Fertility After 35: Egg Freezing, IVF and Perimenopause

Jaime: Just because you're getting periods, right, you can be getting periods into your 50s, it does not mean that you're able to get pregnant. The quality of your egg is so far reduced that it would not translate into a healthy pregnancy.

Nikkiey: Hey, everybody, what's going on? Welcome back to The WarriorBabe Show. Today I am joined by Dr. Knopman. Is that how I pronounce it?

Jaime: Yeah, that was perfect.

Nikkiey: She is a double board certified reproductive endocrinologist. She is director of fertility preservation at CCRM Fertility in New York and the author of her book, Own Your Fertility. She's also known as the queen of egg freezing. She combines leading-edge science with a deeply human approach to reproductive care, helping women better understand the hormonal shifts that we all experience and the ways they impact fertility, including the often overlooked stage of perimenopause. So I'm excited that you're here, Dr. Jaime. Welcome to the show.

Jaime: Thank you so much for having me.

Nikkiey: You're welcome. Like I said before we even hit record, I'm just stoked to pick your brain on this topic. But before we dive into the buckets that I want to navigate with you, can you share what first led you to this space? What led you into reproductive endocrinology and women's fertility in the first place?

Jaime: Yeah, sure. So I knew I wanted to be a doctor since I was eight years old, in the second grade. I read this book about Elizabeth Blackwell, the first female physician in the U.S., and I was like, that's what I want to do. When I got to med school, I knew I wanted to do women's health. I thought it was probably going to be breast cancer surgery. But after going through rotations, I realized I really wanted women's health, not necessarily anything surgical, and went into the field of OBGYN. I was fascinated by hormones and how the whole system worked. I used to say it was like watching the philharmonic, right? The conductor, the brain, has to lead and all of the instruments have to listen. And that's how I picked reproductive endocrinology and infertility. It's funny, because my passion with hormones really shifted and I became a fertility preservation doctor. But that's how I got into the field initially.

Nikkiey: That's awesome. So it kind of took on a life of its own into this specific niche area.

Jaime: Exactly. Yeah.

Nikkiey: Okay. So let's dive first into the bucket of women trying to conceive while they're in this stage of perimenopause, but maybe not even knowing they're in perimenopause. A lot of women think it's still associated with our later 40s or 50s, when we start to go into perimenopause or menopause. But now we're seeing these hormonal shifts earlier. Even for me personally, people on the podcast know that I've shared a hormonal journey I went through last year and the year before from freezing my eggs. And last year, I feel like I woke up and things were different with my hormones. I'm only 35, and I'm realizing these hormonal shifts begin to happen earlier, and sometimes when women are actually trying to conceive. So can you explain what perimenopause actually is and when it truly begins?

Jaime: Yeah. So perimenopause is a term we throw around a lot, especially now. It's funny, last night I did a talk for like 40 twenty-plus-year-olds, and I was like, you know, menopause is so hot, and perimenopause. And they all looked at me, and my friend, who's my co-author, was like, no, it's just hot on our Instagram because we're in menopause. I was like, yes, that's true, I guess. But perimenopause can last anywhere from one to six or seven years, because it's the changes that occur before menopause. So a lot of these diagnoses wind up being retrospective, right? To be called menopausal, you need to have no menses for a year. With perimenopause, we usually start to see a hormonal shift. The periods, which used to be regular, become irregular. It's often accompanied by diminished egg quantity, diminished ovarian reserve. And this can happen, unfortunately, for some women at younger ages than we would expect. We're seeing a lot of these younger ages because we're seeing a lot of women come in to freeze their eggs, let's say in their 30s, and you'll pick it up because you'll say, wow, this woman's menstrual cycles are all over the place and her egg quantity testing is quite low. And together that helps us make the diagnosis.

Nikkiey: Interesting. Why do you think it's happening earlier than expected?

Jaime: It's a good question. I don't know if it happens earlier or more frequently. I think we diagnose it more because we're seeing more women have children at later ages. Let's go back to my grandmother. They all had their kids in their early 20s, so they didn't experience infertility the same way. If they went through perimenopause at 38, which is abnormal, they didn't think anything of it, because they were like, oh, I had my two kids, maybe I'm just having early menopause. It didn't clash with their fertility like it does now, because so many of us have our kids later.

