Tick Tock - Let's Talk Biological Clock


At the age of 35, I was faced with some pretty upsetting news from my doctor, news I was not prepared for. Although I looked younger than my years (thanks, maternal genetics!), my ovaries were operating at less than peak capacity. I had offhandedly requested an AMH blood test (more on that shortly) at my yearly physical, and the results were surprisingly...bleak. If I wanted to have biological children one day, my doctor advised that I get to a fertility specialist ASAP. One day I was planning an Eat Pray Love trip to India, and the next I was jumping into three back-to-back rounds of egg freezing within six months.


Luckily, I found the helpful doctors at HRC Fertility to help me through the process. With the guidance of their compassionate doctors and staff, I can now say that there are 19 of my microscopic frozen eggos in their Encino location. With eggsurance aggressively marketed towards women, we wanted to demystify some of the concerns and questions surrounding the fertility industry and the egg freezing process itself. Luckily we were able to interview Dr. Diana E. Chavkin, a Board Certified Gynecologist, Reproductive Endocrinologist and Fertility Specialist from HRC’s West Los Angeles clinic, before she left on maternity leave. Who better to talk to than a fertility specialist, currently pregnant, thanks to the help of colleagues at her clinic? (There’s a Hair Club for Men, “I’m not just the president, I’m also a client!” joke in here somewhere, but I am not going there!)


How did you get into this specific area of medicine?

Dr. Chavkin: Well, I knew for a long time that I was very interested in women’s health, and reproductive health in specific. I ended up going to medical school, and really falling in love with medicine and surgery. Ob/Gyn was a great fit for me, and I was just fascinated by the reproductive cycle. It’s just completely fascinating, and it just keeps getting more fascinating the more in depth you go. So, I’m a trained obstetrician gynecologist, and did an additional fellowship for three years where I specifically focused on reproductive endocrinology. It really is just a beautiful career path. I feel like I get to be involved in building families lives, there’s nothing more rewarding than that.


If a woman wants to learn more about the current state of her fertility, what steps should she take?

Dr. Chavkin: It’s a really good question, I find more and more that women need to be their own advocates. Doctors in general are becoming more busy and can’t always think about everything. If you don’t have a major medical issue that you’re bringing to the forefront in your yearly exam, your Ob/Gyn may not think, “Okay, your 34-35 years old, you want to have children, but you don’t have a partner now, do you maybe want to think about freezing your eggs?” A lot of doctors are great at thinking of things like that, but it’s a little hard to put the full responsibility in the hands of the Ob-Gyn. I really think that women need to take it upon themselves to be proactive and start asking questions before waiting to be referred by the Ob-Gyn to a fertility specialist.


You don’t even necessarily have to wait to ask some of these questions to your Ob-Gyn, women can ask themselves; are they in your mid-30s? Are they interested in having children in the future? Are they, for whatever reason, not ready to have children right now? If that’s the case, in my mind, regardless of what their ovarian reserve is or fertility potential is, it warrants a deeper conversation with a fertility specialist. I think once you’re in your early 30s, you just need to know the biological clock on your ovarian reserve is going to decline with age.


There is no harm in freezing your eggs; the only thing is it takes time and money, and you may not end up using them. It’s just an empowering thing to be able to do. Yes, it costs money, but in the grand scheme of things it offers amazing freedom.


What exactly to you mean when you’re referring to the “ovarian reserves”?

Dr. Chavkin: When we’re talking about the ovarian reserve, we’re talking about essentially two things; egg quantity and egg quality. The greater your ovarian reserve, the greater number of eggs you have in your ovaries, and the greater the quality of those eggs, the better chance you have of conceiving. Those things will decline with age. We know that a woman is born with all the eggs she’ll ever have, and those eggs in her body will undergo chromosomal changes over time. This is essentially the theory behind egg freezing; you freeze a number of eggs at a specific point in time to make sure they are no longer undergoing these chromosomal changes.


To assess the ovarian reserve we would do a few indirect tests; we would do an ultrasound where we look at the follicles in the ovaries; the greater the number of follicles at any one point in time, the greater the ovarian reserve. We also look at the FSH (follicle stimulating hormone) and AMH (Anti-Mullerian hormone) levels through a blood test, both hormones are are produced in response to the current follicle count. In a consultation we use the information from these three areas to assess ovarian function. We also want to make sure to establish if a woman is having her period regularly, that she’s ovulating once a month.


Treating infertility often dominates the conversation, but what measures can someone take to preserve their fertility?

