EP 293 Ozempic Babies, Miscarriages, & All Things IVF with Dr. Armando Hernandez-Rey

The Wholesome Fertility Podcast

Dr. Armando Hernandez-Rey is Conceptions Florida’s medical director and triple-board certified in Reproductive Endocrinology and Infertility; Obstetrics and Gynecology; and Surgery. Dr. Armando Hernandez-Rey has over 24 years of experience in the medical field. He graduated from Universidad Autonoma de Ciencias Médicas de Centro America in 1998. He attended medical school at the University of Miami Miller School of Medicine for his specialization in Obstetrics and Gynecology. He specializes in treating patients with polycystic ovary syndrome (PCOS), recurrent pregnancy loss (miscarriage), and severe endometriosis. He is especially interested in fertility preservation (eggfreezing) for patients who must delay childbearing for personal or medical reasons, including cancer and systemic lupus erythematosus. Dr. Hernandez-Rey is an assistant clinical professor at the Herbert Wertheim College of Medicine at Florida International University and serves as an ad-hoc reviewer for the prestigious peer-reviewed journal, Fertility and Sterility. He has also published several articles and chapters in medical literature.

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For more information about Michelle, visit: www.michelleoravitz.com The Wholesome FertilityFacebook group is where you can find free resources and support: https://www.facebook.com/groups/2149554308396504/ Instagram: @thewholesomelotusfertility Facebook:https://www.facebook.com/thewholesomelotus/ Transcript: Michelle (00:00) Welcome to the podcast, Dr. Hernandez -Ray. Armando Hernandez-Rey MD (00:04) Thank you, Michelle. Thanks for the invitation. It's really an honor and a privilege to be on your show, on your podcast. Michelle (00:09) Yes, well, I've heard a lot about you over the years because I've had a lot of patients go to you. And one of the things that I've heard is that you do really well with surgeries and fibroids and you're able to in and but in a way that still preserves fertility. So that was one of the things that I've learned. Armando Hernandez-Rey MD (00:32) Well, reproductive endocrinology and infertility as a subspecialty is a surgical subspecialty as is OB -GYN, which is a mandatory path to get to the infertility route. Unfortunately, a lot of the newer generation is not operating because they're not taught, not through no fault of their own, they're not taught. The reality is that it is... Michelle (00:47) Mm -hmm. Armando Hernandez-Rey MD (00:55) for a myriad of reasons this phenomenon has happened. Number one, the minimally invasive surgery tract has been developed where you have the person who's really just really perfected their obstetrical skills. And then you have the gynecologic oncology route and the pelvic urogynecology or pelvic reconstruction route and the minimally invasive surgical route. And a lot of the reproductive endocrinologists, have said, you know what, I'm going to forego surgery and I'm going to refer it out. My personal philosophy, and this is in no way critical to absolutely anybody, it's just my own, is that I went into medicine to be a surgeon, I actually wanted to be an orthopedic surgeon. I ended up not liking it, I had a very bad fracture when I was in my teens playing competitive soccer, and I really had some PTSD from that fracture, so I just couldn't see myself doing orthopedic surgery, but I somehow found my way towards OBGYN, absolutely loved it. And eventually towards the reproductive endocrinology route, which encompasses a lot of surgery, should you allow it. And so yes, like you said, fibroids are an important part of fertility. you, tubal reconstruction used to be much more important than it is now. People are more, are bypassing that route and going directly to in vitro fertilization. Endometriosis, as I said, I was running a little bit late today. I was in a very, very complex endometriosis case with a patient with bilateral endometriomas and complete frozen pelvis and scar tissue. And, you know, just a little bit longer, I had to work with the colorectal surgeons to do some resection of the colon because it was, you know, endometriosis is such an awful, awful disease. So yes, to answer your question, I... Michelle (02:41) Yeah. Armando Hernandez-Rey MD (02:44) Absolutely love surgery. I think it's an integral part of the infertility journey to get a patient from being infertile to getting them to a high level of success with any sort of treatment. And hopefully it's more conservative than having to resort to artificial insemination or in vitro and with just surgery and corrective surgery, we can help the couple achieve a pregnancy. Michelle (03:07) Yeah, and I think it's important because I think that a lot of people might not realize that there are certain people that specialize in this or have experience doing that, doing surgery and really getting in there