 So I'm a reproductive endocrinologist and infertility expert and I have been, I guess, my training has been in the fertility, you know, specialty. I'm an MD and I did my MD at the University of Florida. I did my residency at NYU and fellowship at the University of Connecticut. And then I came to the area. It's been now about like over 10 years, I think, at this time. So I'm very happy to talk about, like I said, this topic that I came to learn about when I was actually in medical school at first. I was like a third year medical student and it was quite shocking. So yes, thank you for being here today. And we'll see if there's any, you know, questions I hope that I can answer as much as I can in this felony myths about our ovarian reserve. So our topic today is very reserve aging and egg phrasing. And so, you know, I'd like to discuss like why, you know, why this topic is important. How is this relevant to today's world? What does it mean when we say ovarian reserve and we talk about that? What is it sometimes confusing the terminology for patients? Once we find out what ovarian reserve is, then I also want to talk about what factors affect ovarian reserve. Is there anything that can be done, that we can do? And then how does egg phrasing work? Because you probably have heard a lot about egg phrasing. You know, it's actually, I just came back from a meeting from the American Society of Reproductive Medicine and one of the apps, just one of the presentations was about egg phrasing. And in that phrase used in TikTok, I'm not an IT person that much, or like social media by much, but TikTok apparently, you know, is teaching a lot of patients and our population out there. And so most of the information comes from TikTok apparently these days, like a large proportion of information is from patients. And then it's about like over 50%. And like maybe 20% from doctors and even less than that from universities. So I feel like probably need to do more of programs like these where we can reach to patients from physicians from, you know, like experts in the field. Who can benefit from egg phrasing? What medications are needed to freeze your eggs? And what kind of treatment timeline looks like? And then down the road, what do you do with these eggs? Like, well, what does it look like if I'm going to use them? So that's what I'd like to discuss today. Now, to start with the relevance is that certain things are facts of life, meaning that, you know, we all get older. And while we can exercise and have control over our diet and a lot of parts of our health can be, you know, modified by our behavior, some things cannot. And one of those is our age. So we are born with all the eggs we'll ever have. This is this is just a lot by the time you are actually like 20 week fetus and your mom's boy or any woman basically will have the most eggs that you'll ever have like six to seven million eggs. But by the time a female baby is born, you know, like the female babies drop now to one to two million at birth. So you lost so many eggs in 20 weeks. By the time that a woman reaches the first period, the eggs are now down to about 400,000. So this is, you know, important to know that aside from that every day we lose eggs, it's kind of sad, but it is true. Now we don't see a significant decline in the reserve for the most part until you reach like your 30s and maybe a little bit more like 35 or so. Now that's in terms of the client of the quantity of eggs. So we were just talking about quantity, but quality also declines with age. And the importance of this topic is also because there's been a global reduction in fertility rates. So this is like despite what we may think, there's really a problem whether, you know, we're postponing it or patients are having more difficult time to conceive and like a lot of factors in our society, you know, like we want to go to school, want to be, you know, financially successful and independent. These things can have an impact on childbearing at some point. So you can see this graph, this chart essentially can illustrate that as a woman gets older, the fertility rates decline. You see the black line, as you can see the sharp decline like after 30, you know, and then more so after like 35, it's a substantial change in the ability to conceive. At the same time, the miscarriage rate will go up. So that's exemplified by that red line. And so this shows that there is a decrease in quality of eggs. So this is actually something that doesn't change is kind of overall fact that we know that as we get older, it's more difficult to get pregnant. And it's more difficult to stay pregnant. And the second part of staying pregnant has to do with the quality of the eggs. So once a woman gets pregnant, you know, as you get older, there's a higher chance of miscarriage, because typically the embryo may not be normal. Now, what is the ovarian reserve? What does that mean? What do we talk about when we say talk about egg reserve? So the ovarian reserve or egg reserve refers to the number of eggs that a woman may have at a certain point in time. And so there are three main markers that we can use to assess a patient's egg reserve, like the pool of eggs, if you will, that a woman has at a given point in time. So one of them is AMH, antimular informant. This is a more, nowhere marker of egg reserve that has been studied. It is thought to be more stable than FSH levels. And the higher the number, the more eggs a patient has. The lower the number is usually related to a lower number of eggs. Now, what is a good number? So the other thing to keep in mind is that these markers of egg reserve have been used in patients undergoing fertility treatment or patients with infertility diagnosis. So while it is useful to some extent, you know, the numbers have to be used with caution. What I mean by that is that if somebody has