Dr. Lucky Sekhon on why “just lose weight” is never the key to fertility

If you’re struggling with fertility — just like if you’re struggling with weight — there are countless factors that could be to blame. But you are not one of them. This was the message that reverberated in the room at Weight Watchers Book Club’s second gathering held at WW HQ and livestreamed for members. To celebrate the release of The Lucky Egg, Weight Watchers’ chief experience officer Julie Rice welcomed author Dr. Lucky Sekhon, M.D.  — an NYC-based reproductive endocrinologist, infertility specialist, and OB/GYN — in a conversation led by Sami Sage, cofounder and chief creative officer of Betches Media and a longtime patient of Dr. Sekhon. 

Read on for the highlights from their informative and inspiring discussion, and follow Weight Watchers on Instagram to RSVP to the next book club.

On why The Lucky Egg needed to be written

Dr. Sekhon: In my day job as a doctor, I never really thought about being an author or writing a book, and something that I've said time and time again is that this wasn't a big master plan, this was something that demanded to be written. Because I thought to myself: How is it that we don't have an all-encompassing resource that's written by an actual fertility doctor that actually helps people get pregnant? There are a lot of other voices and noise in this space, and I've observed that my patients have really struggled to find a good resource that gives them the tools that help guide them to drown out the noise and know what to focus on.

On insulin resistance and infertility

Dr. Sekhon: Insulin is basically a hormone that is essential for storing your blood sugar effectively in all of your cells in your body. Imagine it's like a key that unlocks the cells and allows the sugar to go from your bloodstream, where it's kind of got a pro-inflammatory effect, and for it to be stored away.

Insulin resistance is exactly what it sounds like: You can't get that key to open the lock. [This] can impact not only your ability to ovulate, but it might even impact egg quality. The reason is that when your egg is being matured and getting ready to be ovulated or extracted (if you're doing an egg retrieval), it's undergoing something called genetic reorganization. That's where a lot of errors happen, and they happen naturally because of the wear and tear of aging. But if you have an insulin-resistant environment, and you have too much testosterone around those eggs that are being matured, it adds to the errors. So, someone who's young and you presume they're not gonna have any problem getting pregnant, they are at a higher risk of things like miscarriage, because the number one driver of miscarriage is chromosomal errors.

On the impact of weight

Dr. Sekhon: One thing that promotes being more resistant to insulin is weight gain, especially around the midsection. 

Yes, weight can be a factor in infertility — and there may be some insulin resistance going on —  but it’s never the only thing. There are people of all shapes and sizes and weights that are able to get pregnant.

I hear from people this idea of, ‘Okay, well, this is what seems like the obvious factor, so I'm not even going to look at you or investigate all the other things.’ There could be more than one thing going on. I think [a provider] saying, ‘That's your issue, go lose weight,’ as if it's such an easy thing to do overnight, especially when it comes to a time-sensitive issue like fertility, I think [merits] a second opinion, including a full infertility work-up. Because if there are things like a tube is blocked, or the sperm count is low, those are things that you could be working on, or working around, instead of just focusing on one aspect.

On understanding reproductive health before trying to get pregnant

Dr. Sekhon: Why aren't we telling women in their 20s or early 30s to at least get one pelvic ultrasound? Because you'd see if someone has polycystic-appearing ovaries. PCOS is a condition that's very mysterious and can be associated with insulin resistance. It can be associated with irregularity in the cycle. 

A lot of people go to their doctors, and they're like, ‘I think I could have this, because I heard someone on a health podcast talking about it.’ Their doctor will be like, ‘No, you don’t meet all the criteria.’ But let me tell you, there are so many people whose diagnoses are being missed. You have to have 2 out of 3 of the following: irregularity in the cycle, polycystic-appearing ovaries, and/or signs of excess testosterone. It takes very little to rule that in. 

It's just really important because it's not just about getting pregnant, it's also about your long-term health. If you have PCOS, you also have a predisposition to developing things like high blood pressure, diabetes, — especially later in life —  and high cholesterol.