because it is important to find somebody who's specialized if you have a complicated case. Armando Hernandez-Rey MD (03:23) I think it's important. I think people feel well taken care of. Again, my perception, people feel well taken care of when everything is done in house. Meaning, you know, there's no messages that get lost as you refer a patient out who may have the minimally invasive surgery knowledge, but not necessarily the focus on infertility, reproductive endocrinology. Michelle (03:33) Mm -hmm. Armando Hernandez-Rey MD (03:50) specialist has and I think people feel comfortable with that. Michelle (03:52) Yeah, absolutely. Because there's some people that will take out fibroids, but they're not doing it with fertility in mind. You know, for many women, it could just be just taking out fibroids, but you're doing these things with fertility in mind. Armando Hernandez-Rey MD (04:07) There are many great surgeons out there that are not infertility specialists. You know, I want to make sure that I'm clear. I just think that I was, I always love surgery. I happen to do surgery and I feel my patients feel very comfortable with me doing the surgery and not being referred out. It's what I think. You know, the journey, the infertility journey is very complex. It requires a lot of a woman in particular more than the male and to be Michelle (04:25) Yeah. Armando Hernandez-Rey MD (04:36) you know, passed around, it gets complicated. And I think it's nice to be able to offer that service to patients. Michelle (04:44) Yeah, for sure. And then you do specialize in miscarriages. Armando Hernandez-Rey MD (04:49) Sure, I mean, I think we all really have a focus on on as you know, we're all specialized in miscarriages and and PCOS and all that there's some people that tend to see More miscarriage patients or they people will refer miscarriage patients to us We have a particular kind of focus on that, you know, I think a lot of it is genetic, a lot of it is immunologic, a lot of it is just taking a holistic approach to things and not just focusing on one or the more common causes of infertility. And even now, I think that, you know, the use of supplements, which maybe 15 years ago was maybe considered some snake oil. Now, I think there's a lot of provocative data that has shown that supplements do work, in particular in Michelle (05:18) Mm -hmm. Armando Hernandez-Rey MD (05:44) cases with recurrent miscarriage. And now we have the ability to measure those levels and we are now ability to supplement those levels and they have tremendous impact positively on these patients. Michelle (05:57) And what supplements have you seen help with miscarriages? Armando Hernandez-Rey MD (06:02) Well, I think a lot of it has to do with what the cause of the miscarriages is. Oftentimes, believe it or not, miscarriages can alluded to fibroids, it could be anatomical, sub -mucosal myoma. Well, there's not gonna be any supplement that's gonna help with that. It's just purely the surgical route or the diminished ovarian reserve, Michelle (06:07) Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (06:29) cause for recurrent miscarriages, which is older women or ovaries that are behaving or eggs that are behaving older than what their chronological age would dictate, you have a higher chance for aneuploidy. And in those cases, there's a variable cocktail of supplements that we use, including ubiquinol, including N -acetylcysteine, including vitamin E, even melatonin has been shown to be very, very effective. And I can go on and on, even alpha lipoic acid. Michelle (06:50) Mm -hmm. Armando Hernandez-Rey MD (06:57) as well. There's some very nice studies coming out of Mayo Clinic that have shown that aflalipoic acid is very, very good for recurrent miscarriages. So again, things that we thought were, well, they can't hurt, now we know that they absolutely help. Michelle (06:57) Yeah. Right. Yeah. I mean, that's great because it just helps to know that there's something that people can do that really does make a difference. And it's not just like in theory with miscarriages when it comes to immunology. I'd love to talk about that because I know that that's a big one. Actually, I did see a study that showed that women who have are more sexually active, that their immune system calms down. It behaves differently in the luteal phase. Armando Hernandez-Rey MD (07:31) Mm -hmm. Michelle (07:44) so that it's able to receive life so that it's not seeing like the sperm as an invader the, yeah. Armando Hernandez-Rey MD (07:50) So women that are more sexually active than others, it's probably a function of repeated antigen exposure, which is the more the woman is exposed to the antigens of the sperm, more there becomes an acquiescence by the immune system to be more receptive of that embryo. Because remember, the embryo is Michelle (08:06) Mm -hmm. Armando Hernandez-Rey MD (08:19) a haplotype, meaning it's half female, half the woman, half the