an AMH level done, and it happens to be a little low, it doesn't mean they cannot get pregnant. So this isn't say you can or cannot get pregnant. None of these markers of egg reserve, one AMH that we talked about so far, second FSH, and the third is antrophobic. We'll try to describe it a little bit, but none of these markers will tell us that someone is fertile or not fertile. So sometimes patients come to see me, like, I want to find out about my fertility, but we're a little bit limited. I can tell you maybe like, what you look like, you know, you're 30. And what is your AMH? Like, is this appropriate? Is it low? Is it very good? So it's an objective, as like I said, an AMH levels will drop with time. What's a good number or an average, you know, around two-ish is kind of like this pretty good. Anything under one, more so under .7 is concerning. And again, that doesn't mean someone cannot get pregnant. It just means that the number of eggs that someone has at a given point in time is lower. And we never make more eggs. So remember the first graph which showed the decline in egg reserve, it just goes down. Now, the markers may be stable or may substantially drop. We don't know. So like one point in time doesn't usually give us a whole picture. Sometimes we need to repeat it in six months. If it's kind of low, we may have to repeat it again. So we could use this to track somebody's egg reserve. Over the course of time, it's going to the time. So the FSH level is another hormone. This hormone is created by the brain, the pituitary. And so the higher numbers indicate that the egg reserve is poor. What that means is this hormone, FSH induces dematuration and basically the growth of the eggs in our ovaries. And so as that number gets high, it's sort of like saying to the ovary, like you need to start, it's time to start making an egg. And so if that signal is higher, it's usually because the end organ or the ovary isn't responding so much. So high FSH levels are not good. So anything above 15 is very abnormal. We typically are comfortable with if it's under 10. If it's between 10 and 15, it's sort of like, oh, something's happening, there are some changes. And the last thing is the antropholic count. Antropholic count refers to the number of eggs that we see or follicles that we see on an ultrasound. The eggs we cannot see because they're microscopic. But a patient like in that graph that you see at the bottom, we see that this ovary has lots of those little follicles. This is probably an ovary that's the patient's PCOS with many, many follicles. This is a little bit less, not as big the ovary. And this is maybe like an average ovary with good size of the ovary and the antropholic number. And then this is an ovary like just one follicle. So that's not good. And so these are both the three of them actually are markers of egg reserve. With the changing in the times, we see that there has been a push to having babies later. So we know that it's important to know what our reserve is like if somebody is really interested in having a baby with their genes, a biological child. This is also important as there are more women in the workforce. And we know that each year of childbirth delay increases long-term fat salaries. So because of that companies have been very smart to provide these services and benefits to patients, you know, like you give patients benefits to go see the doctor for medical conditions. And this is important because our reproduction is not forever. It's not like, you know, infinite. So we really need to make sure that if we have good, you know, if a woman wants to advance her career, like part of that, and if they like to have a baby, biological child, then this is important to try to do something to prevent infertility down the road. So a lot of companies, like I said, are offering benefits that allow women to freeze their eggs. We know that it used to be an experimental label with egg freezing up until 2014 actually. And it's been actually since that time to now there's been an increasing number of women undergoing egg freezing cycles and more so after the pandemic and a lot more after the pandemic. I mean, if I just remember, you know, there was a time when we had to stop procedures, but then shortly after there were many patients who were either single or like, you know, there were problems in the relationship status getting older, you know, people cannot date with, you know, the like social distancing, it just became very difficult. So more and more women have, you know, reached out to preserve their fertility. Now, what does not affect your egg reserve? Eating, drinking, toxic habits, I mean, did that can have an impact depending on how much someone does some things maybe slightly reversible. We know that smoking alcohol is not good for the eggs. Women who smoke go through menopause at a younger age than those who don't smoke. We also know that egg donors, we don't, we don't take smokers anymore. But back when everything started and we used to have egg donors, you know, anybody who was young, they smoked or not was not a criteria for exclusion. But the eggs from smokers were poorer quality than those who were not smokers. So we know that it can affect egg reserve. But in general, it doesn't have a substantial impact like down the road exercise also you could exercise, like I said, but you cannot make your egg reserve better. So some things you can make it worse, but not improve stress also will not make somebody's egg reserve decline substantially, contraception, like birth control pills. A birth control pill is something that kind of keeps a patient from ovulating, but does not diminish their egg reserve. Even when somebody's on the pill, the egg reserve declines. Like it doesn't like just pause the process of apoptosis, which is cell death essentially that happens in the ovary over