On the questions you should ask your doctor

Dr. Sekhon: One thing that I think everyone should do when they're seeing their OB/GYN or a fertility doctor is to have objective data. Track your cycle and your symptoms. I also think bringing someone with you to a consult can also help. You’re gonna get more out of your doctor visit if you are going into it armed with a list of questions, and if you have a support person there to help you kind of stay on track with your questions. 

In terms of questions to ask, I think if you have anything that seems problematic with your cycle, don't accept, ‘Oh, it doesn't matter, you're on the pill anyway, you'll just get pregnant and that'll fix everything.’ Really probe that you need to understand what's going on with your body, and understand why certain tests are being run, and what they could mean, and what the potential diagnostic tree would look like. Asking about things 5 or 10 steps ahead will help you kind of anticipate and have a better context and understanding. If you go into any scenario and you understand the why behind it, you're going to feel more in control, and you're going to have more agency.

On going on (and off) GLP-1s

Dr. Sekhon: GLP-1s work by slowing gut motility, and making you feel full for longer, and by making you more sensitive to insulin. If you are directly treating, in an effective way, the thing that is causing you to not ovulate regularly, of course that’s going to make you fertile. 

The advice is, ideally, that you get off of [GLP-1s] 2 months preconception, because that is considered enough time for it to get out of your system. This is mainly because of the lack of safety data.

On supporting someone going through infertility

Dr. Sekhon: Just show up — even if you don't know what to say. You never want to say the wrong thing, so sometimes people make the mistake of just never talking about it or asking about it. Something that I've done in my personal life and relationships is I'll send a text message if I know someone's had a retrieval. ‘Hey, I'm just checking in and I'm thinking of you. Please don't feel the need to respond to this.’ It’s a knee-jerk reaction to want to give platitudes or say things like, ‘It's gonna work out.’ But that actually can be very triggering to people. Let them be the guide. Sometimes they're going to want to talk about it, sometimes they just want to have a laugh. But show up, be there, and if you're pregnant, don't be weird with how you announce it and exclude them from the announcement. Tell them ahead of time.

On myths and misconceptions about birth control

Dr. Sekhon: I have yet to meet a single patient who has infertility caused by being on birth control. It just doesn't happen, and it doesn't make sense that it would ever cause infertility.

Most forms of birth control are working to prevent an unplanned pregnancy by preventing that signal from being sent out in the first place. Or you have an IUD, which is like a bouncer that's preventing the sperm from getting into the VIP fallopian tube lounge. So those are the main mechanisms of contraception, and they're immediately reversible. The only exception to that rule is an injection called Depo-Provera, which is a progesterone that gets released very slowly in your body. So, it could take 6 months for your ovulation to come back, even after it's supposed to have worn off. But even that is never going to cause any sort of long-term effect on your fertility. 

I'll go one step further to say that you might be, unbeknownst to you, treating a gynecologic condition that could predispose you to infertility later down the line. Shutting down that signal means you're no longer feeding a process like endometriosis. You're also allowing your body to soak up all the extra testosterone, so if you have excess testosterone as someone with PCOS, you're actually balancing your hormones — which is the opposite of what all the wellness gurus will have you believe. 

I'm seeing droves of 20-somethings who are coming in saying, ‘All my friends in my friend group are getting off the pill just to see what our bodies can do, because we're really worried we're screwing our bodies up by being on the pill.’ And I'm like, ‘Well, do you want to get pregnant right now? No? Well, then what's your plan?’

On the supplements you actually need

Dr. Sekhon: There’s a lot of needless supplement taking. I think there is a role, however, for certain supplements when you have known deficiency. A lot of us will have vitamin D deficiencies.  A lot of women are also iron deficient, and it's a lesser known fact that this can lead to infertility if it's not treated. Iron is allowing you to have enough red blood cells to support oxygenation of your entire body, and that's a major thing that you need to not only live, but to be able to have enough energy to support a growing pregnancy. 

Outside of a deficiency, everyone who wants to get pregnant should be ideally on a prenatal vitamin 3 months preconception and during the pregnancy, and even while postpartum, especially if you're breastfeeding. It should contain folic acid. That is the only form of folate that is proven.