Posted on October 22nd, 2020by RMANY

Ep 36: Oncofertility with Dr. Jovana Lekovich

Fertility Forward Episode 36:

There has been a significant societal change concerning the economy, the science we have developed, as well as the medicine we now practice. Along with many contributing factors including increased life expectancy, a pushback in childbearing age, and other extrinsic factors like illnesses and respective treatments, many people, male and female, are now reaching out and going through the process of fertility preservation. Our guest today specializes in and advocates fertility preservation for women in general. Dr. Jovana Lekovich is a board-certified obstetrician and gynecologist, a reproductive endocrinologist, and an infertility specialist. She cares for patients at RMA of New York’s Brooklyn and Manhattan offices. She is the Director of the Oncofertility Program at Blavatnik Family — Chelsea Medical Center at Mount Sinai. Dr. Lekovich is also an assistant clinical professor at the Icahn School of Medicine at Mount Sinai in New York, where she specializes in treating all aspects of reproductive medicine and infertility. She is most passionate about understanding the principles behind ovarian aging and diminished ovarian reserve as well as fertility preservation for patients facing cancer diagnosis needing gonadotoxic treatment. Today’s topic focuses on and around Dr. Lekovich’s specialty of oncofertility, something we haven’t explored yet on the podcast. Stay tuned for a fascinating discussion around fertility preservation, the process it involves, and more!

Transcript of Episode 36

Rena: Hi everyone! We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Rena: Dr. Jovanna Lekovich is a board certified obstetrician and gynecologist and reproductive endocrinologist and infertility specialist who cares for patients at RMA of New York’s Brooklyn and Manhattan offices. She's the director of the oncofertility program at Blavatnik Family Chelsea Medical Center at Mount Sinai. Dr. Lekovich is an assistant clinical professor at the Icahn School of Medicine at Mount Sinai in New York where she specializes in treating all aspects of reproductive medicine and infertility. She is most passionate about understanding principles behind ovarian aging and diminished ovarian reserve, as well as fertility preservation for patients facing cancer diagnosis needing gonadotoxic treatment. Whoa, that was a mouthfull of words in your bio! We are so happy to welcome you to our podcast.
Jovana: Thanks for having me. Very excited to be here or there
Dara: Virtually there!
Rena: But we're so excited. We've never delved into you specialty oncofertility on here before. So I'm really excited to talk about it. And I know that I'm going to learn a lot from you as well.
Jovana: Thank you. Thanks for having me. And thank you for devoting this episode to this important topic, which I think is getting more and more interest and financing, especially this year, since it became available to many more people in our state.
Rena: So what exactly is oncofertility?
Jovana: That's a good question. So oncofertility or fertility preservation for cancer diagnosis is a specific niche of reproductive medicine where we focus on preserving fertility for both male and female patients who are facing a malignant condition and the malignant condition itself is often not the cause or often not the reason that imposes harm from future fertility, but rather treatments that are needed to treat these conditions are the ones that can hurt future fertility in both women and men, which is why we focus on preserving fertility prior to these treatments are being initiated.
Rena: So can you give an example of what one of those would be?
