Facilitated

18| The Fertility Spectrum: A Functional Medicine Approach (Female-focus)

• The Facility Denver • Episode 18

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Infertility affects 19% of women in the US, yet conventional medicine often labels cases as "unexplained" before rushing to expensive interventions that bypass rather than address underlying issues. We share how functional medicine views fertility as a spectrum with modifiable factors, where improving overall health can naturally enhance conception chances.

• Infertility defined: inability to conceive naturally for 12 months (or 6 months for women over 35) despite frequent unprotected sex
• Male factors contribute to fertility issues in approximately 43% of cases, either alone or in combination
• Current ART (assisted reproductive technology) success rates hover around 25% nationally
• The functional approach begins with comprehensive testing: hormones, thyroid, nutrients, inflammation markers
• Tracking cycle length, ovulation timing, and luteal phase duration provides crucial insights
• Vaginal microbiome health significantly impacts conception and implantation success
• The "golden egg" concept: it takes 90 days for optimal egg development, making preconception care crucial
• Key interventions include blood sugar regulation, antioxidant support, stress management, and toxin reduction
• Supporting sleep and circadian rhythm improves melatonin, a crucial antioxidant in ovarian follicular fluid
• Endometrial receptivity depends on balanced hormones and a healthy vaginal/uterine microbiome

Check out our Female Preconception Assessment that includes comprehensive fertility testing and a 90-minute review visit. 


Want to take the next step with functional medicine? Learn more about our new patient process and lab testing at www.thefacilitydenver.com

For more insights, tips, and behind-the-scenes content, follow us on Instagram @thefacilitydenver

Stay curious, stay proactive, and we’ll catch you next time!

Mitchell:

Welcome to Facilitated, where we bring you real stories, strategies and science from the world of functional medicine. I'm Dr Mitchell Rasmussen, a functional medicine practitioner.

Kate:

And I'm Kate Daugherty, a certified nutritionist. We are the owners of the Facility, a functional medicine clinic here in Denver, Colorado.

Mitchell:

We help people improve their biology and get out of their own way. We help people improve their biology and get out of their own way. In my view, our work is about getting to know the person with the condition much more than it's about understanding which condition the person has. As I always say, diagnose the biology, not the disease.

Kate:

On this podcast we break down complex health topics, share real patient cases anonymized, of course and explore cutting-edge wellness strategies so you can make informed decisions about your health. Quick heads up before we dive in this podcast is for education and general information only. We're here to share insights, not to diagnose or treat. So if you're dealing with a health issue, chat with a qualified healthcare provider before making any changes. All right, let's get into it, we're going.

Mitchell:

Good morning.

Kate:

It is morning this time.

Mitchell:

A lot of noise outside.

Kate:

I hear baby crying. It's not my baby.

Mitchell:

Your baby's too old to be crying like that.

Kate:

She cried so much this morning.

Mitchell:

Why.

Kate:

We're having a rough time with drop-off, with daycare drop-off, and I told her if she's going to cry she has to go in the baby room. She can't be in the toddler room. And then she wanted to go in the baby room and she cried more because I wouldn't let her go in the baby room.

Mitchell:

It appears you can't reason with a two-year-old. Is that correct? Yeah, I have this image of how, how it could be, and then you're working with a so undeveloped brain that it's just not it's probably me she plays me so. But then just no emotional regulation.

Kate:

No, it's not too unsimilar like working with you every day.

Mitchell:

That's funny because I was thinking about well, where does she get that? So I think she gets that from you, all right. All right. So we were just talking and then an elephant sounded like a herd of elephants walked by A little distracting.

Kate:

I wish we could show everyone a picture. Our setup right now. We've got one, two, three, four, five, six pillows blocking the door.

Mitchell:

To try to create better sound.

Kate:

Poor man's sound boundary.

Mitchell:

Yeah, so we'll see how this goes. We were just saying what are we excited to talk about today?

Mitchell:

we are going to get into a big topic, which is infertility, fertility, conception, preconception, all things reproductive health kind of a topic that we found ourselves really niching out, niching out with, and it's been fun because I think up until this, up until maybe two years ago, we didn't really we knew we liked working with, you know, chronic inflammation and individuals with autoimmunity and trying to help them, you know, keep their immune system more balanced. But this was, I think, the first, what would you say the the first topic or the first illness or condition?

Mitchell:

condition that we really found ourselves leaning into and it's so rewarding because helping people have a child who really want to have a child, they're ready to be solid parents.

Kate:

So let's talk about this term, nebulous term infertility. Infertility is defined when a woman cannot conceive naturally for at least a year, despite having unprotected and frequent sexual activity. This changes with age. So what's the cutoff age? 35 above 35. It's cannot conceive naturally for at least six months, despite having unprotective and frequent sexual activity. Current stats are that it affects 19% of women in the United States, but it can affect males as well. It's the focus is always on women, but male only. Infertility is in about 8%.

