Ep 1018 ｜ Former IVF Doctor Blows the Whistle ｜ Guest： Dr. Lauren Rubal
Episode Stats
Length
1 hour and 5 minutes
Words per Minute
158.09386
Summary
Dr. Lauren Rubal spent years as a reproductive endocrinologist and infertility physician working with patients through the IVF process. Eventually, she woke up to the ethical and moral issues with IVF and she opened her own practice that helps couples from a holistic standpoint get pregnant naturally.
Transcript
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Dr. Lauren Rubal is a double board certified integrative medicine doctor in OBGYN.
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She spent years as a reproductive endocrinology and infertility physician working with patients
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Eventually, she woke up to the ethical and moral issues with IVF and she opened up her
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own practice that helps couples from a holistic standpoint get pregnant naturally.
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And today she is going to tell us all of the scientific medical ins and outs of the IVF
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She is going to tell us things that you probably did not know goes into the entire procedure,
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There is a lot that she told me that I did not know about this whole process.
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And what we should be thinking about when it comes to fertility and pregnancy.
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This episode is brought to you by our friends at Good Ranchers.
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Use code ALI to check out this GoodRanchers.com code ALI.
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Dr. Rubal, thanks so much for taking the time to join us.
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If you could just tell everyone who you are and what you do.
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I am an OBGYN who did a fellowship in reproductive endocrinology and infertility, which is a three
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year subspecialty after the four years of OBGYN residency, practiced as a full scope
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And as I tell everyone, my biggest career achievement was leaving all of that behind, opening my own
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practice dedicated to a more restorative reproductive medicine model and also in the meanwhile, completing my
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So I'm now double board certified in that plus OBGYN.
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We talk a lot about IVF on this podcast, and that's because it's in the news really more
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I feel like a lot of Christians are thinking about reproductive technology in a way that
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we didn't really think about even five years ago.
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And so I'm so excited to get to talk to you, someone who is such an expert in this, but you
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worked in the IVF industry, if you will, or specialty for a long time.
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And of course, then you didn't have any qualms with it.
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And so tell us what that was like and what your thinking was then.
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I mean, I think that it goes without being said that infertility is a profound and unique
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And the couples who are undergoing it, I just have so much empathy for.
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So I think that first and foremost is so important to always remember.
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With that being said, I know from my experience, I was so focused at the beginning on just trying
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to help those in that suffering, help those who were trying to conceive or were having
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And I was also focused on the end goal, which was the child.
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But as I practiced the tasks of my profession, I really began to question a number of things.
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But the first part of this was, well, is this really the best approach?
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Is this the panacea that we've all been told it is?
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Number two, are we actually getting to the root cause?
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So I felt like I was just starting to treat women as though they were just, I was really
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And I wasn't focused on the whole person, body, mind, soul.
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And so I felt there was this incompleteness in my approach to identifying what was going
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And then the third part was really seeing the sequelae of what couples and women went
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through as they went through all of these aggressive procedures.
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There's obviously a moral and ethical component, but there's also the physical.
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It's very difficult to be injecting yourself with multiple medications daily, on average for
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There are side effects that you're battling against and procedures that you're undergoing.
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And then, of course, the continued waiting game of infertility.
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And so all of these factors really coalesced into, again, my decision to stop and have a more
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And I think that also speaks to women's health in general.
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So much of women's health, we're told our fertility needs to be suppressed, that we need to
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be on pharmaceuticals for a myriad of different conditions that all have one very similar
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It didn't feel like it was as tailored as it should be.
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And before we get into your kind of like awakening and transition professionally, I want you to
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answer some just basic medical questions that a lot of people have about IVF, because what
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I found and what was true for me is that there is a lot of ignorance and not to try to use
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a pejorative term, but there's just a lack of knowledge about what IVF actually is.
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And when we think about it big picture, without thinking about it too hard, it's easy to just
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be supportive of it in every case, because having a baby is great.
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And I want someone who desires to have a child to be able to do that.
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And if IVF is the means by which they get to have a child, then I think it's easy for
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But not everyone knows everything that goes into the in vitro fertilization process.
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A 32-year-old married woman walks into your office, or not anymore.
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But back when it was just this kind of IVF approach, or the old fertility methods that
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And she said, OK, you know, we've been trying to have a baby for two years.
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Like, what does that process look like from there?
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And so the conventional process would be, of course, to try to diagnose the reason why
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And so that couple will undergo a slew of testing, which, of course, they still perform,
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whereby we're looking at both the factors within the woman's body, such as issues regarding
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her eggs, whether they're being released from the ovary, the number of eggs, the hormone
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balances that exist within her body, such as thyroid, for example.
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We'd also look at the structural components of her reproductive tract, which include the
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uterus, the fallopian tubes, which are where the sperm and the egg meet within to form
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And then finally, we'd look at the male partner, and we'd assess his sperm through a semen analysis.
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And so that would be the very standard infertility workup that a couple would first undergo.
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Again, knowing now what I know with the breadth of further knowledge that I've gleaned in these
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last several years, I would say that, at least for myself, I can only speak for myself, that
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I overlooked a lot of factors that may still contribute to infertility, which is why this
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is unexplained diagnosis, meaning the woman's ovulating, at least one tube's open, the sperm
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We give that couple, okay, well, this is unexplained.
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That diagnosis ranges from anywhere between 10 to almost 50% of the time, depending on what
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And it's interesting looking now, when we actually get to the root cause of this, we can get that
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So that's just one example of why conventional treatment versus this restorative reproductive
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Okay, so when someone walks in, and basically everything kind of looks good, and it looks
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normal, that's when they're given unexplained infertility, because I've heard that a lot.