the course of time. It still happens whether someone's on the pill or not. And evolution, yeah, we're having babies later. You know, celebrities are having babies later, and it's like great, but sometimes unfortunately, not everything is disclosed like patients in general who are over 45 tend to have babies using a donor egg. So that's something that isn't always disclosed, or you know, it's a lot of privacy, of course, but for some women, it may give them the hope thinking like it's okay, I could wait because so and so had a baby, but you know, sometimes, again, not knowing that it might be an egg donor. Now, if you were to freeze your eggs when you're younger, then you could be your own egg donor. So that's how we look at, you know, the ability to freeze somebody's eggs. So again, I cannot emphasize enough that age is the most important actually factor that will affect somebody's ovarian reserve. Other medical conditions that can affect that reserve include endometriosis, a condition like where you have can can present the spades. And it's really difficult sometimes to diagnose some women with endometriosis don't have pain infertility, patients with pelvic surgery, if somebody has only one ovary because they had a cyst, and they have to remove the cyst, patients who've had chemotherapy, because of a cancer diagnosis or radiation exposure, or, and the other part is genetics, you know, some women will have better egg reserve than others because it was part of the family, you know, one of the things I always ask is, did anybody in the family had premature ovarian failure or premature menopause? So those things are important, and it can affect somebody's ovarian reserve. Now, how does egg freezing work? So an egg is frozen and an egg is a single cell which has lots of DNA inside, but you cannot, you cannot find out if this egg is of good quality or not, unfortunately. So we, we cannot know that we can only freeze and mature eggs, mature eggs are the only ones that can be fertilized down the road. But we cannot at this time, tell if this egg that is frozen will give rise to a live birth. So what happened, like I said, was the evolution of egg freezing is it became, it changed in the, in the lab in terms of how the eggs were frozen. Started with the slow freeze is a technique that allowed the eggs to be frozen with a control rate of cooling. It was a slow dehydration. However, what happens that it was very time consuming. There were also crystal formation within the, the cell is one. So like I said, so that led to poor egg thaw rates. So when the egg doesn't thaw well, then we have a low chance of survival of the egg. Of course, poor fertilization rates. And since I'm trying to think the time, this was when I was at UConn in 2007, right, is I remember we were starting to study vitrification. So the vitrification protocols, and that was when we're like doing randomized studies to see if this new technique was successful. And it was. And now today, pretty much is what is used vitrification, which allows for fast cooling rates. It takes a very quick, it's a quick procedure. And what it, what it does is basically dehydrates the cells so that when the egg is thawed, there are no crystals formed at the beginning. And so less chance of also damaging any organelles within the egg. So now more important, more recently, there's also looking at ultra rapid vitrification. But this I won't discuss in more detail, because it's also like kind of not really, is still in this experimental stages. So we don't use that. But vitrification has substantially improved the ability of these eggs to be frozen and survive the thaw. And today, the fertilization rates are comparable to whatever the age of the woman is at the time of the egg freeze. So it's actually very good. Now, another thing that can be confusing, I just wanted to talk a little bit about is freezing eggs versus embryos when it comes to fertility preservation and what you can do about aging. So prior to 2012, whenever anybody came to talk to me about freezing their eggs or fertility preservation in general, we had to make embryos, we couldn't freeze eggs. So it's changed now having said that there are patients who would like to freeze embryos. These are tend to be patients who are in a committed relationship or who, you know, they know who their partner will be down the road. And so why freeze eggs versus embryos? Well, an egg is not fertilized, so it's just the patient's property, if you will. An embryo comes from an egg and sperm. And so now it's divided. It has many cells. One egg and one embryo are not equal, meaning that you need to have many more eggs to get to one embryo. Many eggs started out being fertilized and over the course of development, they will not make it and then you get one embryo. So, you know, an embryo has more cells and it's stronger and has better implantation potential, of course. The potential is much better when you have an embryo. But like I said, things that can be kind of tricky here is that it comes from an egg and the sperm. So, when it comes to any kind of, you know, changes in marital status or no longer people being together, it can be difficult to, you know, know the disposition of the embryos. So, or, you know, unfortunately, like death and all these topics we talk about with, you know, like patients. So today, egg freezing is really the preferred mode of fertility preservation for women. Again, a little bit more about that. We talk to think about all of this, you know, the eggs currently their success is similar to the IVF at the time of freeze. For embryos, you need a sperm. We do have more experience when we talk about embryos, but the disposition could be difficult and challenging. So now who can benefit from egg freezing? Well, you know, the technology before it was extended for what we kind of call like social freezing