Kate:

And a combination is like a third 35%, yeah, which is a huge clue to the environmental factors.

Mitchell:

It's wild that we just put it on the woman all the time and we don't. But I'm saying as an establishment, it's always what can the woman do? And again, a third of the time there's a combination of factors. I mean, we just had a gal. She's been trying to do everything she can for nine months and kind of putting a lot of the blame on herself, shouldering the load and her husband. I mean, we ran a sperm test on him and not a lot of swimmers.

Kate:

That's got a little bit of work to do.

Mitchell:

Yeah, not a lot of good motility, not a lot of volume, not a lot of concentration of sperm. So it was kind of interesting where, in that case, I mean, let's go buddy, you got some work to do here.

Kate:

Takes two to tango.

Mitchell:

Yeah.

Kate:

So most common risk factors for both male and female is age. Age is the biggest one, so women over 37 and men over 40. We don't think about men's age as often, but it is a risk factor when they are above 40. Mostly when you talk about the sperm morphology, motility.

Mitchell:

DNA yeah, the DNA changes yeah.

Kate:

Weight is a risk factor, over or under weight, stis for both partners, and then smoking and alcohol. So those are the most common risk factors for both men and women. When we think about infertility causes in a female, we go into multiple categories. We have ovulation disorders, so PCOS, polycystic ovarian syndrome, pcos, hypothalamic dysfunction, hypothalamic dysfunction, premature ovarian failure. We have tubal infertility, which is blocked tubes, blocked fallopian tubes, where the egg can't make it through the uterus to be fertilized. Endometriosis, uterine and cervical abnormalities like the shape of the uterus, polyps, tumors, as well as cancers. When it comes to male causes, we think about irregular sperm production or function, sexual problems and structural problems, so premature ejaculation, ed blockages. And then exposures, so chemicals, pesticides, radiation, even anabolic steroids.

Mitchell:

And don't forget things like varicose seals epigetamitis you know things that lead to excessive heat production in the testicle. That's a common thing we see with varicose seals. All that blood that pools around the testicle can cause high heat.

Kate:

Yes, there is a huge category here of male infertility which we are acknowledging is important, but for today's podcast episode we are going to focus on female. We'll circle back to male, stay tuned. So you alluded to this term unexplained infertility.

Mitchell:

Yeah, it's so disrespectful.

Kate:

What do we mean? Unexplained. It's a label, it's something we can label someone with and it's no obvious issues in either partner. It's often a combination of subtle hormone imbalance, egg quality issues, sperm function abnormalities or problems with the embryo development or implantation.

Mitchell:

And even things like impaired receptivity of the endometrium. We might talk about it a little bit later, but conditions like endometritis from group B, strep or E coli or Gardnerella or even ureaplasma we know that that can change the ability for an egg, once it's fertilized, to even implant which I guess maybe we'll talk about later, but I think that's more when we even think about chronic miscarriage right, which falls under the unexplained fertility category.

Kate:

Right. I think it was Leslie Stone who said she hates the term infertility, and I totally agree. She says we should be calling it subfertility. So it's a continuum or a spectrum with modifiable factors, that you can shift your position along this spectrum, and I think it's very empowering to think of it that way, where we don't have to get everything right. It's how many things can we shore up? Can we get a few of them, some of them right? Shift you further along that continuum towards fertility.

Mitchell:

Like we always say, a healthier body wants to conceive. And at the end of the day, when we think about those categories you said from egg quality to poor sperm mechanics, to receptivity, to the endometrium and implantation failure, sperm mechanics to receptivity, the endometrium and implantation failure Really what we're talking about is all the things in our environment that can lead to elevated oxidative stress, poor inflammatory cytokine control and essentially altered immune cell function. So that's why we talk so much about toxicity. Nutrient density on top of just, is the thyroid working? Do we have good hypothalamic control? It's really the cytotoxicity coming from oxidative stress, chronic inflammation and poor immune system balance. So in my world it's about let's go upstream and let's figure out what's driving those factors.

Kate:

And it's such a dichotomy to the conventional medical system where you are struggling to conceive. You speak with your gynecologist first and they might refer you to a fertility clinic. You get to the fertility clinic. You have three options. You can go IVF, in vitro fertilization, iui, intrauterine insemination or trial. Some fertility meds, like Clomid is one of the most popular ones. It's expensive and it's an emotional strain. It's a financial strain. The national success rate of any assisted reproductive technology 25%.

Mitchell:

Wow, and we're not making the woman any healthier through that process.

Kate:

No, there's one goal.