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You even see it in the Instagram bios of some people who are chronicling their IVF process.
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So that's basically what they mean, that for whatever reason, they can't make a baby,
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And is that typically the diagnosis that someone is given before IVF is recommended to them?
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Well, there's a variety of different diagnoses, which makes sense, because there are a couple
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A third of the time, it's based on what we call a female factor.
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There's something going on within the woman's body.
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A third of the time, it's a male factor, even up to half, it's both.
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Common reasons why people go to IVF immediately include issues with the sperm, issues with the
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tube, such as the tube being closed, or low number of eggs, which is called diminished
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And then say that woman who walks into your office, she falls into one of those categories.
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So from that point, what would happen is a woman typically starts an IVF cycle with her
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period with that bleed, although many times women will also be given birth control pills
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for varying reasons or be given injections before that projected start date of the IVF
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cycle for even a couple of weeks in order for the physician to, in a way, become the exogenous
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Because typically what happens in our endocrine system, which is just our hormones talking
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to each other, our endocrine system is comprised of hormone messengers so that the brain can
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talk to whatever organ it needs to, and the organ can talk back.
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And in a woman's natural cycle, there is what I think of as a race to ovulation every month,
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meaning there's a group of eggs that lines up, but only one egg at the end of the month,
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the end of the cycle can be released, can be the winner of that race.
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So every follicle that's contains an egg is, is, uh, ideally will become a mature egg.
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How it happens is that a woman's given daily injections for on average, a couple of weeks
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But before those eggs can be released again, a couple of weeks later, they'll undergo a procedure
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This comes after multiple visits every other day, almost on average four to five visits
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with the fertility doctor, at which point she's going to undergo a vaginal ultrasound to
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Because as the follicle grows in size, the egg inside is maturing.
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And so we're, that's being monitored very closely.
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And then finally, the day of that egg retrieval comes, the woman is, um, typically given conscious
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And then while she's asleep, there is a needle that's placed through the vagina under ultrasound
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guidance and into each of those eggs and the, um, the, into each of the follicles, which
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And then the eggs are suctioned out and that's done with every egg in both ovaries.
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The eggs are then handed off to an embryologist in a lab.
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And then the embryologist looks at the eggs, determines that they're mature.
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And at that point, they'll place the egg in a dish, either surrounded by a lot of sperm,
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They'll select a sperm that ideally is moving forward, that ideally is normally shaped.
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And they'll physically place that sperm into the egg in a process called ICSI or intracytoplasmic
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And the next day, the dishes are checked again.
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And 80% of the time on average, they'll then contain an embryo, a fertilized egg.
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And, and can I ask, this is, um, an uncomfortable question that we have actually never talked
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So we hear, okay, the sperm, they, you use the sperm and you put it in the dish or you
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Um, but something that is overlooked is how you actually get the sperm.
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I feel like we don't really think about that or talk about that, but that has its own like
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Like, how does the father then give his sperm to then fertilize the egg?
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Well, the vast majority of the time it's done through masturbation.
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And so, um, I think that I've certainly talked to a lot of male patients who, who have said
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what a uncomfortable and embarrassing process that is because there are specific collection
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rooms whereby they'll go and collect and then hand off the sample to the embryology lab.
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So a man very often is watching or looking at porn in order to masturbate, to give the
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And you would say that's the majority of cases of IVF?
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I mean, I think the other way of collecting would be to do it through the process of intercourse.
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Um, and I know for, certainly for some of my couples who don't want to interrupt that
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unitive and procreative act, you can use a perforated condom.
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So that way that act is still, um, less set in that regard.
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Um, but that is not the majority, that is absolutely the minority of the time.
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So you said that after the, which by the way, just to like pause there, I feel like that
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is not talked about very much at all when it, when it comes to the ethics and the morality
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But so I just want everyone to kind of like take that in if they didn't already know that
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But once that egg is fertilized, you said that there is an 80% chance that after waiting,
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once they're in the Petri dish, that there will be an embryo.
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Um, how, well, how many eggs are typically collected, would you say in a typical egg retrieval?
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It depends on the woman's egg number and it depends on the type of stimulation that's employed.
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Um, what we would call a good prognosis patient would typically have eight to 10 follicles,
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each of which would contain an egg in each ovary.
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And so the average number for good prognosis would be anywhere from about 20 follicles being
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I would say from those, maybe perhaps there'd be about 15 mature eggs retrieved out of those.
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If we assume an 80% chance of fertilization, that's 12 embryos.
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Um, and we contrast that to someone who has something like, for example, polycystic ovary
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syndrome, which is a condition whereby women have an imbalance in their male and female
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hormones and they also have irregular cycles, irregular ovulation, but those women may have
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So I can, uh, remember, uh, reading or hearing about even up to 50 plus eggs being retrieved
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On the flip side of women who has that low egg number, they may be get, uh, there may be
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only three eggs retrieved in that, in that case.
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So say a woman has a dozen eggs that are retrieved.
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I would say the, again, the majority of the time, yes, all those eggs, all those mature
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There are cases, especially with higher egg number, whereby the eggs themselves could be
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frozen in order not to create so many excess embryos.
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I mean, again, I don't know if there's a statistic on that, but I would say the majority of the
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time that those would be attempted to be fertilized.
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Um, and then you said, I know I'm kind of bouncing around a little bit as the questions
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come to my mind, but then you said there's an 80% chance that an embryo will form from
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So then that embryo has one of three fates at that point.