Jovana: So for instance, an example would be in most conditions, most malignant conditions, this will be the mechanism of injury, but one of the classic examples, one of the most common examples that I face in my everyday work would be breast cancer. It is a fairly common cancer. It’s actually the second most common cancer in women of reproductive age. And even though the cancer itself is not affecting ovarian function or uterine function, right? Most of the protocols that are involved in treatment of breast cancer, unless it's a very, very early stage that does not require any further treatment besides the surgery will involve certain chemotherapeutic agents that carry a lower or a higher risk of either completely destroying the ovarian function or leading to a very diminished function through basically destroying all the sites in the ovaries. And so this would be an example where when an individual is diagnosed with breast cancer and the treatment plan consists of future chemotherapy or even radiation that also has this potential, they are advised to consider freezing their eggs or embryos if they're in a relationship or using donor sperm prior to that treatment, knowing that the treatment might cause problems with fertility in the future from minor diminishing infertility to actual complete loss of ovarian function and menopause. But there are examples where cancer itself can lead to diminishing or destruction of fertility and that would be invasive cervical cancer. That requires a hysterectomy, which would be the removal of the uterus, or let's say ovarian cancer that requires removal of the ovaries. So those would be some of the examples. Breast cancer, as one of the most common things that I see also carries another risk, which is not necessarily through the treatment, which we just mentioned earlier, but rather specifically, women who are diagnosed with estrogen receptor positive breast cancer are advised to be on anti-estrogen therapy for at least five years after treatment to prevent recurrence of the cancer and the newer studies are suggesting even 10 years. So that inevitably leads to, you know, this, iatrogenic indicated delaying of childbearing . And if you're diagnosed with breast cancer at 36 and you have to be on this therapy until you're 46, natural conception of 46 is very unlikely.
Rena: So this seems like it would be very time sensitive. Like you, obviously, you wouldn't be planning to do this until you've got a diagnosis and then it seems like it must be kind of rushed because if you know that you have cancer that you need to treat, you don't then have months to put off treatment. So how does that work? Are you able to get this in prior to starting treatment?
Jovana: So yes, Rena you're absolutely correct. One of the big differences in fertility preservation for cancer indication and for some medical conditions that also require these sorts of treatments. It's not just cancer, but most of it is going to be a malignancy that requires chemotherapy. But one of the biggest differences from, you know , preventative fertility preservation or elective fertility preservation is the urgency of the consults. I can give you an example just from yesterday that, you know, one of the oncologists called me at 11:00 AM while I was seeing patients making an urgent referral for fertility preservation for a woman who has been diagnosed with invasive cervical cancer and who needs to have a surgery to remove a certain portion of her cervix and the uterus and go through staging and start radiation immediately because the cancer is advanced. So she called me at 11 from her office and I was seeing a patient 12:30 PM. And this is something that myself, as well as RMA are really committed to, we're committed to seeing patients within 24 to 48 business hours. There is no time to see them differently because most of these patients will have a treatment plan in place. And most of them will not be able to delay it significantly because that could lead to the advancement of the primary cancer and lowering their prognosis of survival.
Dara: Oh, wow. I mean, that's great that RMA is on it in terms of getting in touch with those patients as soon as possible. I'm also assuming that the protocol is somewhat different for these patients in terms of priming them or medication-wise. Can you walk us through that?
Jovana: You're absolutely right. Dara. So for a lot of patients when we're starting any sort of controlled ovarian stimulation, either for IVF or for purposes of freezing eggs or embryos in a non-medically indicated setting, we have the ability to affect and manipulate the start of their cycle for timing purposes or for purposes of diminished ovarian reserve. And being able to synchronize the follicular growth in women who were early recruiters of the follicles. And a lot of those options are actually not available to us in the cancer population and there's several reasons for that. First reason would be that many of the cancers that I see in my patient population, namely breast cancer for instance, are going to be estrogen receptor sensitive, or we know that their progression is driven by estrogen and therefore any priming would not even be possible because for most of them, it is contraindicated to use birth control pills which is what we use for priming. Another parallel and how we do things differently in this patient population is going to be, you know, the actual start date. Ideally we want any non-medically indicated process of control stimulation we want to initiate the stimulation of the ovaries before the brain makes the recruitment of the dominant follicle, which for most women in the elective setting would be day two or three of the menstrual cycle. In cancer patients we don't have that luxury of waiting until their day two or three of their next cycle, because the patient that I saw yesterday was day six of her menstrual and I would have to basically wait for three weeks to be able to start her at that time. And so we utilize a lot of this approach that it's called a random start, which is basically starting them pretty much anytime they show up for a consultation or within a few days. The only time you don't like to start, these patients would be if they're peri-ovulatory, a day or two before ovulation or day or two after ovulation, because that leads to potentially lower oocyte yield at the end of the line. But any other time is really okay in several studies that demonstrated that their simulation is not going to be inferior in terms of that oocyte yield as a day two or three stimulation. And then finally, again, going back to these estrogen sensitive malignancies, which would be uterine cancer, types of ovarian cancer, breast cancer, we attempt to keep their estradiol levels very low and in a regular nonmedical indicative stimulation, as a consequence of stimulation of multiple follicles, estradiol levels increases significantly in comparison to a normal menstrual cycle when you only have one follicle growing. And so this is something that we always try to avoid in patients who are facing estrogen sensitive malignancies, knowing that even the shortest possible exposure to elevated estrogen could lead potentially to the progression of the disease. So we use a medication that is called Letrozole or Femara, which is an aromatase inhibitor and it prevents actually production of estrogen so that we keep their estrogen levels low through the stimulation that's preventing this potential risk in their specific group of cancers.