Nikkiey: Yeah. Okay. So on that point, if someone is still having a regular cycle and she feels like she's doing everything right, it's still shocking to learn that her fertility may be shifting and getting pregnant isn't happening as easily as she thought it would later in life, at 35 or 40 years old. How does perimenopause impact fertility in that respect, even before cycles are irregular?

Jaime: Well, number one, if your ovulation is irregular, it's harder to time when to have intercourse. So whether the egg quality is good or not, if you don't know when you're ovulating, because those ovulations are not coming at regular cadences anymore, timing can be challenging. But the biggest hit that we see is that the eggs we're releasing have so much less potential than they did 10 years before.

Nikkiey: I want you to dive into that a little bit, because that was something that really egged me on in terms of freezing my eggs. I don't have children yet. I want children. But being 35, I know that's when quantity and quality start to decrease and ovarian reserve starts to diminish. Can you elaborate on what that actually means?

Jaime: Yeah. So we as women are born with all the eggs we're ever going to have. We never make new eggs. And most of us start to see a fairly significant decline once we hit our 30s. There's this stat that at 32, you've lost 90% of your eggs. And it's not just that you have fewer eggs present. It's that the egg that's there has way less chance of making a healthy pregnancy. And these two things tend to align right when most women are trying to start their families.

Nikkiey: What would you say are the biggest misconceptions women have about their fertility window?

Jaime: Oh, that it's inevitable, that it just goes on and on. I coined this slogan when I was in fellowship: menses does not equal motherhood. Just because you're getting periods, and you can be getting periods into your 50s, it does not mean that you're able to get pregnant. The quality of your egg is so far reduced that it would not translate into a healthy pregnancy.

Nikkiey: Interesting. How can someone make the quality of their eggs better?

Jaime: If you figure that out, you and I will be sitting on a beach in, I don't know, St. Barts. We'll be like, sorry, we retired. We don't work. No more Philly, no more New York. We're done.

Nikkiey: Or you'll buy the Eagles and go watch all the games. Well, let me ask this, because I know a lot of women have stress or burnout as well. Could that be a cause? Or is it just our genetic makeup?

Jaime: I think we're an amalgamation of a lot of different things. I think the primary cause is definitely genetics. I always say, I got breast cancer at a young age, and I'm very healthy. I watch what I eat. I exercise. I do all of that. I got breast cancer because of my genetic makeup. It had nothing to do with my lifestyle. Now, that doesn't mean there wasn't something I did to push it forward. I'm certain there probably was. But we are limited by our genetics. We can't overrun our genetics. That doesn't mean we don't want women to be healthy versions of themselves when they're trying to get pregnant or when they're pregnant, because a healthier body leads to a healthier pregnancy. But unfortunately, it's become this motto where people say, oh, eat right, take this supplement, and your egg quality will get better. We know that is not true.

Nikkiey: That's a nice thing to hear, because a lot of people think, oh yeah, if I do all these things right, then that will make this happen.

Jaime: Well, I think we also want control in an uncontrollable process. I'm a control freak. I look for how I can make this better, that better. And unfortunately, a lot of times you can't, and you just have to sit back, be so uncomfortable in that process, and say, I'm doing everything I can, but unfortunately I can't control this.

Nikkiey: Yeah, I appreciate that. I'm the same way, I try to control everything. And you can't control genetics. It's just what it is.

Jaime: Yep.

Nikkiey: So for anybody going through hormonal shifts and experiencing early symptoms, like for me, I got my blood work done last year and I have low testosterone, low DHEA, my thyroid is low, and a couple of other things are a little bit off. I'm working to make that better, because obviously I want to be able to conceive naturally. As you get older, what are some encouraging words you would tell women who are going through this or potentially facing a, you know, geriatric pregnancy?

Jaime: I'm definitely not a fan of that geriatric pregnancy term. I'm like, oh God.

Nikkiey: Neither am I. But that's literally what it's called.

Jaime: Because it makes you feel like crap. It's like, don't be such a hater. That was a term we used to describe pregnancy in women above the age of 35, because once you crossed the threshold of 35, your risk in pregnancy was greater than the risk of invasive testing like an amniocentesis or a CVS. So we used to say, oh, once you're 35, you're geriatric, you should have invasive testing. Now we offer invasive testing to everyone, so that line in the sand isn't necessarily there.

Nikkiey: That's nice to know. Someone in my family found out they were pregnant and called in for an OBGYN appointment, and just because she said her age and it was a first pregnancy, they were like, oh, we'll see you tomorrow. It makes you feel like that's just what it is.