Dr. Chavkin: It’s hard to predict who will undergo an accelerated loss of fertility. You may be above or below average in ovarian reserve, but it’s hard to determine where you will fall within that range. What I would tell my younger fertile self, is the only thing you can really do is freeze your eggs. There are other environmental issues and exposures (to cleaning products, plastic ware, etc.) that may affect a woman’s ovarian reserve, but those are things that are very hard to scientifically measure and assess, hard to test, and hard to avoid. Do the toxins from paper receipts or the toxins from the car gurgling gas affect our fertility? Probably, in the same way that it affects all of our cells and could possibly put us at risk for cancer too, but there’s not a way to avoid some of these factors. Really a lot of it comes down to genetics. It’s just really hard to predict, the only thing in someone’s power is either to have a child early, or freeze their eggs. There are obvious things that can lower your ovarian reserve; smoking will definitely have an effect, but short of something very obvious like that, there is no clear magic bullet to preserving your fertility short of freezing your eggs. Many incredibly healthy women in their late 30s who have been juicing, eating right, and working out with a trainer, come to my office and are surprised to find out that they have a low ovarian reserve and may need an egg donor, something they may not have expected until their late 40s. It’s really just a little bit random and hard to predict how fast your ovarian reserve will start to deplete. It’s misleading for people to think that if they just eat organic and stay healthy, that they’ll be avoiding some problems down the road.


What misconceptions do you think people have about the egg freezing process?

Dr. Chavkin: Women often ask if they’ll go into menopause after egg freezing. The answer is no. Depending on the individual, during a woman’s normal menstrual cycle, about 10-20 or more eggs “wake” from their resting state and undergo a process called follicular activation and recruitment. Most of those eggs don’t make it through the cycle and die off in the natural process of atresia (the degeneration of those ovarian follicles which do not ovulate during the menstrual cycle), but usually one egg survives. It’s that egg that ovulates or gets released in the middle of the month. In the process of egg freezing, no additional eggs are “awakened” meaning that only that group of eggs that would naturally have been used for ovulation or lost to atresia are now being frozen in time.


Another question that comes up is if women on birth control pills (which prevents ovulation) keep their eggs longer and lose their fertility at a later age? Again, the answer is no. Even though birth control pills prevent ovulation and prevent an egg from being released from the ovary during the month, the eggs are still lost through atresia. Freezing your eggs will absolutely not affect your fertility later in life, it’s just ensuring the retrieved eggs will no longer age.


What do you think a patient should look for when trying to find the right doctor to begin any fertility process?

Dr. Chavkin: It’s so important on so many levels to connect with your doctor, and feel supported by their staff. You should feel confident with the clinic, their lab, their reputation, and the ability of the facility to take eggs and create embryos. There are a lot of new agey practices that are trying to tailor to the millennial market by offering frills, but at the end of the day you want to go with a clinic that has a good reputation, not just in freezing, but in turning those eggs into embryos, and into pregnancies. That’s number one, you need a really good IVF clinic with a good track record for pregnancy, the success rates have to be there. Be sure you feel like you can ask questions to your doctor, that they’re accessible to you. You don’t shouldn’t feel like you’ll be lost in the medical system. One of the things I really pride myself on here at HRC is that I will see my patients from the very beginning through every single step along the way. I don’t have techs doing my scans, I don’t have any other doctors making decisions for me, I will do my patient’s retrievals, no matter when they fall. I am 100% my patient’s doctor. I think that really helps medically to ensure things don’t fall through the cracks, it helps patients feel really well taken care of, and it helps from an emotional standpoint that one doctor is with you through the entire journey.


What does the egg freezing process look like? What should a patient expect, both physically and emotionally in going through this?

Dr. Chavkin: The process basically uses the body’s normal system, but we kind of hijack it a little bit. Your brain naturally secretes hormones called gonadotropins that stimulate the follicles in your ovaries. The follicles get recruited, one follicle becomes dominant and the other ones die off. That dominant follicle will then release an egg in the middle of the menstrual cycle during the process of ovulation; if it meets sperm, pregnancy occurs, if it doesn’t, a period occurs two weeks later. That’s the natural, basic process.

What we do in an egg freezing process is to save the eggs in a given cycle that would have been lost in the natural process of atresia and ovulation. Many times we will give a woman birth control pills for 2-3 weeks to control things from a scheduling standpoint and to get a more synchronous response. After the pills, or at the beginning of the menstrual cycle, the patient will bleed and we’ll have her come in for a baseline ultrasound to take a look at her ovaries, get her bloodwork, and make sure that everything is essential suppressed and ready for us to begin the stimulation process.