Dara: And Letrozole is somewhat new in the fertility realm, but that's amazing. I had no idea that it could also be used in this case.
Jovana: Yeah, Letrozole is actually a medication that is used. It’s FDA approved for use of breast cancer recurrence in women who have estrogen sensitive breast cancer. There are two medications that can be used. One is Letrozole or Femara, which is typically used in postmenopausal women, or can be used in premenopausal women also with some suppression of their ability to ovulate. And then you have Tamoxifen, which is a selective estrogen receptor modulator, which is an older drug. So by parallel, you know, Tamoxifen has been used to keep estrodiol levels low in women with the previous cancer to prevent recurrence. It's brother called Clomid was used for ovarian stimulation and the first studies were done in the sixties and Israel. And so this is not a widely used drug for ovulation induction, and superovulation so similarly to that, you know, examining those two medications from the same group of medications, we also figured using Letrozole could potentially lead to the same effect of being able to stimulate fully for growth while keeping estrogen levels low. So it has a different mechanism of at action from Clomid, but it is actually used quite effectively and it's superior to Tamoxifen in keeping estrogen levels low, but we also use it at least in the past 10, 15 years, we use it for mainly for patients with PCOS. who are not ovulatory.
Rena: I was on Letrozole as part of my protocol. And I remember finding out that it was also used to treat cancer and I like really had to wrap my head around that because…
Jovana: There's one caveat though with this medication and several of my patients have experienced it. I don't know if you experienced it Rena when you were using it in the past, but there was one such a study that was not published. It was an abstract presented at a conference. And I believe that the conference actually took place in Canada and it showed a possible increase in congenital anomalies in women who conceive while they're taking Letrozole. If the rate in normal population in general population with 3% of developmental problems of the fetus, that rate was found to be about 4.5% in women who had been using Letrozole, which is why the advice was to suppress ovulation for women who were using Letrozole for breast cancer recurrence prevention. However, several prospective randomized trials have refuted those findings specifically in patients where this drug is used for ovulation induction for patients with PCOS or for superovulation in patients who have unexplained infertility, who are ovulatory and still not getting pregnant. But because of that one abstract, this medication will still have that black box warning and it happen to a few of my patients that when we prescribe these medications for PCOS because it's a drug of choice, actually superior Clomid that they will be put aside by less educated pharmacists and we'll be told that they shouldn't be taking this if they're trying to conceive because it could cause problems, even though in the setting of ovulation induction, you would use this at least two weeks or three weeks before actually getting pregnant.
Dara: Wow. And this is only from one study that this warning came about?
Jovana: It wasn't even a study. It was an abstract that was actually never published in this study.
Dara: Oh, wow. So it goes to show you, you have to be careful when you just, because research is being done, you have to look deeper to see, is it just an abstract, is it an actual randomized controlled study or is it just an observational study?
Jovana: That's right. That's right . Because the level of evidence is going to be different.