or like, you know, for fertility preservation was started to be used with patients that who had cancer. So if somebody is undergoing chemotherapy and they were diagnosed with cancer, ideally we tried to freeze eggs before they undergo chemotherapy. It's not to say that, you know, someone cannot go through the process after, but the damage that can be incurred by their chemotherapy medication into the eggs is, you know, passed. And so we do not know how those eggs will function afterwards and also depends on what kind of cancer treatment a patient had. Radiations, the same thing. It is, you know, it can cause decline in the egg reserve. And so ideally we would like to freeze eggs before that. Now, some patients within the matrices have severe symptoms. Some patients within the matrices know that they'd like to have a baby, but they're in the matrices and pain is so severe, they are getting older, don't have a partner or do have a partner, but they're not ready. So that is certainly an indication to proceed with egg freezing. As a woman gets older, then you'll have yet another factor, not just endometriosis, but then the age factor. Known to disease, somebody's had a history of pelvic inflammatory disease or any kind of other conditions prior surgery that could affect the function of the fallopian tubes. Somebody had an ectopic pregnancy and they had tubal damage. They had to remove the fallopian tubes or tube. Then in these situations, egg freezing is also something that, you know, can be discussed if somebody would like to have a baby down the road and they know they would need in vitro, down the road is always better to have eggs the younger you are. Other genetic conditions that come up, I've had patients that didn't know, but in talking about their history, oh, my sister went through menopause a little younger or my mom had problems and we can check for genetic conditions that could be in the family and I found some things that we didn't know about and one of them, like I said, fragile eggs, other conditions that could mean that the patient is at risk of having fertility problems on the road. So those are reasons for freezing eggs. Anybody with autoimmune disorders sometimes also, you know, if they're going to have medications that can be toxic like methotrexate and whatnot, so all those can have an impact on the egg supply. And another, you know, indication is patients who are, you know, transgender who are going and say that like I've had patients who are born, you know, female, genetic female, but will be undergoing medication to become a trans male or they're going to be on testosterone and they want to have a life, you know, as a male, so then you can actually harvest eggs before they undergo through the whole process and we're able to save eggs if they would like to have a baby down the road. And, you know, it varies on a case-by-case basis. Some of these patients will not be carrying the pregnancy, but they'll like to have a biological child using their eggs. So there are social indications which we kind of talked a little bit about earlier related to career advancement, somebody who wants to delay their childbearing because they're not ready, again, like either, you know, whether it's emotionally or they're not ready, like financially. You know, if somebody doesn't have a partner, you could always, you know, buy sperm, but some patients don't want to yet or not ready for the baby yet, you know, so those are possible indications for freezing your eggs. You know, in stable relationship, I mean, some patients, I've met patients who've been on a relationship where the partner may not have been sure if they want a baby or like, yes, maybe, maybe not, but you know, I always say like, I think if if it is that important for a woman to have a biological child, I have to say there's like almost no regret. I haven't had any patient that says to me, you know, I wish I, I'm happy I didn't freeze my eggs. It's quite the contrary, you know, like they sometimes come down the road, like, I wish we could have done it back then. I'm no longer with my partner. I mean, and also this, the concept of age, unfortunately, as it is real, but it, you know, it's difficult for partners sometimes to understand that and it may make us a little more on edge about it and more anxious. So many times when patients freeze their eggs, it gives them that peace of mind that, okay, well, I have these eggs. I don't know what the future may hold, but at least I did something about it. And a lot of times, you know, there are studies that are shown also that there's a, you know, immense amount of satisfaction from patients that are able to freeze their eggs and at least feel at ease and allow, you know, the relationship to go wherever it needs to be without the extra pressure of like, well, I'm getting older, what are we doing here? And sometimes, sadly, I've had patients that were pregnant and had a loss, but again, age is really important. If somebody happens to get married later in life or has a partner, they have a baby 38, and they have a loss, you know, that's emotionally very difficult to cope with, of course. And the time still goes by. So I've had patients that would, you know, have decided to freeze their eggs, you know, before they go ahead and attempt again, at least you kind of stop the clock at that point. And then if, you know, they think that it's something they like to do and have a baby down the road when they are emotionally in a better place, then they can actually do that. So what medications are we using to freeze eggs? And I'll talk a little bit about also like side effects and things like that here. But we sometimes use oral contraceptives. It's a little counterintuitive, but it is to be able to schedule the procedures. So we kind of recycle coordination. We sometimes put patients on the pill. Sometimes