Fertility is not a topic we should only be allowed to understand after something has gone wrong. It is foundational health information. It is information about our hormones, menstrual cycles, ovarian reserve, inflammatory burden, anatomy, partners, and future choices.
Dr. Thais Aliabadi and Mary Alice haney sat down with reproductive endocrinologist Dr. Natalie Crawford to talk about the fertility questions far too many of us are told to postpone: What does ovarian reserve actually mean? Does birth control hurt fertility? When should we see a specialist? How do inflammation, endometriosis, PCOS, autoimmune disease, and male factor fit into the picture?
Dr. Crawford practices at Fora Fertility in Austin, Texas, hosts the As A Woman podcast, and is the author of The Fertility Formula. Her central message is refreshingly direct: we deserve data about our bodies before time, failed cycles, or pregnancy loss make decisions for us.
Table of Contents
- Why early fertility education matters
- Fertility can reflect overall health
- Finding medical causes and lowering the inflammatory burden
- Food, insulin resistance, and fertility
- Trimester zero and why male fertility belongs in every plan
- Fertility testing should not require a year of failure
- AMH and ovarian reserve: information, not a verdict
- Endometriosis, PCOS, anatomy, and missed diagnoses
- Does long-term birth control hurt fertility?
- Age, fertility, and making choices before time chooses for us
- Our most important takeaway
Why early fertility education matters
Why did you decide to focus your work on fertility education?
Dr. Natalie Crawford: We kept hearing the same painful sentence from patients: “If I had known this sooner, I would have made different choices.” That is really the heart of it.
After completing OB/GYN residency at Parkland Hospital and then a three-year reproductive endocrinology and infertility fellowship, I entered private practice and saw how much information people were missing. Women were often not taught the basics of their cycles, hormones, ovarian reserve, fertility treatment, or the medical conditions that can affect their ability to conceive.
When we do not have foundational knowledge, we lose agency. We cannot advocate for ourselves as effectively, ask the right questions, or make choices that align with our own goals. That is why I began educating online and eventually created longer-form resources, including my podcast and The Fertility Formula.
Fertility was once treated as a taboo conversation, often held in silence and shame. Thankfully, that is changing. We are finally asking for clear, reliable information on our level, in language that makes sense, long before we are in a fertility clinic facing an urgent decision.
Fertility can reflect overall health
What is the connection between fertility and long-term health?
Dr. Natalie Crawford: Fertility can be a marker of overall health. The ability to become pregnant reflects a certain state of cellular and hormonal health. Infertility is not always simply a diagnosis to place in a chart. It can be a red flag that tells us something in the body needs attention.
That does not mean infertility is anyone’s fault, and it absolutely does not mean every outcome is controllable. It means we should ask better questions. If the body is struggling with ovulation, egg quality, implantation, sperm health, or pregnancy maintenance, we should investigate the possible contributors and improve what we can.
For patients who have experienced infertility, this is not meant to be frightening or fatalistic. It should be empowering. We can use fertility concerns as an opportunity to look at health more broadly, identify risks earlier, and change the trajectory where possible.
Why is inflammation such an important piece of the fertility conversation?
Dr. Natalie Crawford: Inflammation itself is not bad. It is an essential immune response. If we cut our arm, inflammatory cells help begin the healing process. Reproduction also depends on carefully timed inflammatory processes.
The concern is chronic inflammation, when the immune system is persistently activated and carrying more burden than it can effectively manage. That can interfere with the brain’s hormone signaling, how the ovaries respond to signals, egg quality, chromosome alignment, cell division, ovulation, and potentially many other steps involved in conception.
We like to think of inflammatory burden as a sliding scale. Some exposures and stressors are beyond our control. But some daily factors can raise the burden: poor sleep, frequent alcohol intake, highly processed foods, added sugars, chronic stress, and toxin exposure. The goal is not perfection. The goal is knowing that the small things we do repeatedly matter.
Symptoms can also be vague, which is exactly why they are too often dismissed. Bloating, fatigue, headaches, insomnia, brain fog, and trouble concentrating may not point to one single diagnosis. But they can be a reason to take a step back and ask whether something needs further evaluation.
For more context on how metabolic health, body weight, stress, nutrition, and other health factors can influence conception, read our guide on how health can impact fertility.
Finding medical causes and lowering the inflammatory burden
Where should someone start if they think inflammation may be affecting their fertility?
