and for me I sit in my room and for the

last over two decades from time to time I've had couples saying >> we're not having to have a baby we never want to have a baby and we're just great with each other and I appreciate that

>> and it's my job to make sure that happens. Do you also find them

happens. Do you also find them regretting eventually?

>> Yeah, once in a while they'll come back after seven years and we want it now.

>> But many of them have really thought it out right from the start of their relationship. Then I have a couple who

relationship. Then I have a couple who comes to me who is happy that they are pregnant. Then I

have a couple who's coming to me who is struggling to be pregnant. And then I have a couple who comes to me where there's a pregnancy and they say it's not wanted and we don't want it.

And you know what all four situations are their choice >> right?

>> So I believe my philosophy as a doctor has to be if she wants it I want it right.

>> In fact in fact obviously when I first heard it sometimes it would you had to keep a totally straight face but that was their choice and I hear it more and more and I

respect it. And when I tell my patients

respect it. And when I tell my patients their options when they're struggling to conceive, I will say, "Let's do it the simple way. If it doesn't work, we do

simple way. If it doesn't work, we do some treatment like an IUI. If it

doesn't work, we do an IVF. If you don't do an IVF once upon a time, we talked about surrogacy.

We talk about the option of adoption."

And then I say, "You know what? It's

also okay not to have a child."

Sometimes couples need someone who they consider their guide to be telling them this, giving them permission for that and say you can be perfectly happy. And

I'll actually sometimes and I'll say this just to reassure them with a wicked gleam in my eyes and say, you know, there's always at least one time when a parent has thought, I could have done

without this. I could have had such a

without this. I could have had such a great life. So that's fine. So at the

great life. So that's fine. So at the end of the day, people have to do what they want to do as long as they've had

all the options before them. Now when it would be unfair would be if in a relationship there's discordance between partners, >> right?

>> And one is forcing his or her preference on the partner. And that is something I sometimes see where >> I I see for me I would champion what the

woman wants.

I'm totally out there.

>> I'm totally out there most of the time and I help them work things out but finally it's something that they have to work out for themselves.

>> Right. So before we go to the treatment plan and once we know a couple has infertility issues before we go there I would like for you

to tell us one story that seems like now when you think about it was magical it had definitely had God's hand in it because when I enter your clinic the

first thing I noticed that was you have this very warm vibe to you and you know the clinic is full of baby

pictures and baby little sculptures and I I do you believe in God and you know I'm sure

>> now now you that that's a tough one. So

So I I am proud of religion and my religion because of the culture but I'm not religious.

>> You're not religious. So sometimes when you have when you see a story that >> but I but I see miracles all the time.

That's what I'm asking.

>> I see that all the time and I'm telling you I see the most impossible things happening.

give us >> I mean I I can't even put a number to them but I know I have this one patient

of mine who maybe late 30s came to me very low AMH did a basic treatment didn't work the

center for an IVF didn't work to me pregnant with a low AMH I've delivered this absolutely beautiful girl child

and her AMH is even lower. And then some time ago she was traveling and this is just in the last few months and she had a positive test but she had a chemical

pregnancy. She still has a low AMH and

pregnancy. She still has a low AMH and now she's conceived again and the pregnancy is doing great.

>> She has no business to be pregnant but she did.

>> That's my point. As long as a woman is menstruating and ovulating even with a low amate she can conceive. But what she shouldn't do is sit around waiting for a

miracle because sometimes you have to make miracles happen.

>> Right.

>> Right. So it's it's amazing and we see I I mean I've got a long list of people everyone from the from any patient of mine to the biggest celebrity and you

won't believe the kind of AMHs they've conceived with. You won't believe the

conceived with. You won't believe the kind of challenges we've gone through in pregnancy. Sometimes the real miracle

pregnancy. Sometimes the real miracle becomes when you have a difficult complicated pregnancy and you somehow pull it through and we've got this amazing child at the end of it. So we we

are we truly privileged but like I said most of the time we are there we are there for the ride with the patient and the woman I'm looking after and her family and doctors shouldn't always we

have to stay humble because a lot of this is happening and we are just bystanders.