we have to use estrogen pills also and lieu of oral contraceptives. And they really depends on the case. The idea is to try to prevent one egg from growing ahead of the path. So these are kind of the things that we do before somebody undergoes the cycle of like control ovarian hypersimulation. So what does that mean? That means we're going to hypersimulate the ovary, we're going to give hormones or like these endogenous gonadotropin. So this is what our body makes, but they are synthetic forms. So of those endogenous gonadotropins that are given, so they're recombinant, FSH essentially, they're produced in the lab. And then we usually, the patients will give it to themselves in a form of an injection, typically daily. And the idea is that under the influence of these medications, like if you can see here, I'm not forget my cursor is working well there, but the patient has a period, they may be on the pill before. And then they start taking the injections. The injections are going to make the ovaries respond in a way that will make many eggs grow. So like they are there, they're developing, but they'll improve and kind of like many of them grow once a month. We release one egg and so only one egg grows, all the rest of them don't, because our bodies release those hormones in a cyclic kind of manner. But when we have these levels at a very high rate, as opposed to sort of going up slowly, then what's going to happen is that they get many, many eggs to grow at the same time. And so if they continue to grow, eventually the woman will ovulate. So we have to give another medication to prevent ovulation, and that is called like a GmRH antagonist or like Satchotide, Gameralis, these are other names for these medications. This is one type of protocol, a different protocol is where we use Lupron, which is our GmRH agonist. In that case, the patient is completely suppressed, and then we start giving medications to have those follicles grow. Once they get to a good size, and it's a decision made by usually the doctor, so I will like to look at the patient and see the size of the follicles and the number of estrogen, estradiol level that they're producing and other hormones like LH, progesterone and ratios. And then once they get to a good size, we'll have them take an injection called HCG or human coronagular tropin. In some cases where a patient has a very aggressive sort of response and a lot of eggs that are produced and we have to prevent them from developing ovarian hyper stimulation syndrome. And in those cases, we have to give them something called Lupron that will prevent them from getting very sick after the eggs are mature. So the intent of this last injection is to make those eggs in the ovaries mature so that by the time we get the eggs, we do the egg retrieval, we can get mature eggs. So now side effects, you know, it varies from the medications, but in general, most patients, once they are going through the cycle, which can take, you know, anywhere from like eight to 12 days or so of medications, maybe like six visits during that time, you know, patients have to come in the office to be evaluated. And side effects are bloating. And again, like, you know, feeling a little moody sometimes. But for the most part, the mood changes are not too significant, meaning it's the bloating that is the most common side effect. Okay, so now one thing that I just wanted to kind of mention is that for oncology cases, of course, there's a few more things that we usually talk about that it records an interdisciplinary team. I'm usually in touch with the oncologists or any of the, you know, surgeons, if it's a surgical case, to make sure that we address any kind of aspects of the patient's care, because we do not want to delay treatment for their cancer. So at times, this is a little bit different, but it's also a form of egg freezing where we freeze eggs for these patients on an emergent basis. So they'll come and say, you know, I have, I'd like to freeze my eggs because I'm going to have chemo in a couple of weeks. And so we have to get them started right away. So in those patients, we don't have the time to do the birth control pill. We still can get good successes in terms of the number of eggs retrieved that really depends on their egg reserve. And we do know that women who have cancer diagnosis and under undergoing egg freezing probably may have a slight or poor response than if they don't have a cancer diagnosis, but it's still possible. And again, depending on the age and factors like being egg reserve, the number of eggs that we are able to retrieve varies. Mental health support is also very important. Sometimes it's very difficult to even talk about this, but I think lately, you know, there's more and more awareness about freezing eggs and fertility preservation for these patients that the discussions are happening. But there's always, you know, they can always be more. And this is something that needs to be addressed. The patient needs to make up their mind, right, and make the decision like, is this something I want to pursue or not? But at least it's really important that it is a subject that is brought up to the patient, particularly if they haven't had children. And even if they've had children, you know, we cannot assume that because someone's had a child already that and now they have this diagnosis that they may, you know, not want to have another child. I mean, it is part of, you know, a healthy like life if somebody wants to have a baby and complete their family down the road. So we just need to discuss that with patients and let them make that decision. And it's hard because there's so much at the time of the cancer diagnosis, but it's something that at least should be discussed. As I said, you know, we're available in this rapid access to treatment and patients should go to a clinic and