Fertility after 40 – Dr Jain on the Egg Whisperer show video transcript

Welcome to the egg whisperer show, a program exclusively designed to promote reproductive health awareness and discuss fertility preservation options. Here is your host, Harvard educated fertility specialist, Dr. Aimee. She’s known as the Egg Whisperer.

Dr Aimee: Welcome to the Egg Whisperer Show. You guys. I’m so excited. I have a rock star of fertility on, Dr. John Jain. Hi, John. Thanks for joining me today

Dr Jain: Hi Dr Aimee, good to be here.

Dr Aimee: I’m not Dr. Amy, John. I’m Aimee to you! We’re going to talk about something that’s near and dear to my heart, especially as a woman who’s in her 40s, and that’s fertility and pregnancy over 40. And of course, there’s no better person to talk about this than you because you run one of the most successful egg donor banks. (And I know guys, when I say egg donor at 40, don’t feel like I’m giving up on you!). Not just a bank but also agency in terms of running egg donors through fresh cycles, one of the best that I have ever seen in my entire life, in the entire world. So I applaud you. So thank you, John. I just had to start off by saying that.

Dr Jain: Thank you, well, we’ve had some great success together.

Dr Aimee: It has, it’s been really special for me to be able to refer patients to you, because I know they’re going to be in really good hands when they see you. So just talk a little bit about yourself here, or I’ll talk about you actually.

So you’re a board certified reproductive endocrinologist, and a pioneer in the field. With at least 20 years of academic experience, well, at least 20 years of experience and a lot of that academic, including a decade as a decorated professor of OB GYN at USC School of Medicine. And at USC, you also spearheaded egg freezing research and subsequently created the university’s egg freezing program. That’s one of the things you’re very famous for, certainly. And you now bring that expertise to Santa Monica Fertility. And you’re dedicated to advancements in the area of cryopreservation through cutting edge research as well. So welcome to the show, but I’m super curious. Why did you decide to go into fertility?

Dr Jain: Great field. Isn’t it? We, both you and I, made the right move. I think, you know, back when I was in residency in the early 90s, I felt like a kid in the candy store, it’s such a great field. There’s OB, there’s high risk OB, there’s gynecology and all the women’s health fields. And then there was reproductive endocrinology, and it was innovative and exciting and technologically cool. I actually saw it is sort of blossoming into a real remarkable science and being able to help build families. And I was really interested in how, as professionals, we would be able to improve childhood health through embryos, you know. And look, 30 years later, it’s kind of becoming true where we can do a lot more and, help patients become parents, both families and all the cool in vitro stuff and the molecular genetics. I think it’s still phenomenal and wonderful field to be in, but that’s how I picked it. And I’m glad I did.

Dr Aimee: Yes, it’s really fun. I mean, obviously it comes with its challenges of course, but I agree. I agree with you. Thank you for sharing that. Tell us about Santa Monica Fertility. Tell us about what made you start your own practice.

Dr Jain: Well, you alluded to the fact that I was at USC for quite some time. You know, we don’t really hit our stride till we leave fellowship and get out and practice. So I spent some extra time in academics and I’m really happy I did. When I was there, I did a lot of work on egg freezing, which was very novel at the time in the early 2000. It was one of the first clinical trials actually in the world. And then I actually created the first donor egg bank in California, way back in the day, maybe before its time. And it was that egg freezing technology that led me out of USC. So I built Santa Monica Fertility to do that, to offer egg freezing to women who want to freeze their own eggs, and to pursue donor egg banking. Now we’re talking almost 20 years later. So today, we talk about egg freezing and women are like ‘yeah, I want to freeze my eggs’. It’s sort of commonplace. Do you know, in 2009, I did the national debate at the American Society of Reproductive Medicine and my side was that women should be allowed to freeze their eggs if they’re consented to do so. Well, that was contentious at the time. We sped ahead, 12, 13 years later, now it’s commonplace because it does work and it’s a great thing.

I came to Santa Monica Fertility, we froze eggs for women. Then I built the egg bank and now we’ve metamorphosized into a third-party reproduction center. So we focus on donor eggs, both fresh shared cycles and egg bank, and surrogacy. And we put it all together with the medical care, an integrated practice. Patients find it less stressful, and the success rates speak for themselves. So it’s a nice way to practice and we get a lot of babies and that makes me really happy.

