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Fertility and Sterility On Air - Unplugged: May 2025

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The following transcript was automatically generated.

In this month's Fertility & Sterility: Unplugged, we take a look at articles from F&S's sister journals! Topics this month include: efficacy of hCG in restoring spermatogenesis in men using non-prescribed androgens (1:31), assessing prediction models for the risk of OHSS in women undergoing assisted reproductive technology (13:51), utilization of a 3D in vitro co-culture system to characterize embryonic mechanisms associated with implantation (25:09), and a look at TikTok’s growing influence on supplement advice for patients with PCOS (33:38).

F&S Reports: https://www.fertstertreports.org/article/S2666-3341(25)00050-9/fulltext
F&S Reviews: https://www.fertstertreviews.org/article/S2666-5719(24)00043-4/abstract
F&S Science: https://www.fertstertscience.org/article/S2666-335X(25)00022-9/abstract 
Consider this: https://www.fertstert.org/news-do/tiktok-replacing-doctors-rise-pcos-supplement-advice-online

View the sister journals at:

 

Welcome to Fertility and Sterility On Air, the podcast where you can stay current on the latest global research in the field of reproductive medicine. This podcast brings you an overview of this month's journal, in-depth discussion with authors, and other special features. FNS On Air is brought to you by the Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine.

Hi, everyone, and welcome back to another episode of FNS Unplugged, your favorite FNS podcast, one that's been gone for too long, and we're so excited to be back. I think every time we have a short absence, it's always good to blame someone. I think this one will blame Molly.

Molly, you want to share with the listeners a little bit about what's been keeping you busy? Well, we came right back. I got back from maternity leave, we recorded right away, and I was a little bit sleep-deprived, and I forgot to hit record. So an hour later, we realized our mistake, and then it took us about a month to get rescheduled after that.

So sorry for the absence, guys. The first one wasn't that good anyway. This next one, this one is where it's at.

And so here we are. We're doing it live the second time, but really delighted to be back. We still have a great set of articles to tell you about.

Probably weren't expecting to hear about how TikTok plays into patient education, but we're going to be talking a little bit about that. But let's save that one for the end. That one's mine.

Molly, why don't you start with, tell us a little bit about what's coming out from FNS reports this month. Great. So the paper I chose from FNS reports is the efficacy of human chorionic gonadotropin hormone in restoring spermatogenesis in men using non-prescribed androgens, a study by Dr. Diederik Smit and Dr. Peter Bond.

And they're both located in the Netherlands. So I know on this podcast, we've talked a ton about the really widespread increasing use of testosterone, the very negative impact on fertility, and the fact that probably most concerningly, many men are not getting appropriately counseled on the negative impact of testosterone on sperm count and on fertility. And I actually had a patient recently whose prescriber said it would help his fertility.

So my new practice is give me the name of all the prescribers. I will be calling all of them to talk about this. So starting with some numbers from the introduction to this paper.

So the authors talk about how athletes, especially bodybuilders will use a blast and cruise method, which I knew nothing about in which they'll use bursts of really high doses of androgens and then have periods of low dose testosterone in between. So the authors describe a prospective study of 100 men using androgens. And they found that three fourths had a total modal sperm count of less than 40 million and a quarter had aspermia.

And it actually required a whole year off androgens to get these guys back to baseline levels. So the authors write about how many men are really resistant to stopping testosterone for the purposes of fertility, because they may have really significant withdrawal symptoms, especially if they've been on testosterone for a long time, of course, and they're worried it can impact their athletic performance. And I guess we can imagine if someone's career is bodybuilding, it can impact their career as well.

Listen, some of us have to give up on our passions early on in life. You know, it was a fork in the road and I was either going to become a bodybuilder or a reproductive endocrinologist. And yeah, the world is.

Let me tell you this. I'm not recording a podcast from Muscle Magazine right now. So you all know how it panned out.

Yet, yet. Here we are. Well, interestingly, in the Netherlands, where this study is taking place, they have a harm reduction clinic and they will actually do evaluations for other known health risks related to androgen use.

And I see that difference between our countries, right? In the Netherlands, guys using androgens for this purpose, they actually have a harm reduction clinic because they're treating it as a harmful use, whereas in the U.S. we're kind of prescribing it all over the place. But for patients in this clinic who desire fertility but are unwilling to stop androgen use, HCG can be prescribed. And as most of our listeners know, HCG, due to its structural similarity to LH, acts on the LH receptor and stimulates leydig cells and can support sporanogenesis that way.