office that has expertise in these cases. So what's the process like? What is it, you know, what the patients have to do, what do we ask? Usually we really, you know, there are some things that the patient can do to improve on things, right? Or say like, you know, if you're smoking, try to like quit as soon as possible, ideally three months before the cycle. If somebody is drinking a lot also, I mean, these are things that we don't think of drinking how much of impact it's going to have. But it really is, it does have an impact in terms of like anesthesia use actually. So patients who drink more will have more tolerance. So the amount of medication that's given to them at the time of induction of anesthesia is going to be more. So there is something about that not necessarily about their response to stimulation, but those are the things that could be, you know, improved on. Again, as I mentioned before, we may pre treat with birth control pills or an estrogen patch and the medications are by injection as the way described earlier, they may be given twice a day or sometimes it's usually at most like twice a day. But there may be a number of medications. Most of the time is something to make the X grow like follicle stimulating hormone and HMG. So these are two and then an injection to prevent the eggs from obulating and maturing. And so that's another injection. The blood work and ultrasounds are done early in the morning so that we can have results by the afternoon. And typically the the nurses will relay messages. So the doctor will review. So I review them at the results of the testing and then we give next steps on that day for the next day. So it's a process that demands a lot from from the patients, you know, in terms of being around. So it's important when we say like a few vacation plans or whatnot, like let us know because we don't need to around or, you know, patients need to kind of at least not that you have to take nobody has to take time off from work, patients come in, go to work and no problem. The only time that a patient needs to be off is for the time of the of the egg retrieval. So now what is this egg retrieval that we've talked about so much? This is how we get the eggs. So if you see here, this procedure is done at a surgical suite. So there is an anesthesiologist who will take care of the patient that way. They're comfortable and not in pain. And and that we're able to do this safely. So the reproductive endocrinologist is the person that will be doing the egg retrieval. And then rheologists is the person that's going to get those eggs for us and for them. The procedure itself is relatively quickly. It's takes about maybe 15 minutes of actual time, depending on, you know, how many eggs somebody has, somebody has five eggs, it'll be shorter, somebody has 30 eggs, it'll be a little longer. So if you see here, this is a depiction of the vagina and the probe and the vagina with a needle on top. And this, we do it on the ultrasound guidance so that we can see directly where the needle goes. And we drain each follicle. So the egg is microscopic and it's floating around inside that fluid filled structure that's called a follicle. And we drain it. And so we drain it, we go to another one, we drain it and go on and so on. And we try to do that for, we have to do it for both sides. So we go one side, drain the whole like ovary. We take the needle out scan again and make sure that we got all the eggs. And then we move that probe to the other side and inject the needle against similarly. Most patients should be fine to return to work. The only thing is usually anesthesia, we usually say no driving for 24 hours because of anesthesia. But in terms of the procedure itself, you know, it's a small needle that goes into the ovaries. So the risk of bleeding is there, but it's really minimal. Most patients bleed, but then it will stop and it shouldn't be anything, you know, significant. But we monitor the patients after they're done with their retrieval for some time in the postoperative area. And they usually leave us comfortable walking, you know, pain free and by night is kind of like back to normal. Sometimes, and I tell patients, you know, it might sometimes gets a little worse before it gets better in terms of the amount of bloating that someone experiences, especially the more eggs somebody has, the higher the discomfort that they may feel the pelvic pressure. Now, another question that I get also is like how many, that how many eggs do I need to have a baby, right? And it really depends on age. I mean, these are kind of like some of the estimates that in your 20s, you know, you need like out of one of eight to 10 eggs should give you a baby and your 30s 15 to 20 and your 40s, we know them more than 20. Again, this kind of illustrates the quality issue we have as we get older. So a younger patient will need less eggs to get one baby than an older patient. Okay. Now, how many, these are other questions that sometimes I have, you know, like, well, how many eggs do I need to fall? And what do we do down the road? Like, that's, that's a very good question. Because once you throw them out and you expose them to sperm, you know, and many patients that come to see me don't have a problem, like they are trying to freeze their eggs for just kind of like prophylactic, if you will, right? So you don't know if there's an issue until maybe we thought the eggs and survival rates for egg thoughts about like 90%. But if we get like 50% of the thought, and there's something that we didn't know maybe about these eggs or like, you know, patients or maybe there's a problem intrinsically at the level of the eggs. But like number of eggs to throw will have to be sort of driven by between the conversation with the patient and doctor and a lot of it by the age at which the eggs were frozen. Once that happens, then