Rena: I remember even just asking my doctor, because I think, I don't know if it was the pharmacist or someone said, well, this isn’t FDA approved. So then I was like, wait a second. Why am I being prescribed a medication that's not FDA approved? And then my doctor had to explain to me like the nuances of the whole thing, but I remember being really freaked out .
Jovana: Yes. It can be scary. That's typically the call from a patient who calls the service or emails us frantic at like seven or 8:00 PM after they picked up the drug. Like , are you actually giving me something.
Rena: Yeah it’s scary. What am I putting in my body? Hold on a second.
Jovana: It can be scary, but I'm sure that your doctor explained to you this and that, you know, explain the data behind it and why this is, it's very hard refuting these findings in the eyes of the watchdog and the same goes for estrodiol. And we don't need to talk about it now, but I'll mention it to you, but it same goes with estrogen, which all of our patients are on for going through IVF, getting pregnant. It's also a category D and because one of the drugs from the group of estrogens, the ethysylvester used to cause birth defects and normal uterine development and cervical cancer. So all drugs with estrogenic activity have this label.
Dara: Oh, wow. Let's talk about men. Do you also work with men and how is the protocol any different. I'm sure it is in terms of medication?
Jovana: Yes. So basically, yes, we work with men as well as women. And for men, fertility preservation is actually much easier, less expensive and much quicker. Exactly. Which is why, you know, fertility preservation for men has always been covered. And fertility preservation for women who are also facing cancer has just gained coverage in New York state just this year, because it is more lengthy and more expensive. For men it's quite simple actually they just need to masturbate in a cup and preserve their sperm. There's typically no need for any stimulation because men have readily available mature sperm cells in each ejaculate. They have millions of them. And usually within one to several ejaculates, you'll be able to preserve ample amount of sperm that can be used in the future to ensure biological offspring. There are some nuances in certain populations, such as patients who are very sick. For instance, patients who are hospitalized or in the ICU, let's say a man diagnosed with bad lymphoma that is in the chest and causing problems breathing or causing leukemia that is presenting as sepsis and stuff like that. For those men, it can be a range that they actually produce a sample at the hospital and then their family members can actually bring it in for freezing to our facility. And then there's a very specific population, which is the most unfortunate population of all, which are pre-pubertal boys. And the reason why I'm saying they’re unfortunate is that in pre-pubertal boys, there are no mature spermatozoa or sperm cells. There is no production in the testicles that production starts in puberty. And so there's just STEM cells called spermatagonia that are present in the testicles that are not activated yet. And so the option is really lacking in this patient population because freezing sperm will just give you seminal fluid. There are no spermatozoa in the ejaculatory. And so testicular tissue is what can be frozen, but this is highly experimental. And unfortunately there are no live births reported from this procedure because what it would entail would be basically freezing testicular tissue and we have been advising this in hope that in the future, we'll be able to coerce these STEM cells in the testicles called spermatozoa to coerce them into differentiation, into mature sperm cells. And that has been done in humans, but in a highly experimental setting. And we do work with a pediatric urology department specifically, Dr, Nehamahotra that I just connected with recently because she joined Sinai just a month ago as a new attending, but she specializes in freezing testicular tissue for pre-pubertal boys in hopes of being able to yield spermatozoa from this tissue in the future.
Dara: So there's a lot more to be done in terms of research in that area?
Jovana: That's right. As you know, the general field of reproductive medicine is moving at the speed of light. So I'm really hopeful that for some of these boys, they won't be, I mean, it's been done, it's been done in several species, including humans. So, but it's still highly not advisable to use it in a clinical setting because we still don't know what the risks are potentially and so forth.
Dara: I was doing a little bit of research today on oncofertility. It's not necessarily something in my wheelhouse and I found an interesting thing. I'm not sure this is a commonly done procedure where they can actually shield part of the ovaries for radiation. They basically move it, whether they remove it or whether they can push it into a certain area to help shield it. Is that something that's commonly done?
