How Women Can Improve Their Fertility & Hormone Health | Dr. Natalie Crawford
In a Nutshell
Fertility serves as a key indicator of overall hormonal, metabolic, and cellular health, with low AMH signaling reduced egg quantity (not quality) and risks like early menopause, warranting immediate testing for proactive planning like egg freezing or natural conception. Optimize fertility and hormone health through five non-negotiables: 7-9 hours sleep, stress reduction, muscle-building exercise, anti-inflammatory high-fiber diets (avoid ultra-processed foods, red meat excess, gluten/dairy if sensitive), and toxin minimization (no cannabis/nicotine/alcohol/NSAIDs outside periods, fragrance-free products, glass over plastic). Supplements like CoQ10, omega-3s, vitamin D, and low-dose melatonin support egg/sperm quality; track cycles/ovulation, stop birth control 3-6 months pre-conception, and advocate for early HRT in perimenopause to extend ovarian lifespan and reduce disease risks.
These notes were generated by AI and may contain inaccuracies.
Everybody should get an AMH test. It is a very important marker. If you want kids one day, ask your doctor for this test. It is not a test of egg quality. Egg quality involves genetics and egg competency, but AMH is a measure of how many eggs you have. That knowledge can be really impactful for how you view your future and your plan.
Welcome to the Huberman Lab podcast, discussing science and science-based tools for everyday life. Andrew Huberman is a professor of neurobiology and ophthalmology at Stanford School of Medicine. Dr. Natalie Crawford is a double board-certified physician specializing in obstetrics and gynecology, fertility, and reproductive health. Discussion covers actionable steps all women can take to improve reproductive and hormone health to enhance probability of successful pregnancy and because fertility and hormone health are strong correlates of general health and longevity.
Dr. Crawford shares what all women, regardless of age or reproductive goals, can do using lifestyle, nutrition, supplementation, and prescription medical tools she uses in her practice. Honest discussion on biological versus chronological age infertility: age is not just a number, but many women successfully conceive in their 40s. Learn documented knowledge and Dr. Crawford's clinical observations on women's health and fertility.
Dr. Crawford has training, clinical acumen, understanding of new research, and ability to communicate actionable steps for improving female health. She has a new book: The Fertility Formula: Take Control of Your Reproductive Future, focusing on reproductive health, hormone health, and their impact on female health short- and long-term.
Podcast is separate from Huberman's Stanford roles, aims to provide zero-cost science-based information. Episode includes sponsors.
Dr. Natalie Crawford, welcome back. Congratulations on The Fertility Formula. Completing a book is no small feat, especially one offering advice not just for pregnancy but viewing fertility as a health metric.
Fertility is a health marker.
Dr. Crawford wrote the book after educating patients and people online about fertility. Writing involved working with editors and refining within word count; she was 20,000 words over.
Huberman insists people in his life read the book because fertility indicates health arc, not just for those wanting children.
How should people think about fertility as a readout of health? Fertility is a sign of good hormonal health, cellular health, metabolic health because it requires many moving parts to ovulate, allow sperm fertilization, implant, and get pregnant. Ovarian function impacts daily feelings.
If you have infertility, you have increased rates of metabolic syndrome, cancer, heart attack, stroke, and dying early. Infertility does not directly cause these; it is often the first warning sign of something wrong, like chronic inflammation or insulin resistance impacting long-term health.
Dr. Crawford had her own infertility journey.
For women of reproductive age, discuss direct and indirect measures of fertility for health span and lifespan risk factors.
For women in perimenopause or post-menopause, fertility remains a health marker. As long as you have a menstrual cycle, you are ovulating and could theoretically get pregnant. Perimenopause is the transitional time with lower egg count, cycle changes, and hormone dysfunction, but pregnancy is still possible. Patients say "I thought I was past that stage based on age," but periods provide a window into hormonal health, especially knowing ovulation timing and cycle phases: follicular phase and luteal phase.
Menopause is defined as 12 months without a period, meaning ovarian failure for 12 months. Ovaries no longer respond to brain signals, no estrogen or progesterone production. Metabolic health completely changes. Age of menopause impacts long-term reproductive health outcomes; past cycle characteristics inform current cellular health.
Tide is turning on hormone replacement therapy (HRT). Can start at any time: perimenopause, at menopause, or even before 12-month cutoff. Disservice to require ovarian failure, no estrogen, feeling terrible before allowing HRT. Estrogen is loved by reproductive endocrinologists.
Huberman notes caution in paralleling men's and women's hormones but thematically: testosterone replacement therapy (TRT) for men became available earlier. Old idea: no TRT unless below 300 ng/dL. Now, can optimize within normal range to alleviate symptoms.
Relieved similar for women: no strict cutoffs like no periods for a year. Two periods per year does not mean no therapy deserved. "R" in HRT is dangerous, implying augmentation within normal range to feel right.
We outlive our reproductive hormones. Yet, they are essential for day-to-day function and to feel our best.
Should evaluate symptoms, offer hormone therapy without harsh cutoffs. Protective: cardioprotective, lowers Alzheimer's risk, bone protection. Learn your body, know normal to advocate, gain agency over health.
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Wish for nomenclature: hormone replacement therapy for out-of-range low, hormone augmentation therapy for pushing within normal range. Super-physiological led to fears from anabolic steroid use (estrogen and testosterone are steroids).
10 years ago, 40-year-old woman pre-menopause taking estrogen seen as risk, not benefit. Professional organizations called it menopausal hormone therapy (MHT). Difference: replacing (e.g., embryo transfer cycle, give estrogen and progesterone) vs. supplementing body's production to appropriate levels.
HRT given for premature ovarian failure (before age 40) even with low-end function, accepted for long time. For menopause, frowned upon due to WHI (Women's Health Initiative) and fear-based tactics.