the eggs are fertilized with a procedural called XC intracetoplasmic sperm injection. And then once we make an embryo, the embryo can be put back in the uterus, or we could test it further with a, it's a procedural called preemptive genetic screening, for usually for unemployed to confirm that the genetics of the embryo are normal. And then any embryos that are left over can be also frozen. So now this point we have the X over thawed, inject them with sperm and make embryos. And then these embryos that are left over, like if we put one back, we're not going to put more than one usually. So we put one back and the rest that are left can be frozen for use down the road as well. So this is kind of alluding to what I was saying. So the egg, it looks like that. This is some mature egg. So it's egg is thawed. Then it's injected with sperm. This is the needle that is used to pick up an sperm and inject it inside the egg. So that is called XC. Then now the embryo, I'm sorry, the egg will be fertilized. Hopefully I don't have a picture to be in here. But like, then what happens is the embryo develops. So over the course of time, this is kind of like a blast, like a blast, I'm sorry, a cleavage stage embryo with many cells. But now this is a blast. This is like a day five embryo. Now the embryos reach the blast as a stage on day five, six or seven. And at this point, the embryo can go back in the uterus like so. So we do an ultrasound from above here. And we put the embryo in a teeny catheter. Usually this is, I don't like this because there are two or three here and that's not good at all. I'm sorry, but it's usually just one. And yeah, we only put one typically depending on the age. If somebody fills their eggs at 39, yeah, maybe we'll put two or something like that if we're not testing them. If we are testing them and the embryo is normal, definitely we only put one. And again, any embryos that remain can be filled in for later use. So this is actually, you know, I have the cover Bloomsburg business week from, I believe 2014 that at that time, it's just became sort of now no longer experimental, freeze your eggs for your career. And this woman Bridget Adams actually froze her eggs at the time. Unfortunately, you know, not all stories end up great. And I mean, like I said, well, I have many patients that have had babies with frozen eggs. The story about her, just to kind of follow up on what happened, I think this was maybe came up maybe a couple of years ago, she froze 11 eggs at the age of 39. So again, 39, 11, you know, she probably would have needed to freeze more, maybe have done a couple more cycles. So unfortunately, she didn't have a library from these eggs. She subsequently went in on to use a donor egg and she does have a baby. So that's good for her. But this kind of brings it back to like, you know, what else do we need to know about this, you know, how this is kind of like, where the gap of like, yes, it's great to freeze your eggs, but like, you need to know how many we need to freeze depending on your age. So, so this is data that we're still kind of acquiring. I have here, you know, what percentage of them have an embryo transfer. And let me see if I can share with you, I had my, you know, our embryologist, look at these and I wanted to see what is our data like just internal also that we can kind of look at this. So he said, we had 30, okay, it's a small data set, but a survival rates of eggs that were vitrified is very good. In the past 12 months, we've warmed 748 eggs, 92% survived, and 73% were fertilized. So this is, this is very good. And the pregnancy rates are pretty much on track with the age of the patient. So these are, these are good. And again, you know, the numbers, the more data we have, the better we're going to be able to guide our patients. This QR code I have here points you to this link that this is aside from bringing women's health where you can plot your age. And basically, the number of eggs that you would need to acquire a library, this is actually pretty cool. Let me see if I can try to get and I can I get it. But it's actually very nice because just go to this and you will see that it'll tell you depending on your age, say I saw I think yesterday 39, okay, number of eggs, if you get like 20 eggs, what's the chances of a life of one live bird? What are the chances of two live birds? And so that can guide patients. And again, they also say this is internal data for them, but it's sort of helpful. It's a good program too. I think ideally, you know, every center will have a program like this, you know, like a little bit of AI to be able to help us and algorithm to give a guidance to patients. But in general, it's really important to be transparent that, you know, patients may need more than one cycle and depending on your age. So the younger you are, the less number of eggs you need. That's the bottom line. So I am done with so far what I wanted to talk about today. And I hope that I was able to give some answers to patients or anybody interested about the egg freezing process. And so if you have any questions, please feel free to reach out. I do have an Instagram account. I could be better about that. I'm working on that. But, you know, reach out and anything that anybody would have questions about, please let me know. Oh, great question. No, not at all. There is really like I was saying, those markers of egg reserve are for most of the time, patients who are trying to get pregnant and don't get pregnant. So unless somebody specifically tells their doctor, oh, you know, I've been, I've been trying and it's not happening. If anybody's over older than 35 after six months, it's basically an indication. Aside from that, I think if anybody, if it's in the history or somebody wants to know, I mean, you probably could do the tests, right? But like I said, the limitation