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The first is for, well, I mean, regardless, let me, let me actually back up because what
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happens from there, even before the determination of what happens ultimately with the embryo is
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They're kept in those dishes for a period of days and in an incubator in order to simulate
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the temperature, the humidity, all the conditions whereby they would naturally be within the
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They go from one cell to hundreds of cells just days later.
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And the process of maturation means they actually, the embryo forms an inner cell mass.
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So they're beginning to grow and develop into again, what becomes the baby and then what
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And this is all happening naturally in the fallopian tube or in these dishes.
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And so an embryologist is checking on them throughout this process.
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They're being potentially manipulated because in the case of, for example, embryo biopsy,
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they would, an embryologist would actually place a needle into the embryo, suction out
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some of the cells, and then send that off to a lab to screen the chromosomes within those
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So there's a lot of potential options, but that brings us to, again, the one of three
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One fate is that a few days after their life, they will be transferred back into a woman's
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uterus in order to see if implantation, if pregnancy occurs.
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The second fate is that they will be biopsied, as I mentioned, in order to undergo chromosome
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And they will be frozen in liquid nitrogen-containing canisters as well.
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So what it means is there's, well, what does grading mean?
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There are different ways for the embryologist to determine the morphology of the embryo.
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What that means is an embryologist knows that there's a very typically precise set of growth
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and symmetry of the cells, for example, lack of debris within the embryo, him or herself.
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And those will correspond to certain grades that have been spelled out in different systems that
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But the ultimate reason for grading is because there's been data supporting the fact that
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embryos that look more symmetric, that achieve a certain number of cells or a certain stage
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in development at the time that they should, may have a higher chance of leading to a live-born
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And you said that there's the biopsy possibility.
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Do all parents choose to get that kind of testing?
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Because you said that that looks at the chromosomes.
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Does that, is that how gender is determined or, or what is being looked at there?
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And the reason for that is because all chromosomes are screened.
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And so they'd be called either euploid, which means screened chromosomally normal.
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They can be checked for specific genetic disorders.
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The majority of the time though, again, it's, the embryos are screened for just chromosome
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And so again, that 46XX, 46XY would be typically looked at very commonly.
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And to answer your question about how common that is, I would say the most recent data nationwide
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of IVF clinics in 2021, it was the last year that they've been able to publish that data
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show that at least half of all cycles are PGT, which is pre-implantation genetic testing,
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So it's very common now and the number has increased.
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Well, because I hear very often, especially when it comes to say like two men that are
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using an egg cellar and then also a surrogate is that, and even with Paris Hilton, like Paris
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Hilton used a surrogate and she knew the gender of all of the embryos that she had on ice.
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She was like, I have like 12 boys and I'm still trying for a girl, whatever it is.
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So I guess I thought that all IVF patients know the gender of the baby before it's even
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transferred, but I guess that's not, that's not the case.
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They'd have to undergo that biopsy process in order to get the chromosomes from that embryo
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because that embryo has a unique set of chromosomes, right?
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And so therefore that embryo would him or herself have to be biopsied in order to understand what
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How often would you say, um, there might not be an exact statistic on this, but for those
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who do undergo or their embryos undergo that genetic testing, how many then decide, okay,
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if that baby has down syndrome, for example, that's a chromosomal disorder, do they decide,
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okay, we're not going to move forward with transferring that embryo.
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We're going to try again for a healthier embryo.
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Like how often are decisions made based on any kind of chromosomal signs of some kind of
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I mean, the, the standard typically is that if that embryo is deemed, screened, chromosomally
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abnormal, that embryo will not be transferred back into the uterus.
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There has been, um, a move more and more towards some centers being open to attempting that transfer.
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And that also goes for pre-implantation genetic testing for the screening process.
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I liken it almost to, uh, this embryo is almost like a, a lots of different cells, almost like
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a soccer ball, if you will, sometimes that there are, um, white areas of abnormal cells,
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but also black areas of normal cells, for example.
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And if you biopsy the wrong area, you might erroneously conclude that that embryo is not
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chromosomally euploid and therefore would not have that embryo eligible to be transferred.
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Again, the data is very new in this regard, but there is, there are case reports in, in
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the literature showing that some of these embryos that then, you know, of course, informed
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consents obtained, everyone agrees that we're going to go ahead and transfer this embryo in,
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And there have been reports of chromosomally normal babies born, um, to these, uh, abnormal,
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So do parents even have, cause you said you, you mentioned or alluded to the fact that some
00:26:18.240
centers won't even consider transferring a chromosomally abnormal embryo.
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And that could mean like a baby with Down syndrome.
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And of course we know that people with Down syndrome can have like fulfilled and very joyful
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lives, but that could be like the kind of baby that we're talking about that they deem
00:26:37.700
almost, I don't want to, you didn't use the term incompatible with life, but it seems like
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that is almost the judgment being made by saying, okay, this embryo is going to be discarded.
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Like, do the parents in that case, do they have the choice?
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Are they ever told, Hey, we, this baby has Down syndrome.
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Um, what do you want to do or are they not even informed about what happens to those embryos
00:27:04.480
I would say that typically I, I can only speak for myself.
00:27:12.960
And so I will tell you that in my prior practice, you know, there, I had such a blindness, Ali,
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um, that, and there's a lot of reasons for that.
00:27:23.520
But with that being said, you kind of just think, okay, this is a aneuploid and you, it's
00:27:31.260
There are plenty of situations, not just Down syndrome.
00:27:33.880
I think trisomy 18 is another one that there are children with trisomy 18.
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I personally know of one that are able to lead lives that are, it's not, it is compatible
00:27:48.800
There are plenty of others like Turner syndrome and, um, but there's this blanket thought
00:27:59.120
So for the embryos that are deemed healthy or the ones who don't go through genetic testing,
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um, well, how many, how many healthy embryos would you say someone typically ends up with?
