Female fertility: optimizing reproductive health, diagnosing and treating infertility and PCOS, and understanding the IVF process | Paula Amato, M.D.

Peter Attia

Jun 9, 2025

Episode description

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This is part two of a two-part mini-series on fertility and reproductive health. Paula Amato is a leading expert in female reproductive health and infertility, widely recognized for her contributions to advancing fertility treatment and research. In this episode, which follows last week's conversation on male fertility, Paula explores the biology of female fertility, including how hormonal changes regulate the menstrual cycle and ovulation, what those patterns reveal about fertility potential, and why both partners should be evaluated early in infertility workups. She discusses the role of the fallopian tubes, the causes of miscarriage, the impact of age and lifestyle on fertility, and treatment options for conditions like PCOS—including the emerging use of GLP-1 agonists. The episode also covers the evolution of IVF, advances in pre-implantation genetic testing, egg freezing, and the promise and limitations of next-generation reproductive technologies.

We discuss:

The finite nature of a woman’s egg reserve, how it changes over time, and the basic process of ovulation and fertilization [3:00];
How hormones influence egg selection, and how and why chromosomal errors lead to most miscarriages [5:30];
The full journey of conception—from hormonal cues triggering ovulation, to fertilization, embryo development, implantation, and early pregnancy risks [16:30];
How infertility is defined and diagnosed, and the broader trends contributing to rising infertility rates [25:15];
Fallopian tube damage: how STDs and scarring impact fertility and raise ectopic pregnancy risk [31:30];
Unexplained infertility: how doctors evaluate ovulation and cycles—and why more research on women’s health is needed [41:00];
The defining symptoms of polycystic ovary syndrome (PCOS), its hormonal characteristics, and its relationship with insulin resistance [44:00];
Managing PCOS without pregnancy: cycle regulation, androgen suppression, and insulin resistance treatment [46:00];
The treatment approach for women with PCOS who are trying to conceive: GLP-1 use, ovulation induction, and timing protocols [49:45];
Barriers to getting informed fertility care for PCOS: limited provider knowledge and access, insu

Episode description

View the Show Notes Page for This Episode

Become a Member to Receive Exclusive Content

We discuss:

The finite nature of a woman’s egg reserve, how it changes over time, and the basic process of ovulation and fertilization [3:00];
How hormones influence egg selection, and how and why chromosomal errors lead to most miscarriages [5:30];
The full journey of conception—from hormonal cues triggering ovulation, to fertilization, embryo development, implantation, and early pregnancy risks [16:30];
How infertility is defined and diagnosed, and the broader trends contributing to rising infertility rates [25:15];
Fallopian tube damage: how STDs and scarring impact fertility and raise ectopic pregnancy risk [31:30];
Unexplained infertility: how doctors evaluate ovulation and cycles—and why more research on women’s health is needed [41:00];
The defining symptoms of polycystic ovary syndrome (PCOS), its hormonal characteristics, and its relationship with insulin resistance [44:00];
Managing PCOS without pregnancy: cycle regulation, androgen suppression, and insulin resistance treatment [46:00];
The treatment approach for women with PCOS who are trying to conceive: GLP-1 use, ovulation induction, and timing protocols [49:45];
Barriers to getting informed fertility care for PCOS: limited provider knowledge and access, insu

Mindsip insights from this episode:

Discontinue GLP-1 agonists two months before pregnancy in PCOS patients

GLP-1 agonists are increasingly used for weight loss in PCOS patients, but must be stopped at least two months before attempting pregnancy due to a lack of safety data.

#fertility

#GLP1

Acknowledge unknown factors affecting embryo implantation success

Even a chromosomally normal embryo selected through genetic testing only has about a 70-75% chance of implanting, highlighting that there are still unknown factors for success.

#fertility

Freeze eggs in early to mid-30s for optimal quality and cost-effectiveness

The most cost-effective time to freeze eggs is in the early to mid-30s, as this is the age where you are most likely to eventually need them and the quality is still high.

#fertility

Explore in vitro gametogenesis for egg creation from skin cells

In the future, in vitro gametogenesis could allow for the creation of new eggs from a person's own skin cells, a process already successful in mice.

#fertility

#genetics

Utilize mitochondrial replacement therapy to reverse age-related decline

Mitochondrial replacement therapy is an emerging technology that places the nucleus from an older egg into a younger donor egg to leverage its healthier mitochondria and potentially reverse age-related decline.

#aging

#mitochondria

Understand that miscarriages are often due to chromosomal abnormalities

The vast majority, close to 90%, of first-trimester miscarriages are due to chromosomal abnormalities, not anything the patient has done wrong.

#fertility

Get semen analysis to uncover underlying health issues

It's recommended that men get a semen analysis even when not trying to conceive, as it can be a marker for other underlying health problems, much like a woman's menstrual cycle.

#fertility

#testing

Increase funding for women's health research to address reproductive health gaps

A significant reason for the many unknowns in female reproductive health is that research in this area receives only about 10% of the overall NIH budget.

#research

#women

Choose letrozole over clomid for effective PCOS ovulation treatment

Letrozole is now considered a better first-line treatment than Clomid for inducing ovulation in women with PCOS, as studies show it results in higher pregnancy rates.

#fertility

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