Jovana: So it's fairly common because like for instance, the perfect example, it will be the patient that I just saw yesterday with cervical cancer, who will need a procedure called tricollectomy, which is removal of the cervix and the lower portion of the uterus in placement of abdominal cerclage to prevent preterm labor in the future. She will also most likely need the radiation and the radiation, even though every attempt is made to localize it to that lower uterine tissue or cervical tissue or vaginal tissue at a cancer may be inevitably it has its spread and has any abdominal or pelvic radiation inevitably can't be to the loss of eggs by basically the destruction of the DNA and death of the cells. And so the ovaries, we call this over a PEX C where basically during a laparoscopic surgery, the ovaries are being pulled out of the pelvis and attached to the anterior abdominal wall. That way they're going to be removed out of the pelvis and hopefully outside of that radiation field. It is not ideal because a lot of times the spread will still reach them because you can only pull them so much. They're still attached to the uterus. You can only pull them so much, but in some instances it is definitely worth doing because it can not be harmful necessarily for a patient. It might be harder conceiving naturally because you're moving the tubes out of the pelvis and tubes typically will pick up the egg from the pelvic fluid, not from the and just jumped from the egg into the tube, but there are live births reported after over affects as well.
Rena: What about insurance coverage for all of this, you know, because given the time sensitivity and everything, is there different insurance coverage for oncofertility versus fertility?
Jovana: Yeah. So this is what I've been alluding to at the beginning of our conversation is that luckily New York state became a mandated state beginning of this year, which basically the happiness of this mandate is on the employers. And basically the law now says that every employer that hires more than a hundred employees has to provide benefits through insurance that will allow an individual to preserve fertility in the setting of a medical condition, not just cancer. Most of these are going to be in cases of cancer, but also in the setting of a medical condition treatment of which has the potential to diminish future fatality. And when I say medical conditions, that can also be benign conditions. For instance, having a resistant multiple sclerosis or mythenia gravis that requires chemotherapy or having autoimmune disease that is resistant to immunomodulating therapy then requires chemotherapy or having endometriosis or recurrent benign ovarian tumors, the removal of which is taking a piece by piece of the ovary. Those are all indications. Unfortunately, for patients who are insured by Medicare or Medicaid, that government is still not required to cover these treatments, but at least for patients who are privately insured and who work for larger companies, they will have insurance. There is a lot of altruism out there, and we do work with all possible organizations that provide coverage for those who are less fortunate or who don't have coverage through their insurance and don't have ability to afford this type of treatment. There are Heartbeat and Livestrong organizations that provide medications for free. Ferring which is a pharmaceutical company that makes and menopure that provides medications for free for cancer patients. And most recently a wonderful organization called Chick Mission has been providing coverage. It's a nonprofit organization that has been providing coverage for patients facing cancer. Its founder is a woman who has survived several types of cancer actually, and has established this donation and this fabulous program that has helped so many of my patients
Rena: I've seen you post about that on your social media. That’s wonderful to know that about the CIC mission, everyone check them out. And also the generosity of the drug companies too. I think that's really heartwarming. And then for anyone that's listening from New York state, if you want to look into the nuances of the insurance mandate, it's called the fair access to fertility treatment act or FAFTA. And that's what was passed for the second round this summer, which provided coverage to more New Yorkers. But if you just looked at if there's more information about coverage there,
