330: Resiliency Radio with Dr. Jill: Perimenopause: Silent Fertility Disrupter w/ Dr. Jaime Knopman

Hey everybody, welcome to Resiliency Radio, your go-to podcast for the most cutting-edge insights in integrative and functional medicine. I'm your host, Dr. Jill, and with each episode we dive into the heart of healing and personal transformation. Join me as I interview thought leaders, world experts, medical leaders, medical detectives, and everyone in between, just bringing you great practical information to help you on your journey to optimal health and healing. Today is no different. You're going to want to stay tuned as I talk to reproductive endocrinologist and fertility expert Dr. Jamie Knotman. You're going to enjoy this interview if you're looking for options to help you have children in the future or now. If you're hitting perimenopause and wondering, "Can I still conceive?" The answers to your questions are going to be captivating and will be inside this interview if you stay tuned. I say stick around and you'll hear it all in just a few minutes. Before we jump in, I just want to remind you that we are accepting new patients at Flatiron Functional Medicine, my clinic in Louisville, Colorado. I have a PA, Faun, and a nurse practitioner, Hannah, who are spectacularly intelligent for complex chronic illness. They are getting busy and getting full, but we are still accepting new patients. If you want more information or want to schedule a free uh 10-minute call with one of them, you can call 303-993-7910. You can also email us at info@flatironfunctionalmedicine.com. We look forward to hearing from you. And guys, if you haven't yet checked out the website drjillhealth.com, I've got products and services and our best-selling Dr. Jill Beauty Line. We have kits like the Mini Miracle Kit, the Hair Regrowth Kit, and Dr. Jill Favorites, my three things that I don't leave home without. Um they are powerful peptide-based, retinol-based formulas that are clean and non-toxic and really do produce results. I swear by them. Okay, guys, let's get to our show. Let me introduce our guest. Our guest is Dr. Jamie Knotman. She's a double board-certified reproductive endocrinologist and infertility specialist serving as a director of fertility preservation of CCRM fertility in New York. Graduate of the University of Pennsylvania and I and I School of I'm sorry, I Can School of Medicine at Mount Sinai. She's completed a residency and fellowship at New York University Medical Center. She's nationally recognized for her expertise on fertility preservation, IVF, egg freezing and reproductive endocrinology. You're going to love this interview. Let's join Dr. Jamie Nutman. Dr. Nutman, I'm super excited to have you on the podcast and talk about a very hot topic but maybe a slightly different bent than we usually do. Our title is perimenopause, the silent fertility disruptor. We're going to talk about how this might happen before you know it and all the things related that women want to hear or maybe their partners want to hear who are listening. Um but before we do, I always want to get to know my guests just a little bit more and tell me about your journey into medicine and then into this field. >> Sure. Um so, thank you so much for having me. Um my story is sort of like maybe typical. I always knew I wanted to be a doctor. Um I was in second grade, I read a book about Elizabeth Blackwell and I was decided that that was what I was going to do. I was going to become a physician. And um my path there was pretty linear. I went to med school after college. Between med school and college, I worked at Memorial Sloan Kettering in their breast cancer department so I thought I wanted to be a surgical oncologist. Once I got to med school, I realized that I didn't want to do that. I really just wanted to take care of women and OBGYN seemed like a more fluid path there. So, I became an obstetrician and gynecologist and from my OBGYN residency was fascinated by hormones and subspecialized in reproductive endocrinology and infertility. >> Wow, very very cool. It's so interesting too. Like you with medicine, we go into that thinking it's one thing and then we kind of see, you know, like, oh, maybe that's not exactly the kind of thing I want to do. And I love hearing about the journeys and then how we end up where we're at and >> Yeah. >> It really really interesting. So, fertility has been a defining topic of conversation the last decade and and becoming more more important because the rates of infertility are climbing. And that might be a good place to start. Um, do you know any basic statistics on what we're seeing for both men and women? And obviously we're going to be focusing on women's health, but why