When a couple knows that they have infertility issues and realize it's time to go and meet a doctor, you said that you wouldn't immediately recommend an IVF treatment.

>> No. So, first of all, don't wait for the infertility issue, >> right?

>> I think women should find a doctor that they can visit. I would want and I'm fortunate that I generally have it in my practice but I would want every woman to

go to her doctor preconceptionally maybe even before she gets married or maybe even before she gets in a relationship and go from time to time to take good care of herself

>> particularly if they are planning conception near future one year two years whatever there's a lot of things she can do to prepare how come we prepare for everything with

so much effort you prepare for a journey and for a holiday and you don't prepare for this journey. Now some of the most simple things which are overlooked are basic tests for her I mean today we see

so much vitamin deficiency find out what your levels are and make sure you take adequate treatment for them. I don't believe in everyone

them. I don't believe in everyone popping every pill. Find out what your levels are at that point in time. There

are two viral infections which I dread during pregnancy. There's reubella which

during pregnancy. There's reubella which is German measles and varicella which is chickenpox. Find out your antibbody

chickenpox. Find out your antibbody titus. If you don't have antibodies, get

titus. If you don't have antibodies, get vaccinated before you get to pregnancy.

These are viral infections which can cause the worst birth defects which are completely preventable. In fact, the

completely preventable. In fact, the first time a virus was linked to a birth defect was in the 1940s when German measles was and thankfully now a child

is getting vaccinated. But a whole generation of women, the women who are at the moment late 20s, 30s were never vaccinated against this and should take the vaccine. What about the HPV vaccine?

the vaccine. What about the HPV vaccine?

If you're waiting for some time, prevent cervical cancer. Get your papsmear done.

cervical cancer. Get your papsmear done.

Ask for it. Somehow this country has been so negligent when it comes to something this important. If every woman had a papsmear, there would be no cervical cancer in this world. The

fourth most common cancer in the world.

Second common in our India in women.

preventable. Just take care of yourself.

Next, I move on to fertility. Let's do a reamage. Now, you can have a

reamage. Now, you can have a conversation saying, "Listen, you're fine. You have some time or you maybe

fine. You have some time or you maybe think about something else.

Give her her supplements. Any woman

who's even dreaming of a pregnancy should be on folic acid. Reduces birth

defects by over 50%. We used to see a very common birth defect.

>> Is it safe to just taking folic?" So the west has actually fortified food with >> folic.

>> Our country hasn't. So take a folic acid. You can't have a simpler more

acid. You can't have a simpler more cheap kind of medication to take. So

these are the kind of the an ultrasound.

With age there are a few things a woman has to accept. Her uterus may develop fibroids.

She develops a condition called endometriosis which is a very real problem today. the

kind of you know >> the numbers we are seeing today >> endometriosis with the lining of the uterus grows outside the uterus at one point we started seeing it in women 30s

not today I'm seeing it in a woman in her 20s as well partly endocrine disruptors partly environment but also the fact that

so you know sometimes in a lighter vein I tell a woman she says doc why did I have endometriosis or why do I have fibroids And I tell her, "Because you

don't have 12 children."

Because the default setting of nature historically was for a woman to be pregnant throughout her life.

>> Right?

>> And you just have to go back two generations in our lives and see our grandmothers and their mothers and they all had 10 12 children and in one generation we went to two and now maybe

we've gone to one and if it's one it's later. So when you stop menstruation by

later. So when you stop menstruation by being pregnant, you actually prevent a lot of the modern medical problems women face. Okay, this

is a reality. Does this mean women should have children early? Absolutely

not. But women have to be aware of it.