Jaime: The reality is you do need more surveillance as you get older and you're pregnant, because you're more likely to have diabetes in pregnancy or high blood pressure. So we do want you more closely monitored. But a lot of women who get pregnant in their 40s do just great.

Nikkiey: Okay. So let's talk about what you're the queen of, which is egg freezing. How did you get that title?

Jaime: So I was a fellow around the time that egg freezing was coming out, and I was very fortunate to write a lot of the papers with the people who were starting the process. Then I left my fellowship and went to work at a practice, and I'll never forget, the senior guy in the practice said, you're 35 and you have ovaries, you can be the head of egg freezing. I was like, okay, cool. And it just became my thing. I saw so many young women freezing their eggs that it just became my jam.

Nikkiey: I love that. So as you said, it's become more visible in recent years, especially among women who want kids but haven't had kids yet.

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Nikkiey: When is it right for an individual to think about freezing their eggs?

Jaime: So the OG egg freezers, as I affectionately call them, the women who froze their eggs when we first started egg freezing, were in their 40s. It was out of desperation and there was no other option. The problem was those initial studies said, oh, egg freezing is terrible. Egg freezing was terrible because the quality of the egg was already terrible. Now egg freezing is done for women in their 20s and 30s, and that's empowerment. It's, I'm going to take control of my future, as opposed to my future taking control of me. So if I had my way, and of course everyone's going to say that's how she makes money, every single person would freeze their eggs in their 20s, because it would give everyone optionality down the road. And that's really the name of the game: optionality. I'm not saying that if you don't freeze your eggs, you're going to have infertility. I'm not making that leap. I'm just saying if you don't do something, you are more likely to face fertility struggles as you get older.

Nikkiey: Absolutely. What do you feel are the biggest mistakes you see women make when it comes to waiting or assuming they have unlimited time?

Jaime: That they sit in my office crying at age 38 because they're like, what happened? Where did this all go? And I'm like, it's just normal. It's a natural part of aging. But then you're so far down the road that it may be hard to get what you want.

Nikkiey: And is that where a lot of people come to your office and do IVF?

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Jaime: So if women have not frozen their eggs and they come in struggling to conceive with a partner, frequently we'll do IVF pretty early now, sooner rather than later, because we know IVF offers the best success. If women come in without a partner and they're electing to be a single mom by choice, I might say, okay, let's do IVF but fertilize with donor sperm. It depends on the timing and the situation.

Nikkiey: Okay, got it. I've also seen a few people go through IVF multiple, multiple times. Can you talk about what happens when IVF happens and it doesn't take?

Jaime: Usually when people do multiple cycles, it's one of two things. Either they don't get any healthy embryos, meaning they're doing genetic testing of their embryos and all the embryos are abnormal, or they do get a healthy embryo, we transfer it, and it doesn't work. So you could have failure, and I don't like to use the word failure, but you can see failure in either of those places. It's rare that someone goes through IVF and doesn't get any eggs. That doesn't happen frequently. What happens more frequently is someone goes through IVF, gets eggs, but those embryos don't test chromosomally healthy.

Nikkiey: Gotcha. I'm seeing somebody who's on their sixth or seventh time.

Jaime: Yeah. It's horrible.

Nikkiey: Because it takes a lot from the body.

Jaime: Well, it's also so emotionally taxing. It's hard to stay in the process. There will be times where I'll say to patients, I don't actually think this is going to work. I don't have a crystal ball. It's not a hundred percent or zero. But I've watched you go through several rounds of IVF without success, and I want you to be a parent, so we have to think about a different way. It may not be a way you ever dreamed. It may not fulfill your initial hope of how you'd become a parent, but it will get you to have a child. And that's really the end of what you want.

Nikkiey: I want to backtrack a little and ask, for women who do want children one day, when should they start getting testing or gathering information? You mentioned genetic testing a couple of times.

Jaime: I think it should be part of the OBGYN checklist. We go to our OBGYN and he or she does a pap smear, breast exam, STD testing and contraception. That fifth pillar should be fertility planning. Okay, you're 27, what are you thinking about for kids? It's not a shameful question, like, what do you mean you don't have kids? It's more, how do you see this future going and how can we help you?

