Melanie Cole, MS (Host): Most people don't think about fertility until they're actively trying to conceive. But fertility awareness in your 20s and early 30s can change outcomes significantly. We're here to talk about a proactive fertility assessment, what it involves, what it can and can't tell you, and why the $99 fertility check is designed as a low-barrier entry point to that conversation.

Welcome to Fertile Edge, a podcast presented by the Reproductive Science Center of the San Francisco Bay Area. I'm your host, Melanie Cole. And joining me today is Dr. Ravi Agarwal. He's a specialist in Reproductive Endocrinology and Infertility at the Reproductive Science Center of the San Francisco Bay Area.

Dr. Agarwal, thank you so much for joining us today. As we've learned over the years, ovarian reserve declines with age, but is there a variation that exists with individuals of the same age? And can early testing reveal where someone really stands? Who should be thinking about fertility testing?

Ravi Agarwal, MD: Yeah. Great question. I think that there is a lot of variability from person to person. So by virtue of that, really everyone should be thinking of checking where they stand. You know, we kind of always are preaching that egg quantity and egg quality are both really important. We think that egg quality is really much determined by your age.

That really doesn't change much from woman to woman, but quantity is extremely variable. It depends on your genetics, your lifestyle, your overall health, what medications you're taking. So because of that, everyone can be in a different spot. And I think all these things that we think about as like positive reinforcement that your egg quantity should be fine, "I'm healthy in every other way, so my egg quantity is clearly not going to be a problem." Unfortunately, that's always not the case. So, just getting checked, reassuring yourself that you are okay, or learning if there's a problem, knowing that sooner rather than later, all of which can drastically help you in the grand scheme of things.

Melanie Cole, MS: Makes so much sense to start investigating this earlier rather than later. So, tell us a little bit about RSC's $99 fertility check. What tests does it include? Kind of walk us through it a little bit.

Ravi Agarwal, MD: Our $99 check involves just a simple blood test that patients can do at a local LabCorp or a Quest. And we specifically need it to be done on either the second or third day of your cycle, right after a period starts, because that's when these hormones are most interpretable. And it really just checks three hormones: AMH or anti-Müllerian hormone, your estradiol level, and a third hormone, your follicle-stimulating hormone or your FSH.

And it's a really pretty comprehensive look at not just your egg quantity, but your ovarian health in general. And it's a really good screening test to see if you might even have some other conditions like polycystic ovarian syndrome, if you might be going into menopause early. So, just these three tests alone can give us a lot of insight into not just your health now, but just also in terms of your fertility for the future as well.

Melanie Cole, MS: So, that's pretty comprehensive. Tell us a little bit about what these results actually mean. You just mentioned AMH and FSH and estradiol. Can you tell us what all these mean? What are we looking at when we're looking at these results?

Ravi Agarwal, MD: So, I think each individual test, each of those three labs tells us really a lot in and of itself. I think the  anti-Müllerian hormone or the AMH is probably the most valuable. We think of that almost as like the gas tank in your car in terms of how many eggs you have left. It's a little bit of an interesting test because we know that your AMH level, whether it's really, really high and great for your age or, if on the flip side, if unfortunately it's a little bit low for your age. That AMH level on its own doesn't tell you whether you're going to have difficulty getting pregnant or not.

It doesn't translate to your chance of getting pregnant naturally. But we do know that it definitely and very much tells us your chance of getting pregnant if you did need some sort of treatment in the future. So, we kind of have general recommendations of how long someone should be trying to get pregnant before they get treatment, six months, 12 months, kind of depend on your age.

But we might want to change that recommendation based on your AMH level and how pressing it might be for you to start some sort of treatment. I think AMH is also particularly helpful for women who are interested in egg freezing. We know that egg freezing is 100% a numbers game. One of my colleagues at RSC talks about each egg that you can get as like a raffle ticket, and every raffle ticket gives you one chance at winning the grand prize down the road.

And by virtue of that, with egg freezing, the more eggs you can freeze, the better off you're going to be in the future if you do need those eggs. And AMH directly correlates to how many eggs you can freeze in one cycle. So, I think it's valuable for women who are considering it to really tell you if it's a valuable option for you in general and when you might need to do that.

And the other two tests, the estradiol and the follicle-stimulating hormone, really those also in and of itself give us a lot of information and a little bit more information of just how the ovary is functioning overall. So, for women who are a little bit older, late 30s, early 40s, can kind of tell us where you are on the menopause spectrum, whether you are going to go into menopause around the average age of early 50s or if you might be even going to menopause a little bit early. But for other women, it can also be really informative. It can can give us insights into whether you might be at risk for something called polycystic ovarian syndrome. Just if the ovaries are kind of firing on all cylinders or not. Ovaries are very sensitive to any sort of stress on the body: diet, crazy workout plans, intense diets, emotional stress. And those labs can tell us if maybe the ovaries are a little bit victim to that stress or if they're kind of working normally and are unaffected by whatever else might be going on in your life.

Melanie Cole, MS: This is so interesting what we can tell now from just a few markers of ovarian reserve. And what you're talking about is just so interesting. So Dr. Agarwal, tell us how you counsel patients in their 20s and even into their 30s that might receive unexpected results. And how does it differ if a woman is in her 20s versus in her 30s and she gets some results that are a little bit unexpected, what's the difference in how you counsel them?