And you know one way of preventing many of these problems today, birth control can be much more than birth control. And it's so sad that

birth control sometimes gets neglected and that's why women end up having an unwanted pregnancy which they have to keep or not keep deciding depending upon what they do. But today birth control

actually has a lot of other benefits which are non-contraceptive like the birth control pill can prevent endometriosis can prevent ovarian cysts

can prevent ovarian cancer.

the intrauterrine device which releases a hormone a hormonal device can prevent uterine cancer. So women have never been

uterine cancer. So women have never been made aware of these things where they go to the doctor and say I want quality birth control. I'm not afraid of it but

birth control. I'm not afraid of it but tell me what's safe for me and tell me what other benefits can it give.

>> But why does birth control have such a bad rep as well? Okay, there you have to understand once we carry forward everything which was probably true 40

years ago. The pill we have today is

years ago. The pill we have today is nothing like the pill we had 30 or 40 years ago. Number one. Number two, you

years ago. Number one. Number two, you know, bad news is always put out there. Media doesn't

help and social media helps even less.

It's something >> you must get on a birth good birth >> if you need to >> if you need to after your doctor and in consultation today I'm on the fourth

generation of a birth control pill >> today all the many things I'm not saying it'll suit every woman >> right >> it won't and then you need to decide who takes it and who doesn't like so there's always

>> people take it casually for acne and >> no that's not casually for acne >> they take it because it is a medical treatment for certain medical problems

with their excess male hormones >> I understand but I think that it's also So, >> so >> given as a first >> no so today a large number of patients

who are on the pill are not even taking it for birth control.

>> Yes.

>> Okay. So now for example we mentioned acne could be one part of what we call as excess male hormone hyperandrogenism.

>> Okay.

>> Polycystic ovaries or periods are irregular that will have long-term implications. So in this case I could

implications. So in this case I could use progesterone to regularize her periods or I could use a combined pill.

Now if I use the combined pill what am I doing for her? I am bringing down the level of abnormal hormones and it is so you could do all the treatment you want locally but unless you treat the cause

it's never going to work. But not all acne need the birth control pill. So you

got to decide which one does and which one doesn't. So those are the cosmetic

one doesn't. So those are the cosmetic benefits of the pill. So I often tell my patients that the pill is extremely safe.

Some women are dangerous.

>> So if you are very overweight, if you have a lot of lipid issues, cholesterol and stuff like that, if you are a heavy smoker, if you're someone who suffers

from migraine, then we have alternatives for you other than the birth control pill. But for the others, the pill is a

pill. But for the others, the pill is a very very safe thing to do if they need it. And when would a woman need a pill?

it. And when would a woman need a pill?

One, if she wants reliable birth control, but she should know about other birth control methods as yet. Very often

in someone who's either not not ready for children, not even in a regular relationship, not married, birth control pill is excellent. Though in this woman,

I will always insist that she always also uses a barrier, a condom.

because she needs to protect herself, not just from pregnancy, but from infections. The pill is fabulous for

infections. The pill is fabulous for pregnancy, hopeless for infections. So,

it's always double protection. And I'll

go one step further and tell her, don't ever tell the guy you're on the pill because he'll try and get out of using the condom. That's our secret. So,

the condom. That's our secret. So,

that's how you probably So, you need to stagger it according to need and to want. And sometimes I think if women are

want. And sometimes I think if women are given this kind of information they always make the choices which suit them the most

>> and but so now if all else has failed and we get to do IVF.

>> Yeah.

>> What is IVF?

So when a woman is now, you know, diagnosed as being infertile, you know, they've tried for 12 months or 6 months, they've done everything right, their timing is right, and she hasn't

conceived, then she definitely needs to come under medical care. The first thing I would do is I'd help her pinpoint ovulation.

I might, depending upon her menstrual cycle, give her the fertility meds, very safe, but need to be monitored. The one

thing I always tell them is one is a risk of over stimulation which is very rare but a slightly higher chance of having a twin pregnancy almost 8% with

the medications. The next step, if it's

the medications. The next step, if it's an unexplained infertility, she's fine, he's fine, they're not conceiving, is to move on to a procedure called intrauterrine insemination, where you

stimulate the growth of the follicle, do ultrasounds, give her a trigger, and take the husband's semen, process it, make it better, and put it inside the

uterus. So, it increases your fertility

uterus. So, it increases your fertility by almost 25% over natural. And if this hasn't worked, >> it increases by 25% over your natural >> over your natural capability. And then

finally if this hasn't worked you come to an IVF.