And it's used for men with hypogonadotropic hypogonadism. And since androgen use also causes basically a hypogonadotropic hypogonadism state, HCG is then proposed to return some fertility in individuals that are still using androgens. So they did a retrospective study of men using androgens who desired fertility.

The HCG dose they used was the, they used a 250 microgram recombinant HCG, which is about 6,500 international units. As we know, many of us are using that in our clinic, but they had the ability to give lower doses as well. And they would titrate it down.

And most of the, most of the men of the study were on 1,500 to 3,000 international units a week. The men in the study were also transitioned to a lower maintenance dose of testosterone or of a testosterone ester. And it was 125 to 150 milligrams per week.

And they were recommended to stop those high dose burst cycles. And semen analyses were collected at baseline and then at three to six months. So just a reminder, retrospective study, a lot of variability here.

So what did they find? So it was a really small study, only about 19 men were included and notably 15 were azospermic on presentation. With initiating HCG, most men actually did have improvement. So 16 out of 19 improved their total sperm count.

17 out of 19 improved total motile sperm count. The total motile sperm counts mean was 1.1 million pre-treatment. So quite low at the point that you're generally, if you see that in your clinic, you're getting two night testing, you're talking about IVF.

And post-treatment, it was 66.8 million total motile sperm count. So a huge improvement. 11 out of 19 had a now considered normal total motile sperm count, but six did remain oligospermic and two remained azospermic.

And there were six pregnancies in that cohort. So still for all of these men wanting fertility, six pregnancies is relatively low. The paper has really nice figures within the manuscript that show each individual sperm counts over time from the pre to post-semen analysis.

It's kind of this really small descriptive study. So you can show that level of detail. Some of the guys did really well and had this huge improvement, but some actually had very little improvement or none at all.

So I think that's something that for patient counseling is really important. This might work, this might not, or it might only have a modest effect and you're still going to need IVF. Was there anything, Molly, that the author said was unique about that group of patients who didn't respond? Were they older? Had they been on it for longer at higher doses? Any kind of magic about that group or just, it happens? Yeah, they tried to tell which factors would predict or influence response.

And I think just because it was so small, or maybe just because of the characteristics of this condition, they were not able to find who would do better or worse. So they didn't find that age was associated, duration of TUs. I think a lot of us would point right to duration of TUs or dose.

The weeks between the semen analyses didn't make a difference. And then the dose of HCG, they did not find an association either. At least none of these were statistically significant.

And with the caveat, this is all a pretty underpowered study here, but an important finding, an important study to be done. My takeaways from this. So I think I probably didn't pay enough attention on my urology rotation.

Hopefully Dr. Hedges is not listening here, but the impact of testosterone use was actually even more profound, even worse than I was aware of. This is obviously a self-selecting group for kind of baselines of fertility or infertility, men trying to conceive. But I found that the azoospermia rate was really high in this population.

And I'm starting to see that the longer I've been in practice, like the guy says he's on T. I'm not surprised now when I'm seeing azoospermia on the semen analysis, but I was when I started practice. Great that the HCG worked in the majority of men and it worked fairly well, but it's interesting that we don't really know who's going to respond well and who won't. I also have to wonder if some of these individuals have underlining pathology that resulted in low sperm counts at baseline as well.

So does someone have a degree of hypo, hypo? And that's where they even started testosterone. So they actually were treating maybe buying testosterone on the street or androgens on the street, but they actually were treating a real medical condition. And then it's unfortunate that two guys did remain azoospermic in this study.

So I'd be interested if they came off androgens entirely, if they'd have recovery kind of more traditional treatment where they come completely off and then maybe on HCG as well. And then, you know, we only saw six pregnancies. So these people, many of them still weren't able to conceive spontaneously.

There could be other issues going on. Maybe this could get people to IUI or IVF. I wouldn't otherwise be able to, because you only need a little bit of sperm for IVF.

And then also noting the process is really slow. It took really several months for improvement. I have plenty more I could talk about, but I'd love to hear what you guys thought of this study, how it might impact your own practices.

Was it surprising? Was it not surprising to you? Yeah. So interesting study. I think I've got a few thoughts on this.

So first I counsel multiple men on this every week. I mean, this is so incredibly common. I imagine it's common where you all are too, but I will say in Oklahoma, I mean, it is a epidemic.

