Dr Natalie Crawford is a double board-certified fertility doctor. She is also the co-founder of Fora Fertility clinic and Pinnacle Conference, a leadership conference for women in medicine. She appeared recently on The Diary of a CEO to talk about all things fertility. Here are some of her insights:

People should be thinking about fertility much earlier than they currently do if having children is desired. With social media, people are becoming more aware of fertility issues, and today, people have access to technologies like IVF and egg freezing.

One out of five people in the US will face infertility issues when they try to conceive for the first time. One of the reasons is starting later. In the 70s, 5% of people started their family over 30. Now, it’s 30%. Another reason is that people are less healthy. Higher proportions of obesity, and diabetes, plus environmental toxins like microplastics, marijuana use, etc.

People are having less sex, including married couples. The average birthrate in the US is 1.3. Sperm counts have decreased by 50% in the last 50 years. The rate of decline is accelerating. Dr Crawford’s average patient is over 36, has been trying for 1-2 years and is still unsuccessful despite cycle tracking and IVF.

The average man makes 200-300 million sperm in a day. Sperm have a 3-month life cycle: 72 days to grow in the testicle, and 18 days to be ejaculated. If they aren’t ejaculated, they will die while remaining inside the body. Too much abstinence in-between intercourse leads to many dead sperm which will negatively affect fertilization. Hence, when trying for a baby, men should ejaculate regularly if they wish to increase their chances of fertilizing an egg during sex, somewhere between every day to two times a week.

People are becoming more obese, and have high cholesterol, stress, and diabetes. These impact fertility. The brain assesses the state of the body, whether it is in a good state to have children. If the assessment is bad, the brain will instruct the body to shut down the reproductive system, in part, by inhibiting hormones like progesterone and testosterone. Toxins from food, from the air, from kitchen utensils, from clothes, from living environment, etc., contribute as well.

Marijuana and cigarettes (including vapes) are a big no. Modern phones emit less radiation than from the beginning of the 21st century. They are not a significant risk for lowered sperm count. Heat negatively impacts the testicles, lowering sperm and testosterone production. Daily hot tub or sauna use, laptops on the lap, intense cycling (road biking), significantly lower sperm count.

Testosterone replacement therapy designed for improving men’s sex drive, erection quality, and energy negatively impacts sperm count. The signal that there is a lot of testosterone in the body will tell the testicles to stop making more sperm. Men on TRT can ejaculate fine, but the ejaculate will not contain live sperm. Long-term TRT might cause the above issue to become permanent.

A five-month-old female baby in the womb will have the most eggs she will ever have: 6-7 million. This baby will be born with about 1-2 million eggs, have 500,000 at puberty, 300,000 at the time they are trying for children, and less than 1000 left at menopause. Before puberty, eggs that are released to the ovary each month die. After puberty, follicle stimulating hormone will stimulate one of the eggs in the ovary each month. The egg will ovulate.

After age 37, there is a rapid decline in how many eggs are remaining and coming out to be ovulated. Menopause average age is 51. Dr Crawford has met people who ran out of eggs in their 20s.

Many things impact the quality of all the eggs. Smoking, drugs, processed foods, chronic inflammation, and more, lower the quality of the eggs that are left in the body as time passes. Their chromosomes have been altered abnormally, lowering the chance of successful pregnancy. For the above reasons, if you are 35, the chances of miscarriage are 25% (50% at 40), and the chances of getting pregnant in the first place are 15% a month (on average, it will take a little more than half a year of trying to get pregnant, assuming the woman has regular periods, and the couple is having regular intercourse with ejaculation). This is because, of the basket of eggs dropped into the ovary in a given month, about half of the eggs have been abnormally altered by environmental factors. The body does not discriminate between them, and an egg at random will be chosen to ovulate. If one of the bad eggs is chosen in that cycle, it will not have the potential to become a liveborn baby, even if all other conditions are met. Hence, egg number and quality should both be considered and optimized if the plan is to get pregnant and have multiple children. i.e., sustain a healthy lifestyle and start early where feasible, in your 20s.

https://pkwomensclinic.com/a-gynaecologists-complete-guide-to-pregnancy-in-singapore-2023

Women should get their ovarian reserves checked. Some might be running out of eggs faster than others, and that will impact timely decisions (freeze eggs, live more healthily, get pregnant sooner) that need to be made to avoid regret.

Avoid alcohol. Avoid high pollution areas, do not cook with plastic, do not use cooking pans that have teflon, do not touch thermal paper receipts, avoid eating food in plastic containers, use glass to store food, decrease chronic inflammation, sleep well, reduce chronic stress, avoid processed meats, refined carbohydrates, eat more fruits and vegetables. Fat is essential to producing steroid hormones, so eat healthy fats, and whole-fat dairy. Exercising is good, but intense exercise like the kind elite athletes do to train for the Olympics should be avoided.

The average person’s menstrual cycle is between 24 to 35 days. The time to have sex for optimal fertility is the length of the cycle minus 14-19 days. E.g., 35 – 14 to 19 = Day 16 – 21 of a 35-day cycle. AND 24 – 14 to 19 = Day 5 to 10 of a 24-day cycle. Sperm can survive in the reproductive tract for up to 5 days, so intercourse from day 11 in the first instance and day 0 in the second could also work.

There is no sex position that is better at fertilization than another. It’s all about being in positions that allow for consistent ejaculations, which might require a variety because it takes several sessions for most people in their late 20s or 30s (variety is the spice of life). Female orgasm causes uterine contractions that help sperm get to the egg faster. It is theorized that this increases the chance of successful impregnation. Penis size does not matter. Penis sizes vary according to race and ethnicity, and vary proportionately with vaginal lengths in women of the same ethnicity.

For some people in certain professions or life circumstances, having intercourse during the fertile window is not possible. They can do IUI, or intrauterine insemination, where an ejaculated sample is processed and then inserted into the uterus at the optimal times.

There is a dark web of sperm donation where people who wish to avoid using sperm banks for various reasons will meet up with sellers at random places to get sperm. Some find sperm banks too expensive. In the US, a vial of sperm costs 1000 dollars, and one cycle of treatment costs about 2000 dollars. A 15% chance of success with each try assuming 35 years of age means it costs on average 3k x 6.7 = 20k USD thereabouts to achieve a successful pregnancy at 35)

Up to 20% of people have PCOS (polycystic ovary syndrome), and many are undiagnosed. It leads to a host of issues, including irregular periods or not having periods at all. Period issues are among the top causes of infertility. Not having a period is not normal. If the lining of the uterus grows each cycle and the person does not receive the progesterone signal to shed the lining, it can lead to endometrial (uterine) cancer. This is a significant risk in women with PCOS.

Having low estrogen, from lost periods or other reasons, is detrimental to female health. For example, menopausal women are at increased risk of heart disease, stroke, osteoporosis, dementia, etc. Estrogen is protective against these, and not having periods when young is a bad sign. The brain will not function well, the person will feel fatigued all the time. Hence, replacing estrogen is important.

The use of birth control pills that mask underlying problems is a huge issue in women’s health. They are useful in certain cases to sustain hormone levels, avoid terrible PMS symptoms, prevent cancer from PCOS, etc. However, if a woman wishes to get pregnant, she should get off the pill for a while prior to observe any issues with her period and find timely solutions if necessary.