IVF is amazing technology. You know

interestingly I was just thinking 25th of July just 5 days ago is when the first IVF baby was born in

the world >> and she is going to be she's 47 years old now. She's going to be 50 in 2028.

old now. She's going to be 50 in 2028.

Okay. And that was truly miraculous when that happened. Okay, that's one of the

that happened. Okay, that's one of the things which I think has changed the whole profile of they say that today there are more than a million IVF babies in the world.

>> Wow.

>> Okay, so IVF definitely is proven technology. It still has a long way to

technology. It still has a long way to go to be the perfect technology but we are doing it. So now this is when the woman should be having her conversation about her options and her options would

be next you go for an IVF depending upon how complicated it is and I'm a great believer and I always tell my patient that everything's on the table now you've come to a point and if it's

really likely to be difficult I will have a talk about adoption which is fabulous because my patients who adopted actually tell me thank god we didn't have our own baby >> really >> because we now we are I have this child

and so many of them go and go on.

>> Is adoption easy in India?

>> No, but so many of them go on and have their own child after that. That baby

does some magic.

>> Wow.

>> And after they've adopted, they just go and get pregnant.

>> Okay. Very difficult.

>> Very difficult.

>> Which is why I tell my patient, put your name on the list.

>> Yes.

>> It's 3 years away. You can always take it off the list. But you know, if IVF hasn't worked >> and then you feel that there's this emptiness, you've already done something for yourself. Okay. Now she goes for an

for yourself. Okay. Now she goes for an IVF. And IVF it's it's the the medical

IVF. And IVF it's it's the the medical term is in vitro fertilization which basically means the fertilization of the egg. The egg and the sperm are brought

egg. The egg and the sperm are brought together outside the human body in a laboratory.

>> It's not in a test tube. It's called a test tube maybe. It's in a petry dish.

>> Okay.

>> Game changer.

>> Okay. So it first came in when there was tubal infertility. So we spoke about

tubal infertility. So we spoke about anovvulation where she doesn't conceive because she doesn't develop an egg and you can have tubal infertility where pelvic infections have damaged the

tubes. Obviously the tube is where the

tubes. Obviously the tube is where the sperm and the egg meet since they can't meet here. They meet in the lab and then

meet here. They meet in the lab and then you put the embryo back into the uterus.

>> Okay.

>> So that's the reason why IVF is done.

IVF has been a gamecher for male infertility.

>> Why?

>> Game changer. So one type of IVF is called Ixie which is intracytoplasmic sperm injection. You take one egg.

sperm injection. You take one egg.

>> Okay.

>> You take one sperm and you inject it in the egg.

>> Oh, >> so I don't need millions.

>> I can do with a few thousands or few hundred thousands. In fact, I just had a

hundred thousands. In fact, I just had a patient a day or two ago, zero sperm count, been doing stuff and but his testes are still functioning. So, she's

gone to the IVF clinic now and they'll try and aspirate some sperms from the testes and they'll probably be able to use the sperm to have a pregnancy.

>> Wow. Science is

>> okay. So, that's that's now when an IVF is done. So once you've gotten the

is done. So once you've gotten the embryo once the egg and the sperm come together. So we have made great strides

together. So we have made great strides in IVF when it comes to so initially used to struggle to get the woman to ovulate. Now it's almost guaranteed.

ovulate. Now it's almost guaranteed.

Okay. We used to struggle to have an embryo. Now it is almost guaranteed.

embryo. Now it is almost guaranteed.

The weak link in IVF is at the moment that when you put the embryo back into the uterus, >> you can't always make the uterus accepted. And when we change that in the

accepted. And when we change that in the future, it's going to be a game changer.

>> I that's the only weak link right now in IVF.