Mitchell:

Yeah, you're a baby-making factory and I mean we get people that fail IVF multiple times and I mean not even just the emotional toll of having this massive investment fail and you want to be a parent so bad but it's the, the drugs that you're put on to create an insane amount of follicles in one month to be harvested. The pain that a woman goes through physically through harvesting the waiting game I mean no part about that is centered around creating health.

Kate:

And no education in it either. They don't come out of it with any more understanding.

Mitchell:

Yeah, and I mean we have because we work with there's some pretty well-known fertility clinics around us and on one side of their mouth a lot of these physicians will say nutrients and supplements don't matter. And then on the other side of their mouth they have a whole list of supplements that you should take, which I find a little bit confusing. Either it helps or it doesn't help. But I digress.

Kate:

So let's go back into our functional approach, which again not about root causes, but because there's not ever one root cause here, but it's more how many things can we shore up on the spectrum? Do you want to start with some basic preconception labs that we would run to rule in, rule out, kind of where we put our focus?

Mitchell:

Yeah, I mean off the top of my head. We actually created a female fertility panel now, and big things that must be checked off the list medically are things like brain signaling to ovaries for proper ovulation. So that's where we look at that, you know, the FSH, lh coming from the brain down to the ovaries, and then obviously, are we stimulating adequate progesterone production? Remember, progesterone only comes from an ovulated egg. So if we're not having good signaling because of maybe low body weight or chronic stress, poor circadian rhythm, and you're not getting that nice LH surge to create ovulation, we're never going to make adequate progesterone.

Mitchell:

And for progesterone it's kind of a tight window. We want to see you over 15, wouldn't you say over 15 on that ovulation surge, but I don't want you above 40. And we know that excessive weight can cause higher progesterone there, which can actually interfere with the ability to bring a child to term. And this is why I'm big on if we give progesterone to somebody, we've got to be very specific on our dosing and on our timing and testing to make sure that we're keeping you in that, in that window there, stress hormones, obviously vitally important thyroid hormones, you know.

Mitchell:

I mean this is where sometimes we, even if we're working naturally with somebody, if we see a TSH and it's even borderline, we're going to send you into an internist or an endocrinologist to maybe discuss that piece, because we see a lot of success, that blending Exactly.

Kate:

Where a low?

Mitchell:

dose of levothyroxine while we work on everything else can be that one cherry on top of the cake that really gets things moving. I mean nutrient levels. Right, we look at the omega index, your three to six ratio. Are you producing too much arachidonic acid? We just had a gal. Her arachidonic acid was up in the forties, you know, and that's and there's benefits to arachidonic acid. It's a fatty acid derived from meats and things, but it's all about that balance.

Kate:

That balance of threes to the sixes.

Mitchell:

Yeah, and vitamin D deficiency. Vitamin D, potent anti-inflammatory hormone. It's immune modulating, helps with mood, helps with bone health, kidney health, I mean all across the body. And if that's low you are more likely to have this unexplained fertility, simply because, again, chronic inflammation, immune cell imbalance and oxidative stress.

Kate:

So that's a huge one for me, and saying low is not a medical range either. They are actually working on changing this range for conception. Current medical range is 30 as the low end, I think, for conception. They're trying to move it all the way up to 50.

Mitchell:

Wow, that's great. That'll be good because we will get less pushback then as we're trying to get a woman trying to conceive. You know, maybe minimum 45, probably up to at least 65 or so and you know we don't want to go crazy with that probably up to at least 65 or so and you know we don't want to go crazy with that, but that's what the data is saying 30 is not going to cut it.

Mitchell:

But I mean, how often do we get a woman actually in her 30s? It's usually in the teens or 20s, right? I mean, what else are we looking at? We're looking at zinc status. Zinc helps activate hormone receptors. It's good for immune cell balance. If you want hormones to bind, you need active receptor function. So zinc is a massively important nutrient. B vitamins that helps run methylation, which helps balance inflammation. I mean it all goes back to these core mechanisms and we're not even talking about anything fancy right now.

Kate:

No Nutrients selenium, magnesium. We can test coq10, which is an antioxidant that's very important for ovarian for uh egg quality and that's something that we do test in the female fertility panel going back to I was just going to say, even like liver, kidney. I mean again the basic metabolic labs yeah, going back to some of the hormones, we want to look at the balance of estradiol to progesterone to testosterone, total testosterone, free testosterone, as well as shbg sex hormone binding globulin especially if we have any suspicions of this.

Mitchell:

Pcos like picture sex hormone binding globulin does what it says it sops up your sex hormones so they can't freely act in tissues. And back to the estrogen piece. Not a big fan of the term estrogen dominance. It's really about that balance between progesterone and estrogen. But here's an important thing we know you might induce excessive oxidative stress if you chronically elevate your progesterone and you're not thoughtful about it and you can actually become resistant. Progesterone resistance is not often talked about. Just like any hormone can lead to resistance when it's taken or around in high amounts Insulin resistance, leptin resistance, right. So that's where the progesterone swings throughout the cycle are so valuable. You don't just want to redline it the whole month. What else are you looking at? Lipids?