we have is that we don't know the true significance of that. FSH fluctuates also from month to month. So today, like a better test, if we're looking at one, if you ask me, what's the best test at an AMH level, it's a little bit less variable. You know, like it doesn't have so much fluctuation. And it's the one that we're using a little bit more, you know, the more eggs, the higher the numbers. So we do see that like high AMH levels is usually seen with patients with PCOS who tend to have a lot of eggs. And if you have somebody who's young and with a low AMH level, sometimes that is how I've seen patients do. But yes, it's not that all part of routine, gynecological or women's health, you know, at this time. To talk a little bit more about that, it's like I just ran into things, you know, patients teach me all the time and I love it because it's just we we always like know things that they're out there. But like there's a lot of direct to consumer tests where you can buy this kit online and you just get a little bit you get your level done. But of course, you know, it's it might be expensive, it's not covered by insurance, like I don't know. But sometimes if there is an indication, you know, your gynecologist should be able to do the test, it's just it has to be done like FSH, like I said, on day three, the benefit of AMH is that you don't have a you don't need to do it on day three or two, three or four, it's like you can do it at any time of the cycle. However, do not do these tests if you're on the pill, because then it'll be like very scary, it could be low, the pill can falsely surprise that level. So if you're on the pill, like just I wouldn't worry about the tests. Yes, in our lab, we have actually, it's a robot is called a tomorrow machine, it's a good, you know, they're they're in their freezer, basically machines, these are tanks with liquid nitrogen. This tomorrow machine is kind of the newest technology that is like the embryos and eggs are frozen with a with a barcode, essentially, so to minimize any kind of mix ups and whatnot. So it's really like technology that you just put your number then it'll like automatically give you the right egg or embryo. So we have that in our lab. Aside from that, there are also our long term facilities. You know, we use one called the sperm and embryo bank of New Jersey for some gametes or embryos that like patients, you know, prefer to storm off site. Usually, most of our patients keep it with us. But this facility takes embryos from anywhere. We just have to have every time they use store eggs or embryos, we usually check like infectious disease panel like HIV hepatitis so that it's it's good for like the good of all right embryos to make sure that there is no possibility of any contamination happening here. But yeah, so that you can storm off site, usually for long term facility like long term use so we can keep them for up to seven years. Yes, I don't think it's a lot. But there is usually most of the time what happens is when when somebody freezes their eggs or or embryos, that includes the first year of storage. And then after that, it may be like a maybe like a fee or something like that because of the liquid nitrogen machine and whatnot. But it's typically is not a very high fee. So the sperm donor, we do have like a list of banks. I mean, there are banks, if you Google probably, I know like a lot of our patients use Fairfax or California Cryo Bank is just the two biggest banks pretty much out there. But there are many Manhattan Cryo Bank. Now we have a list because you got to be careful. And so we use banks that have, you know, like they're very good, they give us like, you know, have kind of nice, you know, if the if the count if the sperm volume or the count is not good, they'll give you like another replacement vial. So and they have all of the FDA requirements on file. So we have a list of certain banks that we bet that we work with. We don't like to go outside of those banks because there have been situations where the protocols that are in place to confirm, you know, the FDA requirements and quality control are not up to par. So we don't recommend to just go to use any bank, but they can have been said that so for us, we have a list of banks that we routinely work with and we're comfortable with their outcomes. And it's other than that, it's like, you get the list and usually the patient will look at them and, you know, find the sperm and and yeah, they can do an insemination. We can do that too. So yeah, I mean, the age at which the egg is frozen is going to give us the chance of conception down the road. Now, obviously, we do not, there are things that will happen to a woman's body, right? As we get older, things change. And so ideally, you know, over 40, you start to see things like increased risk of gestational diabetes, increased risk of preeclampsia, hypertension. So it's probably not advisable to do it much later, you know, we are our program and this is very pretty much, you know, program to program dependent, but we don't do transfers after the age of 50. So like patients come in by like 48, 49, and we could use their eggs or if they use a donor egg and whatnot. But like, we like the goal would be to have the baby by age 50. That's the goal. Now, that's, that's our practice. That's not the, you know, everywhere. When patients who are older than 50 would like to, to proceed with an egg donor cycle or whatnot. Usually we refer them to Columbia. They do some more advanced and like other testing and whatnot. But yeah, forever is like, yes, I mean, the egg itself is okay, and the embryo might be okay, but then, you know, the uterus, the womb, the factors. So we all are striving for a healthy pregnancy, of course, right? So postpone it, but not to the point that it's detrimental, not just, you know, for the baby, for the mom too, right?