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Dr. Carolyn Alexander: The Golden Egg
Isn’t Carolyn impressive?
What a brilliant woman.
She really is legitimately brilliant.
She is one of those women that you don’t even understand how she gets through a day accomplishing everything she does.
She is a doctor and a mother. She’s a mentor to students at different universities.
She’s written in various journals. She teaches.
When we looked her up, I didn’t realize how accomplished she was. She has all those different letters after her name, which all mean something really big and important. She’s also so optimistic and loving and all about giving people hope in their wish and in their sometimes struggle to have a baby.
We know that. We’ve both been through it. Having a doctor so optimistic and so loving is exactly what you need to get you through those really hard times.
It’s exactly what you need and she talks about the golden egg. I think that is what she tries to get people to focus on. There’s always a way. There’s a golden egg, whether it’s from you or from a donor. There is a golden egg and she gives people a lot of hope. It’s a really good discussion to have because it’s a topic that in the past hasn’t been discussed as much, but now people are becoming more and more open about it.
She opens up I think options for women and families that weren’t available a few years ago.
She’s realistic, optimistic and loving. With us is Dr. Carolyn Alexander. Welcome to the show Dr. Carolyn Alexander. We are excited to talk about this.
It’s very nice to meet you, Dr. Carolyn Alexander.
Thank you for doing this. I so appreciate it. I already knew you as Carolyn Alexander, this amazing fertility doctor, but Mondi then told me to look on your Instagram on the link that’s attached to your account, which I had never done. She had already watched it. We watched it together and I was further blown away by that story that you tell in your clip. Can we talk about that a little bit?
The day that that everything changed when Dr. Howard and Georgeanna Jones told you to go into endocrinology.
It’s the best days of my life at Hopkins. During residency, I thought I would do general OB/GYN like my father.
[bctt tweet=”There’s always light at the end of the tunnel and there’s always a golden egg, whether it’s your own egg or the blessing of a donor egg.” via=”no”]
I have to say my OB/GYN comes from a family of OB/GYNs. I feel like if you can have that gene, that’s a good one. I love that your dad is.
It’s been such an honor and it’s fun helping women. At this moment in my life, I was late for a meeting and I’m never late. I’m super earlier on time and the only chair available was to sit next to Howard and Georgeanna Jones. They were talking to me at the end of the meeting and it was a time that changed my life when he inspired me as well as my other mentors at Hopkins too.
In the clip they said to you at the end of this, “You need to go into this field.” Was there something that you guys talked about that made them do that or is it just your passion for helping women?
He was known for rapid fire questions so he would rapidly ask menstrual cycle. When is ovulation? How high does estrogen go? What is progesterone? Where is it produced from? In the end after asking many questions, he looked at me straight in the eyes and he said, “It seems you really like reproductive health.” I was like, “Um.”
Did you even realize that you liked it so much? Did he make you stop and think, “I must really like this more than I exactly thought?”
Yeah, that’s exactly what happened.
He quizzed you though. It’s a good thing you had all the answers because I feel like I could easily have gotten flustered.
We were talking about this and we both agreed. It’s like Mozart telling you, “You should go into music,” and it’s a big deal.
I never thought of it that way, but it’s true.
The founding mom and dad of this field told you what to do with your life. That’s pretty cool.
I’m humbled by the whole thing.
It is an incredible story.
You’re very humble yourself, but I feel that you have prodigy genes. They must’ve seen that. You went to UCLA for undergraduate and then you went to medical school. Was it at Johns Hopkins or UCLA?
You went to Johns Hopkins for your residency, right?
In what year of your residency did you have that fateful meeting?
At the end of the second year and then I changed my plans and research projects galore and tried to focus my energy on fertility. I learned a lot and I went to a lot of meetings.
Was there an extra year of school because of that?
There were three and I was homesick in Baltimore.
Because you’re from Los Angeles. You were homesick in Baltimore and Johns Hopkins is one of the best hospitals and medical schools. Were there a lot of people going into the fertility field?
There are not too many. I was the only one in my year.
Were you the only female? Are there a lot of females going into it?
When I was a fellow, I was the only female fellow and the rest were men.
I feel like more women are coming up in the field, but yes, because I have been through IVF and most of the doctors that I met with were men.
I also went through IVF for both my children and my doctor was male and most of his practice are male. That’s why I ask.
How long have you been practicing on your own?
I am practicing since 2007.
Mondi and I were discussing how there are a few careers like this but probably, I saw maybe brain surgery, but there are a few careers that you are dealing with that the stakes are so high. People’s hopes and dreams mean so much and Mondi brought up finances too.