Kate:

Yeah, lipids. Metabolic health I think we kind of glanced over that. But glucose insulin A1C, maybe even CRP and ANA, looking at some more advanced inflammation or autoimmune processes going on. Thyroid antibodies in that same category.

Mitchell:

Essentially a broad scan of your metabolic and your nutritional health. I think other categories that we do look at occasionally but this is kind of later on would be toxicity levels, total tox burden. Look for heavy metals, looking for mold toxins, parabens pesticides Indocrine disruptors.

Mitchell:

And that's all stuff that's readily available now. Pesticides, yeah, yeah, and that's all stuff that's readily available now. And 100 if you get a diagnosis of unexplained fertility. Advocate for yourself to go deeper, because there are likely biological mechanisms not anatomical mechanisms that are behind this issue and they can almost always be improved upon the environmental toxin piece of it, the testing piece of it.

Kate:

Our very first intervention is cleaning up the environment in any woman who's struggling to conceive. So, yes, that testing piece might be important a few months further along. But if you're consuming food or storing food in plastic, if you are using perfumes and fragrances and candles, golfing three times a week.

Mitchell:

You know who I'm talking about.

Kate:

We're gonna start with're going to say let's cut that activity out, give your body a chance. Then, if we're still struggling, let's do some testing and see what's lingering.

Mitchell:

And taking it back a step. When you come in and we initially meet with you, our intake process is pretty much a thorough review of your system, your health history, your family history, where we're. You know, we had a gal this week. It's been really long cycles and we're slowly starting to find some pattern here post birth control syndrome and I guess I'm getting impatient for her. She's feeling pretty good about where she's at in a lot of ways because she's so much healthier. But the information we got this week was well, my mom and my sister took a long time to conceive and we all were born healthfully after that. And that's an interesting family history note.

Mitchell:

I mean, when we're looking at these underlying problems before we even look at testing oftentimes I mean are you digesting well? Chronic GI inflammation can absolutely be this trigger of oxidative stress. Do you have chronic infections like Epstein-Barr virus or SIBO and things like that? How's your? You know again, how's your hormone function, your liver function, your ability to eliminate hormones? If you're constipated, you're likely recirculating estrogens which may not show up on a serum estradiol test. But we know that astrobalone within the microbiome is key for metabolizing excessive estrogen and that can lead to these imbalances between estrogen and progesterone. You know how's your energy production, your oxidative imbalance? Do you have chronic allergies or histamine problems, asthma, these Th2 dominant, hyper eosinophilic conditions that are oftentimes associated with excessive histamine production? I mean, that's a massive part. And then, of course, do we have, like luteal phase defects or potentially things like fibroids.

Mitchell:

I mean that's a really big part of my initial history with somebody is all right, we have this ICD-10 code labeled on us. Now let's dive into each individual system and see where these hangups are. Layer that on top with good labs. Let's get to work.

Kate:

Good labs. I would even put cycle tracking in there. It's not necessarily the lab, it's just data. But what is the length of your cycle from bleed to bleed and where is ovulation happening within that? What do your phases look like? So ideally we talk about this luteal phase defect. Ideally we want a luteal phase that's maybe 10 to 14 days. So the second half of your cycle from ovulation to a bleed, ideally 10 to 14 days. So you have adequate time for the corpus luteum to produce progesterone to support embryo development and implantation. Oh, we always start with that part of it. Then we consider total cycle length. So another ideal 28 to 32 days. If a woman comes in with longer cycles, maybe they're 40 days, 50 days, but at least they're consistent. I'm going to start with luteal phase, then we can consider the total cycle timing. But the tracking of it is so important over five, six months. So we see this data when is ovulation happening in the cycle consistently and how long are the cycles consistently?

Mitchell:

and let's say you have a decent luteal phase. You're getting that, you know 10 to 14 days between ovulation and a bleed. If you're spotting for a couple days before you bleed, that's probably a good sign that that was maybe an anovulatory cycle. Or you're spotting for a couple days before you bleed, that's probably a good sign that that was maybe an anovulatory cycle or you're producing suboptimal progesterone. So that's a common question we ask is is there spotting or does it start as a full bleed?

Kate:

we want a full bleed when it starts we glanced a little bit over sleep and stress and circadian rhythm and the lifestyle factors you want to talk about that.

Mitchell:

Well, I mean circadian rhythm, blue light exposure, poor sleep, staying up too late, eating too late, not getting sun in the morning. I mean all of these things disrupt melatonin production right.