Tide turning; women standing up, knowing normal. Many dismissed for painful periods, irregular cycles, bloating, spotting. Track cycle and ovulation to see red flags, not just for pregnancy but hormonal function. Helps advocate in transitional period (perimenopause or diminished ovarian reserve, lasting 5-10 years).
Do hormone therapies always start with estrogen? Typically estrogen, progesterone, testosterone. Women feel bad first from low estrogen: patches, pills, vaginal inserts, cream. Progesterone alone or combined big player; not made without good ovulation. Some perimenopausal feel great on progesterone alone. Testosterone last, depends on scenario. Estrogen and testosterone convert; adequate estrogen + functioning ovaries often no testosterone needed.
Extending ovarian lifespan: Women with early ovarian failure (POI, premature ovarian insufficiency) have more inflammatory markers, chronic inflammation, fibrosis in ovary, higher autoimmune disease or inflammatory disorders.
Variety of factors increase chronic inflammation, lower egg count, associated with earlier menopause/ovarian failure: control autoimmune (e.g., Hashimoto's), treat endometriosis, anti-inflammatory lifestyle (avoid toxins, anti-inflammatory foods, exercise type), likely extends ovarian lifespan.
People concerned about plastics. Microplastics accumulate in ovary, detrimental to function (needed for estrogen, progesterone, ovulation, pregnancy).
Endocrine-disrupting chemicals in plastics associated with worse IVF outcomes, lower live birth rates, longer time to pregnancy (population-based cohort studies, no RCTs). Plastics in food wrappers link to ultra-processed diets.
Toxins contribute to inflammatory burden alongside lifestyle choices: water cup vs. plastic bottle, weights vs. nothing, running, sleep, foods, stress. Choices add up; chronic inflammation matters to fertility.
Common belief: if pregnant once before, easier to get pregnant again later, despite understanding age decline. Is there evidence prior pregnancy makes it easier, separate from proven fertility?
Not a perfect experiment; those pregnant before can get pregnant. Within-person, can they exhale knowing yes?
Dr. Crawford did fellowship research with primary investigator on a large cohort
Time to Conceive study, one of the biggest on natural fertility, examined women 30 and older without infertility history trying to get pregnant. Huge age-related impact on fertility. Standards for quoted numbers: at age 30, 20% chance per month for first child (fecundability: probability of pregnancy per month). At 35-36, 11-12% per month. At 38, 5% per month. At 40+, 3% per month. None are zero, so pregnancy is possible.
For women with prior child trying with same partner, 18-20% up to age 37, then drops. Protective benefit: prior conception confirms partner's sperm presence. Some patients discover male partner has no sperm after years of trying; misconception that ejaculate means sperm present.
Infertility defined as failure after 12 months trying; testing only then: semen analysis, anatomical investigation, ovarian reserve, ovulation check. Most conceive in first 6 months (72%), only 13% in next 6 months. For 35+, shorten to 6 months. Many dismissed by doctors, forced to try longer, discover issues like blocked tubes, uterine birth defect, no sperm, low ovarian reserve. Need preventive approach, test early; if normal, try 6-12 months.
Prior child statistically increases chances, but secondary infertility real: hard time conceiving second child despite prior success. Emotionally hard; unexpected, larger age gaps than wanted, feel caught between infertility community and peers. Age impacts even with prior child: sperm counts decline, egg quality changes (metabolic health), endometriosis/adenomyosis (tincture of time diseases). If trying 6 months without success, get evaluation, especially if older.
At-home sperm tests exist: some plus/minus presence, not full picture. Mail-in tests to CLIA-certified lab valid, provide all parameters. Clinics do semen analysis for anyone. Often roadblocked by PCP or OB/GYN: "just try first."
Data mostly on prior live birth. Prior pregnancy (any outcome) with same partner confirms sperm, at least one functional tube (if intrauterine), body can accept embryo. Top cause of loss: random genetic abnormality.
Dr. Crawford had four pregnancy losses. Shared in book for patients/readers. Emotional rollercoaster, self-blame. Professionally, end of OB/GYN/beginning REI fellowship: felt like failure as future fertility doctor. Last was ectopic; fertility nurse gave methotrexate shot. Dismissed: "relax, do IVF." Made career different; all fellowship research on natural fertility, got masters in clinical research. Passion for why some conceive naturally, others don't.
After pregnancy loss, certain systems intact (good sign), but never dismiss experience. After two losses, evaluate: blood tests, semen analysis, sperm fragmentation, uterine/tubal evaluation. Earlier if heavy bleeding, D&C, period changes. Used to require three losses; Dr. Crawford pushed after two, told need another loss first.
Backwards: menopause only after year no period, two losses for evaluation/treatment. Parallel to psychiatry: no need to suffer year before treatment. Field changing; book aims to transform fertility: proactive, patient-centric. OB/GYN used to handle, now specialized, but force failure first senseless. 80% recurrent loss cases normal tests, but 20% treatable (medication/procedure); 80% need specialized care.
Change definitions, approach reproductive health/hormones/fertility proactively. Women/men driving via talking openly. 10 years ago, nameless accounts; now celebrities discuss IVF, endometriosis, terminations. Drops stigma, highlights wrongness of fail-first.
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Common: prior pregnancy (or thought), mom/sibling pregnant at 42-43, good health, assume time. Life expensive, wait longer to marry/kids. Some: "if right person, would; not alone." For 20s/30s/early 40s with regular periods: urgency to check, what to check.
Women born with all eggs in ovary vault. Peak 6-7 million at 5 months gestation; 1-2 million at birth; 500,000 at first period. Lose monthly; number recruited proportional to remaining (more when young, fewer when older). Eventually ovarian failure (out of eggs; not menopause). Uterus functions; can carry with donor eggs/embryos.