Everything’s on the line going through this.
[bctt tweet=”As we get older, especially in our 40s, or if our hormones are off kilter and not perfect, the chances of a successful fertility are less.” via=”no”]
Being able to hold space for people and be hopeful and optimistic and wanting it to happen for them, but also sometimes it doesn’t work. Sometimes it doesn’t happen. Sometimes people have to try tons of times before it does work out. To be able to hold space for them through that is a really special gift because if it were me, I would feel devastated when it didn’t happen. I don’t know. I don’t think I would be very good under those circumstances. Is it hard?
Sometimes it’s hard and I teach the fellows at UCLA and Cedars. They say, “How can you handle that person crying so wholeheartedly and even the husbands or partner is crying, with this guttural cry. It’s so hard to even hear it sometimes and I think to myself, “There’s always light at the end of the tunnel and there’s always a golden egg, whether it’s her own egg or the blessing of a donor egg or whatever.” There is always a golden egg and I really wholeheartedly believe it.
I follow your Instagram and I always am so touched by how positive you are about the whole thing. About trying again and how it can be this time and let’s do this and go eggs go. It’s really nice. You loved your fertility doctor.
I do and I wanted to say I think having a doctor that is so positive, mine was too. I remember, I’ll never forget the day we went to retrieve the eggs. He went down on his knees and put his hands on my knees and said, “We’re going to go get them. Don’t worry.” He had this positive love, kindness and everything in his eyes. I do think a lot of it is that feeling of inside that you believe that this is going to happen too. Having that with a doctor is very important. It sticks with the patient forever. I’ll never forget that moment.
I went through IVF, neither of my children is from IVF, but we went through IVF first and it was not successful for us and my doctor is great. I think he’s so professional. I have absolutely nothing but respect for him. He was really awesome, but he was not warm and fuzzy and I do wish that I had that experience. He was much more like, “We’ll see. We’ll know. The odds are you never know.” It was very businesslike and it’s hard because when you’re going through everything and the hormone part of it doesn’t feel business–like. It feels so personal.
Is it hard to not give your patients too much hope too? Is it hard to pull back?
I’m really big about showing a PowerPoint slide with statistics, but I always show the positive percent even though whatever percent it is, there is still a positive side of it. I do my best to give realistic chances as well as the continuous hope. I always pose the question, “In your heart, do you want to go full force ahead knowing that your own eggs has a less chance especially in our 40s as we get older or if our hormones are off kilter and not perfect, then the chances are less? Do you want to look at the cost–benefit ratio and look at it carefully to see which way you want to go in terms of donor eggs too?”
Have you had a lot of success with donor eggs?
Do you feel that there is an age where you think, “The chances are much lower?” Is there one particular age or no?
After 44, it is really hard. We’ve had success with 45, 46 and 47 but after 47, it’s very challenging unless they froze eggs. Now, this whole new generation will have frozen lots of eggs so at least they’ll have opportunities to try.
Do you have a percentage of single women who are still young, they haven’t found maybe their partner or not ready to have frozen their eggs?
It’s a hot topic now with OB/GYNs. We’re all discussing fertility especially in the early 30s, even younger in some places or if they have a family history of early menopause. A lot of doctors are bringing it up quicker now to think about preserving their fertility for the future. At least it gives them an opportunity. That’s the way I think about it. It gives them a chance.
When we spoke briefly about you coming here, we were in agreement that it is one of those that with all the science, all the medical advancements and all the different things you can do, there is a certain amount of magic and mystery and you called it the golden egg. There is some unexplainable thing that sometimes it works and sometimes for whatever reason all the odds could be great, everything looks fantastic. All of our embryos looked awesome from however the grading standpoint was and if we still have four left, but the ones that they did transfer did not work with me. It’s funny that it is really like one of those a little bit of faith, a little bit of science and a little bit of hope, all the mixture.
I always recall fondly that my most difficult transfer with like the poorest quality embryo that even the lab was like, “This has an extremely low chance,” is the smartest twelve-year-old kid. The mom brings him every year and she shows me all his videos and everything.
It was your hardest transfer and the embryo if you looked at it grade-wise, did not look great. That’s so good.
One thing I was so happy about, our doctor never told us the grade or anything like that. He kept it to himself and I’m so glad because I never want to know. I remember when they did the transfer at the nurse started to tell us and he came up, “We don’t talk about that.” I think for me, he might’ve known my personality. I would have stressed out and maybe stress my body or something.