Jovana: I ultimately, whenever I talk about, because I see a lot of patients obviously cancer, this is going to be the biggest population of patients that we see in this setting. But there are other groups of patients and individuals in which we also recommend fertility preservation for a specific medical or clinical situation. And one of these populations are transgender individuals who, while they're planning and while they're undergoing their gender affirming transition, which for transmen will involve a removal of the ovaries ultimately, and the uterus and for transwomen removal of the testicles we highly recommend preserving fertility prior to removing all these organs on their way to gender affirming transition in order to be able to have biological children. And then ultimately I really truly am a huge proponent of preventative fertility preservation for women in general because of societal changes and advent of economy and medicine and science. We now live significantly longer than we did even a hundred or 200 years ago. And normally, you know, that event with women's role changing significantly in the past, even just 50 years in terms of independence and education and pursuing careers, both of these scenarios are leading to delaying of childbearing and there's nothing wrong with delaying childbearing. Why wouldn't you have kids in your forties if you're gonna live to 87 which is the median age for women in the United States? Why do we have to have kids in our teens and twenties? And we prefer to use this time to still be young and carefree and pursue education and career. The problem is the ovary that we haven't extended the longevity of this organ for even a day. And so I see tremendous preventative potential in egg freezing for individuals who don't have medical conditions, but rather are delaying childbearing. And one of my colleagues from UCSF, Dr. Levi Greenwood looked into this data and analyzed the reasons for delaying childbearing and women who are electively quote unquote, freezing eggs. And it wasn't pursuing career, actually that wasn't the main reason there was actually lower on the list of reasons. The most common reason was lack of partner. And when life with the partner is the reason for your freezing fertility, then you don't really have an option. The option is what to get donors sperm and to pick up the first guy from the street, just to have a baby and many women are not willing to do that. No one they should be .
Rena: Dr. Lekovich, I have to say you are just sitting there straight . All sorts of , I am sitting here having a very existential debate with myself today that I'm almost 35. I have my amazing daughter from fertility who's almost four, but I am single. And I need somebody to kind of kick my butt like you just did to, I need to empower myself as I would tell any of my patients and do something to preserve my fertility and take my own advice. But it's really scary, right?
Jovana: Why is it scary? What's the risk of the process? And that is another thing that I tell my patients, the risk of the process, the only risk is a potential risk of bleeding from an injury of one of the pelvic vessels, which complicates one in 5,000 to one in 10,000 procedures.
Rena: Sure . For me, it's not the process. I've done it before multiple times. Right. You know , I did have it for my daughter. I think it's more the emotional, you know, and to admit this is where you're at in your life. And it's not where you necessarily thought. I have so many gratitudes and all that stuff , but it's more coming to terms with, okay, hi, here's where you're at. You need to meet yourself where you're at
Jovana: And thing is for cancer patients. It's very similar. And I completely fully understand where they're coming from. When I see cancer patients, when they're being referred to me for fertility preservation, they are so frantic to learn that besides they might not be surviving this and they're facing deadly condition potentially it also might diminish their ability to ever have children in the future. But I turn it around and I tell them that actually, it's a very positive thing that we're even considering them for this reservation, because we're so sure they'll survive this.
Rena: I mean, you're absolutely right. And this is a conversation I have multiple times a day with people that have preserving their fertility it's empowering. And this is the most medically advanced thing available to us. And I think the other end of the spectrum is if then you're talking to myself, you know, a mental health professional, or you a reproductive endocrinologist, and you don't have the options because you didn't do them. Right? And you're then maybe you have diminished ovarian reserve. You don't have good quality eggs. And then you're faced with, okay, I have to use a donor and that's a much more complicated conversation. And I take the stance of my patients. I always want them to come to a place of no regrets. I never want them to come back to me in a year, five years and say, Oh, I wish I had done that. Because unfortunately, as we all know, time, isn't on our side of this. We can't get back time. And the biological clock is real, especially for women. And I think it is extremely empowering and brave to preserve your fertility, be it for oncofertility, or you're single, or you want to focus on your career. But I do think it is easier said than done. You know, as someone who says this all day, every day and I can't even make myself do it right now, you know, it's complicated.