Eggs absorb life's wear/tear. Functions: respond to hormones, make estrogen/progesterone, ovulate. Mitochondria (powerhouse) passed to embryo, controls early growth (male genome day 3). Frozen in metaphase of meiosis II; chromosomes held by meiotic spindles until ovulation (23X + polar body).
At 25: 25 years holding; good position, strong proteins, better metabolic health, strong mitochondria. At 40: 40 years; chromosomes drift ("kindergarteners standing 40 years"), plus metabolic decline (inflammation, insulin resistance, obesity) causes oxidative stress, mitochondrial/DNA damage, spindle issues → more genetic abnormalities.
No direct test for egg quality (genetic normality) and
Egg competency refers to how good the mitochondria are and if it can do its job. It is approximated to age, though not all 40-year-olds are created equal.
Ovarian reserve is how many eggs remain, approximated by AMH (anti-Müllerian hormone) blood test made by granulosa cells surrounding each follicle. More eggs mean more AMH; fewer eggs mean lower AMH. Not perfect due to month-to-month variability and suppression during prolonged non-ovulation (birth control, pregnancy, postpartum). Simple blood test indicating eggs outside the vault, not pregnancy potential.
Every woman wanting children or understanding her reproductive timeline should get AMH checked, against American College of OBGYN advice (only for infertility). Reasons include stress and not predicting fertility perfectly.
Example: Two 30-year-olds, one with 20 eggs (age-related norm), one with 5. Same pregnancy chance if ovulating one egg, but low AMH woman has shorter family-building window, fewer eggs for freezing/IVF.
Low AMH causes (autoimmune disease, insulin resistance, endometriosis, smoking) often contribute to infertility. Investigate/treat causes: 50% of low AMH cases find autoimmune disease like Hashimoto's; treat with thyroid replacement, reduce inflammation to slow egg loss, improve outcomes.
Do not wait; informed decisions change timelines. Options: try pregnancy now, buy donor sperm, freeze eggs/embryos, or none. Active choice from knowledge eases journey vs. regret from denied test.
I asked for AMH 5 years ago. They said not medically recommended. Had I known, I might have done something different.
AMH is newer (past 10 years), use categories: normal, above average, below average, critically low. Ask doctor; if no, order via lab (Quest), online (Function Health), or fertility clinic. Not egg quality test (genetics/competency), but egg quantity check impacting future plans.
Track cycles and ovulation (better than periods alone). Regular cycles good, but ovulation tracking reveals luteal phase length, follicular phase. Ovulation disorders progress predictably:
- Stage 1: Luteal phase defect (<11 days progesterone support), regular cycles but brain-ovary miscommunication.
- Stage 2: Long follicular phase (slow FSH response).
- Then irregularity, amenorrhea.
Missed if only tracking bleeding (e.g., every 34 days seems normal). Track ovulation for hormonal cues.
Out-of-pocket AMH test costs $79. Cheap vs. IVF/egg freezing cycles (e.g., low reserve needs multiples). Physician not gatekeeper; easy lab test.
Comparison to 1980s genetic testing (e.g., Huntington's at Stanford): resistance because "people don't want to know" (stress/dread). Paternalistic/unethical; people smart, handle info, make decisions. Technology advanced; counseling must advance. Most willing to spend on health data impacting life.
Huntington's (autosomal dominant): IVF PGT-M tests embryos blindly if patient doesn't want to know carrier status. Make probe, test embryos without disclosing. Patients avoid genetic kids or use donors.
Myth: Egg freezing/IVF decreases reserve/taps vault, causes early menopause. False; only grows eggs outside vault (FSH stimulation). Body prevents multiples naturally; IVF maximizes one month's cohort (ovulate 1, rest die). Constant egg loss regardless (pregnancy, breastfeeding, birth control). IVF/egg freezing saves eggs that would die, doesn't accelerate loss.
Early IVF (46 years old): no gonadotropins, daily urinary estradiol, abdominal surgery for single follicle. Now vaginal ultrasound needle, purified FSH/LH for multiples.
Younger women yield more eggs/cycle, but delays due to finances/life (no partner). Push for insurance coverage via advocacy/lobbying (possible, some countries cover for birth rates).
Egg freezing keeps opportunity open (not guarantee/insurance policy; investment with ROI TBD). Opposition: ethical/moral vs. IVF (embryo disposition/personhood; discard seen as killing). 17 million IVF babies born. Options: donate embryos, limit embryos/transfers for beliefs (less efficient, costlier, lower success). Restorative Reproductive Medicine (RRM) fans cycle tracking/root causes but some oppose IVF coverage as unethical. Pro-child tech like egg freezing/embryos should be supported.
At the end of the day it impacts me zero what you individually choose to do. But people deserve the tools in the toolbox. They deserve to be presented with all the choices. We could try Clomid. We could try IUI. We could try surgery. We could try IVF. Oh, you're getting older. We could freeze your eggs. They're just more tools. There's more opportunities. And based on your circumstance, your financial, your beliefs, you should be allowed to choose. One's own beliefs that cause you to want to put it at number 10 on the list should not be the beliefs that we enforce on everybody. Especially when we know that IVF can be so powerful to help so many people have a family. It should be something that is offered to you if indicated and you get the choice.
It would be incredible to live in a world or a country where egg freezing was offered to women as people are waiting longer to start their families. It would allow more people to feel less pressure with a partnership and on their relationship, not to feel like, oh, this better work out because my clock is ticking and be able to really feel like they could chase one dream not at the expense of another. We're further in this country than we want to admit from that. We can't even get fertility treatments covered for patients with cancer when we know that chemotherapy is going to deplete their ovarian reserve. We have some states that we can't even get egg freezing covered for them. This is state by state right now. We would love federal protection for everybody. To me, that's my litmus. What your state or your country would do for patients who have cancer, you know, are in this position. And if we're not even willing to move to help them, the idea that we could cover it for everybody, we're still ages away from that.