It is so, so common. And I will say the vast majority of men that are on T have no idea that it's adversely affecting fertility, nor unfortunately, nor do the providers that prescribe it to them. And so, and I feel like it's over prescribed a lot too, to where you could argue that these men don't even really need it because oftentimes like, oh, I'm, I was told I need it because I'm tired.

It's like, well, I am too, but my testosterone is fine. You know, like if these men could come off of it in the first place, there's not probably there's it's unlikely that there's a underlying pathologic reason why they need T aside from just they're tired or have low libido, you know? So I do think it's, it provides a little bit of reassurance though, that when these men do come to our office and they're on HCG, in addition to testosterone, I at least don't have the immediate thought now that, oh, this, you know, there's no way they have sperm, but I still don't think that I'm going to feel comfortable with them remaining on it if they want to optimize their fertility. So obviously there's some things to consider with this study, pretty small powered, it's retrospective.

There's a lot of heterogeneity as you'd mentioned too, but I still think that it gives you a little bit of reassurance that at least they have some sperm recovery while on HCG. It's kind of my thought, but I still don't feel comfortable with them staying on the T. I completely agree with Blake. I think the, there's always that part of me that's like, what happens to sperm DNA with high testosterone exposure? Yes, it's concentrated.

Yes, it's modal. Yes, the morphology is good. I just don't think we have a ton of safety data that exposure to exogenous high dose testosterone levels and super physiologic amounts is a safe thing for that embryo and that resulting child.

That's the part that kind of gives me a fair amount of pause. Question. I mean, with the, it seems like everybody is on T as I'm hearing the same thing from all three of you.

Nope, not me. Maybe Blake. I could get on some T. I might need some T. Ty, check.

Get me some of that. I'm actually not on testosterone. Well, somebody is.

I know it looks like it, but sorry, continue. Certainly have the physique. I got to ask as I tried and failed, but I'm coming back around.

What is the data? You know, with the amount of people that are on it, has there not been a controlled trial in terms of the impact considering, especially to that earlier point that you made, about, you know, this retrospective and maybe T's are only really bad if there's some other underlying issue with fertility. Like maybe T's okay. I'm trying to make my case here.

I think I saw a study that guys on T also had lower morphology. I'm trying to remember where I saw that. So I think Pietro's point about long-term impacts, quality DNA fragmentation or other issues in the DNA is very, very valid.

And I think the next kind of step is, are we going to have to be using this kind of protocol, even though we all feel uncomfortable and we all don't think it's very standard. If every single one of Blake's patients is on T and maybe their partners are AMA or DOR, they can't really take a year to let the T bounce back. And we're using this sperm or they're unwilling to go off it.

Then we do need to look at blast quality, blast development, maybe euploidy rate. I don't know if that will show an impact. Pregnancy outcomes, miscarriage risk, and then eventually neonatal outcomes.

But of course, that's a hard study to do. It may become easier to do now that this is so widespread. All right.

I think we've unmasked the mysteries of the universe with regard to testosterone and HCG. Let's review some stuff. Blake, tell us.

All right. So I'm going to be honest before I start. Something happened to me earlier today.

It's an OR, changing out of my scrubs. And I just recently found out my chapstick is not in my pocket. And I feel like the sky is falling.

So I'm going to try and make it through this discussion. I know it's going to be a little dicey, but I just want to be honest with you guys about that. So I'm reliant on that.

Yeah. We're holding space for you. And I felt fine until I noticed that it wasn't in my pocket.

Now that's all I can think of is I need my chapstick. So anyways, let's dive into this article enough about that. So for the article that I chose from FNS Reviews is entitled, Predicting the Risk of Ovarian Hyperstimulation Syndrome, OHSS, in Women Undergoing Assisted Reproductive Technology Treatments, a Systematic Review and Quality Assessment of Prediction Models.

My first author, Krishnika Vetrivel of King's Medical School in the United Kingdom. A little bit of background before we start. So when you all are dosing a patient for IVF, what are some measures that you all look at that you would think would put a patient at risk of OHSS? Hat size, inseam, neck width.

Obviously. Age, BMI, antral follicle count, AMH. Glove size.

I think I like Molly's predictors a little bit better, Pietro. All right, go on. So yeah, I say this because the risk factors are well known.

And as RAIs, we are aware of protocols that reduce the risk of OHSS. And spoiler alert for this article, the review does have a null finding, but I feel that the context within it is important to discuss. So OHSS is a common, the authors quote about 10%, ranging from mild to severe.

It's a common iatrogenic complication of controlled ovarian stimulation in ART. OHSS can be rarely life-threatening and associated with significant morbidity. Fortunately, that's rare though.