Jovana: It is, it is complicated. I fully agree with you. I think that actually this deadly pandemic we’ve been facing since March in New York and since January in the world has actually pushed a lot of women into pursuing this. And I've seen a huge number of women since March and April who decided to pursue fertility preservation because it brings uncertainty. But also it brings actually more flexibility with your time. A lot of people are working from home and can actually commit to those seven to 10 days of having to come in and have ultrasounds and blood work and do the procedure. What I always tell my patients and honestly, fertility preservation for any reason is number one indication that I see women for or patients for the only reason not to do this is if you have to make a significant financial commitment. And if you don't have the coverage. If you have the coverage for fertility preservation, I don't see a single reason why not to do it because the downside of not doing it or the risk of this process is so extremely low that I really don't see any downsides.
Rena: I completely agree. I mean, I think, unfortunately that's not the case for many people and many people, they don't have coverage . So to think about spending, especially if you think about the demographics of most people who do it would be a single, younger woman, they don't necessarily have $15,000, $20,000 kind of hanging around to just lay out. And so I think it is more complicated. And I think I hate that finances come into people's family building plans. It's there. I don't think have to play a role. That's why, you know, I worked with resolve and, but it's the unfortunate case. I think the more vocal we are about it and speak up, the more things will change. But I think that is the case, which is
Jovana: I like to use this parallel of, so we know that age and declining fertility together are related and associated and there is no it's an indisputable, scientific, and medical fact that's been shown in millions of women in CDC data and huge population-based studies that we know that with advancing age, fertility declines and risk of miscarriage increases. And I like to use the analogy between smoking and lung cancer. The reason that, you know, my grandparents were Holocaust survivors who smoked for 75 years and died in their nineties of old age does not refute the fact that smoking and lung cancer are connected. And so why leave that up to chance why meeting those statistics and actually having a problem if there's something you can do to prevent it. And this is where it comes that I see a huge preventative potential in this. And I'm really hoping that more and more insurances will come to terms and start covering this because especially that we became a mandated state and IVF needs to be covered nowadays in our state as of January, right? Isn’t it a better to cover a process of egg freezing for a 27 year old woman, then down the line to have to cover four or five IVF cycles because she's facing age related decline in fertility?
Rena: Exactly. And you think it was money in the long run, right? If you invest in that or to invest in someone doing IVF, you know, doing genetic testing, doing everything you can to try and have one healthy live birth versus transferring multiple embryos.
Jovana: It's the same as you know, doing mammograms, starting at the age of 40 or earlier for individuals who have genetic risks and treating early stage breast cancer, then down the line having to treat stage four breast cancer.
Rena: Right? Wouldn't you rather be two steps ahead of something and preventative then struggling to catch up?
Jovana: But that is because the social aspects of our lives are not going to change. After all this fight that women had to put up was in the past century and more recent years, I promise you, we will not be going back to having kids in our teens and twenties.
Rena: It's not even realistic. They look at you, you're a physician, right? You've spent so much of your life in school, right? You know, I didn't really start my own career until I was 31. I have to catch up and be in a financially stable place to be able to have more children. And that's not going to happen by the time I'm 35 and I hit my biological clock. And, you know, I think for many women they're just hitting their stride and they want to develop their career. You know, I think we're in such an amazing era right now of women supporting women and women realizing, you know, we are equal to men. We don't need to back out of the workforce. We can work. But then with that comes, we have to take steps to preserve our fertility so that when we are ready to have children later than before we can do that.
Jovana: my great interest actually lies in this fact from the UCSFs study that shows that lack of the partner was the reason number one for pursuing fertility preservation. And I was thinking a lot about it. And especially in New York city where, you know, it’s horrible dating scene. And for a lot of women, things don't start happening before late thirties and early forties. And I was thinking about it and why are men so not committed, but it also comes with all the other changes that were going through it . Longevity of men is also has increased tremendously. It might be a little bit shorter than for women, but we're still talking eighties. Why do you need to get married again in your thirties or twenties. Why not get married in your forties and your family in your forties when you are financially stable, when you will have your career, when you are mature enough. It was a wonderful article. I believe it was BBC or CNN on this and I posted it on my social media talking about pursuing motherhood after 40. And yeah, somebody will say, well, it’s the health risks. You know, yes, there are higher risks of developing diabetes or high blood pressure or growth restriction of the fetus pursuing pregnancy after a certain age. But I guarantee you that we are healthier in our forties now than women were in their twenties, you know, a century ago.