It's not forcing anyone to do anything. Nor is it necessarily the destruction of an embryo. There is a world where the embryos are created and kept frozen. They call that embryo banking. To specify maybe for somebody who doesn't understand, egg freezing, getting those eggs outside the vault to grow, taking them out of your body, and we freeze them right there at the egg state. Making an embryo is going to be thawing that egg, fertilizing it with sperm, letting it grow out to the implantation stage, which is day five or six. Not every egg will survive, fertilize, grow. There's a ton of attrition in culture. 90% of eggs survive the freeze thaw, 75% will fertilize, 50% will make it to the implantation stage, and then not everyone will be genetically normal based on your age and other factors. And then even a genetically normal embryo only has a 65% chance of live birth. Like the science has come far, but we're not there all the way.
They do morally really feel like an embryo could be a potential life. and they do struggle with what to do if they have leftover embryos. And I have some patients who've told me every embryo we make, we're going to transfer. Okay. Well, we want to be really mindful what we do in that circumstance. And even though it's unlikely, I have a patient right now with four children and one embryo in the freezer because we froze five knowing that everyone shouldn't implant based on that 65% number, but we've gone four for four. So like we have to know that if that's what we're doing, we're prepared for how the data may fall because data just helps us guide decisions. Especially when it comes to live. It's zero or 100. It happens or doesn't.
Now if I freeze them as eggs for some patients who have really strong beliefs and they are afraid of that number five, we might take more time or time more money, but we might say let's thaw them and only fertilize two. Let's leave everything else frozen and then whatever makes it embryo we can transfer. And yes, that's not a cost-effective way to go through the process because we might be having to pay for thawing and the fertilization and the transfer more times because there may be nothing to transfer based on that attrition. It can let some patients say, "Okay, I feel better with that process." So just freezing eggs to your point is not making embryos, right? And there's different things we can choose along the way to make an individual person feel comfortable, but we shouldn't be dictating how the field has to function. It would be incredible if we could encourage egg freezing earlier. It would open the door of opportunity and not everybody who freezes eggs will need them, but the peace of mind knowing that there's a chance is really impactful on the human mind.
In insurance, I would think would want to do this because covering all the other stuff is expensive, too. Most insurance doesn't cover IVF. You're not wrong, right? In principle, if I freeze a 25-year-old's eggs, I will have three times as many eggs to work with, you know, than I would if she's going through IVF when she's 37. So, if I'm going to pay for her to do IVF at 37, it'll take so many more cycles. I'll spend so much more money. That one cycle of egg freezing is much more cost effective if I'm covering them both. But we don't even cover the ladder. So many times patients, this is such a hard stretch for everybody. And look, the technology is incredible. As somebody who has an IVF lab, as somebody who keeps embryos on site, it's outrageously expensive. Our generator alone, it's a million dollars, right? Because if the power goes out, like what do we have to keep going? We always say if there's zombies coming, like come to the clinic. The technology to keep up with all the advancements to have trained embryologists, their micromanipulation skills, it's impressive. So it costs money to run a lab like that that will provide results. The process and the technology is really really expensive.
That being said, like I shouldn't be the one sitting here making assumptions again on what you're going to do with your money. And if somebody's in a position where they know their egg count's low and they should freeze their eggs because they're not partnered or they're not ready to get pregnant and they don't have the financial resources, we can sometimes find more money, right? We make decisions every day when it comes to money. we can't find more time. We can't find more eggs or more ovary. So again, this idea that well, what are they going to do about it if they find out they have a low AMH or oh they can't afford to freeze their eggs anyway or oh it's too expensive. We all make individual choices on how we leverage our different resources which I consider to be your time, your money, your physical energy and your emotional energy. And every day you're leveraging them. But when it comes to reproductive health, having a family, like I feel strongly, you feel strongly, which I love, that we should be giving more access and more options to people so that they can pursue this.
And so the argument's across the board too, like why not check an AMH in somebody who's younger? Well, they can't afford egg freezing anyway, so what are they going to do about it? Again, like we shouldn't be making the assumptions of what somebody will or will not do with their resources or with their data. We should be ones helping them get the data and interpret the data, understand what resources or options exist and then the individual has what they need to make the decision.
In the Bay Area where there a lot of tech companies, there's an opportunity at many of these companies for female employees to freeze their eggs. That landed much more controversial than I thought it would. Isn't it crazy? Because the assumption the sort of to some people the tacit message there is don't have kids now work work like crazy and then have them later. But having known some people that worked there and froze their eggs in their late 20s or early 30s, I think they would say the ones I know would say, "Yeah, I'm really grateful that I did that and that the company I worked for paid for it and they got to keep their eggs even though they don't work for the company anymore."
What data supports is that when companies do leverage a fertility package and their benefits, they retain employees longer, employees are happier, and more people utilize the service than would without it. Meaning people freeze their eggs when it's offered to them through their company. And that gives them that peace of mind understanding it's not everything but they feel more comfortable exploring bigger opportunities and they are grateful to the company. They stay with the company longer because that is an investment in your employees. Incredible in Austin, right? A lot of these tech companies have second homes. So we see a lot of these patients also. And I do think that has changed the game for so many people to be able to have access because for many it's not ethical or moral, it's financial. the often the time when you would freeze your eggs when it would give you the highest rate of return, you don't have the resources to do so. So having a company that's able to come in and do that is really impactful. I wish more companies would do that.
You mentioned that birth control can reduce AMH levels, on a month-to-month basis. Is there any evidence that taking hormonal birth control can lower chances of pregnancy when somebody comes off birth control?
Excellent question. Big studies looking at all different types of contraception. No higher rate of infertility. Again, defined as failure to get pregnant at 12 months. So, you come off your contraception at 12 months later when we look, there's no higher rate of infertility than we would have on the population-based level. So, that data leads us to comfortably say birth control is not causing infertility.