mother, and half the male. And the only genes that the immune system of the mother has got to harbor the pregnancy are her own. And so oftentimes the immunologic processes are heightened because it does not recognize the male antigens that are formed part of the embryo in general. But as a whole, I mean, recurrent pregnancy loss, Michelle (08:33) Mm -hmm. Right. Armando Hernandez-Rey MD (08:47) is, is a small portion of the general population and, it's skewed towards advanced maternal age and advanced paternal age. so the immunologic component, while absolutely important, I think it's the one where we're still not a hundred percent sure how to absolutely treat it. Although supplementation and. immune suppression definitely are known to work. It's the testing that I think we still need a lot more work in doing because you know people talk about NK cells and you know that was part of my thesis when I was a fellow. So we talk about NK cells and ANA and antiphospholipids and all of that and the reality is that these tests have very very poor sensitivity in the realm of immunologic infertility or reproductive immunology. And so you may have COVID and then you can test positive or lightly positive for NK cells. And so I think that the overwhelming response by the treating physician is, well, they're positive, they must be immunologically incapable of handling a pregnancy. So therefore we should treat. Michelle (09:40) Mm -hmm. Armando Hernandez-Rey MD (10:04) with nowadays what we use as intralipids. Back in the day, we used to use IVIG that has kind of fallen by the wayside a little bit. I think it's better to treat empirically than to have someone treat or test for all of these different immune markers that really, really in the presence of immunology and reproductive immunology, They have very low sensitivity. Now if you're treating or you're looking for lupus or rheumatoid arthritis or mixed collagen disorder or Sjogren's for sure, they are your go -tos every single time. Michelle (10:44) And what about a PRP for ovaries? What has do you do offer that? Armando Hernandez-Rey MD (10:50) ovaries. American study of reproductive medicine came out with a black box warning that they do not recommend PRP for ovaries. Now, PRP for recurrent implantation failure, poor lining development, there is some very robust data that there may be some room or benefit for this. Michelle (10:57) okay. Mm -hmm. Armando Hernandez-Rey MD (11:14) And we do do offer that. We do not offer intra ovarian PRP because ASRM has a huge black box warning on this. It's a liability. The potential for infection is there. Tubo ovarian abscess have been reported, adhesions, periovarian adhesions, and with very little to no benefit whatsoever. I mean, the whole premise for it is that we are... Michelle (11:16) Okay. wow, okay, I didn't know that. Mm -hmm. Okay, got it. Armando Hernandez-Rey MD (11:42) regenerating the follicle complex and therefore improving egg quality and that definitively has not been shown to be the case. Although anybody who suffers from that as I would be would be like, slide me up. But unfortunately, you know, it's very easy for us to fall prey to things that we desperately want without having the medical literature to corroborate it or back it up. Michelle (11:49) Got it. Right. Got it. So that's actually showing to not necessarily be what a lot of people originally thought, but for the uterus, it has been shown to help. Armando Hernandez-Rey MD (12:15) Yes, we are doing PRP installations and very select group of women with those diagnoses in particular. And. Michelle (12:25) So who would be a good candidate? Somebody who's had failed transfers, inflammation. Armando Hernandez-Rey MD (12:30) Yes, someone with very high quality embryos, high quality embryos that are not getting pregnant. Also patients, for example, patients who have adenomyosis that do not develop a nice lining, a thickened lining. Those have been shown. Our numbers are very small, you know, by no means. Michelle (12:42) Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (12:53) they are in the realm of what a randomized controlled trial should be. We're following the data from the randomized controlled trials and from the literature that's out there. So patients with adenomyosis who have poor lining development, recurrent implantation failure, so patients with euploid embryos, that means a normal embryo that's tested that looks to be high quality. Also, after a second implantation failure, we'll... offer that to the patient as a possibility. Michelle (13:19) Mm hmm. Got it. Awesome. And then also we were talking about Ozempic pre -talk. So I'd love to get your... Yes. Yeah. Ozempic babies. Armando Hernandez-Rey MD (13:24) the topic du jour these days, right? It's right. So as we were discussing, I mean, this, this phenomena is not really a phenomenon that's surprising at all. It is just a, a byproduct, a side effect of, of how the medication works