>> That is one of the weak links in IVF right now. Now, so so basically IVF will

right now. Now, so so basically IVF will give you a success of maybe 30 to 35% per cycle. You remember we talked about

per cycle. You remember we talked about the others being 15% and okay maybe lower for an older woman but that much >> right >> now in an older woman where her eggs are

either not doing what they supposed to do let's say she's in her 40s and she didn't freeze her eggs and she doesn't have embryos >> part next

>> she has every option of going for a donor egg pregnancy a donor usite Pregnancy is where an older woman or a younger woman whose

ovaries have failed and there is something called as premature ovarian insufficiency. What we used to call

insufficiency. What we used to call premature menopause but that's a very crude term. So we don't like the word

crude term. So we don't like the word menopause in a young woman. We say

premature ovarian insufficiency. She can

take the eggs of a fertile woman and she can have her pregnancy. And the amazing thing is she carries the pregnancy. She

gives birth to the child and it's every bit 100% her baby and she's very happy to have it. So I always tell them it's like you are adopting part of someone else's child but it's all yours. So

that's >> and you've seen quite a few of such pregnancies >> because now when you're doing pregnancies in the mid and late 40s many of them would be a donor site which is

fine and as I've always said it's nobody else's business to know and nobody needs to. It's something that's between the

to. It's something that's between the the couple and the doctor. I tell her, don't even tell your parents. Why should

anyone know? It's your baby. You gave

birth your name on the birth certificate. Anyway, so that that's

certificate. Anyway, so that that's basically IVF. Now, there are certain

basically IVF. Now, there are certain other things that can be done with an IVF.

One of the things that's done with an IVF is something called as PGD. It's not

routinely done, but it is available. So

if you're expecting a pregnancy to maybe have a risk of genetic defects and some centers are doing it routinely, you can actually test the embryos before putting

them back.

>> But I heard that it also can damage the embryo.

>> Exactly. So there are certain centers overseas who are doing it almost routinely. They do a PGD for all.

routinely. They do a PGD for all.

Theoretically the risk of damage is there. So most centers maybe in our

there. So most centers maybe in our country don't do it and we deal with the genetics when you come to the 3 month mark in pregnancy but if a couple has a history of a

genetic problem and they don't want to go with this option of having to terminate a pregnancy at 3 months this is definitely an option for them to to exercise.

So now let's talk about the future of fertility which is the egg freezing. Uh

yeah egg egg egg freezing has been gaining popularity and I know girls now as young as 25 26 freezing their eggs because they know that they're ambitious. They know that they have a

ambitious. They know that they have a career but they know that they also want a child and u they really planning in

advance. So again just had a girl last

advance. So again just had a girl last week 26 27 asking me asking me about it no no asking me about it but so so we

started semen and sperms froze very easily and something we've been doing for a long time decades now

freezing became successful later maybe 15 years ago embryos froze better than usite So initially it was always embryo

freezing but now we've maxed the technique of usite freezing. So we maxed it.

>> So >> but it was embryos were frozen a lot before uses because they froze better >> and uses when you froze them when you thought them sometimes when you first

started and the techniques weren't great. It wasn't working. Now it's

great. It wasn't working. Now it's

working extremely well. Now what did I tell the 27 year old?

She doesn't know what's going to happen but something could dramatically change in her life.

It is a medical procedure and like any medical procedures there's always a risk benefit ratio. You are taking large

benefit ratio. You are taking large doses of medication.

You could land up with something called as an ovarian hyper stimulation.

We've had patients where there are now these are extremely rare. So no scaring patients. A woman who needs it does it.

patients. A woman who needs it does it.

So for me it's in my head that a good time to think about this is when you're 30 31 32 years old by which time you've got a fairly good idea of what's going

to happen. A 26 year old is going to may

to happen. A 26 year old is going to may find someone in the next 3 years and then they make this decision together. Uh most women have a

together. Uh most women have a reasonably good fertility at that age.