is this becoming much more of an issue than it was say 20, 30, 50 years ago? >> So now one in six individuals worldwide will struggle with infertility. And the reason that the rates have risen so dramatically, really number one, number two, number three, number four is age, right? We are no longer having children at the same age as that we once were. We were meant to have babies, meaning like our ovaries and sperm and our reproductive organs are at their prime in their in our 20s. But people don't have babies in their 20s anymore in many developed countries. They're pushing having children into their 30s and because of this we're seeing higher and higher rates of infertility. Now I'm always asked do you think there's an impact of toxins or environmental factors? Probably there are. We just don't know what those are specifically today. So I would say age is the primary driving factor and as we get older having children, we're just going to see the rates of infertility continue to soar. >> Yeah, that makes a lot of sense cuz really people are delaying pregnancy, delaying marriage, delaying cohabitation, and all things that lead to fertility issues. So that makes a lot of sense. And then all all women are also getting pregnant later with the help of infertility clinics and interventions and things. >> Yeah. >> Talk about fertility as a vital sign. I like that framework and I think it's important because I think there's a lot of women that don't think of it that way. Do you want to frame it that way and and why it's actually much more than just um, pregnant? >> Yeah, I mean, I have thought about this for a while. We go to our OBGYN and he or she talks to us about contraception and breast health and cervical health and, um, STD screening, but we need that fifth pillar. And that fifth pillar should be talking about your fertility, right? And what do you plan to do down the road and how can you significantly decrease the incidence of infertility? It's always fascinated me that infertility is the one of the only diseases we wait for you to have before we treat you, right? Like, we don't wait for you to have breast cancer and then, you know, like, treat you. I mean, we do, but like, we try and prevent breast cancer. We try and prevent cervical cancer. Why don't we try and prevent infertility because we have a lot of diagnostic technologies and capabilities and treatment options that could do that. >> Uh, that makes so much sense. And so, why perimenopause is kind of the topic? >> I'm just turning off my heat. Sorry, it was so cold in my office and now it's so hot. So, there you go. >> No worries. We can edit easy peasy. >> [laughter] >> As we're on the topic of menopause. I was like, it is so cold in here. Um, I feel like my mom, who back in the '80s used to like scream at us, open the window, close the window. >> Yeah. >> Um, yeah, so so because women are having their children later when frequently it's sort of this clash between perimenopause, menopause and trying to conceive all at the same time, but it's like a trifecta. It's an unhappy sort of trifecta. So, the only thing you can do, right, is frequently, hopefully, have done some form of fertility preservation before so that the chance of this is lower. >> Makes a lot of sense. So, often we're seeing women who come in and they're like 35 and they want to get pregnant and you're seeing, oh, wait, there's AMH issues and whatever else. How would women, um, first of all, how would we reframe that if someone says, you know, they're in their late 20s, but they know in a decade they want to get pregnant? Um what would you recommend to that person and when should we start thinking about this? >> I mean, I think we need to start thinking about it in our early 20s, right? We should go in and say, "Hey, like I think I want kids or I'm not sure if I want kids or if I'm not sure if I don't want kids, but I know I want the opportunity, so I want to at least check my ovarian reserve today, right?" And that doesn't mean that you have to freeze eggs or if that you freeze eggs, you have to use those eggs, but it gives you the opportunity to potentially have genetic children. I mean, I am now like a flood with stories of women who come in who are having fertility struggles in their 40s and we turn around and we look at their eggs and we use their eggs and the eggs are, you know, I say eggs for the win. Those eggs are coming in and serving woman is serving as her own egg donor, right? Her 30, 20-year-old self is being the egg donor now at 40-something. >> Wow, so if they think ahead, there's this real big opportunity for them to do something later that they wish they had. Now, interesting, you'll understand this completely, Dr. Knotman, but