and the effects that positive effects that I have on women with in particular, and ambulatory disorders, specifically polycystic ovarian syndrome, which is often tied to or associated with insulin resistance, obesity, sometimes even overt. type 2 diabetes and the elevated levels of insulin, the elevated testosterone levels, they all work together to create this sort of environment within the ovary and the system of the female which creates an ovulatory disorder or dysfunction. And as a woman loses weight by virtue of the way that these GLP1s or glucocortes Michelle (13:58) Mm -hmm. Armando Hernandez-Rey MD (14:22) Glucagon like peptides work They're very successful. They're very good at number one slowing gastric emptying which in turn slows down the release of sugar into the blood system to the Number one number two it stops the the release of glucose produced by the liver and Number three increases insulin levels so increase insulin levels helps get the the the sugar into the muscles out of the circulation and out of stimulating the ovaries and the theca cells to produce more androgens which then get produced produce more estrogen which then stops the hypothalamic pituitary ovarian axis from functioning correctly and as these levels drop patients automatically begin to have spontaneous ovulation if the system is working and the male has normal sperm and they're sexually active. this is how the ozempic baby phenomena occurs. And what we discussed also is that the concern is of the downstream consequences of ozempic babies given that the current recommendations are to have at least a two month washout period before anybody starts to try to conceive. Michelle (15:32) So two month washout means like really not trying anything. Yeah. And then also, I know like naturally, myonocytol is really helpful as well for insulin resistance. It might take a little longer. And then also metformin has been used as well. Armando Hernandez-Rey MD (15:37) No exposure, right? No exposure. Yeah. Yes. So, my own hospital is, is a, is a great product. my own hospital alone, although you will find oftentimes my, my own hospital with a D chimeric, hospital and really the literature shows that my own hospital by itself is the one that truly has the most benefit might be hard to find. Michelle (16:06) Right, yeah. Right because for a little while they said my own hospital and dechiro, but now they're going back to saying just my own ocital, correct? Armando Hernandez-Rey MD (16:23) Yeah, well the way that it's normally found in the body is at a ratio of 20 to 1. And that's what those supplements show, 20 to 1. Although we know now that in the ovary it's almost 40 to 1 ratio of myoinocytol to D -chimeric, inocytol. Michelle (16:30) Mm -hmm. Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (16:49) Myo Inositol is actually not an essential vitamin, but it's considered like a vitamin, but it's in the category of B8 It's a glucose like peptide that basically helps to Help the system function by processing the circulating blood sugar in a way that's more physiologic and there by lowering insulin levels and thereby also helping tremendously with Michelle (16:56) Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (17:16) regularity of cycles and even spontaneous ovulation as well. And metformin obviously is medication that's been around for many, many years. It is somewhat of a controversial drug. It is an anti -aging drug even these days because we know that insulin levels are so profoundly toxic for aging for the muscle and for the system in general. Michelle (17:29) Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (17:45) And so we know it works, we know that it helps with the efficiency of insulin. And so it's certainly been used for many, many, many years in the presence of patients with polycystic ovarian syndrome. I would challenge people to be a little bit more meticulous about using it in patients who are the lean PCOS. Michelle (18:11) Right. Armando Hernandez-Rey MD (18:11) or the skinny PCOS or the ovulatory PCOS even though insulin levels have been shown to be higher, slightly higher in... Michelle (18:19) So you're talking about being cautious with metformin, not necessarily myonositol. Yeah, yeah. Armando Hernandez-Rey MD (18:22) Metformin, you also don't want very high levels of myelonostetal because they can be, you know, there is some quote unquote toxicity. I think the recommendations are up to four grams per day. I think all the recommendations are four grams per day in two divided doses, two grams in the morning and two grams at night. I've seen patients be on eight grams and 10 grams and toxicity really starts happening around the greater than 10 gram dose. Michelle (18:29) Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (18:52) I in our office we only use it, you know, what's recommended which is the four gram total per day two grams in the morning two grams at night and I don't think it's the end -all be -all I don't think it's you know treating anything in life is multi -pronged. It's not just one single thing perhaps but I definitely believe very wholeheartedly that it does assist in in adjunct treatment, although we certainly have patients put patients on on myocytil and combined with Michelle (19:06) Yeah. Right. Armando Hernandez-Rey MD (19:20) diet and exercise and have been able to achieve pregnancies on their own, which is obviously what we want instead of having to go through treatments. Michelle (19:27) That's great. I mean, I will say that I was very surprised this past year. two different patients came from different, different places, not yours, it was other doctors, but I think the nutritionist there suggested metformin when they did not have insulin resistance or PCOS for egg quality. Armando Hernandez-Rey MD (19:47) Yeah, I'm not familiar with any studies that have shown that have improved that. In fact, when I was a fellow, we were, just as I was coming into fellowship, where I trained, Rutgers was involved with a very well known and publicized study, it's called the PP COAS study, which looked at patients on placebo versus metformin alone versus metformin with Clomid, sorry. placebo versus clomid versus clomid with metformin and there was no difference in pregnancy rates or anything else. I'll go one step further with them going back to the myonocytol. It has even been shown to decrease the rates of gestational diabetes and so in our patients with PCOS with who are you know Michelle (20:18) Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (20:39) Stage one, type one obesity, type two, we'll continue them on the myonostetal throughout the pregnancy and when they leave us and go to their OB -GYN, in our referral letter back, we'll say that we're recommending for her to continue on myonostetal because there have been improvements in sugar levels and glycemic control and reduction in gestational diabetes overall. Michelle (20:54) Yeah, that's good to know. another big one is vitamin D. A lot of people, even though we're in Florida here, we have a lot of sun. A lot of people are very deficient in vitamin D. Armando Hernandez-Rey MD (21:11) Yeah, What it is is a combination of things. Number one, we're not as sun exposed as you think we are. You know, we're always in a car, we're always indoors, it's very hot. And yes, we go out to the beach and there is a lot of sun, but we become very, very sensitive to the sun and to the untoward effects of the sun. Michelle (21:17) Mm -hmm. Armando Hernandez-Rey MD (21:35) So we protect ourselves tremendously. That's number one. Number two is that I think the levels are set higher than what the average person can sustain with just diet and sun exposure. And actually the recommendations now in the infertility world that when you order a vitamin D from Quest, they'll tell you that the levels are, you want them at Michelle (21:38) Mm -hmm. Armando Hernandez-Rey MD (22:04) definitively above 20 Certainly above 30 and now recently now the recommendations are that for them to go above 40 and and and Yeah, I'm not yeah, so I heard I've read 40 I it was a Paper that came out of Either the Lancet or Michelle (22:11) Yes, yep, I've been hearing that or even 50. Yeah. Armando Hernandez-Rey MD (22:27) or fertility necessarily, anyone, one of, that they recommend now for vitamin D levels to be above 40. So that's really hard. I mean, I work really hard. I take a lot of vitamin D and I'm just barely scraping like 50. You know, I take about 5 ,000 units a day, which is what we're recommending nowadays, 5 ,000 units of vitamin D. And I take that every single day and I barely scratch, Michelle (22:38) Mm -hmm. Yeah. Armando Hernandez-Rey MD (22:56) you know, 45, 50 every time I get an average check. So I'm not getting as much sun as I think I am, number one. I am out fairly often. I do play some golf, not enough. And yet it's not enough. So definitely supplementation's important. Michelle (23:03) Mm -hmm. Yeah, magnesium is also important. That's another thing. It's to not be deficient in magnesium because magnesium plays an important role of our absorption of D, which, you know, obviously doing this, I learned, I was like, that's might be deficient magnesium and be taking a lot of D and then their body's not processing, which is why it's important sometimes even in foods, foods have everything. So like, even beef liver, you know, from Chinese medicine perspective is so beneficial because it has iron, but it has it in a combination of nutrients that helps the body absorb it. Armando Hernandez-Rey MD (23:46) Yeah, B6, B12 are incredibly important for iron absorption as well. So all of these things are extremely important. Everything is all intertwined and we're just learning about this. And for us, I've really gotten grabbed hold of this whole longevity thing, hence my aura ring and all of this. And... Michelle (23:57) It is. Yeah. Armando Hernandez-Rey