They know exactly where their life is going professionally and other ways.

they're kind of making their plan for the next few years. She either has nobody on the horizon and I said I said I

always tell them don't worry there is a white knight riding towards towards you honesty you just have to wait for him >> keep an open mind but don't compromise

ever and definitely not for fertility so she could probably think about it at that time now if I have a couple who comes to me another couple came to me

just this week and she's 34 her AMH is and they asked me whether they should do freezing and I had a chat with them and they said

no we probably planning just one child.

I said if you're planning two children please freeze cuz you'll probably need it for your second pregnancy but if you're planning to try within a year or two your AMH is going to see you

through. So maybe you don't have to go

through. So maybe you don't have to go through the expense and the procedure and whatever risk little bit of risk it entails and if it doesn't happen you can

always go for an IVF after a year. So

every patient has to be individualized according to what she wants and every patient has to honestly be explained what she's going in for. Right. Right

now, a younger woman probably might need just one or two IVF cycles.

>> At an older at another age when she's say in the mid-30s, she might need to do multiple IVF cycles because if you're freezing, you need at least eight or 10 or 12.

>> You can't just freeze two or three.

That's meaningless. She'll use them, not succeed, and everything is over.

>> And she also has to be made aware of other options.

>> So, this young woman is told by me that there's something called as a donorite.

and that's available to you. So if you do not conceive later in life, you can always opt for that and you won't believe how many women when they given

this knowledge will say doc that makes perfect sense to me and I'm okay with it. So I will hold on I will do my stuff

it. So I will hold on I will do my stuff and if at some point in life I'm not able to conceive and it's I would even favor an adoption if I can but I will go

for the so when she has this information she makes the decision. So if she says I want my genetics >> right >> please freeze. If she says listen I'm

not stuck on it I just want that child at the end of the day she does it that way >> right >> but she decides >> so like everything everything the first thing I have to mention is AI so

fertility clinics have started using artificial intelligence to help them doing it's it's nent at the moment

uh individualized patient treatments based upon a lot of other characteristics and Maybe in future even her genetics. Okay, they're using AI in

her genetics. Okay, they're using AI in selection of usites, quality of usites and embryos. You know, today AI is going

and embryos. You know, today AI is going to be a game changer in reading an ECG or reading an X-ray or reading a CT scan

or reading an MRI where while the human person might be better, the human person gets fatigued whereas AI never gets fatigued. So maybe picking up selecting

fatigued. So maybe picking up selecting better ones AI might do. So so that's going to be one thing that could happen in future where it'll make what we are doing better. Endometrial receptivity is

doing better. Endometrial receptivity is being studied. Can we not do something

being studied. Can we not do something to trick the uterus into accepting the embryo.

Okay. The third thing that probably is in advance is there are some treatments at the moment again nent stage called ovarian rejuvenation.

>> All right. Yes. where they are injecting stuff into the ovaries to kind of make them function including stem cells.

>> Huh. And how is that working?

>> I would still say it's I know people are pushing it too early.

>> I don't think people should really really be getting into it. They should

wait >> and see how and where this goes.

>> Something that was done which was dramatic. Something that I don't really

dramatic. Something that I don't really favor is there have been cases where a uterus has been implanted. a uterine

transplant has been done.

>> Oh, >> right. But for me, that doesn't make

>> right. But for me, that doesn't make sense because if you're going through a complicated surgery and taking someone else's uterus, why not just put your pregnancy in someone else's uterus and

have a surrogate do it for you?

>> Yeah. But surrogacy is another topic that shrouded. I'm going to come I'll

that shrouded. I'm going to come I'll talk about so this is and the one or two other things that probably we have to look to in the future is

>> medications of course simplified protocols I must must put this out there if there's one thing that we haven't done

for couples and women in public health it's looking after fertility so in you better have the resources in our country

to be able to afford these treatments because it's almost all in the private sector. The private sector has not

sector. The private sector has not always been kind and I know that families have been their future and finances have been wiped out because a

father even from a poor background will sell everything to get his daughter the treatment. And I think that's one thing

treatment. And I think that's one thing that 10% of your population struggles with this. A lot of families get wiped

with this. A lot of families get wiped out because of this kind of treatment and I think the public sector there have been some moves and the government system has to step in or we have to have

more affordable treatments for this and that is something that you know all of us have to champion. I mean nobody should be denied something which is

available to them uh if they want it and it has to be done at in a way that they can access and afford it.