Now if we go and we look more nuanced at different types of contraception, if you look at the birth control pill, what most people are talking about, the birth control pill is a combination of synthetic estrogen, ethinyl estradiol, and a type of progesterone or a progestin. These work by telling the brain, essentially tricking it so the brain doesn't send out FSH or LH. And as we described earlier, those are important in getting you to ovulate. So you don't ovulate when you have taking the birth control pill. And that's why it's a very effective contraceptive choice. However, the half-life of the birth control pill is only 28 hours. So, it's actually quite short. So, you can miss even just one pill and you could ovulate. So, when you stop the birth control pill, your period should come back that next month. So, immediately you should have resumption of ovulation.
Birth Control Pill Masking Underlying Issues like PCOS
A couple of problems with this one is that the birth control pill has some valid medical uses, has some nonvalid ones, but very often, especially in the generation of women that we see right now, they were given the pill potentially for a valid medical reason without any investigation of what it was. So maybe a woman had irregular cycles or some acne and her doctor said, "Well, here, take the birth control pill. It will help." And it did help. But just based on that history, I would sit here and say, "I bet she has PCOS." And the woman though never was told, "I think you have PCOS. Here's what it is. You probably will not ovulate when you stop the birth control and your acne will come back and you should talk to a fertility doctor and here's lifestyle things we can do to decrease insulin resistance." Never had that discussion. So, in her mind, had some symptoms, started the pill, those symptoms resolved. Now we stop the pill and we're not getting pregnant and we have irregular cycles and we start to blame the pill as the reason why instead of understanding that the pill was maybe masking it or treating certain aspects of it.
What I like to say is you're not ovulating on the pill. If ovulation and knowing when you ovulate is one of your most sensitive health markers and really essential information in trying to get pregnant. If you are trying to get pregnant, the egg only lives for 24 hours. The fertile window is the 5 days before and the day of ovulation. Meaning sperm can live in the reproductive track for up to 5 days. Most will stay around for 2 days. That's why the two days before and the day of ovulation have a 20 to 30% chance of getting pregnant compared to a zero% the day after ovulation. It's a very defined fertile window. So, if you know when you're ovulating and you target intercourse, you're going to have a higher odds and get pregnant faster. Data supports that very much so, but you don't know how to track your ovulation because you've been on the pill. So, you don't know how to do that.
So, I recommend that you stop the pill 3 to 6 months before you're really wanting to start your family. So, you can track your cycle, learn to detect ovulation. And if you do have an abnormality, you're not now 6 months of trying or one year of trying before it's evaluated. You can say, "Oh, I can't detect ovulation or my cycles are irregular. Let me go get that investigated now." So, we're not kind of behind in our own timeline.
The progesterone IUD is another one that we talk about a lot. The progesterone IUD is local progesterone that is placed inside the uterus. There's different types that can release progesterone in different amounts. It typically suppresses ovulation in the first two years, but then progesterone levels drop and it tends not to suppress ovulation, but that chronic progesterone exposure thins the endometrial lining to the degree that many women do not have periods anymore. That can be great if you don't like having a period. That can decrease the chance of anemia or menstrual cramping. So it can be very lifestyle positive during those years. But when you stop the IUD, we do see a change in endometrial receptivity at least for 6 months after it's been removed. And it can take time to build that lining back up. So I always recommend that a progesterone IUD is removed at least 6 months before you want to get pregnant. Give the endometrium time to rebuild and regrow and then you'll have better odds of conceiving. We do see a little bit of lower pregnancy rates in those first six months of conceiving and women coming off of the IUD. More of them are getting pregnant in the back six months. So kind of shift your own timeline.
And the birth control I think it's always important to mention in this conversation is one that's not as common, but it's the Depo-Provera shot. So this is a high-dose intramuscular progesterone shot that can prevent ovulation for three months. on population-based levels to use it as an effective contraceptive must get every three months. But one single dose can prevent ovulation for 18 months. So this is that one exception where if you want to get pregnant potentially in the next two years, please don't get Depo-Provera.
Is there any evidence one way or the other that intentional termination of a pregnancy can disrupt chances of getting pregnant again later? No study supports that having a termination is going to negatively impact your fertility later. One caveat is that any intrauterine procedure has the potential to damage the endometrium and result in scar tissue. That could be having an IUD, could be having a fibroid removed, it could be a prior C-section, it can be a prior D&C because you had a pregnancy loss, it could be from a termination. where we see the greatest risk in all of these circumstances is from heavy bleeding or from an infection associated with it. So in general most terminations are done early very routine where we are fearful is when they are accessed in non-safe environments we're seeing more infection or heavy bleeding or even when women are having to travel statewide to access care and they're getting the procedure done later with a higher risk of complication.
Example of Complications from Delayed Termination
In Texas where I practice, there's obviously an abortion ban. And so women who need an elective termination for a medical reason, I had one patient who's been very open about her story. Her baby had anencephaly. So she went through IVF and had a baby that had no brain develop. And they made the decision that they wanted to terminate that pregnancy since that's not compatible with life. They didn't want to have to carry the entire pregnancy. They had to travel out of state to access care. Their first appointment was cancelled. So they had to make another one in a different state. Took them much longer than they wanted. Had the procedure much later. And then she had residual scar tissue inside her uterus. That was because it was done at a later term that we then had to fix before she could get pregnant again.
So I think it's just important to say that across the board, any intrauterine procedure poses a little bit of a risk. No matter what it is, if your periods are different afterward, the hallmark sign is going to be a lighter cycle. So no matter what thing on that list you had done, if your cycle is now lighter afterward, I am worried there could be scarring inside the uterus and we'd rather evaluate that in the clinic. We can do a saline sonogram to just check and make sure there's no scar tissue because that will impact your fertility.