Mitchell:

Melatonin is something that we can test in the body. We don't do it often. It's more about an inventory. And what we know about melatonin is everyone thinks about it as a sleep hormone. Really, it's an amazing mitochondrial antioxidant. We're now studying it for cancer benefits and stress and all sorts of things, not just sleep right and as an antioxidant.

Mitchell:

Again going back to elevated oxidative stress driving this unexplained infertility, we know that melatonin is actually found in the ovarian fluid where the follicles develop high concentrations of melatonin right. Melatonin is massively important in these fatty tissues because it's fat soluble enough to get into those tissues. We'll talk next time about how it improves sperm motility and oxidation there. But we even see that if you can maintain balance in that HPA axis, you'll regulate that LH surge. Melatonin, from a lifestyle perspective again, of balancing that rhythm, is going to help with implantation, it's going to help with egg quality and it's going to help buffer oxidative stress.

Mitchell:

I mean we even see now. I mean it's some preliminary human data but because melatonin is quite safe and and I'm talking 1 to 3 milligrams, I'm not talking 20. I mean maybe 6 during an IVF procedure. But what we're seeing now is it's likely improving the receptivity of the endometrial tissue itself, which will improve thickness of the endometrium and it will also improve rates of implantation. From one little unsung hero, melatonin Everyone thinks about it for sleep, but it can probably literally help an egg stay implanted in the endometrium.

Kate:

The egg quality piece is so important and often, more often, we're seeing women who are waiting to start planning for conception, start trying for conception, so pushing the limits on that age risk factor, so of course ovarian reserves are going to drop significantly. A lot of times women will come in with already having an AMH tested. Amh is a marker that tells you about essentially how many eggs do you have left?

Mitchell:

Kind of yeah.

Kate:

That's the simple version.

Mitchell:

Broad range too on that AMH.

Kate:

To be honest, a low AMH doesn't scare us that much. It's not as big of a red flag to us. Whoa AMH doesn't scare us that much. It's not as big of a red flag to us. But it does mean that we're going to focus way more on what is the quality of the eggs you do have, so the antioxidant support, the circadian rhythm, making sure we're getting good development of as many follicles as possible so that the best one wins and that is the one that releases the egg and develops the corpus luteum.

Mitchell:

I'm glad you mentioned AMH. I forgot to say that, but we can add that and we can look at it frequently if that's what someone wants, but oftentimes that's already run multiple times. It's like the go-to that.

Kate:

a gynecologist will run for you. The other thing a gynecologist will often order is a transvaginal ultrasound. Same thing, we can run it, but it is often something that a gynecologist will run, which is great to use your insurance benefit for that.

Mitchell:

We can coach you up before you go in how to get that covered.

Kate:

And a transvaginal ultrasound is very useful in certain ways, but it does have some limitations. So it gives good information about follicle development. It gives good information about PCOS morphology, even if your labs don't necessarily show the PCOS picture, so your androgens might be normal, but you could still have the PCOS morphology on your ovary. It tells you if there are other cysts, whether benign or functional, like a corpus luteum cyst, which is a completely normal cyst in a woman, or endometriomas, which can be a big problem. It tells you about ovarian reserve so how many follicles are there at the start of a cycle but again does not tell you about the quality of those.

Mitchell:

So timing of a transvaginal ultrasound will make a difference in what it looks like. I mean, if we time it right, we'll even be able to see cervical fluid.

Kate:

Yep, the endometrial thickness, yeah, which too thick or too thin can be problematic for implantation. We can see fibroids, polyps. Those congenital abnormalities like the shape of the uterus can be an issue. We can see signs of tubal blockage only if it's severe fluid filling Right.

Mitchell:

that's typically going to be a hysterosalpingogram.

Kate:

Yeah, which is a great test it tells you about. Are those fallopian tubes open and is fluid able to flow through it so that the egg can? We can assume the egg can flow through?

Mitchell:

it as well. I want you to say the word.

Kate:

Hysterosalpingogram.

Mitchell:

Yeah, that's like when I made you memorize Epigallo, catechin 3, galley, you want to?

Kate:

know something embarrassing.

Mitchell:

Yeah.

Kate:

I had my fallopian tube removed. I had my right side fallopian tube removed. I can't say the word.

Mitchell:

Hydrosalpinx.

Kate:

No, the ectomy, Salpinjectomy, yes. Thank you.

Mitchell:

Just add ectomy to anything and you're covered.

Kate:

So you know, I had my fallopian tube removed. That's how I say it. I can't even say the ooo ooo, ooo for rectomy word either.

Mitchell:

Or ooo site Egg. Well, let's go. When you mentioned the thickness, of the endometrium. I mean, that's where estrogen comes into play, right? And is this a time where you can maybe just talk a little bit about the vaginal microbiome, or do you want to wait?