Dr Aimee: Yes, truly. And I get a lot of really positive feedback about the experience that patients have as well. So let’s talk about fertility and chances for a woman who’s 40. I mean, I see patients a lot of the times that are over 40 and a lot of them don’t know what the pregnancy rates are. I’d ask them a question, ‘what do you think your chances are at 45?’. And they’ll say 50%. And it’s just so hard for me because I’m such an annoyingly positive person. It’s hard for me to be like, well, actually it’s more like slim to none. So in your own words, what do people need to know about fertility rates and natural conception when they’re over 40?

Dr Jain: First of all, don’t change your annoyingly positive way. It’s a good thing, right? You know I think understanding fundamentals is the best. So for me, when I work with women 40 and older, I try to impart on them one simple fact, and that is egg quality, right?

So it all starts with the egg. Eggs have 46 chromosomes. They have to get rid of 23 to make room for the sperm. If they don’t get there at 23, then the fertilized egg has a wrong number. It doesn’t work, that’s it. And that’s pretty easy for most people to get their head around. The egg makes mistakes at all ages, but after 40, 90% of the eggs make the mistake. At 45, almost a hundred percent make a mistake.

Okay. ‘What if I take this herb and this supplement and I cut out sugar and I cut this out of my eggs and get better answers’? No, we can’t change the eggs. But we can get more of them. That’s called IVF; to get more eggs out of the body. Maybe we can find the normal ones. So I think when I tell patients about that underlying factor, that it’s just nature and at 40 is better than 41, is better than 42 by 43, 44 is really getting pretty, pretty bad. I think they get it. It doesn’t mean they shouldn’t try, but with that piece of information and then understand that IVF is not magic, it just gets more eggs out of the body, but it doesn’t help the egg. I think those two pieces of information I’ve found to be very useful to patients.

Dr Aimee: Right? I mean, IVF is magic when it works a lot of times. I don’t think people realize that most of the time, it actually doesn’t work. If you take every single person that does IVF in this country, every year, less than 50% will actually take home a baby. That’s really hard. But I think when you’re over 40, if you were to choose between cycling yourself, depending on your situation versus an egg donor, obviously that will take you up closer to the maybe not hundred percent, but a lot higher. What about men and women? Do men see that same rate of decline when they’re over 40 as women?

Dr Jain: So the answer is no, right?  That men can father children walking through the forties, fifties, sixties, but here’s what’s missing. We don’t know because all the research has been on women and yes, the egg factor and the egg quality factor is a big deal. That’s the driver. But I have found in my own research, that the semen analysis, the sort of the gold standard of sperm testing, does not tell us the whole picture. For the listeners, semen analysis is a microscopic exam of the sperm, looking at the count, the swimmers, it’s called motility, and the shape called morphology. And if it looks good, you’re good to go. And most guys get a pass, right. But remember, the sperm cell is like a delivery truck. It’s bringing DNA, that’s the package, and DNA gets into the egg and makes the embryo, and that’s what matters, and things like advancing paternal age change DNA. Bad habits, you drink a lot, you smoke a lot, you’re sedentary, you don’t exercise, and you don’t take vitamins. You’re going to change the DNA. And yes, it will affect embryo outcome and maybe pregnancies. And so that’s the piece of information that’s missing. I did some research in my egg donation program and saw that it’s real. It’s called epigenetics. So all those bad things I was talking about, they influence how the DNA worked through what’s called epigenetics. I tell my male patients ‘hey guys, you’ve got to kick in here, take those vitamins, behave yourself. Don’t take testosterone by the way. That’s the killer. Right? You’ve got a little, very little to do, compared to your partner’, if you’re in a heterosexual couple. But that’s all we can do today. And I do think it’s a real miss in our field. A real oversight.

Dr Aimee: I agree, I do. I love that. Guys, behave yourself, please. There’s so many celebrities out there and I can think of so many names, women over 40, who’ve had babies and they’ve made it so hard on us, as doctors, because they mislead our patients so often. So what are some of the options? I mean, not to speak about what they’ve done, but what are some of the options that a woman who’s over 40 should be considering when it comes time to conceiving?