Some practical questions about metabolic health, mitochondrial health, and egg quality. In your book you go into this in some degree of detail, but when you think about the things that can really help support egg quality aside from age. In fact, at any age, what are the top contour of those? You mentioned inflammation is the enemy, but inflammation happens all the time and we can't avoid it. But we can certainly avoid exacerbating it. So what are the things that people can do, not do and take?
Inflammation is prevalent in our world and the goal is not to avoid all of it. In fact, acute inflammation is required for conception, right? We need acute inflammation with ovulation. If we just think real physiology, a follicle is rupturing, allowing the egg to be released and then reforming. like we need our acute inflammatory response to allow that to happen to the degree that if women take NSAIDs around the time of ovulation, Advil, ibuprofen, Aleve, they'll prevent the follicle from rupturing.
Yes. So they will go through the hormonal changes of ovulation, but the egg will not be released. So that's why we recommend and fun fact or important to know if you're trying to get pregnant, you can take those medications only when you're on your period. So period cramping fine, but we don't want you taking them for the rest of the cycle because you can prevent ovulation from occurring.
How many people in your experience do you think know that? I don't think very many honestly. Which which is why basic facts about our biology that we never taught. So if somebody's trying to get pregnant, NSAIDs can be problematic. They can be problematic. they can prevent the egg from being released with ovulation. So I think this is important because I will sometimes have patients say well if inflammation is bad can I just take medicine for it. I always want to say your immune system is essential for ovulation and also for implantation so I don't want to turn off your immune system what I want to do though is not have it be so burdened with what we call chronic inflammation that constant activation where it can't even do the job that we need it to do.
So, I like to think about this as that inflammatory burden. And so, we're all exposed to some, but how do we make it better? How do we add to it and make it worse? And really framing ourselves so that we can cultivate resilience within your body. You're going to be exposed to inflammation. Life is going to throw things at you. But you want to cultivate these best practices of your life so that you are reducing inflammation to the degree that you can. And this goes hand-inhand with insulin resistance, which we'll get into. And I usually divide it into like what I call my five non-negotiables of sleep, stress, muscle, food, and toxins. And thinking about how we leverage these to our benefit by giving people the knowledge that they can if they understand their bodies, they can then be empowered to make choices that are in line with their goals.
I hate the narrative that there's nothing you can do for your fertility or that it's all luck because the truth is even if we can't control everything. We have a huge control over our metabolic and cellular health which plays a huge role in our ability to get pregnant for both men and women. So taking control of what we can I think is really important information and one person can take with that and make the choices they want to make. But the worst thing that I hear every single day is people sitting across from me saying, "Gosh, I wish I'd known that information. I would have made a different decision." Why do we make people go through a failed IVF cycle, they have no embryos form, and only then do they make lifestyle changes when we know the lifespan of a sperm is 90 days and sperm are so sensitive. And then we know that even though eggs are in your body your whole life, the 60 days before you get pregnant is when the egg is most susceptible to the world around you. So, this is this time period that I like to call trimester zero, the time before you're getting pregnant where the
Choices made earlier in life can influence ovarian function longer.
Sleep is number one. It reduces excess chronic inflammation and lowers inflammatory markers. Less sleep causes cellular stress and oxidative stress. Gonadotropins (FSH and LH) are released from the brain in early morning hours, so insufficient sleep disrupts hormonal response. Men with less sleep have lower testosterone levels and lower sperm counts. Women with less sleep get fewer eggs in IVF cycles. Subjective poor sleep doubles infertility rate. Poor sleep in either partner prolongs time to pregnancy and lowers monthly fecundability. Physiology is meant to sleep; it's a signal to the hypothalamus (central command station) that life is stable enough for pregnancy, a huge metabolic spend. Aim for 7-9 hours; most women need closer to 7.5 hours, especially in luteal phase due to progesterone production. Tips: dark room, sound machine, sleep mask, cooler temperature. Partners must align: same bedtime, similar practices. Day-to-day consistency impacts fertility via circadian rhythm.
Melatonin released before bed. Low doses (1-3 mg, 30 minutes before bed) improve pregnancy odds and egg quality. Body makes more melatonin at ovulation to counter ovarian oxidative stress. Be careful: many over-the-counter products have 10x the amount (e.g., 10 mg). Pediatric dose (1 mg) augments natural melatonin. Treat like a toddler's wind-down routine for consistency. If already sleeping well, probably no need unless chronic inflammation, endometriosis, inflammatory autoimmune disease, IVF with unexplained infertility, or "bad egg quality"—then anti-inflammatory properties help.
NSAIDs disrupt inflammation required for ovulation—proceed with caution. Cold plunges potently inhibit inflammation like NSAIDs; avoid after resistance training or exercise needing inflammation for adaptation. Recommend against cold plunges when trying to conceive to preserve acute inflammatory response. Nobody likes cold plunges (unlike saunas). Curcumin: potent anti-inflammatory. Cooking with it is fine; avoid high-dose supplements unless doctor-prescribed for specific excess inflammation.
NR/NMN/NAD increase energy; NR anti-inflammatory. Animal data promising for unexplained infertility (normal anatomy, ovulation, ovarian reserve, semen analysis—view as chronic inflammation). Potential benefit for subgroups with excess inflammation, but not for everyone. Human data lacking despite promising animal data. Prefer CoQ10 with robust human data, no negatives—better supplement investment.
CoQ10 and L-carnitine support sperm and egg quality. Start 60 days before trying to conceive; stop CoQ10 in pregnancy due to lack of data (cautious approach). Prenatal basics for "trimester zero": folic acid, CoQ10, omega-3 fatty acids, vitamin D—optimize nutrients, support mitochondrial health for egg quality, no harm risk. For sperm: L-carnitine, zinc, selenium. Specifics in book, tailored to disease state.