Risk factors, in addition to the intelligently listed things that Pietro said, also include BMI, PCOS, high AMH, previous history of OHSS. And then as we know, common risk reduction measures include an antagonist protocol, lupron-only trigger, cabergling after trigger shots, and to freeze all embryos as well, or a combination of all of those. And there are several measures that could help prevent OHSS.

And fortunately, the rate of severe critical OHSS is very rare. So about one to two per 10,000 is what the authors quote. However, an accurate risk prediction remains a challenge to enable early prevention.

The authors state there are several predictions or predictors and prediction models that have been developed, but few have undergone rigorous validation, which is where this review comes in. So this review sought to review and evaluate the currently available prediction models. Looking at their methods, there were about 6,000 citations analyzed.

Ultimately, only 14 were included in the analysis. All were observational cohort studies, which of note, there is a high risk for performance and detection bias of OHSS in these studies. Five of these were retrospective and nine prospective.

Median sample size was 782, ranging from anywhere from 105 to as high as over 256,000. The age was ranging from 20 to 40 years of age. The majority were from Asian countries.

Five were from Europe and one from the United States. They utilized Lupron agonist in three studies, antagonist in one study and a combination in the other. So obviously some heterogeneity there.

Only one model, the authors really were upset about this or sad about this. Only one model had implementation program using a smartphone. They were really sad about that.

So looking at the results, the most common predictors, we already know these, but here we go. Maternal age, antral follicle count, BMI, AMH, the number of eggs retrieved, serum estradiol. The majority of the studies included high risk of bias, largely driven by poor model development methodology, specifically in data sampling and analysis.

There were several studies that were pretty vague in reporting the diagnosis of OHSS, the incidence and the severity of OHSS. The authors also discuss how professional societies differ a little bit in their classification of definitions as well. So making it a little bit more difficult to tease out the results in these studies.

Only a minority of the models were developed within a large cohort size. Only two studies included over 10,000 cycles, for example. These were from heterogeneous populations, which may also reduce the model's applicability in our practice.

So in conclusion, many clinics have adopted a freeze-all approach and use a Lupron-only trigger. Clinics, for example, such as mine, that still commonly perform fresh transfers may benefit from a prediction model for OHSS. So for example, based on their stimulation response and if they should consider a fresh transfer or not, but also serve as counseling tool prior to trigger shot and subsequent transfer in a fresh cycle, for example.

The majority of studies in this review were modeled to predict OHSS prior to the cycle start, but not during the stimulation, which I felt was a big limitation and the authors did discuss that that would or to acknowledge that that would be more helpful. There are several interventions that could help mitigate the risk of developing OHSS in a high-risk patient, but accurate risk prediction is key to enable an early adoption of preventative measures. The authors also discussed there's no clinically appropriate and validated prediction models for OHSS among women undergoing controlled stimulation.

And lastly, the authors illustrate the need for a well-validated and calibrated prediction model that could inform both patients and providers alike the risk of OHSS and the optimal time to intervene. And of course, as a lot of studies we discuss nowadays, they say eventually the use of AI could be very helpful as well once they do have models validated. So, Daylon doesn't like that.

So, obviously, a long ways to go here. As I mentioned before, we even started discussing this. We know a lot of the risk factors, a lot of the ways to mitigate risk for OHSS.

So, kind of a null finding study. But anyways, what are your thoughts? What do you guys think about the study? I like a null burger, but I mean, I don't want to throw shade on it because I think it's a major challenge. And as you're talking through it, it occurs to me that the real limitation of this show is that we don't have any like OG REIs here.

You guys are all younger than me, and I'm a young man still. Even though my T is dwindling, I'm still a young man, for God's sakes. With the right amount of T, we can make you un-dwindle.

I'm good on that. But I'm serious about the lack of any old heads because I don't even know. I feel like the temporal component here is a real factor.

I would want to know what were the timelines where all those studies were done. Retrospective over what span. Has the practice changed so much? And awareness changed so much? And like you said, freeze all, different triggers.

So, there's so I would need to confine the analysis and the prediction model within these different modalities and regimens, right? Because otherwise, I'm not surprised that it's a bit of a null finding because it's hard to really compare. It's like a fruit salad. I mean, forget apples and oranges.

So, that's my non-clinical perspective. What do you have to say to that with your fresh, fresh minds? Young, young, high-T minds. Not you, Molly.