Is there a way that this these treatments can be made cheaper?

>> Oh, definitely. Oh, definitely. And

again, this is something that a lot of the medications can be available at lower cost, I believe. And I believe when a system like the public system

takes it up, it will be available.

You can do an advanced treatment of infertility at sometimes a fraction of the cost at which it's happening nowadays if you took advantage and

passed on all the benefits to the patients. And I I'm not saying anything

patients. And I I'm not saying anything is people are asking for anything which free. They just saying make it more

free. They just saying make it more affordable.

>> Absolutely. And whether it be an NGO, whether it be you know charitable institutions, I think it should be the government because it is a responsibility of the

people in health to make sure that if you've got such a large number of people who need it, make it available at least in many places in every state which

people can go and access. There's also

surrogacy that we haven't discussed and I know that there's a lot of judgment around it and I think it's

based on also halfbaked information that people seem to have. So what are your thoughts on surrogacy?

>> So basically surrogacy is a very important option when it is indicated and required. Unfortunately,

and required. Unfortunately, we now have a law in our country which has made it extremely difficult, very difficult if not almost impossible.

So what happened was surrogacy basically is used when a woman for whatever medical reason is not able to carry her own pregnancy

either because of a problem in the uterus. Some women I've had patient a

uterus. Some women I've had patient a patient of mine who had no uterus, an absent uterus, right? Uh patients who whose uterus has

right? Uh patients who whose uterus has been damaged by a procedure or by tuberculosis and there's no way she'd be able to

carry her own pregnancy. In this case, absolutely wonderful. I had a patient of

absolutely wonderful. I had a patient of mine who had eight miscarriages and then finally we had a baby with surrogacy. more than one but this was

surrogacy. more than one but this was like eight miscarriages so there was no other option and in these cases surrogacy was indicated and then of course surrogacy was done for other

reasons one was of course social surrogacy where a woman felt that she didn't want to be pregnant right personally I feel that is a choice it's

for the woman to make not for society to judge or decide but maybe it was not a medical reason to do it and then surrogacy was of course used single

parents same-sex couples and so this was the situation. Unfortunately,

the situation. Unfortunately, it wasn't managed very well and there was a lot of exploitation of the surrogates which is why activists came in and they passed a law. Now I think the law went

over the top because it kind of took away something which was extremely important for women >> because there are medical conditions that >> Absolutely. Okay. So in this case what

>> Absolutely. Okay. So in this case what happened was they suddenly said it can only be altruistic which means that originally you

contractually had someone else carry your pregnancy for you for which the person had to be looked after and reimbured not allowed in our country now altruistic is not easy that's how it

started you may not always have someone who can do it for you I always believe that having someone in the family doing it for you is a little messy you want

that to happen. So that's where we at now. Fortunately, recently there have

now. Fortunately, recently there have been a few cases in whom on a case-bycase basis we've actually managed to get courts to give permission but

it's extremely difficult. So this is where we are at. Is it useful?

Extremely. Is it important? Absolutely.

Should we have been more responsible in how we did it? We should have. We should

have looked after those women better. we

should have not exploited the couples the way it was was very expensive. So

all those things were didn't work out well but that didn't mean it was a very it was a very important intervention that was available to us which at the moment has been taken away. I hope at

some point in time we'll find some way of >> middle ground >> a middle ground we like like anything something gets overdone restrictions

come in but a lot of women who would otherwise benefited from it lost that benefit so it just comes in the scheme of things

you do it simple you do an IUI you do an IVF if you can't have your own eggs you do a donor egg if you can't use your own uterus use is a surrogate and then there are permutations and combinations and

today theoretically it's so interesting that one child can have many parents >> one person >> one person's egg

>> another person's womb >> one person's womb and there might be parents who've actually contracted this whole thing out >> oh my god this is >> so theoretically

that's possible and there again if you're looking at the future I think regulations and laws also need to kind of take care of many of these things and they will. I'm sure they

will.