I like it that the ugly duckling embryos can turn out fantastic. For me personally and then other women that I know, when I was going through IVF, I was so annoyed. I was very open about going through it and I would say we were going through IVF and people would say, “You’re 37,” and I would say, “It’s not me, it was my husband’s issue.” I would throw him under the bus in front of people and he didn’t care. It was fine. It’s like half and half. Sometimes it’s the men with all different things. Do you see that a lot?
It does. I think the hardest couples are the ones they’ve been trying for a year and he didn’t want to do a semen analysis. That’s a little tricky and then when we finally do and it’s concerning, we always say, “At least with men, we have an opportunity to improve the sperm with antioxidants, changing lifestyles, avoiding hard alcohol and things like that.
Sperm quality can improve, but egg quality, can you or no?
It depends. Acupuncture to me seems to help as well as a lifestyle change and decreasing stress even though that’s hard to say.
What are your feelings on that number? That scary number when any woman is trying to get pregnant and it’s not happening yet. Is that AMH?
It’s the Anti-Mullerian Hormone.
Do you find that to be an accurate indicator of success?
I think it’s case by case because sometimes it seems that the AMH is quite low and then women get pregnant easily and, in some circumstances, the AMH is low and it feels like a struggle to get the follicles to grow. It’s not a perfect number. I do warn people that there’s a lot of testing we do, but we put your age and prior ultrasounds into consideration before we make a big statement of, “I’m super worried,” or something like that.
That number is not the end of the line, it’s just part of the picture. Do you think that as egg quality decreases and egg numbers decrease, do you feel like sperm quality decreases as men get older or no?
The Washington Post and New York Times talked and a lot of phone calls came through I think because of our age too. Men at 45 could consider freezing sperm if they’re not done with childbearing or don’t know what the future brings. We are using actually frozen sperm now more frequently in men who are in their later 50s or 60s than to use their fresh sperm.
Why is that?
It’s for genetic autosomal dominant disorders as well as a little complicated data but a slightly increased risk of autism and developmental things.
Men have some things too because I feel like forever it’s always like, “You better hurry up. The time is ticking,” and you never talk about that with men and it’s nice that we’re all in it together. That’s how I feel.
[bctt tweet=”Freezing the eggs is preserving fertility for the future.” via=”no”]
Do you believe in genetic testing during the IVF process?
I also think it’s a case by case discussion because it’s very complex depending on the woman’s age, the man’s age and how long they’ve been trying. If they’ve tried IVF previously and embryo development. I’ve had lots of pregnancies with no genetic testing, but it seems that our average age of women that we see is 39.9. We‘re seeing a lot of older women. I think in the Midwest and other places, a lot of the women maybe are younger too. I’m not sure, but age matters in terms of genetics and we do want to have a genetically healthy embryo as well and as much as we can tell.
My doctor did not advocate it too much and we went ahead and did it. I’m so happy we did because of our nine embryos, only four of them passed the test. I always wondered why he didn’t push us to do it. He actually tried to talk us out of it. I was 35 at the time.
We didn’t do it when we did IVF. We should have it because I’m also wondering why none of those stuck. I don’t know if there are any problems with them, but we never did it because it was an added expense. It was like another $5,000 so we were like, “We’re not doing that.” Was it a lot for you guys?
It was. At the time our company paid for it so that’s why we said, “Thank God. Go ahead and do it.”
Once I was having all these problems and I wasn’t getting pregnant and IVF didn’t work, then we did do. They asked me if I was Jewish and once I got pregnant, I was and then I did that. They advised the Counsyl test and I did that one and there are things that come up for sure.
That’s really helpful. The genetic screening is a little different than checking the embryo itself. The genetic screening tests for autosomal recessive disorders that we all could carry and it is important if both partners have the same exact gene, then there’s a one in four chance the embryo may get both genes from the parents. When we check genetics of the embryos, we’re doing a preliminary screening to check for chromosomal issues and the bigger chromosome level.
When we were talking about doing this podcast, you brought up three really awesome topics that we should definitely discuss. One of them I mentioned is vaginal rejuvenation. You talked about it from such a standard I hadn’t heard and that sounds so great. It’s not just about tightening up your vagina. It’s all sorts of women who have had chemotherapy who have their dryness issues sometimes.
They can’t take hormones for hormone-dependent cancer, then they can’t help the skin of the vagina improve with estrogen. The laser helps them get their skin back and I always say it at least gives them a chance so that the rejuvenation can make intercourse easier and as well as lifestyle and everything.
Especially in women who have had breast cancer, it can happen at any age, in their 20s and their 30s. If it’s painful to have sex, it’s terrible and how nice that that can help maybe sometimes. You also mentioned there are some women who have young women too that have chronic yeast infections and that can be helpful there too. That’s so good.