back I was diagnosed with breast cancer at 25, very aggressive and of course I'm 25, right? No children. And I was offered um that egg retrieval and freezing. And what ended up happening because my cancer was so aggressive and I was so young, they thought that the potential process of and I'd love to know your opinion cuz now it's 10 plus years, but the process of you know, inducing ovulation and getting eggs might even be risky and and because I was unsure, I decided not to. Now, because I made the decision at 25 very clearly, I don't have regrets, but it's interesting because um a lot of women, I mean, I because of the breast cancer, I was offered that, but I've never had children and a part of the infertility has been because of the chemo and the radiation and stuff they thought. What would you have said to my 25-year-old self back then? um would you have uh been pro or con for egg retrieval or what would you have any thoughts on that subject? >> I would have been pro for egg retrieval. Yeah, because you Yes, like the theoretical risk exists, right? We all fear and anxiety of will this make my cancer worse? Will the delay for 2 to 3 weeks make it worse, you know? But we know that that does not appear to be the case and that's why we offer egg freezing electively to so many patients because we now know that that really can come in and be the savior frequently down the road after surgery or chemo or whatever it may be. >> Yeah, that makes so much sense. Again, I just had to decide and I've always learned in my medical history that I when I made a decision, I always just felt like I'm doing the best with the information I have and I'll never look back or regret. So I don't have regrets, but I also have never had a biological child. And part of that is because of my journey, so I understand this so well in a different lens because I've been through it. Um and for women to have that opportunity, especially if they're facing something and they don't know about their future. Um so super important. I love that you answered that so clearly. Um What uh Oh, here's the other thing I want to mention. So a lot of women I'm just finding out that are in my practice are like, "My insurance covers this." How That surprised me when I first heard that. >> It's so we're seeing it more and more. I mean, this When people ask me what's the biggest game changer, of course it's improvements in technology and awareness, but more than that is access to care, right? More and more women are being able to do this because their employer is going to foot the bill. >> Yeah. >> So I just sat with a woman who's going to leave You know, I I was joking around. I'm like, "I know things before anyone else does." cuz patients will be like, "I'm going to leave my job." and I'm like, "Okay. Don't worry. I'm not going to tell anyone." But I want to access my benefits before I leave and that is why people are doing this or able to do this when previously they may not have been. >> Is it true? I mean, in my recollection, this was rarely covered. Is this pretty new in the last 10 >> Yeah, I'd say in the last I think COVID was a real big turning point. The numbers of women freezing their eggs went up dramatically in 2020, not only here, abroad as well. And now it's I mean it's like 800-fold greater, right? And and with that rise really what was parallel was the rise in coverage from employers. >> Okay, amazing cuz that should surprise me when I heard it. I thought, "Oh, it is more common." And again, that's not my area of expertise, but um so you mentioned that this may or may not be as known as some of the basic factors of aging, but what are your thoughts around endocrine-disrupting chemicals, poor sleep, poor diet, insulin resistance? Are there other factors that have evidence-based that could be contributing to infertility as well? >> I mean, we definitely know insulin sensitivity, right? Women who are not ovulating at regular intervals because of insulin sensitivity, obesity, that is definitely contributing to fertility struggles, right? The impact of toxins and disruptors, I don't I don't think there's clear data on that yet. I think we all surmise that there probably is an impact, but to what degree? And these are incredibly hard studies to do, meaning like how do you parse out you know, the impact of Equal, or a sweetener, you know, Sweet'N Low on that stat versus this, or phones, or you know, laptops, or whatever it is. I think it's it's it's very very challenging. I think we have all recognized that there is a need to lead a clean and healthy lifestyle is possible, and that is going to benefit every organ in your body, including your ovaries, including your organs, right? All of those organs. So I would