Over past 10 years, shift at ASRM (American Society for Reproductive Medicine) meetings from IVF-heavy to lifestyle. IVF incredible but limited by eggs/sperm quality—control variables. Public curiosity drives research. Cohort studies confounded by healthy user bias; RCTs in IVF show CoQ10, vitamin D, omega-3s improve mature eggs, embryos, genetically normal embryos, pregnancy rate per transfer. Emerging: inositol for PCOS (decreases insulin resistance), N-acetylcysteine for endometriosis/chronic inflammation. Old school vs. new school: older physicians from era of less patient knowledge, dismissive of questions on CoQ10/lifestyle. Lifestyle reduces inflammation, affects hormones, ovarian response, egg/embryo numbers/quality. Prioritize core lifestyle first, then supplements. Treat each patient as "n=1" experiment—tune into body responses.
15 years ago, dismissed as nonsense; now promising (e.g., clinical trial for dry AMD via mitochondria/photoreceptors; dermatology journal cover). Chronic inflammation affects hypothalamus, ovaries, egg quality. Data inconclusive but beneficial: systemic (e.g., panel) improves ovulation via whole-body inflammation reduction/brain sensitivity; ovarian-directed (abdomen) or intravaginal wand (closer to ovaries) may benefit egg quality. Sunlight provides red/infrared + circadian benefits, pro-fertility/pro-hormonal health—no need for panels.
Idea: fertilize eggs under red light (mitochondrial health key for chromosomal arrangement); lab lighting may not be optimal. Possible in incubators. Anecdote: 11-year-old daughter's science fair—chicken eggs under blue/green/natural light; blue light highest hatchability, UV lowest, red detrimental (nature mysterious).
Don't smoke, don't drink. Cannabis: 15% US women report use in pregnancy (more preconception). Most concerning in practice. Detrimental to sperm (production, quantity, testosterone, DNA fragmentation)—female partners have higher miscarriage rates. In IVF, day 3 embryo halts often link to undisclosed male cannabis use. For women: prior year use decreases eggs at retrieval by 25%, fertilization by 28%, increases miscarriage, decreases live birth rates. THC crosses placenta; edibles highest. Avoid all forms for fastest pregnancy, best outcomes, hormones, ovarian longevity, sperm/testosterone.
Cannabis use should not be a part of that.
Avoiding cannabis is crucial for optimal brain development in children; even if not making a child "dumb," it may prevent them from being as smart or healthy as possible. For men, it's a short-term decision to stop, as cannabis decreases sperm count and quality, which affects embryo programming, placenta development, and is associated with earlier birth. Women breastfeeding should also avoid it. The outcome of having healthy children outweighs the risks, especially compared to harder daily decisions.
Nicotine, cannabis, and alcohol offer no advantages for health through fertility, hormone, or pregnancy lenses. People may cite anecdotes of success despite use, but individual journeys differ, and recommendations are stronger for those with infertility, older age, or challenging scenarios. Control controllable factors like these behavioral toxins to optimize body function.
Substances are politicized: cannabis shifted from left-associated to broader acceptance with rescheduling, media pivots without focusing on data. Nicotine is now right-wing associated; in a recent talk to 4,000 young people, 30-40% used oral nicotine daily (12-70 mg).
Oral nicotine correlates with disrupted ovulation, hormone response, and pregnancy success due to brain effects; avoid in any form when trying to conceive. Most egg quality data from cigarette smoking, which enters the ovarian vault, decreases egg count, accelerates menopause, and harms quality via cellular changes. Oral pouches tank sperm counts.
Population growth discussions shifted from overcrowding fears to concerns of too few people; neither extreme is true. Decisions like avoiding toxins are easy and short-term. No need for perfection or permanence; reducing inflammation from better sleep, stress management, building skeletal muscle (top way to reverse insulin resistance and support hormonal health), more fiber, anti-inflammatory foods, cutting ultra-processed foods, removing toxins, and productive stress management lowers inflammatory burden. People feel better, recognize red flags from poor habits (caffeine, poor sleep, nicotine), enabling optimal function for best egg/sperm quality when trying to conceive.
Intuition from extensive experience complements science, like embryologists selecting sperm/eggs or chefs applying art to chemistry.
Key takeaway: Tangibly improve fertility by decreasing inflammatory burden via lifestyle; crucial for delayed pregnancy, older age, or low ovarian reserve to optimize egg/sperm.
GLP-1s (e.g., for PCOS/insulin resistance) powerfully restore ovulation, improve IVF via weight loss (fat cells produce estrogen, cause inflammation). Now exploring low-dose for endometriosis or probable endo in unexplained infertility (50% have endo, but surgical diagnosis only, no lab test). In patients with unexpected poor IVF outcomes or chronic inflammation, 3 months low-dose GLP-1, then stop and cycle: more embryos in lab. Colleagues nationwide observe anti-inflammatory effects targeting inflammatory burden; utility for hard-to-diagnose cases.
Direct inflammation reduction independent of fat loss, especially in non-obese or autoimmune patients with mistriggered immune responses.
Caution for skinny patients: low body fat risks hypothalamic amenorrhea, luteal phase defect; use super low doses with experienced providers, goal not weight loss but inflammation reduction.
Compounding pharmacies make GLP-1s; gray market peptides shut down, but compounding protected. Lower doses likely more affordable than full patented doses.
HGH used off-label (no FDA approval for egg quality) improves outcomes in right patients. Partner's study: same IVF protocol next cycle + HGH yielded better embryo development/maturity. Low dose (e.g., 1 IU/night) during stim (2 weeks). Extrapolating to pre-stim use; field embraces cutting-edge if mechanistic sense, especially end-of-journey after basics optimized.
Criticize "just do IVF" mentality ignoring lifestyle (anti-inflammatory food, no wine nightly, sleep); optimize 5 non-negotiables for resilience to handle occasional disruptions.
Experimental add-ons like HGH become standard over time (scoffed 15 years ago, now common); medicine advances by not waiting for perfect RCTs if physiology fits, with shared decision-making.