Dr. Natalie Crawford: First, we need to look for medical causes. Inflammation can be driven by conditions such as celiac disease, endometriosis, PCOS, Hashimoto’s disease, and other autoimmune disorders. We cannot simply tell someone to sleep more or eat differently without also considering whether they need a diagnosis and specific treatment.
My own experience shaped this perspective. I had undiagnosed celiac disease during my fertility journey and experienced four pregnancy losses. After identifying the issue and removing gluten, that pattern resolved. The point is not that gluten is the explanation for everyone. The point is that finding the underlying cause can matter profoundly.
Even with normal initial testing, we should not assume “nothing is wrong.” The diagnosis may simply be harder to identify. That is why we prefer the phrase undiagnosed infertility over unexplained infertility. It acknowledges that normal routine labs do not always capture every relevant process.
What are your five non-negotiables for lowering inflammation?
Dr. Natalie Crawford: These are the five daily pillars we can influence:
- Sleep: Consistent, restorative sleep supports hormonal, metabolic, and immune function.
- Stress management: Chronic stress can affect glucose regulation and contribute to inflammatory load.
- Building muscle: Muscle is metabolically active and supports healthier insulin sensitivity.
- Anti-inflammatory eating: Whole foods, fiber, healthy fats, fruits, vegetables, and fewer ultra-processed foods are a practical foundation.
- Avoiding toxins: Reducing exposures where we reasonably can is part of optimizing reproductive health.
We do not need to do all of this flawlessly. We need to recognize that our ordinary routines are health decisions, and those choices accumulate.
Food, insulin resistance, and fertility
What does anti-inflammatory eating look like in real life?
Dr. Natalie Crawford: It is not a restrictive, trendy diet. We are talking about whole foods, fruits, vegetables, fiber, healthy fats, and reducing ultra-processed foods an
d added sugar. Knowing the “why” helps us apply this without fear or rigidity.
Insulin resistance is one of the reasons this matters. Many people hear that term and think it applies only to diabetes or PCOS. It does not. Insulin resistance can be present in people of different body sizes and can be missed without a specific evaluation.
Here is the simple version. We eat food, it is broken down into glucose, and glucose becomes fuel for our cells. Insulin, made by the pancreas, helps glucose enter the cell. When glucose and insulin rise and fall together normally, the system works beautifully.
But chronic stress, poor sleep, frequent high-glycemic foods, ultra-processed foods, and eating patterns that repeatedly elevate blood sugar can lead the body to produce more insulin. Over time, cells become less responsive to insulin and need a larger amount of it to respond.
High insulin levels can be inflammatory and can alter ovarian response to the same hormone messages sent by the brain. The ovary may become more androgenic and less responsive in ways that affect estrogen production and ovulation. This is one reason insulin resistance is relevant to both fertility and PCOS.
Our resource on PCOS and polycystic ovary syndrome further explains the relationship between insulin resistance, irregular ovulation, and long-term health.
What nutrients should we prioritize?
Dr. Natalie Crawford: Start with fiber. The gut microbiome relies on plant-based fiber from fruits, vegetables, legumes, and other plant foods. That microbial environment plays a role in inflammation, food processing, and insulin resistance.
We are living in a high-protein moment, and protein has value, but fiber has been underrepresented. Fruits and vegetables should be staples, ideally present at every meal. Higher fruit and vegetable intake is associated with better sperm parameters, improved ovulation, shorter time to pregnancy, and improved IVF outcomes.
Healthy fats also matter. Cholesterol is a building block for hormones. Nuts, seeds, olive oil, avocados, and full-fat dairy products can all have a place in a fertility-supportive eating pattern. We do not need to fear fat simply because many of us grew up in the low-fat era.
Trimester zero and why male fertility belongs in every plan
What is trimester zero?
Dr. Natalie Crawford: Trimester zero is the period before pregnancy when we intentionally prepare. Although eggs have been in the body our entire lives, the 60 to 90 days before ovulation are an especially meaningful window to focus on lowering inflammation and optimizing health.
It is also important to remember that fertility is not a woman’s responsibility alone. Male factor accounts for about 50% of infertility. Both partners should be part of the plan. That includes nutrition, sleep, exercise, toxin reduction, avoiding heavy marijuana use, and addressing relevant health concerns.