Nikkiey: Can we talk a little bit about the egg freezing journey? I feel like I'm having a little bit of PTSD. When I was on this journey, a lot of people reached out wanting to know the science behind it. I know the science because I asked the doctors I was working with a lot of questions, but I would love for you to explain the ovarian stimulation, what's going on and how you're gathering all the eggs. I ended up with like 20 follicles at one point. And can you explain what happens with the hormones shifting and changing? Because by the end, my estrogen was like 6,000 and I was raging. I didn't even know who I was.

Jaime: Everyone has a different reaction when they go through egg freezing. Some women are going to have an estrogen of 6,000 and some are going to have an estrogen of 600. We can only stimulate what is there in the ovaries. We can't make new eggs. For most young women coming to freeze their eggs, the process takes about two weeks. They come into the fertility clinic every two to three days for blood work and ultrasound so we can see how their body is responding to the fertility medications. When do we need to increase the meds? When do we decrease the meds? And when do we take the eggs out? The medications are subcutaneous, which means you inject them into your abdomen. Then you take a final shot that triggers maturation of the eggs, and the eggs are extracted in an operating room 35 hours later. That's the high level of how it goes. In terms of how many eggs you get, the more eggs you get, the more you're going to feel it. So if your estrogen was 6,000, it makes sense that you felt pretty crappy by the end.

Nikkiey: What a fun journey that was. But all for the greater good and the vision of what needs to be done. You've said this phase can quietly derail mental health and relationships. I think that's such a powerful statement, because so many women internalize these changes as personal failures, as we talked about earlier, whether the egg doesn't take, egg freezing isn't as easy, or getting pregnant is hard. What happens hormonally that contributes to the mood instability, the depression, the anxiety?

Jaime: Well, I think at baseline, fertility is such a weighted topic. Most of us as little girls play house. We put a pillow under our shirt and pretend we're pregnant. It's something we think is inevitable. So if somebody takes that away from you, it's very hard to conceptualize. It's such a heavy topic, and you're right, the hormones are all over the place. Your estrogen goes high, your estrogen goes low, your progesterone too. So it makes the process so hard to endure on top of everything you're going through emotionally.

Nikkiey: How does it affect our brain specifically?

Jaime: There are a lot of receptors for different hormones in our brain. So when our estrogen is high, versus when estrogen and progesterone are high, versus when everything is low, we're going to feel that differently.

Nikkiey: How do fertility struggles combine with these shifts?

Jaime: It impacts a woman's sense of identity. I think you feel like you can't do what your body is supposed to do, and you get mad. You're mad at your body. You're like, what the F? You're supposed to do this. And that anger often gets put onto other people, whether it's your physician, your friends or your partner, and that can be hard. I have had several patients be very mean to me, and I can usually take it up to a point. Then I'm like, I understand this is so hard and I'm so sorry you're dealing with this, but you can't be mean to everyone here, because we are really trying to help you. I can say that as a physician, but relationships can fall apart. If you're with somebody and this occurs, it can be challenging to stay in the relationship.

Nikkiey: 100%. I want to lighten it up a little bit. What is your coolest client testimony from the egg freezing journey or IVF, either one?

Jaime: What I find the coolest is how many people send me their friends. There's no bigger compliment than sending a friend, a colleague, a sister or a family member, because that means I did a good job. And that to me is very rewarding. Sure, the positive pregnancy tests and the babies, all that makes you feel good. But people trusting in you and then telling their friends to trust in you is a pretty big compliment.

Nikkiey: Do you love seeing the people who have success, and seeing the babies being born?

Jaime: That pushes you forward, because without a reward, it's hard to do what you do day in and day out. It's not easy being in health care. It's not the easiest job. There's a lot of burnout. So seeing the wins on the other side helps us all push forward.

Nikkiey: If there was one thing you could change about how women are educated on this topic, what would it be?

Jaime: Oh, that's a good one. I think sex ed and health class need to be redone. We teach people how not to get pregnant, but we don't teach them how to get pregnant. And trust me, I have teenage daughters. I'm not psyched for them to run around saying, oh, my mom taught us how to get pregnant. But we need to teach them that there is a finite period when their fertility is around, and if they don't address it, it's going to be lost.

Nikkiey: Another question about labs. Let's say someone is struggling to get pregnant, and that can be a hit to them personally. Why me? What is my body not doing that I thought it would be doing? What labs should people get if they're struggling with this?