>> We've spoken on in detail on many things and if you would if you could put this in like a fivepoint takeaway to someone who's

looking to get pregnant sometime in the future who wants to be a mother but maybe not now. If you could put all of this in like a fivepoint takeaway,

tests lifestyle and 15 months in advance, 15 months before you plan your pregnancy, start the process. So, if you

could concise this a bit, >> the first thing is be healthy, >> right?

>> Make sure you look after yourself.

That's extremely important. Diet,

exercise, live a healthy life. Secondly,

educate yourself.

Be prepared. Make lists. Make points.

Go prepared to your whoever is looking after your health, your doctor and do stuff. Thirdly, know your own health

stuff. Thirdly, know your own health status and your fertility status which will help you make decisions again along with the specialist but do it for yourself.

Fourthly, do not ever feel pushed by anyone else to make these decisions for you. make them yourself and don't

you. make them yourself and don't delay things for the wrong reasons.

You can always I'll tell you that. So

sometimes people look at things sequentially. You mentioned sometimes

sequentially. You mentioned sometimes things can run with each other >> and you don't have to wait for something to be done before you do the next.

>> You need a goal before you >> you give your permission yourself permission to do things simultaneously and side by side. So you make your decision accordingly and finally you

take the call but be prepared for it. So

if you feel that no it's not going to happen in the near future but I'd like to do it for myself freeze your eggs freeze your embryos freeze both and when

time comes they are available to you may not need them you'll conceive when time comes but if you don't conceive it's already available to you and remember that okay

the big thing comes in which maybe I'll just put in here elder mothers elderly parents And society will have its own opinion on that.

>> You do things >> you see that judgment >> around society society reproduction and older mothers older parents.

>> So I see this particular I see it within the profession and outside the profession where everyone believes it should have happened earlier

and that's not your decision to make.

She made that decision support her on it. Now, what are the consequences of

it. Now, what are the consequences of having a baby later in your life? Well,

there are health issues. Obviously,

there'll be more diabetes, more hypertension. But if you're a healthy

hypertension. But if you're a healthy woman, we'll take care of it. Don't

worry.

>> There is a slightly higher chance, not significantly higher chance of having a child with a genetic issue, obviously, you have to be prepared for chance.

>> Yes. So, so for example something like tricom 21 what we call down syndrome >> with her own eggs at the age of 25 it's 1 in 2500

at the age of 35 it's 1 in 350 at the age of 40 it's 1 in 40 and then every year it goes up okay she

knows about it my job to test for it and she has to be aware that if it's not going to be a healthy pregnancy we let it And this is something that we decide and

talk about beforehand. So genetic issues on the plus side is she's doing it when she wants. I always say that women at

she wants. I always say that women at this age are wiser, more balanced as far as the pregnancy is concerned, more resourceful.

A younger woman doesn't have all the advantage of those years and resources that an older woman has. And I once read this statistic which is quite interesting. It said

couples who have babies when they older actually live longer.

Her mental acuity is better because the child is keeping her. Okay. So, so there are pros. At the end of the day, it has

are pros. At the end of the day, it has to be her making the decision with all the information given to her at the right time and we stepping up to

support. I think that yeah there are

support. I think that yeah there are pros and cons both ways but we must leave the choice to the woman and you said that brilliantly.

>> Again for me it always boils down to what she wants.

>> I think you've given a lot of women hope. I know that some women might have

hope. I know that some women might have might be just like they don't want to think about it because they might think it's too late. So, I think that you've given a lot of women a lot of hope and I

hope they use this information wisely.

>> Thank you so much, doctor. This was an eyeopening episode, especially because you chose to be honest and also extremely detailed in explaining

everything associated with a woman's health, her fertility, and her options.

So, thank you so so much for being here on Take 20.

>> It's been a privilege. It's been a privilege.

Oh my god.