Dr Jain: To further your observation about celebrities and those in the public eye, I think the idea is, if you’re rich and famous, you’ve the special doctors, maybe the Dr. Aimees of the world, who can get you pregnant. Right. Unfortunately, the ovaries of celebrities don’t know how special they are. The statistic is still true. If you’re 45 years old, your eggs are prone to that mistake. I talked about they’re prone to poor egg quality and the chance that you’re going to have a baby from your eggs is really, really low. No matter how famous you are. Now of course, some say, not just celebrities, that ‘I froze my eggs when I was younger’ or ‘I made embryos when I was younger’. Okay. That does happen. It doesn’t happen that much, but it does happen. One more point is that I think they’re just trying to protect the baby. They’re the mother, and they want to tell the child at the right time that they came from an egg donor. So I do get that, but you’re absolutely right. It is misinformation or at least it’s inferred as misinformation. So women over 40, it’s important to realize that there’s unfortunately a time window. If you’re not pregnant within 6 months, if you’re a heterosexual couple, you’ve got to get a workup. Make sure you’re not missing something like the sperm, for example, is bad. And then the goal of treatment is to get more eggs on a given month. So you can find the normal or the good quality egg, and have a baby. So you’ve got to take shots to make multiple eggs and do artificial insemination, or you take shots and make a bunch of eggs and then do IVF, but all roads kind of lead to increasing the odds. And that’s what’s important to do as soon as you can after 40.

Dr Aimee: Are you on Twitter? I’ll do the quote of the day. I’m going to quote you “the ovaries of the celebrities don’t know how special they are”. Do I have your permission? I think that’s a really good one to make the point that, it’s the 50-year-old, who’s having a baby, and makes it look so easy. And she’s a celebrity, she’s still a 50 year old.

And so that’s hard for me to see because patients literally come to me and they’re like “Dr. Aimee, I know you’re an amazing doctor. I want what she had and I know any doctor can do it for me it’s you”. And I’m like you’re 50 years old. I’m going to introduce you to Dr. Jain. Okay. Your work is great and talking more about your work as far as egg donation, how does it work?

Dr Jain: You know, it’s a hard decision for women, you’re giving up your eggs, right? So I always tell women and patients, you have to try with your eggs as far as you can, or as much as you need to. That’s your journey. Only you can define when you’re ready to move on. Sometimes somebody needs to be told it’s time. But it’s a hard decision.

I also tell my patients when they tell me I’m ready for egg donation, I say, well, actually, you’re not ready for it. You can’t be ready, but intellectually, you’re ready. I get that because you want to give birth and you want to be a parent and that’s okay. And I find that that’s an important partnership that way. So when it comes to choosing a donor, these are women in their twenties and in my egg bank, we’ve done all the homework, as have other egg banks. That’s the genetic screen, the medical screen, the psychological screen, their liability, all those things. And with egg banking it is even better because the eggs are already in the bank.

So the patient and her partner just need to focus on what they like. And they have some choice because they’re giving things up too, right. So they get some choice here. It might be the ethnic background. It might be eye color, height, academic progress, whatever it might be, but they have a choice on that. Sometimes they look for a donor that’s proven or they had babies. Although first-time donors work just as well, but that’s really, the process is getting the emotional and psychological readiness for it and then picking the donor they want. And then when they pick a donor, they pick a number of eggs based on their goals, because we can correlate the number of eggs to the number of blastocyst embryos.

Those are five day old embryos that are made from the eggs. So from eight eggs, we’d normally get three blastocyst embryos, which we freeze by the way. Then every time we transfer one of those donor egg embryos, our success rates are about 65 to 70% live birth rate. Nationally It’s about 50 %. If it doesn’t work the first time, they get a second transfer, by that time 90% of people have a baby. So that’s, that’s how it works for us. And then if they want to choose the sex of the baby, that can also be done. A variety of things like that, but that’s sort of the big picture is the readiness, the selection of the donor, the selection of number of eggs, to build their family.

Dr Aimee: I love that. That’s very easy to understand and I have to tell people, not that I want people to think that these results will be seen everywhere, but for any patient that I’ve referred to you or any that you’ve taken care of over the years, I think we’re at 100%. And every transfer has led to a healthy pregnancy and baby, and I just think that shows the quality of the work that you do there. So thank you for that.

And what about surrogacy? You talked about how you really feel your clinic is doing third party reproduction as a whole, from egg to baby. And you now have incorporated surrogacy. Can you tell us a little bit about that?

Dr Jain: Yeah, sure. So we have gestational surrogates. The other type of surrogacy, traditional surrogacy, where the surrogate provides the eggs, we don’t do that nor does really many people do that. Surrogates are women under 40, healthy, had their own children. Not had any problems or pregnancy problems, are healthy with no medical problems. They’re hard to find, there’s a real shortage in the country. Some of the big agencies have a year waiting list. We have our own surrogates here for our patients and for close friends and close doctors that we know, present company included.