00:28:12.120
I know there's so many factors that go into that, as you've already explained with the number
00:28:15.540
of eggs and the age and all of that, but what is like the average number of embryos created
00:28:23.700
So let's use that, um, kind of middle of the road, good prognosis patient example again,
00:28:29.300
And so remember we, there were 12 embryos that were created, right?
00:28:39.140
And so about six embryos, I would say on average, will make it to blastocyst stage, which is
00:28:45.440
typically day five of their life and is what we consider a mature embryo.
00:28:51.380
And so again, out of those, if that, um, couple chooses to have chromosome screening performed,
00:28:58.800
perhaps about half of those will yield euploid chromosome screen, normal embryos.
00:29:06.640
Um, and so that would be then three embryos if biopsy was done.
00:29:12.260
If it's not, then there would be about six embryos, um, of which depending on the woman's
00:29:19.220
age, anywhere from one to even potentially up to three or more would be transferred back
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Um, so she could have three of those embryos transferred simultaneously.
00:29:37.700
And that has their set of criteria depending on the woman's age and different prognostic
00:29:43.340
But what's interesting is that they actually published again in this most recent CDC report
00:29:48.300
of us clinics, the average number of retrievals of egg retrievals needed to achieve a live born
00:29:53.940
baby and Allie, even in the best prognosis age group, which we consider less than 35 years
00:29:59.480
of age, the average number of egg retrievals, remember all that whole process that, that,
00:30:03.940
that couple and that woman have to undergo the average is two.
00:30:07.700
And in a woman who's over 40, the average is, I believe over nine and perhaps even 12,
00:30:13.860
but definitely over nine, which is just, just, you think about these women, um, really it,
00:30:21.680
it, it, again, it takes, it can take a toll on many, um, couples and women as they're undergoing
00:30:28.660
On the woman's side of this, you said before the egg retrieval, she has to inject herself
00:30:45.960
with, what is it that she's injecting herself with?
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There's different type of, first of all, hormones that are used.
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As well as other injections designed to prevent premature ovulation.
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And then, um, so those are the main type of injections used.
00:31:03.700
So she's injecting herself typically at home with these shots.
00:31:09.120
As you said, she's got the multiple doctor's appointments to make sure that the eggs are
00:31:14.380
She goes through the egg retrieval and she's kind of put under, like you said, a twilight sleep
00:31:20.060
Um, there was that, I don't know if you saw that.
00:31:21.840
I think it was New York times podcast, this horrible story of these women who were being
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told that they were being put under or being told that they were given fentanyl and they
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And the nurse was stealing the fentanyl and putting something else in there.
00:31:36.580
And they were completely awake for all the egg retrievals.
00:31:41.100
There's just so much that happens in this reproductive industry that a lot of people don't know.
00:31:45.660
But anyway, so they get the egg retrievals, then they start the, uh, fertilization processes.
00:31:51.220
You just explained, but what does the woman do while that fertilization process, that growing
00:32:05.100
If there is a, what we call a fresh embryo transfer to be performed, meaning five days
00:32:10.860
later, for example, the embryo is going to be placed back into that woman's uterus.
00:32:15.180
Then the woman will undergo, uh, just preparation of her uterus is what it's called.
00:32:21.580
And that's by giving hormones as well in different ways.
00:32:26.560
And so that might include more injections that will include pills, um, as, as well as potentially
00:32:33.320
So that would be her preparation and then more, um, scans, uh, to make sure that the uterus is
00:32:43.260
So, yeah, getting the uterus ready to receive that embryo so that it's hospitable for the
00:32:50.260
embryo to implant, for the placenta to grow and all of that.
00:32:53.780
And what is the transfer process like both for this, uh, embryo and for the woman?
00:33:01.440
And so the transfer process, I'll start with the embryo.
00:33:10.780
Again, if embryo, if the transfer is happening with a embryo that has not been frozen, then
00:33:17.700
what will happen is the embryologist will take the embryo and what we, that's what it's called
00:33:22.600
is load, place that embryo into a long transfer catheter.
00:33:27.040
And then at the same time, what the woman is experiencing is that she'll be, um, on a table,
00:33:34.760
there will be typically an ultrasound on her abdomen in order to watch as, um, the, the catheter
00:33:42.340
is placed through the vagina, through the cervix and into the uterine cavity.
00:33:46.420
Um, and then, um, you actually can see the air bubbles surrounding the embryo being placed
00:33:56.860
Afterwards, the embryologist will then take the catheter to ensure that the embryo was indeed
00:34:01.780
placed, um, within the cavity or is no longer in the catheter.
00:34:06.200
Um, but typically that transfer process is done while the woman's awake, the, the couple
00:34:12.960
is together in the room, um, and is, is quite comfortable typically.
00:34:19.840
Sometimes if it's difficult to enter the uterus, um, then it can be uncomfortable for that woman.
00:34:26.980
But I would not say that the cervix, so the cervix doesn't have to be dilated at all.
00:34:37.140
And in those cases that, that could be very uncomfortable.
00:34:41.000
So at that point though, she doesn't really know if she, yes, the, there is a living embryo,
00:34:46.240
which as you've already said is scientifically its own individual that is inside her uterus,
00:34:56.620
So she wouldn't necessarily get a positive read on a pregnancy test yet, right?
00:35:02.160
No, she wouldn't at all because, um, yes, you're correct.