In the stimulation process, the patient will essential take the same hormones that brain produces (FSH and LH), but will be administered herself in the form of a subcutaneous injection in the belly or thigh. This is used to stimulate the follicles and eggs in her ovaries, and are taken from 10-12 days.


At some point in the middle of the cycle, she will start an antagonist medication to prevent eggs from being released, because we want the eggs to stay in the ovary so they can grow and remain there until the retrieval process. During the 10-12 days of taking these hormones, the woman will come in for bloodwork and ultrasounds to monitor the process and make sure her follicles are growing appropriately.


Then she’ll take a final trigger shot which is given 35-36 hour before the egg retrieval. The retrieval is a minimally invasive surgical procedure done under anesthesia (the patient will not be awake during this process). During that time we use an ultrasound probe in the vagina attached to a needle. A very small puncture is made through the vaginal wall, which then enters the ovary. The fluid from the follicles that enclose the eggs is sucked through this very thin needle. The fluid is then handed off to the embryologist in the embryology lab. They examine the fluid under the microscope to evaluate for the presence of microscopic eggs and freeze the eggs that are mature and viable. This is essentially the hardest part of IVF. In the future, if this woman decides she wants to do IVF with her fertility doctor, then she’s already done the hardest part. Once the eggs are thawed and injected with sperm, an embryo hopefully forms, and we go from there.


What do we know about the viability of fresh vs. frozen eggs?

Dr. Chavkin: Before 2013, egg freezing was considered experimental. Since then we have gathered data to take away the experimental labeling and prove that it should be offered as preventive care for fertility preservation. Especially for women under 35, we know that if you take an egg and you fertilize it right away without freezing it, your chances of getting an embryo are the same as if you used a frozen egg. A fresh or frozen egg will give the same chance of pregnancy.


Do you think there is a stigma around infertility, and if so how could we change that perception?

Dr. Chavkin: So many things around women's health for most of history has been shrouded in secrecy and guilt. I hate to say it, but we live in a paternal society that doesn’t always respect or recognize women's health as in the way that it should. We are only just having insurance companies recognize infertility as a diagnosis for coverage. Men can have access to Viagra that’s covered by their insurance, but female infertility is not even recognized as a medical diagnosis.


We need more powerful women advocates and politicians who are willing to speak up about it, we need more lobbying for women. So much of women’s healthcare needs to be improved. There’s just so much stigma around so many of these things, but the more women talk and write about it, the more future generations will feel comfortable openly discussing it. I’m already seeing the change happening in my practice. Parents are even helping out with their kids, some when they’re about to finish college and start a long PhD program, or go into the Army, and don’t want to worry about starting a family soon.


What sort of aftercare do you recommend for your patients, and what do you tell them to expect?

Dr. Chavkin: Everybody is so different, but there’s no question that your hormones are going to change. I try to emphasize to my patients that their estrogen will be higher than it’s ever been in their whole life, and plummet in away it never has before. I have a follow up with my patients to see how they’re feeling. Most women do feel fine, but there can be some sort of letting down after being on such high levels of estrogen. I always like to have resources for people to refer to, like reproductive health psychologists and social workers that I work with look for signs if someone needs to speak with somebody. I have the resources to give to my patients, should they need that after the process.


What advancements do you see in the future for fertility?

Dr. Chavkin: One of the most exciting areas of research is in oncofertility, fertility preservation for cancer patients. Chemotherapy can affect the ovarian reserve, so egg freezing is all we can offer right now. What’s being researched now is the ability to take out a piece of ovarian tissue and freeze it before going into any sort of chemotherapy or radiation. If we can figure out a way to get mature, healthy eggs this way, it could potentially allow you to get thousands of eggs. The holy grail is to be able to get that tissue for potentially thousands of primordial eggs, and then to be able to get eggs to form in the lab. It’s a development that could help the entire field.


About Dr. Diana E. Chavkin, MD, FACOG :

Dr. Chavkin is a graduate of Barnard College, Columbia University, and New York University School of Medicine. She’s a Board Certified Reproductive Endocrinologist, Fertility Specialist and Ob/Gyn at HRC Fertility Clinic is West Los Angeles. She has been recognized by Top Doctors Los Angeles for her work in the field, and she’s a woman’s health consultant featured in Cameron Diaz’s “The Body Book”.


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