We pre-screen our surrogates, so they’re ready to go. Basically women who cannot carry the pregnancy because it poses a risk to their life, if they have a medical problems or there’s a risk to the child’s life, are candidates for surrogacy. As are women who’ve tried fertility treatments that haven’t worked. And the surrogate does not have a genetic link to the child. That’s the egg and sperm provider. They do however nourish the child, the fetus. And so it does matter that they are healthy and live a healthy life during pregnancy. But at the end of the day they’re disconnected genetically.

California has great rules because at 21 or 22 weeks, the hospital gets a court order saying ‘hey, when that baby’s delivered, it belongs to these people out there’. And they’re the ones on the birth certificate. Now, some other states have really favorable laws too. And so getting a surrogate out of state of  California, this is not a bad thing, especially in these virtual days where people can follow pregnancies virtually.

Dr Aimee: And what about gay men? How does it work for them?

Dr Jain:  Yes, we actually have a lot of gay clients. We’re kind of built for their needs. Gay guys have the sperm. Oftentimes you have two sources of sperm. But we have the eggs and we have the surrogate, and the medical care. Just like any other couple or single person, they pick the eggs and we create the embryos and the surrogate carries it for them.

We also work with HIV positive men who are undetectable with the virus. That’s been shown without question to be a non-transmissible state. And so we really pride ourselves in being a full service package to that community, who encountered bias and prejudice and may have a lot of an understandable anxiety going through all these steps.

Dr Aimee: Patients just have so many options out there when it comes to egg banks now more than ever. If you were someone who was looking through options, what kind of things should a patient be looking for when picking an egg bank?

Dr Jain: Yes, we only take 2% of the donor applicants and we pre-screen everything, we have to really believe in the donor and her reliability, in their genetic and medical history.

And then we know all the donors, we’ve met them. I do the care of the donors. And so when we speak to our intended parent, we speak from a point of an in-house program. Some of the larger banks don’t have that. They bank the donors’ eggs in one place, then they’re shipped to many different places. Now I don’t think that’s a negative per se. Someone who’s going to get healthy eggs and the cost might be affordable, and they might be in a small town in a smaller state. And that’s just all they have. So that’s great. They have a family. That’s all good. But the experience is important, and the trust is important.

We also build in the plan to have backup embryos as part of what we do. And we almost universally always have extra embryos so that we can do another transfer if the first one doesn’t work. We do it at no additional cost. And that’s how you get to that high success level, right? Because the first transfer might be 65, 70% by the second transfer, it’s 90% of live birth success rate. Patients also get nervous if they only have one embryo. I spent a lot of time when I brought up the program thinking about the anxiousness and the patient experience and how this somewhat feels better and more confident.

Dr Aimee: Is there anything else you want to add and share with our followers today

Dr Jain: I think it’s something you also do as professional, and that’s providing good information. You know, there’s so much misinformation out there, whether it’s the lay public or it’s medical doctors. I think patients just have to ask questions and not become victims of the misinformation. Yes, your friend may have taken a supplement and she got pregnant. It doesn’t mean that’s the case with you. So you may not need to cut out sugar and alcohol and, and caffeine. You may not need to have a restricted diet, pick and choose what feels good for you, realizing that nothing’s going to change the egg. It’s just unfortunate. But it might change how you feel. And then on the other side with doctors, I so frequently see patients who really didn’t know what they did, and I find that kind of appalling because it’s not helpful really, you know, and it doesn’t feel good. So I encourage patients just ask the questions, why are we doing this? How is this going to help me have a baby? And so I think the number one message I have is just be informed.

Dr Aimee: Ask the questions, exactly. Who’s my doctor going to be that day. I joke and I say, there’s three people that work here: me, myself, and I. You’re going to get one of us. So if one of us isn’t here, you’re going to get the other one. So how can people find you in your clinic?

Dr Jain: Well, it’s easy. It’s just SantaMonicaFertility.com. And it has a link to our egg bank and has a link to our surrogacy agency. And we are people that pick up the phone here, not to say that automated systems don’t work, but that’s what we do. So give us a call, send an email, get a contact sheet, and I’m happy to talk to you.

Dr Aimee: And who doesn’t love going to Santa Monica?

Dr Jain: That’s right. It’s wonderful place.

Dr Aimee: Well, thank you, John. Thank you for making my patients parents. Thank you for all the work that you’re doing, pushing our field forward. And I really appreciate you.

Dr Jain: Well, thank you for saying that, thanks for the trust in the program. It’s been great work with you. Thanks for today.