I have a confession to make. In three years of fellowship at Daylon's Stomping Grounds, one Weill Cornell Center for Reproductive Medicine, I saw two cases of OHSS that required hospitalization. And both of those cases were patients that had not been cared for by our practice.

They had come from other practices. I think in the modern era, OHSS is an entirely preventable iatrogenic complication of ART. Not entirely.

Sometimes you get surprised and a patient sneaks up on you with a really low HCG or you do a luteal start and someone's surprised pregnant and you find out about it mid-cycle, you name it. But I think in the era of the GnRH agonist trigger, the cryo wall, the ability to push to blast for freezing, we just got to be a little bit more conservative and ask ourselves, do we really need to push the limit here and get this patient sick or should we do the right thing and be safe? I just haven't seen a lot of it. And that's my disclosure.

No. And fortunately, we just don't see it very often. And like you said, sometimes patients, even someone without risk factors really can still have OHSS.

I mean, a few weeks ago, we had a patient who really, she had a dual trigger antagonist protocol, but she was planning for a fresh transfer, but really not that impressive of risk factors at all in terms of egg number, her estradiol level. And she got pretty decent amount of ascites and was very uncomfortable. And we ended up doing a tap on her and it was our third year fellows first time to see a tap.

And, you know, it was like, Hey, I just realized you probably haven't seen one of these. So since you're about to graduate, maybe you should, but we just don't see it very often, fortunately. So, so still patients every once in a while, we'll get it unexpectedly.

And so I think knowing how to manage it is something that's important. But even if you have say a prediction model, like these authors are talking about this patient wanting to fit in that prediction model, but it's still important to know how to, how to manage it. But we just don't see it very often, unfortunately.

Yeah, I would like to do more fresh transfers than I do. I think, you know, very low OHSS risk with the freeze all strategy, of course, and lupron only triggers and anti protocols, but I think we probably could do more. And we know that there is a slight, you know, obstetric risk of frozen embryos, or we believe that to be true based on the data we have.

And then there's other advantages of fresh transfers for some patients as well. And I find that when I'm deciding about a fresh transfer, I tend to chicken out a little bit early because I'm nervous about OHSS. And sometimes I do call my more senior faculty who practiced in the days of OHSS.

And I said, is this a safe one for a fresh or not? Because I actually don't have that gut feeling just yet about when to do a fresh with a higher E2. Sure. Long lived lupron trigger when you're worried or when a prediction model tells you, you should be worried.

But at the end of the day, it's always good to rely on those older attendings who've seen it before and like, just have a bad gut feeling about it. It's kind of like when the nurse asks you, hey, do you want to type and cross them for blood? You always say yes. You know, so there's something that the universe is trying to tell you.

And if someone's like, should we cry a wall? The answer is always yes. You should. You should.

You never regret a cry wall. That's fair. Daylon, bring us back to lab reality.

Talk to us some basic science. I'm fatigued about hearing about clinical testosterone and HCG. I'm fatigued about hearing OHSS.

Lull me back to awakeness, basic science. Yeah, I know what you need is a nice basic science story about mice. That's really going to get you up and going.

You said it, brother. Well, you're going to be disappointed, I'm afraid, all of you guys, because I got no mice story for you today. I got something first I just want to reflect.

I mean, what's so great hearing this conversation, admiring your guys, you know, maturation as clinicians and I would say clinician-scientists, is that you get the benefit of, you know, overlapping with the real, you know, the makers, the movers, the godfathers and mothers of IVF and assisted reproduction. So you can make that call and ask for that advice, because that's the great thing about our field, right? It's at the point of the spear. I got a story here from science that's a little kind of back to the future.

I'm going to come back to that. But it's representative, I think, of the all the exciting science and application to medicine. And first, I just want to highlight, like, embryo models.

I don't know if you guys are following this, but these human embryo models, while they're really very controversial, I think the amazing thing about them is they allow us to gain insight into this black box that historically has been impenetrable of implantation, early embryo development, gastrulation, all those things. And there's been amazing progress made whereby these stem cells can be assembled into these little simulacra of a pre-implantation human embryo that undergoes early embryonic patterning and development. And there's all kinds of debates.

Are you calling these blastoids? Did I get that right? Well, there are blastoids, but we're even going further than that now with these gastroloids. And I think we have to be very careful in the naming of these things because they do attract a lot of scrutiny, especially in this highly charged political environment and this climate. Politics aside, one of the most amazing applications of these embryo models is that they unlock our understanding of early embryo development during this peri-implantation phase, right? Which is, of course, this black box of human embryogenesis today.