Kate:

Let's talk about endometriosis and then that. So because transvaginal ultrasound a huge limitation is it can't really diagnose endometriosis. The gold standard for that is laparoscopy, and that is invasive. It's a clinical diagnosis more than anything else. Let's see what levels of estrogen are. If there is an endometrioma, we can see that, but the uterine endometriosis is kind of harder to see.

Mitchell:

Direct visualization is often needed. Yep.

Kate:

So all right, green light vaginal microbiome.

Mitchell:

I mean this is kind of a new. This is new on the horizon and we're finding relevance here with there's a couple of companies that actually run at-home vaginal microbiome tests. It's quite amazing. A swab comes to your house and I mean evy does a tiny yeah, tiny health, which I've actually leaned into more because it seems that they do a little deeper exam on the microbiome itself specific for fertility yeah, you know, and this is where we talk a lot about, especially if you have low body weight and say you have a, you know something like recurrent yeast infections or recurrent gardenerella like bv and things like that.

Mitchell:

Low body weight is often associated with lower estrogen. Right, and estrogen plays a crucial role in keeping that vaginal microbiome balanced because it actually promotes the production of glycogen. We know the more estrogen that's around in a balanced way, you'll be able to pull more sugar into those tissues, which in turn that will actually support your vaginal microbiome to make lactate. It's a fascinating process we talk about with our patients all the time. Estrogen stimulates this maturation and proliferation of these epithelial cells in the vaginal area and that leads to an increase in glycogen storage there. The more glycogen you have, it can be used as a substrate, essentially a food that's metabolized by all these bacteria that should be present there, specifically the lactobacillus species that will actually help you produce lactic acid. Well, lactic acid is an acid and it lowers the ph. If you have a lower vaginal ph, a nice acidic environment, maybe a ph around four or so, this acidity will actually be crucial for maintaining that ecosystem and it will inhibit harmful bacteria like gardenerella group Group B strep E coli.

Kate:

Even some of the aerobic species like Enterococcus or Streptococcus.

Mitchell:

We have air quote good and bad bacteria, fungi, everywhere. It's about that balance. We talk about this with every ecosystem. Ecosystem it's about having enough maybe 80 to 90% of the good ones around so that you can keep all of the potentially harmful or dysbiotic microbes down. So we know that estrogen actually acts indirectly on that microbiome because of the glycogen uptake, the vital nutrient for these bacteria to maintain that nice acidic environment.

Kate:

And I think I talked about this in the fiber episode, or maybe in a blog post I wrote I can't remember what medium I put this on but when it comes to microbiome balance, so gut, microbiome balance, we do not know everything. We know far from everything, but what we do know are associations. And so in the vaginal microbiome it's the same thing Higher levels of lactobacillus species are associated with higher fertility rates. So it's not a perfect science, it's an association, but it's an easy intervention that's worth looking at.

Kate:

Especially if you've had multiple unsuccessful IVF treatments or implantation failure in any regard, if it's multiple miscarriages or even chemical pregnancies.

Mitchell:

Yeah, first thing I think about ureoplasma strep. Let's dive into that environment Again, layering on top the hormone piece, and just really try to create a better access here for support of that tissue so that the egg wants to stay that are checklists of going through things.

Kate:

I would say number one is tracking the cycle, seeing where ovulation is happening, thinking about that progesterone development, looking at the hormones on day 21. A starting place have we ruled out subclinical hypothyroid, so TSH below 2.5, considering the medication if that makes sense. The PCOS spectrum physiology, which is lab testing visualization.

Mitchell:

So androgens, insulin and stress hormones.

Kate:

HPA axis dysregulation, chronic stress under eating, maybe even looking at a saliva adrenal testing to see what the cortisol curve looks like. The LH surge or weak follicle maturation supporting top-down brain signaling to the ovary, inflammation affecting ovulation or implantation. Suboptimal metabolic function, insulin resistance, low energy availability, which goes to mitochondrial health. And then the interventions that come in support the blood sugar, sleep and stress management. Anti-inflammatory diet and lifestyle, so high omega-3s, high priority on antioxidants, less oxidative stress, less endocrine disruptors which I mean what are we looking at there?

Mitchell:

we're looking again at the plastics and stuff, but we're also looking at water filtration, shower filtersumes, air filters in the house, because furniture off-gasses volatile organic compounds. I mean there's a lot of factors there.

Kate:

Callback we have a whole podcast episode on environmental toxicity. It's been so long, we almost forgot. Yeah, it's been so long, we almost forgot.

Mitchell:

Yeah.

Kate:

Some of the go-to interventions we'll use. We use Vitex a lot Vitex, or Chaseberry to support pituitary signaling. It also improves progesterone. It's a great option when we do see low LH or inconsistent ovulation.