We want partners to come to the table with the healthiest eggs and sperm possible. A semen analysis should not be an afterthought, especially when it is a relatively straightforward test that can provide essential information early.
Fertility testing should not require a year of failure
When should someone have fertility testing or see a fertility specialist?
Dr. Natalie Crawford: We can see a fertility specialist at any time. We do not need to wait until we have been trying to conceive for a year. The traditional definition of infertility often uses 12 months of unsuccessful trying, but that framework can leave people feeling as though they have to fail before they are allowed information about their own bodies.
We can ask about ovarian reserve, have a pelvic ultrasound, assess menstrual patterns, screen for relevant medical conditions, and obtain a semen analysis for a partner before trying or early in the process. We should not have to wait two years only to discover that a partner has no sperm, or that there is a uterine issue, endometriosis, a polyp, fibroid, thyroid disorder, or autoimmune condition that could have been identified sooner.
In Dr. Crawford’s practice, the ideal patient is often the “not yet” patient: someone who may want children in the future but is not ready to try today. Earlier information does not force a decision. It gives us more options and time to make choices intentionally.
A thorough fertility assessment may involve:
- Ovarian reserve testing, including AMH when appropriate
- Pelvic ultrasound and antral follicle count
- Assessment of cycles and ovulation
- Semen analysis for a partner
- Evaluation of uterine and pelvic anatomy
- Screening for endometriosis, PCOS, thyroid disease, autoimmune conditions, or other concerns based on symptoms and history
For a practical overview of what these evaluations can include, visit our guide to how fertility testing works.
AMH and ovarian reserve: information, not a verdict
What does an AMH test actually tell us?
Dr. Natalie Crawford: AMH, or anti-Müllerian hormone, is one marker of ovarian reserve. It is produced by cells surrounding the follicles available in a given month. Think of the ovaries as a vault containing all the eggs we will ever have. Each month, a group of eggs comes out of that vault and grows in follicles. One typically ovulates, while the others do not continue developing.
When the vault is fuller, more follicles tend to be recruited. As it becomes less full, fewer tend to be available. AMH gives us one data point about that process. It is not the complete picture, and it does not predict every person’s ability to conceive spontaneously in a particular month.
But it can be incredibly valuable context. A low AMH in a younger person can open important questions: Do we want children in the future? Should we consider egg freezing? Do we need to adjust our timeline or family-building goals? Is there a medical reason ovarian reserve appears low for our age?
Dr. Crawford explained that an AMH below 1.0 is broadly considered low, while “low for age” requires more nuanced interpretation. For example, a value that may appear within a laboratory reference range can still be concerning in someone in their twenties if it is much lower than expected for their age group.
Low AMH does not mean we cannot conceive. Two people of the same age may both ovulate one egg in a particular month, even if one has a lower ovarian reserve. But reserve can affect the length of the reproductive window, potential response to fertility treatment, and sometimes reveal a need to look more closely for endometriosis, autoimmune disease, genetic conditions, or other contributors.
Endometriosis, PCOS, anatomy, and missed diagnoses
What should a fertility workup avoid missing?
Dr. Natalie Crawford: We need to look at fertility in buckets. Start with ovarian reserve, hormones, and ovulation. Include male factor. Evaluate anatomy with pelvic imaging. Ask about symptoms and risk factors for endometriosis. Consider PCOS and autoimmune disease where appropriate.
We should not rush directly to IVF without asking basic questions. A pelvic ultrasound can identify fibroids, polyps, signs of adenomyosis, ovarian findings, or structural differences in the uterus. Additional imaging may be necessary to assess issues such as a uterine septum.
Endometriosis deserves particular attention because it is often missed or minimized. Symptoms and history matter. Newer diagnostic tests may help identify some cases, including a saliva-based test in the United Kingdom and a blood-based test in the United States. However, a negative test does not automatically rule out endometriosis, especially when symptoms or imaging findings still strongly suggest it.
This is a major point: a test should not become another tool for dismissing someone. If symptoms persist, we still deserve to be evaluated by an experienced clinician who understands endometriosis and can discuss individualized next steps.
Does long-term birth control hurt fertility?
Does taking the pill for years cause infertility?
Dr. Natalie Crawford: For oral contraceptive pills, the evidence does not show long-term harm to fertility. Studies comparing conception rates 12 months after stopping the pill do not find a different rate of conception due to long-term use.