And the study I'm teasing today, with just a little brief teaser, I invite you guys to take a look, is representative, as I said, of these cutting edge methods that leverage ex vivo culture to unlock, in this case, blastocyst implantation. And while this study uses actual blastocysts, not mice, human blastocysts, and it's not an embryo model study, it got me really excited for two reasons. One, as I alluded to earlier, it's a bit of a back to the future to these ex vivo co-culture models that are familiar to me and perhaps you, Pietro.

But also, the way that this 3D co-culture system that was developed in this story might be applicable to larger scale studies of human embryo models, which I think is the next phase for ART, is screening to understand using this scalable approach and material, which are these human embryo models, which are not actual embryos, I want to emphasize, but allows you to get large numbers and look at any number of things that may affect earlier embryo development and potentially be able to optimize outcomes, right? So first, let's get to the group. This is a study led by Mandy Katz-Jaffe, who's at Colorado Center for Reproductive Medicine. And what they did here is isolate epithelial and stromal cells from endometrial biopsies and separately plated them in this 3D matrix that they then co-cultured with individual human blastocysts.

Now, this is not completely novel in itself. I kind of have been calling back to this work that was done decades ago at my center here, Center for Reproductive Medicine at Cornell, that went really deep on endometrial co-culture with embryos. And I will disclaim, the results were modest at best.

And I would say the approach has been widely abandoned. But here they breed new life into that paradigm. And I especially like it because it's the platform and the approach.

It demonstrates efficacy and generates results, right? You can observe the actual system. It's not based on like other co-culture endpoints in the past, like implantation, pregnancy, live birth, things that can be affected by any number of variables along the way. This is actually results that you're seeing in the dish.

And they seem to validate it in this platform. They got discernible differences, not only in terms of the cellular behaviors, but objectively in terms of gene expression. Now, I want to caution, the results here are descriptive, right? But they're generated from a pretty large cohort of 72 top grade surplus blastocysts.

So, I would say they really do diligence on getting good quality material. I'm not surprised that they're able to demonstrate differences given that starting point. And I think it offers a really exciting glimpse of the possibilities in a future, which we're circling around right now, where any number of these embryo models, blastoids, gastroloids, that you can scale up and look at a lot of questions that are relevant to assist reproduction and embryo development.

So, I encourage our listeners to have a look. Now, I'd love to hear what you think about this paper, but also would love to hear your take on these rapidly advancing embryo models. Does this ability of stem cells to form structures resembling a post-implantation embryo in a dish, like all the politicization of that, does that, like, do you have to figure that in when you talk about personhood and address some of the maybe patient questions about disposition of embryos or anything along those lines? I don't want to make this a political discussion at all, but I think in this case, it really is pertinent.

. Blake, I'm going to let you take first stab on this one. I feel like this is a probably a conversation that you have a lot more frequently in Oklahoma than I do in Massachusetts or Molly does in Washington, Oregon, excuse me. That's a loaded word "personhood" I feel that this research is really extremely fascinating, you know, what just what I'm thinking of the process of what the authors did in this study and just how elaborate it is and how interesting it is to completely aside from, you know, you answered the word personhood and that opens up kind of Pandora's box.

So, of course, that's kind of a word of contention here in Oklahoma, and we try not to talk about it too much, because less is more, I feel like less, less information and knowledge when it comes to what they discuss behind the Capitol doors is probably for the better. You know, if you, we always promote, we discuss what we do in IVF, we really try to emphasize family building. And you even mentioned, you know, discarding a few clumps of cells that stop dividing in a dish, whether or not it came from, you know, you know, biopsied cells or wherever it came from, like the study is talking about, if you're talking about disposition of cells that could lead to a pregnancy, then people get real squirmish when at the Capitol.

So, it's a tight rope to walk for sure. And, you know, I think that's something that not just in Oklahoma, but in a lot of states, that's going to be a delicate topic to approach. And when it comes to research on these things, too, of course, you're going to have a lot of people feel very strongly to not do it.

And there's going to be people who say like, well, you know, we're just looking at cells. And this isn't something that necessarily becomes a human being. And it's going to help, help promote research and a lot of people down the line.

So, people think of this just very, very differently. So, we could have a whole podcast in and of itself. I know we've even mentioned that, I think in a previous podcast, we could have a whole podcast talking about this type of stuff, but it's a loaded topic for sure.