Mitchell:

Or even something like uricoma long folia, whoa Right, tongkat, tongkat Ali, which can support LH production as well. And when we I mean, would you say typically, it seems like what we're doing with things like Chaseberry would be consistent usage for maybe a period of 90 days or so and not really pulsing it based on the cycle, because it's really more of that brain, the hypothalamic pituitary ovarian, the HPO axis.

Kate:

We might start pulsing it beyond the 90-day mark, but for that initial period it's consistent use.

Mitchell:

And I think the big one you need to really stress on here is the optimal thyroid function. I know you kind of glazed over it, but I mean your thyroid is your master regulator. If you want to be pooping normally and you want adequate control of things like bloating or heartburn, if you want temperature regulation and mood, energy, sleep patterns, I mean the master regulator is really that hypothalamic, pituitary thyroid axis. If that falls, I don't know how we're going to recover adrenal or ovarian function. You know, I mean that's I would say is the probably one of the most important initial steps is work up that thyroid adequately.

Kate:

You have to have that functioning optimally for any chance it's hard to prioritize because I think blood sugar regulation is like right there with thyroid.

Mitchell:

Well, and what do we know about blood sugar dysregulation?

Kate:

leads to hormonal imbalance, stress issue, hpa axis issues.

Mitchell:

So again, it's so hard to prioritize well, and it's so many right, and I think that is one thing, especially with unexplained infertility, where we will throw more at a couple because you're on a tight window, you know if you're motivated yeah, if you come in with, you know most people that come in with to us.

Mitchell:

I mean, I, we recently had a, a gal. I think it was like 160 symptoms for that type of person. You're not trying to get pregnant. I've just got to clear out some mess. What did I tell? I said I want you to do a 10 minute walk in the morning, I want you to do some air squats and I want you to chew your food yep that's not if you're trying to get pregnant. Right, it's going to be those and about 11 other things, but, like you said, you're motivated. Now's the time.

Kate:

So blood sugar, inositol, berberine, sometimes.

Mitchell:

Sometimes, yeah, alpha lipoic acid meal. Timing right, even the order in which you eat your foods. What is that I love when you talk to patients about this?

Kate:

So having fiber at the start of your meal. Eat your vegetables first, then your carbs.

Mitchell:

Dang. Our parents were right Just eat your vegetables, get them over with. Dang. Our parents were right Just eat your vegetables.

Kate:

Get them over with. We talk about antioxidant support. So you said ALA, but also CoQ10, resveratrol, glutathione.

Mitchell:

Ergothionine, vitamin C, annatto, tocotrienols which are a fat-soluble vitamin. That's a potent antioxidant. Which are a fat-soluble vitamin. That's a potent antioxidant. It's been shown to improve liver health, lipid metabolism, but it will penetrate fatty tissues.

Kate:

We think about things like DEM or calcium deglucorate when we are looking at this estrogen dominance picture.

Mitchell:

How dare you Zinc?

Kate:

Minerals, of course.

Mitchell:

Wow, I mean, if you aren't eating oysters, you probably need to be on a zinc-copper supplement.

Kate:

B vitamins majorly important there too, methylation support. So lots of directions to go, but again personalized. So let's look at the data first and decide which of these actually makes sense to support your biology?

Mitchell:

and I want to go back for a second. When you talk about blood sugar management, let's simplify something neurons in the body, everywhere, brain, body, everything is communicating with neurons. That's kind of our electricity, tells our body what to do. They need oxygen, they need stimulation and they need fuel. So insulin resistance or maybe hypoglycemia, low blood sugar, robs our neurons of one of their needs and then a big thing for an oxygenation.

Mitchell:

That's where the B vitamins come in, as well as iron Too high or too low. If we know that unexplained infertility is primarily a result of increased oxidative stress and somebody maybe has poor iron metabolism and their iron is high, that drives issues that lead to inflammation. It's called the Fenton reaction. You can Google it. I'm going to stop there. But same way, if we have low iron, iron helps you carry oxygen. If you're hypoxic now your neurons aren't receiving adequate oxygenation. And if the neurons begin this process and the hypothalamus and the pituitary and I would say the brainstem activation from a stress perspective, if you have iron metabolism issues, it is going to be a massive hole in the machine where we're not going to get adequate brain to go and add signaling Right. That makes sense in my head.

Kate:

A lot of stuff makes sense in your head. Yeah, that makes sense in my head. A lot of stuff makes sense in your head.

Mitchell:

Yeah, point being nutrients, minerals, metals all of that is so important to be balanced.

Kate:

Balanced, not high. So such a wide spectrum and I want to go back to it's all about making you the healthiest we can to support a pregnancy, Again in extreme dichotomy to a fertility clinic, and it doesn't have to be that or we are not trying to replace always a fertility clinic. I think we actually do have a number of patients who were supporting in their IVF or IUI journey, genetic reasons, structural reasons, and it makes sense for them. But I mean, I want to challenge why not, why not pair the functional medicine approach with the conventional approach?