advocate for a healthy lifestyle as opposed to going sort of rogue and doing you know, and doing a variety of diets and exercise. >> Well, we do have evidence on the epigenetic expression of methylation on the ovary quality and that. So, I think that we're going to probably have more and more and as an environmental toxin expert, I do see that there are in studies that show some correlation. But like you said, we just need a lot more evidence. But the truth is, avoiding is never going to hurt you. >> Right. But [clears throat] the one thing I say to patients is like, we can see people clean up their life and go, you know, really hardcore and all that and still have bad IVF outcome, right? Like I think probably a lot of this is genetics that we just don't know genes yet as they relate to fertility. But I do think that that's probably a big contribution. >> Hey guys, just a quick commercial to remind you. Dr. Jill Beauty has been best-selling just flying off the shelves. We have some incredible products like my Dr. Jill favorite kit and also the mini miracle kit. These have been the best-sellers the last 6 months and it's hard for us to keep them in stock. If you want to check it out yourself, go to drjillhealth.com and get 10% off your first order. Okay, let's get back to the show. Absolutely. So, when someone comes in, say they're 27, they're like, I don't know now, but I think I want to have children. I want to do, you know, freezing my eggs. What are some of the markers you do to test? What would be like a typical lab order of the >> basic >> Sure. So, we do ovarian reserve testing and that includes ultrasound, which is a way to look at ovarian reserve and to follicle count. And then we look at blood testing called AMH, anti-mullerian hormones. And these parameters are used to analyze ovarian reserve or egg quantity. Now, it's very important to remember that one's egg quantity does not tell us about one's egg quality. So, just because my egg quantity testing is abnormal, does not mean my egg quality is going to be abnormal. It means that if I do egg freezing, I'm not going to get 20 eggs, right? And if I do egg freezing, I might need to do more than one round of egg freezing to get to an ideal number. But, it does not mean that I am infertile, right? Or that my egg quality is subpar. >> Okay, that makes sense. Can you give us some basic numbers as far as what ideally AMH should be and how many um follicles should be counted approximately? >> That is a hard question because it's not a one-to-one linear transition, right? So, I would say if I see a 25-year-old and her AMH level is 1.5, that is not normal, right? At 25, we're going to want to see that at least in the threes. But, if I see a 42-year-old and her AMH is a 1.25, I'm going to say that is great, right? Like, it is going to be largely driven by patient age. And then there will be certain factors that I would anticipate the AMH being low. So, if I see a woman who has had ovarian surgery, let's say for ovarian cyst, and her AMH level is low, I'm not going to be surprised, right? I'm going to say, "That's [clears throat] probably where I would expect it to be." So, there's factors that sort of tip me off for what may happen. But, it's you know, I've never been a fan of these ovarian reserve calculators. People will say like, "Oh, put my AMH into a computer and it'll spit out how many eggs I need, etc." Because we're so much more than a number. It's just like people are like, "Is AI going to replace embryologists? Is AI going to replace physicians?" No, because there's the human side and the art of everything we do. Will it enhance what we do? Of course. Hands down, we know that, right? Does AMH help us dose our patients? Of course it does, but it doesn't take away our clinical judgment. >> Mhm. Yeah, that makes so much sense and I really love that cuz there isn't even in functional and integrated medicine, there's not these hard and fast guidelines. It's this spectrum of illness and wellness and and everything that we see. So you've become kind of a national um leader in fertility for preserving for can- fertility preservation for cancer patients like my story. I want to know a little bit more about that. Would you expect post chemo for that AMH to be affected by that? Um and then we already talked a little bit about this, but what's your general approach to a woman who's um facing, you know, significant therapy that could affect ovarian function? >> Yeah, so so definitely the chemotherapy can reduce AMH cuz chemotherapy is designed to kill rapidly dividing cells, right? That's why it works against cancer. But women who are given chemotherapy, it doesn't just treat their cancer, it also can reduce their egg quantity. So