Thanks, Daylon. I'm going to lighten up the mood here for a second and tell you a little bit about TikTok and fertility. I teased it at the beginning, but I mean it.

We are going to talk about TikTok and fertility. There's this really cool article that came out in Consider This that looked at TikTok as a source of supplemental advice for people, particularly individuals with PCOS. And what these authors did is they analyzed the top 100 English language TikTok videos that had a hashtag PCOS supplements attached to it.

Here's what they found. They noticed that about 50% of the posts were educational, 40% were personal experience-based, but yes, you guessed it, 10% were promotional. 50% of these videos were created by patients, 25% of allied health professionals, and that means nutritionists, acupuncturists, people who are in the allied health professions.

Only 1% of it was actually made by physicians. Seems like a real shame. It's an opportunity for us to be part of that conversation and share some evidence-based knowledge, but it seems like patients are having these discussions and allied health professionals are having these discussions.

In these 100 videos, there were 92 unique supplements that were cited. I know of one over-the-counter supplement that I recommend. It's called a prenatal vitamin.

There are 448 total mentions of supplements. That's an average of four and a half per video. Blake, what do you think the most common supplement mentioned as it relates to PCOS was? PCOS? Oh, myonostal.

Yeah, that was the most common one, but then there's some weird stuff like magnesium. Here on the Reels or the Instagram, magnesium's good for sleep, it's good for anxiety, apparently it's good for PCOS too. People are talking about fish oil, vitamin D, mostly around the theme of insulin resistance, but also general wellness and weight management as themes for PCOS supplements.

Suffice it to say, the quality of the information that these videos were sharing with PCOS patients was not great. You may not have done this, but there's actually two good ways to score the quality of information. There's the JAMA benchmark criteria, which evaluates the author, the attribution, disclosure about information that is both transparent and credible on a one-to-four scale, four being the best, one being the lowest.

The average JAMA benchmark score for these videos was 1.7, meaning poor transparency, limited source disclosure, a little shady. Then there was this other score called the Modified Discern score, which is a tool that assesses the reliability and quality of health information, looks at sources, balance of risk and benefits, decision support for patients, one-to-five scale, five being the best. The average score here was 1.3, so low quality content, biased content.

In total, three quarters of these videos had undisclosed financial conflicts of interest that were not apparently mentioned in the videos. A lot of them included affiliate links, product endorsements embedded within the content. It's exactly what you see on social media.

It's a place where people are going for health information, but unfortunately also being sold things, and the quality of the information they're getting is poor, and physicians, I think, are missing out on the conversation or at least the opportunity to give people some evidence-based recommendations. The authors of this paper basically said physicians should strongly consider participating in social media to counter misinformation and make sure that we establish a physician presence in these digital spaces where so much information is being consumed. I'm not on TikTok.

I have an Instagram, but I don't do much on it. I used to be a Twitter guy, now it's X, but no one's really having these conversations anymore. It feels like the community is talking to itself, physicians, allied health professionals, embryologists, you name it, on LinkedIn, but I think there's still a ton of patient conversation that's happening on Instagram, on TikTok, on Facebook, and I feel like we're missing out a little bit on being part of that conversation.

Blake, Molly, what do you guys think? You guys have patients who come to you with these questions, and Daylon, I'll put a plug in here. I think your wife is pretty prominent on social media in kind of a different realm. Would love to hear your guys' opinions on all of this.

Well, let me start with that. She does it to make money. What does she do on social media? I didn't know this.

She's a very big deal, Blake. She's an influencer about wellness. Don't worry, not on ART.

She's not going to steal any of our thunder. I will say my experience with that, with her, it's pretty clear what the conflict here is. One, yeah, it's financially driven.

People who post, they do it to make money. If they're trying to increase their influence, it's to make money. The algorithm, obviously, what drives the interest, it's not going to be some level-headed, straight conversation from a doctor.

Then to your point about the doctors participating, I think the problem there is, one, they have money, or they have a way to make money that they don't need to get out there and influence, and I think there's a fundamental conflict with, in order to become a big voice, you almost have to be a strident voice, an extreme. I don't think it's in anyone's interest for their healthcare practitioner to have any extreme views. Yeah, they don't have the time.

They're busy. You guys are busy. You have time to post 10 times a day or whatever it takes in order to catch the algorithm? I don't think so.

I don't have high hopes for your ilk, the good guys getting out there and making a lot of great influential statements that are going to bring us back to center. That's the bad news. The good news is that you can clean up the mess.