How would that work?
They think that the rugae, the actual skin of the vagina has little biomes or areas where it has the bacteria or yeast caught up and maybe the laser improves the vascular supply to that area. Normally the vagina is self-cleaning and healing. It improves that in general too.
Have you seen an increase in doing the vaginal rejuvenation? I know you wouldn’t do it, but do your patients talk to you about that?
A lot of people are asking about it and we do see young women with premature ovarian insufficiency which is earlier menopause than the average age in the United States is 51.
Is that the average age? I’ve been wondering.
I’ve always been wondering. I thought it was 40 something.
It depends if women smoke. If we smoke, it’s earlier, the age of average menopause as well as if you have a family history of early menopause then it can be earlier.
Should we ask our moms?
It’s helpful to know.
If my mom smoked, would that make a difference?
It might have.
Another thing you brought up that you said you had seen more of or maybe a lot of, is that young woman with undetected chlamydia. You said it is a big factor in infertility and that you’ve seen that a lot.
I give a lot of talks to the sororities to how to protect your fertility for the future because they don’t think about it. It started with my patient who does the sweatshirt embroidery for all the sororities and then she brought up, “Why don’t you go talk to LMU, UCLA CEED and all the different schools around the area?” I talk to them about protecting their fertility for the future. It’s not a hot topic at the time, but when you get older, it may be important.
It sticks with you. At least you have that knowledge now.
Maybe a lot of those girls are on the birth control pills and they think that’s fine. They’re not getting pregnant. They think they know. Is it permanent? Does it affect their fertility permanently?
Untreated chlamydia can hurt the fallopian tubes and it can be permanent, but it’s caught often because she may be symptomatic or having issues and get seen and get treated promptly. If you’re treated promptly, then you’ll be fine.
When you say untreated, how long does untreated mean?
It’s not clear.
What are the symptoms of chlamydia?
[bctt tweet=”With embryo development, age matters in terms of genetics. ” via=”no”]
Discharge as well as pelvic pain.
They’re lucky if they have that and it will get caught right away. You have two boys as I do. How were your pregnancies, especially as somebody who knows so much about the process?
My first one was pretty smooth. I exercised a lot. I would like to stare at a Starburst and not eat it. I wanted it. I was so afraid I was going to get gestational diabetes. I was trying to eat carefully and previous to that I hadn’t always eaten healthy. I was trying to do my best during pregnancy and I was a week overdue and got induced. Even though I really wanted to go into spontaneous labor, I tried.
I was induced with my second one. I was sad about it. I really wanted just to let it happen but because of my age, they told me that after 40 that 40 weeks was all they would sign off on.
Now, it’s earlier.
My son’s not even two, what is it now?
The pendulum swung back again that around 39 to 40 weeks. We’re trying to encourage women that even though we want nature to bring on labor and I totally agree with it. They are noticing that if we go a little past, there are more complications.
That’s what my doctor was really concerned about.
What do you mean by placenta complications?
My doctor was concerned with me that apparently the placenta, once you’re older could just stop giving nutrients to the baby and you don’t know that. Is that called something?
It’s placental insufficiency but I think it’s also as the baby gets larger, there’s more risk of shoulder dystocia. It can cause complications to the baby and other health things that are sad to think about. As well as our blood pressure when we’re older can go up to.
It’s a huge factor in labor delivery like eclampsia and stuff like that. When I was having my second one, I’m convinced that they put the due date book because I had a high-risk OB. I went to my regular person and then the high-risk person because of my age and they kept putting the date. I would tell them when my last period was and I’m like, “That’s not 40 weeks.” I swear they made my due date earlier and then they said that I had to be induced. I think it was probably around 39 weeks that they did induce me and thank God everything’s fine and he’s fine. I heard there can be really serious complications. Did you have a placental issue?
Yes, with my second one when I was 24 weeks I fell. It was an accident. I tripped over something he was playing with and I fell in a very unusual way. I was like, “Please don’t let anything happen,” and then exactly eight hours later I started bleeding. I got myself quickly to the hospital. It was really challenging. I was actually on bedrest for about ten weeks and every little bleed or every little worry or cramp, I would get so scared that the baby comes out. Anyone on bedrest, I feel for you and I can completely understand. For ten weeks I laid in bed.
Was that from the fall?
You are for 34 weeks.
I begged to go back to work and then I went into labor really quickly after that.
Your body was in shock by going back and getting up.
That day I stood all day but I actually, she let me go back to full work at 36 weeks and then Dave was born.
How were your labors?