Jaime: I always say, if you're struggling with fertility or infertility, you should go see a fertility doctor. A lot of times we want to Google it or Reddit it or ChatGPT it, and those resources are great, but this is what we train to do for, unfortunately, a kabillion years. I went to four years of med school, four years of residency, three years of fellowship. It took a long time. ChatGPT can break it down, but there are things I know because I spent so many years doing this. So you really want to go in and get a fertility evaluation.

Nikkiey: And when women go in for this, what language should they be using to advocate for themselves when talking to their providers?

Jaime: That you want an evaluation. Even if someone says, oh, you're 28, you can wait, don't worry, your eggs are good, say, no, I want to do this. I'm in charge of my own body and I want to do this.

Nikkiey: Yeah. That was alarming for me last year when I got my lab work done. My ovarian reserve was actually low, and I was kind of sad and shocked, because I want kids and that hasn't happened yet. So definitely get checked, because you could feel great on the outside and feel like all things are going well, but until you get the markers of quality and quantity, those are the main things, and blood work too, you don't really know the true story.

Jaime: Yep. A hundred percent.

Nikkiey: Is there anything I didn't ask you that you talk about every single day with your patients?

Jaime: Well, I'm going to pull it over. This is the book that came out on January 13th. I always tell people I wrote the book because I'm very loud, but I'm only as loud as the four walls of my office. So I want to share the message of what I've seen and what I know with everyone else. The title of our book is Own Your Fertility. My initial title was Wear Sunscreen and Freeze Your Eggs, which I thought was an amazing title, but the publisher didn't think it was as amazing as I did. It's a chapter title now. But I do love the title now because it really is true. Own it. You own it. Don't let it own you. And that's not to say you have to have kids, or you have to freeze your eggs. Your path can be whatever you want it to be, but you should be the one marking that path and paving the way, not having it done to you.

Nikkiey: Amen to that. When did it come out? I thought it was upcoming.

Jaime: I think we had to reschedule or something. It came out January 13th.

Nikkiey: Oh yeah. Congratulations.

Jaime: Thank you. I've learned that it is exhausting selling a book. I feel like I'm back in my days as an OBGYN intern where I don't even sleep.

Nikkiey: There you go. Hey, you're conquering things all the time, growing. That's good. I also saw surrogacy on there, so I'm interested, really quick before we hop off, to ask you about that. How do you guide clients who go down that route, and how do you navigate a mom who may be struggling with, hey, I'm not the one carrying my baby, I'm choosing to have another woman carry it?

Jaime: Surrogacy is a beautiful way to have a family. First of all, surrogates are gifts from God. As somebody who hated pregnancy, not once but twice, every minute of it, I'm always like, wow, you are an angel. It's beautiful that we can offer this, and offer it successfully, to women who can't carry, single men, or male-male couples. And I think we have to remember we all come to being parents in different ways. Long gone are the ways of my parents, the 1950s. It's very different now. So you're going to be a mom or a dad, and it may be in a non-traditional way, but that doesn't make you any less of a mom or dad. In fact, it probably makes you more, because you wanted that kid so badly that you would do absolutely anything to get them.

Nikkiey: Love that. That was a beautiful answer. Thank you for being here and for bringing a lot of clarity. I can feel your compassion and your passion for this topic.

Jaime: Oh, thank you.

Nikkiey: It's really cool to see how it brought you and landed you in fertility. This is a topic a lot of women are navigating quietly, so thank you for the work you do every single day and for bringing more encouragement to this field. For anybody listening, if this resonated with you, Jaime, where can women find you or find more information about you?

Jaime: Sure. You can find the book on Amazon and at Barnes and Noble. I have a website, drjaimeknopman.com, and an Instagram, @drjaimeknopman. I spell my name J-A-I-M-E. I could kill my parents for doing that, because J-A-M-I-E Knopman is getting a lot of my emails. And I work at a fertility clinic in New York City called CCRM New York. Always happy to help in any way I can.

Nikkiey: Awesome. If anybody is on the East Coast, go check her out. Thanks, Jaime, for being here. I appreciate you.

Jaime: Thank you so much. Have a great day.

Nikkiey: Thank you. Real quick, if this episode resonated with you or gave you the push you needed, I'd love for you to pay it forward. Drop a quick rating and review, share the podcast with someone who might need it, and help me keep spreading the word. Your feedback not only helps the show grow, but it might be the nudge someone else needs to kickstart their transformation. Thank you so, so much for your support.