Ravi Agarwal, MD: Yeah, I think that these labs are just one piece of the puzzle. I think that women are always trying to think about factoring in when to have a kid in their life plans, and I think this is just one more piece of information that you can use when trying to make those big decisions. I think that our goal is not to kind of upend your plan and have you scrap whatever you were hoping for, and then need to change everything based on these results. It's just about being more proactive if necessary and working with what your labs or kind of taking into account what your labs show so that your plan can be made possible in the future.

So, to your example about women in their late 20s who probably weren't even thinking about having any sort of issues with fertility in the future, if we do have that unexpected result of a low AMH level, then I think the only thing that that would really change in our counseling is, "Hey, instead of rolling the dice on getting pregnant in the future and only doing some sort of treatment, if necessary at that point, why not we just be a little bit cautious and think about freezing some eggs now? Because if you did have issues in the future, knowing your AMH is a little bit on the lower side, it'd be a lot easier to get pregnant with eggs you have frozen from today as opposed to trying to start the process from scratch when you're a little bit older.

So, doesn't need to derail plans, doesn't need to change how you're thinking about anything. But just we have wonderful technology these days to help with family building at every stage of life, and I think it just is important to know what is available to you and what you might be interested in doing sooner rather than later.

Melanie Cole, MS: So, you just mentioned egg freezing as something as an option to consider. Tell us a little bit more about that, Dr. Agarwal. Tell us about outcomes and when they're most efficacious. And we were talking about women in their late 20s. I mean, our eggs change. I'm a woman post-menopausal, so you know, I know that my eggs changed as I was getting older.

And so, when is the best time to consider freezing eggs? And tell us a little bit about that process.

Ravi Agarwal, MD: Yeah. So, we know that egg quality is declining with time, unfortunately. You know, I think while we all like to think that we're aging gracefully, and like a fine wine, unfortunately, the biological clock is still ticking for those eggs. And I think the beauty of egg freezing and why it's so, so powerful is that if you freeze eggs, if you did need to use them in the future, they'll always work as well as your age, essentially, when you froze those eggs. So, no pun intended, but you're really freezing your fertility in time.

So, consequences of age on eggs are those eggs are less likely to turn into pregnancies in the future or in general, and pregnancies resulting from older eggs are more likely to result in miscarriage. But the beauty of freezing eggs is that if you froze eggs when you're presumably like early 30s, no matter when you use those eggs, whether it's just in your mid, late 30s or even in your 40s, then those eggs are always going to have the pregnancy success rates and the very low miscarriage rates of someone in their early 30s.

Not just that the outcome's really good, but we've gotten really good at just knowing how to use eggs now. Not even as recently as maybe five years ago, survival rates of eggs was in the mid 80% range. So, many women are going through this process and just losing a lot of eggs in the process, which is a terrible feeling. But now, we've approached survival rates of close to 90%, 95% for eggs. So, we know that if we're going to freeze eggs now, they're going to be around in the future for you to use.

Melanie Cole, MS: I love that you say that it's sort of a point in time to preserve your fertility. That's really a cool way to think of it. So, Dr. Agarwal, you've given us a lot to think about, and this $99 fertility check is really such a great thing to consider.

If there was one thing that you could tell people about their own fertility before they even start trying to get pregnant and to think about these things, what would you tell them? And give us your best advice here.

Ravi Agarwal, MD: Yeah. I do a lot of these phone calls a week, and it's great because I feel like I not only just get to, you know, connect with patients on just a really easy, low stakes level. But I feel like it's really helpful, because for better or for worse, for many of these phone calls, You know, these results come at a little bit of a shock to the women doing them.

And I think the one misconception, the one thing I wish people knew was that just because you think everything is working well doesn't necessarily mean that your fertility, your numbers, your egg quantity are going to be okay as well. Just because you have periods every month does not mean that your ovaries are functioning perfectly normally and that you're actually ovulating or releasing an egg every month, which we can figure out on these tests. Just because your mom got pregnant when she was 45 doesn't mean that you're also going to be able to get pregnant when you're 45, and that your quantity and your quality are going to be great. Just because you're healthy in every other sense, you don't take any medications, you work out, you watch what you eat, so therefore just because of that, your ovaries are going to also be totally healthy and normal. Unfortunately, that isn't the case also. There's a lot more play in terms of how your ovaries are functioning and your egg quantity and just more than what you can control, but a lot of external factors as well.

So, no one ever regrets doing this test and just finding out that everything is okay, but a lot of women regret not doing it sooner, knowing that there is an issue that they wish they would have discovered earlier.

Melanie Cole, MS: What an important point to end on, Dr. Agarwal. That was really a great discussion. You gave us a lot to think about and some important things to consider, especially for women in their 20s and early 30s, even before you start trying to get pregnant. This is such a great way to kind of find out where you stand.

I mean, I wish this had been around when I was that age because there's so much unknown when you're trying to start a family. And this is a way to really get that picture. So, thank you so much for joining us today and sharing your incredible expertise. And to learn more about RSC Fertility Check or to schedule an appointment with an RSC fertility specialist, please visit rscbayarea.com. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Melanie Cole. And thanks so much for listening to Fertile Edge, a podcast from the Reproductive Science Center of the San Francisco Bay Area.