MD (24:09) I'm just trying to apply a lot of the things that we know today work for longevity medicine and anti -aging principles to the infertility world because it's all intertwined. It's all intertwined. Michelle (24:16) Yeah. without a doubt. It's funny because that you say that because I always say it's pretty much anti aging. Yeah. Armando Hernandez-Rey MD (24:26) Yeah, totally, totally. They're even coming up with a way to stop menopause. Michelle (24:36) wow. How? Armando Hernandez-Rey MD (24:37) which is extremely interesting. Believe it or not, recombinant antimullerian hormones. Michelle (24:42) How is that? Explain that. Armando Hernandez-Rey MD (24:46) So the way that antimullerine, the function of antimullerine hormone at the level of the ovary is that it stops follicular recruitment. That's why women with PCOS have higher AMHs and therefore they have higher egg counts and higher, they tend to go into menopause later on, et cetera. That's because they have high levels of antimullerine hormone. So by reproducing or creating it in the laboratory and then from an early stage, This is in its infancy, by the way, okay? So this is, yeah, this company, I believe she's a Harvard scientist, biochemist or something, who's coming up. My point is that, listen, that it's all intertwined, aging and even in menopause, for God sakes. Now I've been doing this for so long that I now, Michelle (25:18) It's new. Mm -hmm. Armando Hernandez-Rey MD (25:39) seeing menopausal patients who were like, you know, listen, you took care of my baby, you're a reproductive metachronologist, you understand the science, will you treat me? And, you know, like, and I realized, like, somewhere, some women got like, they got a some bad luck thrown their way because, you know, with the WHI results and the way they were interpreted, they made hormones bad. And somewhere along the way, someone said, It's okay for women to suffer from menopause, just suck it up. Like it's not okay. That's not okay. That's not okay. And so if you start from very early on and, you know, and, and really practice what you preach, which is healthcare and not sick care, which is what we practice in the United States, you know, we're just very, we, we're not proactive. We're reactive to when a patient is sick instead of early intervention, early screening and all of that. Michelle (26:25) Yeah, absolutely. Armando Hernandez-Rey MD (26:30) And that goes for the infertility world and that goes for a woman's long reproductive life extending past menopause. I think we still have a lot of challenges to overcome, but I think that we're heading in the right direction. Sorry to digress a little bit. I went off on a tangent there for a second. Michelle (26:43) Yeah, for sure. no, it's okay. But you know what? I love the passion and I love that, that, you know, ultimately is great. It's important, very important, because it's true. And I agree a lot with what you just said, that we should be proactive when it comes to healthcare. I mean, really when it comes to so many things and something else that I... that I read, it was an animal study. It was a study on, I believe it was like, I don't remember which kind of animal it was. I think it was like either sheep or cows or some form of those where they actually gave them oxytocin right before IUI. And that improved the chances of the conception rates, which I thought was very interesting because I think that that's one of the things with IUI that's missing because obviously you're taking away the connection. that is usually there when you're just under natural circumstance. And I thought it was interesting because I was looking into it for something else to understand from a Chinese medicine perspective, because they have this heart -uterusconnection, that connection, the bonding. And so what I found was interesting too is that oxytocin increases around ovulation and after intercourse. And usually what they look at it as its role is usually for labor. not so much conception. So I was just going to kind of like pick your brain on that. Any thoughts on that? Armando Hernandez-Rey MD (28:13) Well, I mean, oxytocin is secreted at the time of... I'm not sure of ovulation, I didn't know that. But definitely at the time of... Michelle (28:21) or it increases around that time, like right before ovulation in the cycle, a woman cycle. Armando Hernandez-Rey MD (28:27) What we know that it's involved is at the time of orgasm. And so this may promote uterine contractility, which is what is used for intrapartum, to promote contractility of the uterus, to promote descent and eventual delivery. And we know that it's intimately involved in orgasm, we're seeing. Michelle (28:33) Mm -hmm. Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (28:55) during intercourse and orgasm and so with you know the projection of with the secretion of oxytocin and it causing uterine contractility obviously not at the same level that it does during labor but at smaller amounts then I can see how there could be a role for oxytocin in artificial insemination. Michelle (29:18) even in fertility in general and because it's got to be there for a reason why would the body produce it around that time? Armando Hernandez-Rey MD (29:25) Well, yeah, I guess, but it's either IUI or IVF and we definitely don't want oxytocin during the IVF cycle. Michelle (29:33) Right, because you don't want to contract, right? Armando Hernandez-Rey MD (29:35) Right, because we're transferring an embryo where there should not be any oxytocin. And you can have the most beautiful embryo, but if you screw up the embryo transfer, through no fault, just because it's a difficult transfer for a myriad of reasons, and you cause uterine contractility, then there's a high likelihood of pregnancy not occurring during that time. Michelle (29:57) Right. I think it would be an interesting thing to look into for IUI. There might be something to it, because if it works with animals, and the animals obviously have similar certain functions that we do, mammals, that seems like an interesting thing. Armando Hernandez-Rey MD (30:10) Yeah. I think there's not going to be a lot of resources put into improving IUI, to be honest with you. IUI, I think it is what it is. And I mean, I think the majority of research is going to go to improving even more IVF rates, because I think ultimately patients are going to want to go more. Michelle (30:22) Mm -hmm. Yeah. Armando Hernandez-Rey MD (30:40) towards IBF, no matter how hard we try to say, hey, listen, there's this option or this option or this option. It's more become a more of an instant gratification society. Number one, number two, people are waiting longer. So therefore they're more pressed for time, if you will. And I think there will be less of a motivation to go down a treatment option that frankly, Michelle (30:48) Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (31:07) You know, has a low pregnancy rate. Michelle (31:09) Right. And then my other question is, what are your, thoughts about a lower intensity cycle? like lower amounts of hormones for older women. In some cases I've heard it might be a little better. you do? Yeah, yeah. Armando Hernandez-Rey MD (31:24) We use it all the time. Yeah, we use it all the time. I think it's... a very successful option in cases with severely diminished ovarian reserve. I think that the senescent ovary does not do well with high impact medication or high doses of medication separately, but you know, jointly the medication costs are exorbitant and you end up having the same number of eggs that are mature, that get fertilized with a mini stent protocol as you do with Michelle (31:38) Okay. Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (31:59) a high dose regimen. Michelle (32:02) Okay, so you've seen good success with that. Armando Hernandez-Rey MD (32:06) Well, I mean, not good success because generally these cases are, we've seen success. Let's call it that. Because the patients that you're treating with these medics, with this protocol are patients who are POI, you know, premature ovarian insufficiency, diminished ovarian reserve, poor egg quality, high rate maniploidy. So these are your poor responders essentially. And they're very... Michelle (32:12) Yeah, okay. Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (32:34) specific factors that propel a woman to have success with this protocol compared to her twin sister with almost the same testing who doesn't do as well. Michelle (32:47) Got it. And then lastly, we talked about this in the pre -talk, let's talk about marijuana and sperm, data is showing. Yeah. Armando Hernandez-Rey MD (32:55) I don't do it myself, but I have no problem with people that do. What the data has shown that we're just becoming more and more familiar because the overwhelming number of people who are using cannabis and open about it, which is the second part, which was very difficult to conduct studies because it was so people were ostracized. They were looked at. not the wrong way and seen as in the fringe. And now it's, you know, it's so mainstream. but so now we're, we're keenly aware, of patients were able to analyze them and what we know without a shadow of a doubt that the potency of the cannabis that's being produced these days is anywhere between eight to 12 times more potent than I think I use the joke of the guys at Woodstock back in the sixties, right? Michelle (33:21) Mm -hmm. Mm -hmm. Armando Hernandez-Rey MD (33:46) where everybody was getting pregnant and everybody was high on life, all of those things. And then what we've also known, which I did mention, is that using the vape pens, whatever types of inhalers as opposed to the traditional joint, if you will, increase the potency of that by a factor of two to three. The cannabis that was already potent to begin with. Michelle (34:08) Yeah. Right. Armando Hernandez-Rey MD (34:14) So what you're