it would be expected to see the AMH levels decline in a woman who's gotten chemotherapy. Now, there's some data to suggest that it will rebound, right? That your AMH may be low and that it may get better as you're sort of further away from the chemo, but unfortunately, there is going to be an impact that is going to arise from getting that chemotherapy. >> Yeah. Is there a certain age? Obviously, I was 25, so there's a no-brainer. If I'm that young, it would make sense, right? But what about a 40-year-old woman or a 42 or 37 or is there a for you as an expert there, is there a certain age within what they're wanting that you'd be like, "Ah, it's probably not worth it if you're going to go into chemo and you're 42?" >> I don't know if there's I don't know if there's ever a it's not worth it moment, right? Like I think a lot of what we do is about patient choice and reproductive autonomy, right? So I think that we have to sit with patients and educate them on the chances of something happening, the chances of success, and then let the patient make the decision for what's best for them, if that makes sense, right? Like >> Totally. >> I am a guide, but I'm not the end-all, be-all. So, I may say to you like, I don't think it's more than 10% chance of success, but if you are aware of that 10% and you want to take that, that's on you, right? Where I think we run into problems is when patients are like, "Wait, I thought my chance of success was 40%, but it's actually 4%," right? They're not well counseled. That to me would be a different situation. >> Mhm. So, you probably find in your practice calculating at least an estimate of where that is helpful for some of their decisions, or you giving them that Yeah, that makes perfect >> Completely, yeah. Because that's also like, I mean, our job in many ways as physicians is we we guide people, right? We don't I think medicine has gone away from the hierarchical, you know, this is what you must do, and I think on to be honest, it's largely due to the influx of women, which I think is great, but I don't think that there is one right answer. I think there's a myriad of right answers, and patients have to make that decision about what's best for them. >> Mhm. I I couldn't agree more. We've much more much less patriarchal, which is thank goodness. >> Yeah. >> Yeah. I can relate to that. [clears throat] Um now, obviously, you treat women, um but men are involved as partners. Um do you typically to have the partner do sperm counts or do any assessment, or are you just focused on if they want a future fertility? Like, where does that land? Do they >> No, I think if there's a partner in place who the patient believes they're going to have children with, we would want to assess their sperm quantity. Uh we have to, you know, listen, like, I'm not a dating coach or anything, but I think you have to tread lightly. Like, when if I'm sitting with a patient and she's like, "Oh, I've been with this guy for 4 months," I'm not calling him in for a semen analysis, right? Because I'm like, "Whoa, pump the brakes." Right? >> Yes, if you're still with this person in a year and you we feel it's going the right way and we want to go and get a semen analysis, great. But, we also want to avoid like the anxiety that may be brought on by saying like, "Oh, let's you know, let's do this ASAP." So, I think we have to we have to um my job is to is to be a good guide in that area. >> Okay, makes perfect sense and I couldn't agree more. Um if a woman in their 30s and 40s wants to optimize fertility, hormone health, or longevity, what are the three highest impact things that they could do right now? >> Number one, don't smoke. I think, you know, we've known this for years how bad smoking is for our lungs and our vessels and our brain, but it's equally as bad for our ovaries. Number two, be aware of what's going to happen to your body, right? Like, I'm not saying that you have to do fertility treatment, but know that your ovarian reserve is going to decline. So, have get educated, have knowledge. And number three, if your periods are so bad so painful that you can't go to work or school, or if you bleed I had a friend of a friend text me yesterday being like, "I've soaked through like, you know, my clothes five times over. What should I do?" I'm like, "You should see your doctor." Like, that's not [clears throat] normal, right? So, we have to recognize that we're not just supposed to like tough it out and be like, "Okay, I'll bring seven changes of clothes and get an ulcer from all the Advil." Like, that's not normal. Use your voice, speak up, and get yourself treatment. >> Mhm, love that cuz yeah, there are women suffering. I feel like the hormonal issues, the