Mitchell:

right and you need to recover post-pregnancy right again. If we're, if we're just looking at you as a baby factory and we're ignoring the fact that you're a human first and foremost and postpartum depression is pretty common and nutrient deficiencies postpartum and all of these issues that we see if a new mother fails to recover adequately, that's where I really get passionate, you know. Let's make you durable and resilient going into this so that on the back end, you have a much better chance of a of a strong recovery, because now you've got a tiny little human to take care of. So let's make you strong. Yeah, the side effect of improving your lifestyle is that everything will get a little bit better and some things will get so much better so like you said, why not?

Kate:

I pulled some stats on the cost. It's scary. Do you want to know?

Mitchell:

Yeah.

Kate:

This was directly from the CCRM website, colorado Center for Reproductive Medicine, one of what three clinics here in Colorado. Current IUI intrauterine insemination cost, with testing, the treatment cycle and the meds $7,490. Current IVF in vitro fertilization, with testing cycle and transfer and meds $32,000.

Mitchell:

And that's for a single transfer, correct? And?

Kate:

that's for a single transfer, correct Single transfer, and that's on the low end. It can increase another $10,000 depending on testing of those eggs, how many eggs are retrieved, how many you're storing.

Mitchell:

Yes, and keep in mind, you're likely to have to have two or three rounds. Not maybe likely, but there's a decent chance.

Kate:

National success rate 25%.

Mitchell:

Right, so this isn't just one shot. You said 32,000.

Kate:

32,000. Yeah, wow, so I did some math. I added up our most comprehensive serum testing, the full-on environmental toxin, the vaginal microbiome, even a transvaginal ultrasound care with us. I budgeted over, budgeted for supplements and care over six months. Four thousand six hundred, that's on the high end and you, you get healthier. Yeah, yeah you're, you're the numbers, dork, so I thought you would appreciate it.

Mitchell:

Yeah, 4,000 is less than 32,000, I'm pretty sure.

Kate:

I can agree.

Mitchell:

Yeah, are we ready to bring it home?

Kate:

Bring it home Okay.

Mitchell:

So big picture. Here's what we think about. It takes about 70 to 80 days for sperm to develop, from the initial onset to a fully mature sperm, and it takes maybe a little bit longer than that for the golden egg to develop. So we talk so much about this idea of the golden egg. Can we give you 90 days to get everything in order and then, once we're feeling much better and labs have improved, can that timer start Right? 90 days Now you've gotten alcohol out already. You've gotten I hope you're not smoking. You know we're detoxifying, we're pooping, we're saying hydrate, all the stuff we've talked about. Can we think about that golden egg, that 90 day window where now we are producing that egg that will be ovulated three cycles from now? That will be the egg that gets pregnant.

Kate:

Yeah.

Mitchell:

Or that becomes an embryo.

Kate:

We have to start thinking about conception way before we're thinking about conception and I wish women would plan for it the way that they plan for a wedding. And I wish women would plan for it the way that they plan for a wedding. The best case scenario a patient comes to us. I'm thinking I want to be pregnant in two years. Great, I love that, I don't love. I'm going to start trying now.

Mitchell:

Yeah, and we get a mix of both. We do.

Kate:

Yeah, and I understand. I totally understand that.

Mitchell:

Well, think fervency. Well, I mean, think about it. We spend so much of our lives trying to not get pregnant right. And then we, by the time we're ready oftentimes especially if you're on birth control for a long time, which we really didn't even talk about much, but it's going to take a while and then you realize how difficult it often is to get pregnant. It usually doesn't happen very quickly. So I understand why we have this idea that well, I could get pregnant at any moment. So I think the moment I start trying it'll happen for me. And then that's usually when people start to look outside the box. You know what options are available and this and that Golden egg 90 days.

Kate:

Well, folks, in classic Mitchell fashion, he decided to talk about something that we weren't quite ready to launch. But you know what? Screw it, let's do it. Let's launch it before we're ready. I will get the back end stuff going.

Kate:

So we do have a new female preconception package. It is a fertility panel with all of these baseline markers that we definitely want to look at when we're thinking about conception and fertility, and we include a 90-minute review visit with us. This is available on our Direct Order Labs website, so you can check that out by navigating through our website, wwwthefacilitydenvercom and going to direct order labs. It is the female fertility assessment. It includes labs and a visit, with both me and Dr Mitchell Pretty excited about it. I will have all of the FAQs that I can answered on that page, cost and easy access to us. So please check that out. For other behind-the-scenes fun, please check out our Instagram at the Facility Denver and don't be afraid to reach out to us. Let us know what topics you want to hear. Next week, male fertility will be coming, so stay tuned for that. Now go facilitate your own health and we'll see you then.