00:35:07.820
And during that process of implantation, that's when the embryo actually, um, and the, the placenta
00:35:13.740
and the uterus, it's actually quite beautiful because there's a very specific window of implantation
00:35:22.600
that occurs whereby there are these special called peanut pods.
00:35:25.680
They're almost these suction cups that, um, from the endometrium and there's a crosstalk
00:35:30.320
between the embryo and the endometrium in any time, you know, spontaneous or through this
00:35:37.200
And that the embryo, the embryo is then drawn up into the endometrium and this starts the process
00:35:42.580
And then after that, the hormone HCG or human chorionic gonadotropin begins to be produced.
00:35:49.600
And that's the pregnancy hormone that you can measure in the urine or in the blood.
00:35:53.980
As you're explaining all of this, it's, it just makes me like wonder at God about how
00:35:59.160
he created the human body and the female body, really like pregnancy and natural conception
00:36:10.720
Like all of the mechanisms and all of the effort that has to go into, if you're doing it through
00:36:16.360
this process to create a child, it's really just the fact that anyone is here is really
00:36:22.320
just beautiful and miraculous and speaks to God's design.
00:36:26.640
I have to tell you one other part that I just love hearing because it just always makes me
00:36:33.420
It's so interesting when couples are having intercourse and the woman's almost going to
00:36:42.540
In fact, there's only a six day period of time where a woman can become pregnant that cycle,
00:36:49.880
Women are not necessarily always fertile, even within that month.
00:36:54.100
But anyway, when they're having intercourse during the time of her fertile window, they've
00:37:00.260
done these very interesting studies looking at labeled particles that get deposited into
00:37:08.380
And they'll see that like sperm within minutes, within two minutes, those particles along with
00:37:15.900
the sperm are in the fallopian tube already after ejaculation.
00:37:20.420
And it's so interesting is that they're on the side that the egg is on.
00:37:30.220
There's a, there's a lot of chemotactic signaling.
00:37:48.400
What is the percentage of transfers that will end in a successful implantation?
00:37:58.140
So let, I just want to set the stage for this because I think that it's hard to parse apart
00:38:06.060
And the reason for that is because, um, there's several factors.
00:38:10.360
The first part of this is just to understand what is the baseline chance of pregnancy per
00:38:16.060
And that's kind of the baseline we should be comparing things to regardless.
00:38:19.140
And so when we think about couples in their twenties, do you think of as almost like best
00:38:24.500
Um, high egg quality and quantity, um, no fertility issues, just trying for the first time.
00:38:30.860
Their average chance of pregnancy per cycle is about 25 to 30%.
00:38:34.480
So just FYI, that's just important to kind of set that stage.
00:38:38.960
Um, with that being said, the way that, um, the data is presented, uh, that I think is
00:38:46.100
helpful to understand it better is how many of intended retrievals are going to yield a
00:38:53.560
Because that's actually what we care about is the baby, um, you know, being born and,
00:39:00.960
And so, um, when we think about best, again, best prognosis, um, there are even all comers,
00:39:25.860
When we compare that to just, there's different ways of looking at the data, but you can compare
00:39:30.940
it to, again, some restorative reproductive medicine measures.
00:39:35.180
There's an interesting study looking at couples who, um, were by all accounts, what we would
00:39:42.100
call, um, hate using these terms in some ways, but poor prognosis, meaning the woman was advanced
00:39:53.160
Um, and when they looked at a series of a thousand couples who then went into, again, this deeper
00:40:01.420
dive by these restorative reproductive medicine approaches, they found that the, um, cumulative
00:40:09.780
live birth rate was over 15%, which is pretty amazing.
00:40:14.540
So, again, there, there's other options available.
00:40:18.540
But to answer your question, that's a look at some of the numbers.
00:40:21.560
I think that people assume that IVF is like the guarantee that you're going to have the
00:40:39.740
baby, that that's just what you do if you're 37 or you're 45, even that you just go through
00:40:45.700
IVF and you're guaranteed to have a live birth out of that.
00:40:50.640
There are some embryos that don't, they don't survive the transfer process.
00:40:54.520
Of course, there are some embryos that won't implant.
00:40:59.520
And then of course, there is the risk of, um, a miscarriage, which again is also a risk,
00:41:05.180
whether you naturally conceive, um, is the risk of miscarriage higher in the IVF process?
00:41:14.280
Well, you're asking compared to spontaneous conceptions is what I'm assuming, right?
00:41:22.280
I would say that's a hard, that's a little bit hard to evaluate.
00:41:25.760
And the reason for that is because we think of women who it's a different population is
00:41:30.140
the kind of term we use, meaning that those women who are experiencing difficulty consumer,
00:41:35.920
that couple may have different risk factors that might change that risk of miscarriage.
00:41:42.380
Um, and so the second part is, is that if they, uh, do proceed with pre-implantation genetic
00:41:49.540
testing with that chromosome screening, you can imagine that that's going to, again, decrease
00:41:56.780
Like I said to you, that will even be used or, or tried, you know, attempted to be transferred,
00:42:02.580
but then it does, uh, have a decrease in miscarriage rate is what the studies show, which makes sense
00:42:10.500
because the vast majority of first trimester miscarriages are due to just random chromosome
00:42:26.080
I just don't know if it's common that I've talked to women who really wanted to go about
00:42:31.580
IVF in a way that is more ethical in the sense that they only wanted to create the number of
00:42:39.200
embryos that they knew they were willing to implant or transfer rather.
00:42:44.220
Um, and that some doctors are very hesitant to do that, to only create like fertilized three
00:42:52.500
eggs, for example, just because the chances of then a successful life birth from that can
00:42:58.900
If you had say, you know, fertilized six eggs, like, is that, have you seen that at all?