They were really good. I tried to not get an epidural because my best friend somehow did it without an epidural. Kudos to anyone who can do that. I applaud you. I had them turn off the epidural and I tried to push through the pain, which I did. It was so painful, but I couldn’t do the interval in between.
I also tried and then both times at about the nine-and-a-half-hour mark, I was done. I couldn’t. My mom did. We had both of us without anything, just with a midwife and my brother is eleven pounds.
I did not experience any of that. In 37 or 38 weeks, my son’s waist is still a little bigger than his body. It was like 95th percentile, but his head was fine. They were afraid that I was going to be able to push his head out, but then get stuck. She said, “If we get stuck, we’re going to break his shoulder.” I was like, “How does that happen?” She was like, “I’ve never done it before because we’re going to do a C-section.” I said, “Thank God.” When he came out, his waist was enormous. I tell her she saved me because she really did save me. He was almost nine pounds and I have more of a petite frame. I do miss having those experiences because with my second now we’re going to do a C-section as well. She’s also looking like she’s going to be more like her brother with a big waist. I do miss these conversations though.
It was exciting the first time going into labor. It’s very exciting when you’re like, “It’s great.” I was sad that I didn’t get to have that second time, but so grateful that my son is healthy. That’s all that matters. As a fertility doctor, you see women and men in their family, whomever, partners, husbands on their journeys to get pregnant. You see them until what week and then they go to a regular OB–GYN?
It is usually until ten weeks.
I’m sure people must be so happy and grateful that they send you or they bring their babies in.
Sometimes if I can make it, I try to run over and catch when they are in labor. A few times I’ve made it, but it’s busy too because I’m at the office and then trying to get over there. Occasionally I walk in and then they’ve delivered or something.
Have you had people come to you for multiple babies?
Yes. That’s the neat thing about the genetics of embryos too is when it’s kid two or kid three, if we did check genetics, at least we know a little more information about the chromosomes, but it’s not always necessary.
I also love how much you love your nurses.
[bctt tweet=”Menopause comes earlier for women who smoke.” via=”no”]
I love my team. I love that so much. I love all the love that you give.
I’m so grateful they get there early. They’re so kind and so wonderful. Unconditional love even when sometimes as women we all know we can get antsy with the process and everything.
Waiting for the pregnancy test once they’ve done the transfer is horrible. I wish it could be shorter. It is the longest wait ever.
The relationship you end up having and forming with your nurse and your doctor is so deep and it’s so sad because the second time around for me, I knew this was it and I long to see him again. It’s like he was as a therapist. Do you find that you are sometimes a therapist and a doctor?
Yes, I’ve told a lot of women who are thinking about egg freezing. I always say how I went out to eat by myself and I sat and watching the Lakers game and I met my husband. When patients are like, “I don‘t know what to do with my life.”
I love that story. I would love to hear that.
I’m the oldest and was the last almost to get married I feel like of my little cousin group and sister group. I was content with my own life and being a doctor and working and everything like that, but I decided to live life, go out and do whatever. I went to get food and watch the Laker game at a bar and I sat next to my husband.
Who talked to who first?
He talked to me, which I was like, “Is he talking to me?”
Were you both doctors at the same hospital?
He is a doctor too.
He understands my whacky life.
Is he the same kind of doctor?
No, he is an internist.
That’s very romantic. For women who haven’t met their person and don’t know what the future is going to hold, but they know they might want to have kids or they do want to have kids, that’s a really hopeful story because it is. If you haven’t met your person at a certain age, you do start to worry. Carolyn, thank you for coming.
Thank you for having me. This has been so nice. I love you guys.
I love you, Dr. Carolyn Alexander. You are in practice in Beverly Hills, Southern California Reproductive Center. Is that right?
People should go see you. Would you recommend women at what age to get a general, “Let’s see what’s happening?”
By 30 unless your periods are irregular, then sooner.
Thank you so much. This was wonderful.
Thank you so much.
About Dr. Carolyn Alexander
Dr. Alexander has conducted extensive research on Polycystic Ovary Syndrome (PCOS) and specializes in the treatment of patients facing the diagnosis of PCOS and infertility. Her other clinical interests include the treatment of endometriosis, unexplained infertility, and recurrent pregnancy loss. She also works closely with oncologists on the fertility preservation of patients who are about to undergo chemotherapy.
Born and raised in Los Angeles, Dr. Alexander received her bachelor’s degree from the University of California, Los Angeles (UCLA) with honors and medical degree from the UCLA David Geffen School of Medicine. She proceeded to complete both her residency in obstetrics and Gynecology as well as her fellowship in Reproductive Endocrinology and Infertility at Johns Hopkins Hospital in Baltimore, Maryland.