infertility, everything is increasing because of stress, environmental exposures, and all these things. Um what's the biggest myth about perimenopause? Like, what are people not thinking about that they should be thinking about? >> I guess the biggest myth, I mean, you can get pregnant in perimenopause, right? You're not in menopause. So, once you if you're still ovulating, still releasing eggs, yeah, the chances go down, but the chances still exist. So, you have to be aware of that. Not because again, not nobody's trying to scare you and tell you like, "Oh my god, like, you know, you're never baby." But, the point is be aware that it can happen, and if you don't want it to happen, you should use contraception. >> Yes, I'll never forget one of my first or second years of practice. I had a lovely woman in her 40s, and we treated her autoimmunity and her gut health, and all of her good stuff, got her eating right and sleeping well, and she came back um very angry because we had fixed her irregular cycles, and she was pregnant at 42 with twins. Now, in the hindsight, it's best thing that ever happened, of course, in the end. But, it was so funny because at first she was so angry, like, "Why didn't you tell me that changing my lifestyle could affect fertility?" >> [laughter] >> And I didn't even think of it cuz it was so obvious, and I learned, I'm like, "Wait, we have to talk about these things." >> Yeah, exactly. And so funny. >> Yeah, I'm sure you've had cases like that, too, where they not expecting, and then >> Well, you know what I've seen a bunch is what are women who I've said, "Oh, your egg quantity is low." Women who are coming to egg freezing, and I say, "Doesn't mean you're infertile. It means your quantity is low." And then they call me the couple months later, and they're like, "I got accidentally pregnant." And I'm like, "Well, what [laughter] happened?" They're like, "You told me my eggs were bad." I was like, "No, no. I did not tell you that. I said your egg quantity was low. I never said your quality. This is not on me." >> Yeah, exactly, exactly. It is funny. And then usually it's a good thing, but not, you know, it's so interesting. Um What are the most exciting breakthroughs in fertility medicine? What's up and coming? What are some things that are maybe still in the pipeline? >> I think the influx of AI in the fertility landscape is going to be pretty exciting, and I'm excited to see where that goes. Um I would say probably the biggest advancements are genetic screening of embryos. We've gotten really good at it, such that we have a lot of um success in um identifying what eggs, you know, what embryos are healthy and which ones are not, and I think that's very, very exciting for the future. >> Oh, I couldn't agree more. And would you say that there's a certain percentage predictability of like having a good success like can you with the data that we have now give a a ballpark estimate of how successful that will be? >> Yeah, so embryos that are high quality, like genetically tested, beautiful morphology, they can have a live birth of rate of 70%. I mean, it doesn't get better than that in fertility medicine, at least nothing we've seen. So, I think that's incredibly exciting, and I can only imagine where we're going to be in, you know, 10 years from now. >> Amazing. How cool. Well, people want to find out more about you, about what you do, about your practice, where can they go to find out more? >> Sure, so I work at a fertility clinic called CCRM New York. We're located on 53rd and 7th in Manhattan. I also have an Instagram page where I try and give good information. It's Dr. Jaime, j a i m e, Knotman. I also have a website, and I wrote a book called Own Your Fertility. It came out this year, January 2026, and I think it's a really good resource for anyone who's thinking of having a baby, has a baby, doesn't want a baby, all things reproduction. >> Amazing. Well, thank you for the brilliant work you've done in the world, and thank you for coming on Resiliency Radio. >> Thank you so much for having me. Have a wonderful day. >> Hey guys, thanks for joining me for another episode of Resiliency Radio. As you know, we have new episodes coming out every single week on Wednesdays, so you can stay tuned. If you want to hit the like or subscribe button and the bell to be notified of future episodes, that way you won't miss any one of these. Hopefully enjoyed this impactful, inspirational interview with Jaime Knotman about fertility and how you can change that course if you act early. If you have any questions or comments, leave them below or anywhere you're watching or listening to this podcast, and I will see you again next week for another episode of Resiliency Radio.