PRP not stem cells (FDA banned stem cell advertising after vision clinic blinded patients with macular degeneration injections).
- Intrauterine PRP: Injected via catheter into uterus (like IUI); for implantation failure or Asherman scarring. Most promise here (less invasive).
- Ovarian PRP: Needle into ovaries (like egg retrieval but infusing PRP); for low ovarian reserve/age-related decline. More nuanced: anesthesia, procedure fees, hypothetical ovary/egg damage risks (no studies confirm).
Recurrent implantation failure minority; most IVF limits are embryo production (3 genetically normal = 95% live birth rate). Ovarian PRP studied, potential for endgame older/low reserve cases with success stories, but exception not rule.
After age 50, increased autism risk, autosomal dominant new mutations (e.g., specific dwarfism), schizophrenia. Data scary but population risks low; bank younger sperm preferentially. If using 52-year-old sperm for desired child, accept small risk increase (most probable: healthy baby).
Age impacts all fertility; control 90-day pre-sperm lifestyle (no cannabis, reduce heat, avoid DNA mutagens like nicotine) to minimize added risk.
Anecdotes (daily weed with 8 kids, kids at 78) are high signal/noise distractions; focus on what matters (e.g., egg freezing doesn't deplete reserve, avoid NSAIDs).
Biotin ≥300 mcg/day (e.g., hair/skin/nail supplements with 10-30x that) for 7 days binds steroid assays, falsifying estradiol, progesterone, hCG, TSH, testosterone results. Stop excess biotin before hormone panels/IVF monitoring for accurate data.
Endocrine disruptors once dismissed as hippie science; now data-supported (e.g., Shanna Swan, Environmental Working Group). Political backlash mislabels data-driven researchers. Complements standard medicine; focus on frequent exposures (daily home products > one-time like lavender/tea tree soap). Quantity of exposure matters most.
Endocrine disruptors impact hormone function through cumulative low-level exposure from frequent use of various products, leading to longer time to pregnancy. The EARTH study, a large cohort study on environmental compounds and reproductive health, examined people trying to conceive naturally and a sub-study on those undergoing IVF. Higher levels of endocrine disrupting chemicals correlated with harder time getting pregnant even with IVF, fewer eggs retrieved, fewer embryos, and poorer sperm counts.
Essential oils are generally fine, but lavender, tea tree, and evening primrose have endocrine-disrupting properties. Scented products contain phthalates, an endocrine disruptor. Unscented products often mask scents rather than being fragrance-free; look for fragrance-free labels, as unscented means something was added to counter existing fragrances.
Thermal paper receipts (e.g., grocery stores, airline counters) are a top BPA exposure source. One-time exposure is low risk, but frequent handlers (e.g., cashiers) should use gloves. Uber drivers face high exposure from air fresheners; remove them for health.
Control the fragrance in your home and products; one-offs like Ubers or planes aren't a big deal if daily exposure is minimized.
Toxins impact health, so provide data for informed choices rather than assuming stress from information is worse. Ignorance isn't bliss, especially with health challenges like infertility.
People want knowledge; colleagues often underestimate this. Dr. Crawford's story: During fertility fellowship with unexplained recurrent pregnancy loss, she advocated for vitamin research amid inflammation epidemiology. Eliminated Teflon (studied PFCs), changed diet, exercise, sleep, cut gluten despite no obvious GI symptoms (felt less inflamed, fewer headaches, less fatigue). Conceived naturally pre-IVF without gluten. Diagnosed with celiac disease a decade later, explaining losses.
Chronic inflammation harms the body; listen to your body through education and self-advocacy. Know what's normal to push back effectively. Even with IVF, optimize eggs/sperm beforehand—some avoid IVF or ease egg freezing via these changes.
Become a scientist of your body: Test a temporary restrictive clean eating pattern (high fruits/vegetables/fiber, cut gluten/dairy/red meat), then reintroduce to identify reactions. Feel better/worse/same guides choices.
Fertility diet tenets:
- High fiber for gut microbiome, hormone health, inflammation, insulin resistance.
- Whole grain over refined carbs.
- No ultra-processed foods or artificial/non-nutritive sweeteners.
- Quality protein: Increase plant-based (more fiber); for every serving plant over animal, better ovulation/higher fertility (suggests healthier fiber-first pattern).
- Red meat controversial: Higher intake linked to poorer IVF embryo outcomes, worse endometriosis staging. Not all bad, but inflammatory for some (increases IGF-1); source quality matters (not studied, but important).
Healthy fats essential: Cholesterol backbone for steroid hormones (need for progesterone/implantation). Encourage monounsaturated/polyunsaturated: nuts, olive oil, fish, algae, chia/flax seeds (omega-3s, cholesterol sources). Insufficient saturated fat impairs progesterone.
If struggling, elimination diets help isolate issues alongside sleep, stress reduction, muscle building, toxin avoidance. Prefer whole foods over processed/wrapped toxic versions.
All recommendations apply: Lifestyle decreases inflammation, improves ovarian response/feeling. Estrogen has anti-inflammatory benefits; menopause raises baseline inflammation. Start now at any age for current/later hormonal health, fertility, ovarian function.
Dr. Natalie Crawford's book: The Fertility Formula: Take Control of Your Reproductive Future. She runs a clinic, does public education, manages family, advances the field via science and teaching. Actionable steps for reproductive health.
Huberman Lab Podcast promotions: Subscribe on YouTube (zero-cost support), follow on Spotify/Apple (leave 5-star reviews/comments), check sponsors. Huberman's book: Protocols: An Operating Manual for the Human Body (pre-sale at protocolsbook.com; covers sleep, exercise, stress, focus, motivation with science). Follow @hubermanlab on social media. Neural Network Newsletter (hubermanlab.com): Zero-cost podcast summaries, protocols (sleep, dopamine, cold exposure, fitness).
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