Dara: Very true.
Jovana: A better life style right. Dara, don’t you agree? The way we live? The forties really our new twenties, except for the ovaries. That's the problem.
Rena: I couldn’t agree with your more. I mean , look , you're talking to someone who got married at 25 divorced at 31. I tried it, I like to tell my friends, I like to try everything out and let you know how it goes.
Jovana: You followed all the rules, you got married, young, you pursued family young.
Rena: I think you're still changing so much in , you know, I think, yeah, by the time you're 40, hopefully you've done your career. You're ready to settle down. You've had the time to work. There's no one size fits all life plan for everyone, certainly. But in terms of your perspective, to me, it definitely resonates.
Jovana: But even if you have kids in your forties, you're still going to be around for them longer than a mother would have been if she had her kid at 16 and died at 35 of plague a hundred years ago. So why not have them in your forties? You have much higher chances of a healthy pregnancy. If you are fit healthy, 42 year old who's managing herself and who does not smoke and drinking as a healthy lifestyle than a 22 year old who has uncontrolled diabetes or obesity or high blood pressure.
Dara: Wow. That was a lot of information. Thank you so much. How we end our podcast is with gratitudes and to see what we're grateful for at this very moment. So Dr. Lekovich, what are you grateful for today?
Jovana: Oh, I'm grateful for everything. So seriously, I go over this every day. And I think that’s one of the, I mean, there are many good things about our field and it's a wonderful field, but it's very easy to be grateful when you face people who are unfortunate to be facing problems with infertility and this anguis and struggling to have a family. And I always thank my God every day for the fact that I have two beautiful, healthy children and that, that family that I have gives me the strength to move forward and to help so many that need my expertise. And I'm grateful for so many things. I'm one of those people that when I wake up in the morning, I go over the list of things that I'm grateful for. And really there are many things in my life that I'm grateful for every day.
Dara: I was going to say something like sunshine. But after that, I'm still grateful for pancakes and sunshine. I’m sure I’ve said versions of this before, but I'm really grateful for RMA for number one, having a job that I absolutely love for helping people on their fertility journey but also everything that I’ve received from working at RMA, working with the doctors and the nurses and the staff and my patients and gratitude and support.
Jovana: I absolutely agree. How about you Rena?
Rena: Oh man. Well, I was definitely having just a day before this podcast, to be honest. And so, you know, I'm really grateful for this discussion and really, you know, I always says I’m grateful for my colleagues , I am, you know, I think I'm , I knew, like I said before, I really didn't start my career until I was 31, but I'm so grateful that now four years later, I feel like I really have a career and work with like-minded people who really understand and who aren't judgemental , which I understand and are built in all different ways. I hope one day everyone understands that, but I'm really grateful for the energy of people I work with, and get it and understand. And they're just really supportive when , and I think over the pandemic, more so than ever has really felt so much of this, like women supporting women, just the sort of moms stand together, working moms that are hard it's been and I really am grateful for the supportive, you know, people , you and Dara and everyone just sort of uplift each other, you know, we're all in this together be it the pandemic or being a working mom, trying to be any kind of mom it's hard. So grateful for all of this.
Jovana: I absolutely agree. And if it makes you feel any better, Rena , I also didn’t start my career until early thirties because I was going through undergrad and medical school and then residency training and fellowship training. And I really just started relatively recently, so, but we're going to live to 87. Amen. Thank you guys so much. This was great.
Dara: Thank you so much for listening today. And always remember, practice gratitude. Give a little love to someone else and yourself. And remember, you are not alone. Find us on Instagram @fertility_forward. And if you're looking for more support, visit us at and tune in next week for more Fertility Forward.

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