00:43:05.280
Like, is that the case that some doctors are hesitant to fertilize a lower number of eggs?
00:43:12.260
I mean, I think that there are certain, what I've heard is that there are certain centers
00:43:16.700
who, for example, won't even consider, um, moving forward with fertility treatments if
00:43:24.700
the, a PGT, if that chromosome screening isn't performed, for example.
00:43:32.780
And I also have listeners, cause I talk about this a lot.
00:43:36.440
And so I get a lot of stories from a lot of moms who have gone through IVF.
00:43:40.920
They love their children, but they realize, wow, there was just so much I just didn't know.
00:43:45.040
And then some who went through IVF, they didn't actually end up getting pregnant that way.
00:43:52.200
So many different stories, even on this podcast that I've had.
00:43:55.600
Um, and one story that I've gotten is a woman who got pregnant with triplets and she was
00:44:01.340
encouraged by her doctor, um, this was after the IVF process to reduce.
00:44:07.020
Um, it does seem like it's more likely to be pregnant with multiples in the IVF process because
00:44:12.440
you could be transferring more than one embryo at once.
00:44:15.780
Um, is that something that happens that you have heard of, of doctors saying, Hey, if you
00:44:20.720
get pregnant with twins or get pregnant with multiples, we can always do a selective reduction,
00:44:25.480
which is aborting one of the babies, um, in the hopes that it will lower the risk to the mom.
00:44:33.680
So I think that, um, the reason why is because in IVF, remember the baseline chance of twins,
00:44:40.820
for example, in the general population is about 2%.
00:44:44.500
In IVF, there's about a 30% chance of multiple pregnancies.
00:44:49.260
If this is another reason why there's such a push for that chromosome screening, uh, is
00:44:55.260
because with chromosome screening, one embryo is transferred back at a time, thus decreasing
00:44:59.840
number of, um, multiple or just chance of multiple pregnancies.
00:45:05.920
But in those patients who do have triplets or more, the standard would be absolutely to say
00:45:13.480
that due to the risks of the risk to the mother and to the, and to the children, which
00:45:20.940
I know sounds very ironic that selective reduction would be recommended.
00:45:25.880
I think that's something that a lot of people just don't think about.
00:45:29.640
I've actually seen, I saw recently an Instagram post from someone saying that she did this,
00:45:35.080
that she went through selective reduction and that it was something that she was happy about
00:45:40.620
that, you know, she said kind of like that it saved her life, but also saved the life
00:45:47.320
And you just kind of choose the baby that's easiest to get to and then abort the baby that
00:45:54.800
And that is also, uh, sometimes an unforeseen consequence of purposely transferring multiple
00:46:01.480
embryos at once is that you could end up with triplets or, I mean, oh, it's not probably
00:46:07.280
often, but you could end up with quadruplets or something like that, and then have further
00:46:18.340
And I think that's, what's so hard is that couples are then faced with these excruciating
00:46:23.940
Maybe not for everyone, as you mentioned, but I would say for, uh, for, for many couples
00:46:29.400
that either at that moment or even in the future, right after it's already occurred.
00:46:35.620
And I think another common one that many couples are dealing with these days are when they've
00:46:45.660
There's over 1 million embryos estimated to be frozen in the United States right now,
00:46:51.860
And, um, they, I think they, these couples struggle so much with what to do with these
00:47:01.120
And I think that's because inherently in, for me, I think that it's because they inherently
00:47:08.820
And so I don't know if I feel comfortable, uh, you know, giving away this embryo for adoption,
00:47:13.580
for example, or donating this embryo to research where the embryo will be destroyed or just
00:47:23.520
It's a lot of very profound and difficult moral and ethical situations that people are
00:47:33.760
So I imagine that all of these questions played a role in you quitting, um, your IVF practice.
00:47:44.880
I mean, for me, yes, like I said to you, I, I love what I do.
00:47:49.020
I think it's such a honor to, to be able to walk alongside the couples that I, that I care
00:48:06.340
Um, with that being said, once my eyes were opened, once I finally started again, I was
00:48:15.740
And I said to myself, like, this is, I'm dreading going back into work.
00:48:21.280
And that's why I decided, um, again, to stop, to leave it all behind.
00:48:31.160
And I say that, like your eyes were opened kind of in what way?
00:48:36.640
That this embryo is a human being and that human being deserve, has inherent dignity and
00:48:46.460
should be protected as the most vulnerable of all.
00:48:58.960
Um, number one, number two is that all of these technologies, just because we can do
00:49:07.900
And what's the ultimate, we're seeing this now almost, it just feels like the, it's
00:49:12.580
snowballing more and more is the fertility industry.
00:49:16.760
Again, there's a lot, there's just not a lot of regulation compared to, for example,
00:49:22.680
the adoption, um, industry where you really have to undergo a very rigorous screening process
00:49:30.300
to understandably become the parents of this, of this child.
00:49:37.660
And I also think that this is starting to be used in ways, again, that, uh, are, have
00:49:45.120
significant ethical and moral, um, questions surrounding them.
00:49:54.720
And then, um, I would say also that I just felt, as I told you before, that we're putting
00:50:01.680
these very expensive band-aids on these issues that are going to persist.
00:50:05.380
And is that actually the best way to do medicine?
00:50:07.880
Shouldn't we instead try to identify the root cause and heal it?
00:50:11.960
And then we're going to be having healthier mothers with healthier babies and helping them
00:50:17.720
in the long run so they can have the longest life possible to care for their family.