However, the pill suppresses ovulation, which means it can mask the natural cadence of our cycles and some warning signs of conditions such as PCOS or endometriosis. It can also suppress AMH readings, sometimes by roughly 30% in people using oral contraception long term. That does not mean we should never check AMH while on the pill. It means we interpret it thoughtfully and may recheck after stopping it if needed.
Dr. Crawford’s personal preference is to stop oral contraceptive pills at least three months before trying to conceive, allowing time to observe natural cycle patterns and identify concerns before pregnancy is the immediate goal.
What about the Depo shot and hormonal IUDs?
Dr. Natalie Crawford: Depo-Provera is different because a single injection can suppress ovulation much longer than many people expect, potentially up to 18 months. It does not mean permanent infertility, but it can be important when planning for pregnancy in the next couple of years.
Hormonal IUDs are highly effective contraception and can be life-changing for heavy periods, anemia, endometriosis, and adenomyosis. We do not want to demonize them. At the same time, Dr. Crawford noted emerging observational data raising questions about prolonged progesterone IUD use, very thin uterine lining, and scar tissue in some patients, particularly after five or more years.
Association does not prove causation. Treatment decisions must always be individualized, especially for people using an IUD to suppress painful endometriosis symptoms. But for some patients, planning IUD removal about six months before attempting pregnancy may allow time for the uterine lining to recover. If periods remain extremely light or do not return after removal, prompt evaluation is important.
Age, fertility, and making choices before time chooses for us
How much does fertility change after 40?
Dr. Natalie Crawford: Age matters, even when we are healthy, athletic, do not smoke, and take excellent care of ourselves. Population data show that after age 40, the chance of conception is generally less than 5% per month, compared with roughly 25% per month at peak fertility. By the mid-forties, that chance is often below 2% per month.
These numbers are not meant to shame or scare anyone. They are not zero, and every individual has a different story. But lifestyle alone cannot fully offset age-related changes in egg quantity and egg quality. This is precisely why earlier ovarian reserve assessment and fertility education can be helpful.
We want every woman to have the opportunity to understand her body, consider her future goals, and decide what information matters to her. Whether we pursue pregnancy now, egg freezing later, or neither, the decision should belong to us.
Our most important takeaway
What do you want women to remember about fertility?
Dr. Natalie Crawford: We deserve information before we are in crisis. We do not need a year of trying, a miscarriage, failed IVF, or severe symptoms to begin asking questions. Fertility is part of health, and health information is not something physicians should gatekeep.
Ask about your cycle. Ask whether a pelvic ultrasound, AMH test, semen analysis, or referral makes sense for you. Speak up if you have symptoms that are being dismissed. Consider your partner’s health as part of the fertility plan. And remember that data is not a command. It is power.
We cannot control every reproductive outcome. But we can insist on being informed, heard, evaluated thoughtfully, and supported in making the decisions that fit our own lives.
Medical note: This conversation is educational and is not a substitute for individualized medical advice. Fertility testing, medication decisions, treatment for endometriosis or autoimmune disease, and changes to contraception should be discussed with a qualified clinician who knows our personal health history.
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Fertility 101 FAQs
Can we get fertility testing before trying to conceive?
Yes. Dr. Crawford supports fertility consultations before trying, particularly for people who may want children in the future and want information about ovarian reserve, pelvic anatomy, cycles, or egg freezing. A partner can also have a semen analysis early.
Does low AMH mean we cannot get pregnant naturally?
No. AMH is a marker of ovarian reserve, not a definitive prediction of conception in a single month. A lower result may still be important because it can affect the reproductive timeline and prompt evaluation for potential underlying factors.
Does long-term birth control cause infertility?
Long-term oral contraceptive pill use has not been shown to cause infertility. The pill can suppress ovulation and mask cycle patterns, so stopping it several months before trying to conceive may help us evaluate our natural cycle.
Why should male fertility be evaluated early?
Male factor contributes to about half of infertility cases. A semen analysis is a direct way to gather important information and can prevent couples from spending months or years trying without knowing a significant sperm-related issue is present.
Can a negative endometriosis test rule out endometriosis?
No. New saliva and blood tests may identify many cases, but they are not perfect. When symptoms, medical history, or imaging still suggest endometriosis, further consultation with an experienced specialist remains important.