seeing in males in particular, and I'm not sure that the literature is so complete on the female aspects, are that we're seeing a high levels of fragmentation. And what fragmentation is, is imagine that sperm is like an Amazon box. And inside that box, there's a porcelain doll that's wrapped in these packing cubes. They're held very, very tight. And under... Michelle (34:26) Mm -hmm. Armando Hernandez-Rey MD (34:40) The best of circumstances, those packing cubes are wound so tight, packed so tight that nothing, if I kick the box off the Amazon truck, nothing is gonna happen to the porcelain doll. Well, as fragmentation occurs and it happens under natural conditions and old guys like me, you know, patients who, occupational hazards, firefighters, exposed to toxins, a lot of people who use fertilizers, et cetera, et cetera. you see high levels of fragmentation. I'm talking about DNA fragmentation. And so what we're seeing is high levels of fragmentation at the level of the DNA of the sperm, which has significant effects on embryo quality, embryo development, and pregnancy rates, and high levels of aneuploidy, which is abnormal embryos. So, Michelle (35:10) So you're talking about DNA fragmentation. Yeah. Yeah. Mm -hmm. Armando Hernandez-Rey MD (35:33) You know, I'm not here to like, you know, slap you on the wrist and say don't smoke weed, but really that's what you're facing. And we know that this happens in women with cigarette smoking. Like this is a well -known cause of an accelerated transition to perimenopause. You know, 65 % of women who smoked a pack a day for greater than 15 years will go into menopause before the age of 40, assuming they started before their 20s. That's a pretty... Michelle (35:40) Bye. Mm -hmm. Armando Hernandez-Rey MD (36:03) ominous number, actually. Thankfully, not many women smoke these days, cigarettes anyway. So I guess the results of cannabis on females is yet to be elucidated, but we definitely have some pretty compelling evidence in terms of the male data that show that it can have detrimental or deleterious effects on sperm quality and not necessarily on numbers. Michelle (36:04) Yeah. Mm -hmm. right, which is what people look at usually when I mean, that's like the, the analysis is always on numbers shape and, numbers shape it. Yeah. And morphology and they won't necessarily look at the DNA fragmentation. That's actually not something that REIs usually initially look at. Armando Hernandez-Rey MD (36:33) Exactly. the thesis in morphology. is done in a well not initially unless there's comorbid situations or things that raise your red flags. For example, advanced paternal age, we always do it. Particularly in egg donor cycles, right? Because patients will be like, well, I'm using an egg donor and why don't I have bad energy? Well, because your husband could be 70 or 60 and Michelle (37:11) Yeah. Armando Hernandez-Rey MD (37:14) And then their fragmentation is completely elevated and through the roof. So yeah. So, you know, firefighters, occupational hazards. Michelle (37:18) Right. So, yeah, it's important. It's important for people to hear this because they can go in and say, the semen analysis was perfect. But that, like what you just said, is not really checked. So they may not, in a healthy, like, younger guy. Armando Hernandez-Rey MD (37:35) It's not as nuanced as we once thought it was. Michelle (37:38) Yeah. Yeah. Interesting. It's, it's fun. It's always fun for me to talk to our, our ease, you know, just to get, to pick your brain and get your thoughts. and you're my neighbors. So it's pretty cool. Armando Hernandez-Rey MD (37:50) That's right. Thank you very much for the invitation. This was really fun. We spoke about a wide array of different topics here. So this was really nice to connect this way. Michelle (37:53) Yeah. Yeah. Yeah, for sure. And I know that a lot of people are going to be like, this is interesting information. Cause I know that what you just mentioned, a lot of it is not common knowledge. people don't know automatically hear about this or really know to think about asking about it. So, so I appreciate all your information, all your good, good data. And, for people who would like to work with you or in town, how can they find more about you? Armando Hernandez-Rey MD (38:27) Well, we are at Conceptions Florida. We have two offices in Merritt Park, Coral Gables and one in Miramar and hopefully soon also in Boca. And I'm there Armando Hernandez -Ray, MD I'm sure. Easy to find these days on Google, but I'm happy to help in any way that we can. We've been doing this for a long time, quite successfully, thankfully. And we take a lot of pride, humbly speaking, but probably also. in having a good footprint in South Florida and the infertility world and trying to offer the best care possible. Michelle (39:01) Awesome. Well, this was such a pleasure and thank you so much for coming on today. Armando Hernandez-Rey MD (39:05) Thank you, Michelle.