00:50:22.880
And we haven't even touched upon that, but there are risks to moms and children that are
00:50:30.820
And thankfully in the overall scheme of things, these risks are rare, but there are relative
00:50:35.180
increases in risks that, that again, I don't know if there's enough attention put on those.
00:50:43.580
So for moms, uh, the maternal risks include an increased risk of 26% of preterm birth, which
00:50:51.680
is, can be devastating because if the babies are born early, they can have problems with
00:50:56.320
every organ system, including cerebral palsy or even death.
00:50:59.280
It includes, um, uh, over doubling of the risk of hypertensive issues in pregnancy, as well
00:51:06.140
as what we call severe maternal morbidity, which is basically a condition that's where
00:51:11.260
the woman gets, the mom gets so sick, she may die.
00:51:15.640
And that could be life-threatening hemorrhage or what's called preeclampsia, which is high
00:51:20.100
blood pressure of pregnancy, where they can even have a, uh, eclamptic seizures or sepsis,
00:51:25.460
which is a back, which is an infection of the body.
00:51:31.020
There's an over five times increased risk of placental problems again, which can lead
00:51:39.280
For the babies, there is an up to 40% increase in non-chromosomal birth defects that may be present.
00:51:48.140
There is an increase in autism as well as a four-time increased risk of stillbirth.
00:51:55.460
Again, thankfully, these numbers are overall low, but I do believe that that may play a
00:52:03.620
And like I said, my personal opinion is that part of that is because we need to do a better
00:52:09.320
job, again, understanding the reasons why people are struggling with this, um, and healing
00:52:17.840
And like you said, it's a very expensive, costly in more ways than one, as you just said,
00:52:24.440
costly financially, but also can be costly for your health, can be costly for the child's
00:52:30.680
Um, there are women who go through rounds and rounds of IVF.
00:52:34.380
I mean, that can really wear on your body and on your emotional state.
00:52:40.020
I mean, what you described for IVF, it's very invasive.
00:52:43.620
I've had three kids myself and even just like the, like ultrasound and then, uh, then when
00:52:52.120
you deliver like the cervical check process, like all of that is invasive and like leaves
00:52:57.920
a mark on your brain that you're like, that was not fun.
00:53:03.580
I would love to never have another cervical check in my life.
00:53:06.740
Like, and so, but you, I listened to IVF and I'm like, well, that's a lot of that.
00:53:10.960
Like, that's a lot of very invasive stuff that someone is going through potentially many
00:53:18.640
That's not nothing that can really wear on your body and mind and, and your heart too.
00:53:27.320
And even for like, again, the finances, there was an interesting study that showed that
00:53:31.320
the average cost to have a live born baby, um, was anywhere from 60 to $72,000 with IVF
00:53:40.500
So this is, uh, it's just, um, it's a, it's a crazy, exhaustive process in so many levels.
00:53:48.740
So for you, these revelations, these realizations about, you know, everything that wasn't being
00:54:08.240
talked about and was kind of just like pushed to the side as far as the ethics and morality
00:54:13.000
of how we treat these women and how we treat these little children, the earliest stages
00:54:20.660
I'm guessing your, your faith had something to do with this kind of awakening, right?
00:54:29.500
I like to, I like to talk about it in both ways, because again, I think there's a clear
00:54:33.940
medical and scientific argument for this, but for me as well, personally, of course, I, um,
00:54:39.300
the Holy spirit for me, just, he, God is so good.
00:54:42.960
Thanks be to God that he did not give up on me.
00:54:45.600
And I felt best his call more and more and more.
00:54:50.100
And to me, I really, it was, it was, I talked about being blind and anything sin blinds, your
00:54:56.700
heart gets so hardened and to have that, um, my heart really just broke open.
00:55:02.680
And, and the, you know, I always think of that verse of, of being washed away and realizing
00:55:11.900
So, um, yes, I, I'm so grateful to God for his mercy.
00:55:20.400
And now talk about, I, you already have a little bit, but more about what you do now, this holistic
00:55:26.840
approach to fertility is someone who, for whatever reason, it took three to four months for us
00:55:34.220
Every time we didn't have any kind of medical intervention or health, but I remember the
00:55:38.040
first time I was 20, 26 when I got pregnant, I guess we probably started trying when I was
00:55:44.860
Um, and I remember my doctor telling me, oh, if you don't get pregnant, you know, y'all are
00:55:51.780
If you don't get pregnant within six months, then we probably need to see about getting you
00:55:55.700
some kind of, you know, just seeing what's going on.
00:55:58.500
I don't know if you would agree with that or not, but that kind of scared me.
00:56:01.440
I remember thinking, oh my gosh, if I don't get pregnant in six months, something's wrong
00:56:05.500
And we did, we did get pregnant within six months, but I have friends who it took them
00:56:11.280
longer than six months and they didn't really have anything wrong with them.
00:56:17.000
I think people don't realize there's not, you can't get pregnant every single day of the
00:56:21.220
Um, and so there's just a lot of misunderstandings and a lot of scary.
00:56:25.700
We talk, um, when it comes to trying to get pregnant.
00:56:28.440
And I think some people think that if they don't get pregnant the first time, because
00:56:32.280
everyone also has a friend like that who gets pregnant as soon as they have unprotected
00:56:35.720
sex, um, you think there's something wrong with you.
00:56:42.320
I always kind of say that the people who get pregnant the first time are the only ones
00:56:46.860
It seems like, but, um, you know, first of all, I would say that knowledge is power.