I will say, I mean, I have several REI friends that are very active on social media, and I can honestly say I know that they're not doing it for money. I know that they're doing it, I know that's a lot of it in general for influencers, but I will say that, and a lot of which, I've probably even listened to our podcast, to be honest, but they do, just out of the goodness of their heart, want to post stuff and educate and promote and really, quite honestly, combat misinformation, which is so prevalent on social media and a lot of the stuff that Pietro's talking about. There's so much stuff online that is just completely bogus, and patients will fully embrace it.

For example, every single time, probably you do, you guys do an embryo transfer, and it's a small talk. What are you guys doing after this? What do they say every single time, every single time? What are they going to do? McDonald's, french fries, all of them. The doctor has to go get McDonald's french fries after the transfer.

Oh, is that a new thing now? Yeah, we both have to go side-by-side in the drive-thru, yeah. No, I have prediabetes. I can't do that.

That's not good for me, but that comes from TikTok. There's just not any data, at least that I know of, there's just nothing on that, but people fully embrace that and everyone does it. Fortunately, eating McDonald's fries is not something as crazy as intravenous lipid infusions, like some people also do, which that's another discussion we won't get into, but there's just so much stuff on social media that it's scary, all the misinformation.

I do think that it is important that as providers we promote the most current up-to-date literature and what is our field saying about these topics and combating misinformation. We can do our due diligence. People are still going to do weird stuff that we never approve of, but that's just the world we live in and it's not going to change because that's just how it is right now with social media.

I like that you shared this. I think I wasn't aware how small the doctor voices are. I go a little on TikTok, mostly Instagram, and I follow all these doctors who I think are great and evidence-based and mostly infertility or OBGYN, and I'm probably only getting my tiny piece of the algorithm.

I'm not aware of the 99%, and if I see that, I'm going to say, show me this. I think how can we elevate each other's voices? How can we promote voices? Then I also am well aware there's also doctors who are not giving evidence-based information and not qualifying. Sometimes I do talk to my patients and say, hey, this isn't evidence-based, but we could talk about this protocol, but they're not qualifying that, and there are doctors who are selling their own supplements, especially in our field.

I think we take a little blame too, but I think we should seek out those really evidence-based voices on social media, Dr. Blake Evans being one of them, all of you guys, and then like and share and try to elevate. I refer my patients to people's YouTube channels that I think are really good as well to get a little bit more information. Can you spell that again for me? What's his name, Molly? Got it.

We'll put it in the comments for the listeners. Yeah, absolutely. I will say, I dabble a little bit.

There are some of my friends who are on social media that, again, they are absolutely not in it for the money, but they have just massive followings and it's very impressive. To your point, Daylon, about being busy, I truly don't know how they make the time for it, but it's really impressive. There's some of our colleagues who have literally hundreds of thousands of followers.

I'm happy if I can make a post in a week and feel like I'm doing a good service just posting once in a week. It's impressive how much that they're able to post and so much of it is just selfless promotion of education and science and what does the literature say. Maybe if you stop sending me all those memes on Instagram, you'd have some time for some educational content for your patients.

We're doing our part here, sharing knowledge and joy at least once every two or three months. I think we checked off our service to the community. We have a good running list of memes we send to each other, medical related.

They're pretty darn funny. They're pretty good. Speaking of doing our part, we're glad to finally be back together as a group.

You can look forward to having more consistent articles now that the brains behind the operation is back. Molly, of course, being back from her postpartum leave. We're excited to be back and we're excited to bring consistent, unplugged episodes to you, all our listeners.

We're so appreciative that you guys continue to tune in and have asked us, where have you guys been? We missed you. Well, we've missed you too and it's good to be back. That's all the time we have for today.

I'm Pietro Bordaletto, your host, and as always, Daylon, Blake, Molly, thank you guys. That's @BlakeEvans and BlakeEvans.com. This concludes our episode of Fertility and Sterility On Air, brought to you by Fertility and Sterility in conjunction with the American Society for Reproductive Medicine. This podcast is produced by Dr. Molly Kornfield and Dr. Adriana Wong.

This podcast was developed by Fertility and Sterility and the American Society for Reproductive Medicine as an educational resource and service to its members and other practicing clinicians. While the podcast reflects the views of the authors and the hosts, it is not intended to be the only approved standard of practice or to direct an exclusive course of treatment. The opinions expressed are those of and do not reflect Fertility and Sterility or the American Society for Reproductive Medicine.

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