00:56:55.480
And so if you're concerned, whether you've been trying for three months or certainly the
00:57:01.880
technical definition of, of subfertility is trying to conceive without being able to for
00:57:09.220
Um, it can be earlier with risk factors, but I always tell my patients, if there is something
00:57:15.660
that you are concerned about, what it's always an opportunity to go in and speak to a professional
00:57:23.080
because they may have some insights to be able to do some testing, whatever you want
00:57:28.980
And you decide together that will allow you to optimize your health.
00:57:34.060
The second point I would say, um, which kind of speaks to the misconceptions is that goodness,
00:57:43.100
I feel like I would have no idea about any of this, um, unless I did what I did.
00:57:48.160
And I'll tell you, Ali, as the purported expert in women's health, I realized after I started
00:57:54.760
digging deeper into fertility awareness-based methods that I was learning some things for
00:58:05.700
In fact, only, I believe about 6% of OBGYNs and family medicine physicians, um, were able
00:58:12.400
to answer correctly regarding fertility awareness-based methods and their efficacy in both achieving
00:58:19.880
And so even though patients are clamoring for a more natural and empowered approach to understanding
00:58:27.100
their own bodies, their own fertility as a couple as well, um, you know, again, I think
00:58:32.560
the data shows that anywhere from 23 to 60% of patients want to use a more natural approach.
00:58:39.140
These fertility awareness-based methods to either achieve or avoid pregnancy, only 1% end up
00:58:45.820
doing so because they didn't feel like they understood it well enough or received proper
00:58:49.560
counseling to do so from their, um, medical providers.
00:58:56.740
And I think that there are gaps on multiple levels, but that's exciting because that means
00:59:02.600
And so what it means to me is that a basic education, um, of again, in middle, middle schools,
00:59:09.720
I feel like the system, when we think about sex ed, there could be of, uh, in my opinion,
00:59:18.640
a much more comprehensive way of understanding what a woman's body is doing and why, and that
00:59:27.700
And it's part of this beautiful, again, miracle and in complexity that works so perfectly.
00:59:34.100
And if it's not working, you can seek help for that.
00:59:36.320
And it'll give you again, the empowerment to understand that that's one level.
00:59:39.820
The second level is educating those of us who care for others.
00:59:44.960
And so, uh, facts about fertility is a wonderful program, um, by my dear friend, Dr. Marguerite
00:59:51.520
Duane, who seeks to help medical students and residents nationwide to understand different
00:59:58.160
fertility awareness-based methods and their efficacy.
01:00:01.020
And then finally, I think that, you know, there needs to be continued calls from patients
01:00:09.780
And so I always tell my patients, I love when they're proactive.
01:00:14.360
Someone was telling me the other day, she said, oh, I don't want to come with the big
01:00:18.920
I have learned so much from my patients, quite honestly, because people do great research
01:00:24.320
You should be proactive, be your own best advocate.
01:00:29.080
If there's something you don't understand or something else you want to consider, make sure
01:00:35.140
It's how I always tell people you have to be able to feel at ease and comfortable and at
01:00:44.160
And that alone, I think, sets you apart as a doctor because so many of us have had that
01:00:48.980
experience with the doctor who just makes you feel like you can't ask questions.
01:00:52.340
And if you do ask questions or you question their authority at all, or if you say, I did
01:00:56.340
research, then they look at you like you're an idiot.
01:00:58.420
And then you're like, okay, well, I guess I'll just do whatever you say.
01:01:01.080
So even a doctor saying, no, I want you to come in with your questions and with your
01:01:08.000
And because you're right, like it took me probably until my third pregnancy and third
01:01:17.120
And like I, at this point, I feel kind of confident that I know what I'm talking about,
01:01:21.400
not about everything, but when it comes to my own body.
01:01:24.420
Um, and so, yes, I totally encourage women to feel confident in that.
01:01:30.480
So you help women with normalized cycles, optimized fertility and miscarriage prevention,
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hormone transition, uh, integrative, integrative tools, um, that a lot of people just don't
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think about, including like mood issues, heart health, like the body really just works
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together and everything affects something else.
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And so often we, we, we have such an isolated approach to medicine today that we just don't
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realize how all of these little things work together.
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And that's part of the principles of the integrative fertility that I am honored to be able to
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As I mentioned before, um, their mental, emotional, physical, and, um, spiritual parts of
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us and that we're, it's a whole systems approach.
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And so the interconnectedness of organs, exactly the importance of our microbiomes, for example,
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the importance of lifestyle changes and how that can truly make an impact.
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And this has been well studied as well as the role of inflammation.
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Um, and, and again, seeking to understand those hormone balances and correcting them.
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Um, and again, my career has been very fulfilling in different ways throughout its 20 year course
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or whatnot, but, um, this current chapter has been really exciting because I truly feel
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again, that I'm healing, helping heal these issues and women are reporting, um, just such
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And it's just, I mean, God created our body so perfect purposely and with such intention
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and there's so much that we can learn about them.
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Like, I'm so fascinated by everything that you do and everything that you've talked about
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Even as someone who opposes IVF, I'm fascinated by that process because, you know, like we already
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mentioned, it just shows how intricate the design of our reproductive systems is, um, and how
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And so the fact that you are giving couples that power and that knowledge and also just
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helping us get healthy in the process really is amazing.
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Um, is there a place where people can, maybe they're in your area, but where they can hear
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I think the best place right now would be at my website, which is laurenrubalmd.com.
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Um, gosh, there's just, there's so much more, even I could ask you, there's so much
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We'll have to have you back on, but I just so appreciate you.
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Yes, all glory to God, but I love how he uses people's callings, people's passions, people's
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own revelations about medicine, the body, the ethics of it all for his glory and to help
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And I appreciate you and your hard work as well.
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It's just, again, all for God's glory, but it's good to be an instrument of his will.