Episode 30: The Ins and Outs of Fertility – Part 2

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[1:35] Cassy Price: Hello, everyone, and thank you for tuning into another episode of Supplementing Health. We’re joined again today by Dr. Sarah Zadek to continue our conversation about fertility for both men and women. Welcome back, Sarah. Thanks for joining us.

[1:50] Dr. Sarah Zadek: Thank you so much. It’s good to be back.

[1:54] Cassy Price: Last week, we ended off talking about conditions such as bacterial vaginosis and candida overgrowth. A lot of those things start their onset when we’re younger. Of course, when we’re younger, our first priority is not fertility or getting pregnant in most cases. It’s kind of a backburner, “We’ll do that when we’re older, later in life,” and that sort of thing. Can this be an issue later on when people are finally ready to settle down and start a family?

[2:23] Dr. Sarah Zadek: Not necessarily. The wonderful thing about the microbiome is that it’s always changing, and every day it could look different. In general, the ratios of bacteria are likely to be very similar day-to-day, but we can see pretty big changes over time. This isn’t something that’s necessarily going to be detrimental to your entire fertility journey for your whole life.

[2:48] But it’s something that if you start getting yeast infections in your early 20s, then maybe by the time you’re 30 or 35, you want to start having kids, and you’re still getting chronic yeast infections, then that’s something I would address. But if you had one yeast infection when you were 18, and you haven’t had anything sense, there shouldn’t be any reason why you would have a yeast problem that would potentially affect your fertility.

[3:15] Now, if you were on multiple rounds of antibiotics and never had a probiotic in your life and you have a poor diet full of sugar and fast-releasing carbs and low fibre, then maybe you’re creating the perfect storm for proliferating bad bacteria, so to speak, and not letting the good ones proliferate and grow. I think there’s definitely room for treatment, whether you’ve had chronic infections or whether you’re dealing with a current one.

[3:46] Cassy Price: How early should men and women start preparing for conception or improving their fertility if they are starting to plan for a family?

[3:55] Dr. Sarah Zadek: We always recommend that you want to give yourself at least three to four months of preconception work. This is something that comes as a surprise to a lot of people thinking that they need to prepare this far in advance. You can even start earlier if you want. It’s never too early to start preparing your body for conception because all you’re doing is making your body as healthy as it possibly can be.

[4:18] Like I said earlier, it takes an egg 100 days to mature, and sperm can take up to 116 days. So the idea is that you want to follow those follicles. Protect them, give them as much energy as you can and all the nutrients that they need throughout their entire development from when they are a tiny little follicle to when it’s a mature egg. I typically recommend patients starting three to four months before you want to get pregnant and start a preconception treatment plan.

[4:52] Cassy Price: Awesome. Some reports I’ve read say that egg quality can be improved with certain supplements. In your experience, is this true?

[5:00] Dr. Sarah Zadek: Yes. I don’t know that there’s a definitive study that’s out there currently that’s reporting this, but just from our observations from different fertility clinics across Ontario, we are seeing the patterns of definite improvement in egg quality and embryo quality when we do this type of preconception healthcare.

[5:24] Cassy Price: So what are some of the supplements that women and men should be considering to help support their healthy fertility?

[5:30] Dr. Sarah Zadek: It’s going to be different depending on the situation. In general, what you’re looking to do is we’re introducing antioxidants, specific ones that help to protect egg and sperm DNA from damage. We’re also considering vitamins and nutrients to make sure that they have everything that they need – for example, a prenatal with folic acid.

[6:00] The whole idea is that eggs and sperm need two things to be able to function properly and to mature properly. They need energy, and they need normal chromosomes and normal DNA. When those are lacking, that’s when we have issues with both fertilization and embryo survival. Those are the things that we’re trying to preserve. 

[6:20] Those are the ones that we’re trying to improve is giving eggs enough energy. It could be in the form of CoQ10, maybe using carnitine to help to shuttle it into the cell. We’re also using antioxidants like N-acetyl-cysteine, alpha-lipoic acid to help to support that as well. In some cases, we might be looking at fish oils and the role of certain anti-inflammatories depending on the picture. Part of it is very person-specific, and the other part of it is just giving eggs and sperm what they need.

[7:02] Cassy Price: So you mentioned that for some, the issue is less about the initial conception and more to do with the implantation or fetal development, resulting in early miscarriage. What are some of the most common causes of an early miscarriage that people can address?

[7:19] Dr. Sarah Zadek: An early miscarriage is usually due to egg quality. Whenever we see a miscarriage in the first trimester, it’s usually because of a poor embryo quality. This could be from the sperm or the egg. Unless we’ve done testing on it, we don’t know for sure. Some fertility clinics can start to test this.

[7:42] Early miscarriages, we’re looking at improving egg quality and chromosomal integrity. We want to use that time to protect the DNA in our eggs and our sperm. From then, we might be looking for testing for DNA fragmentation in sperm. As far as women go, we get a lot of clues also from our bloodwork. Are estrogen and progesterone both in normal ranges? That’s also giving us an indicator of egg quality.

[8:17] For example, if we have low progesterone in our luteal phase, which is the second half, which could cause a failure to implant. Remember, progesterone is the hormone that helps to thicken your uterine lining. This progesterone is actually secreted by the corpus luteum, part of the egg in response after ovulation, and so that progesterone thickens the lining and prepares for the embryo to implant.

[8:47] If you have low progesterone in that luteal phase, it’s often an indicator that we have a poorly functioning corpus luteum. That egg is not able to produce the progesterone that we need to thicken the lining. Without a proper thickened lining or a prepared lining, we will have problems with implantation.

[9:10] Cassy Price: Could the use of hormonal contraceptives or even a previous abortion affect fertility or that implantation?

[9:20] Dr. Sarah Zadek: Okay. There are two things there that we’ll unpack. The first is the birth control pill. The birth control pill doesn’t necessarily – or hormonal contraceptives I should say, in general, don’t necessarily cause infertility. What they do, though, is that they mask the whole picture. For the average person and on average, I’m finding a lot of patients have been on the birth control pill for up to ten years at a time. While you’re taking that pill, you’re suppressing all your normal hormone functions. If there is a problem going on, we don’t know about it until you stop taking your birth control, and you start to have normal and real cycles, and we start to see what your endogenous hormones are doing.

[10:03] The other thing about the birth control pill is that it does take a lot of energy to deconstruct and detoxify these hormones out of your body, so we have to keep that in mind too when it comes to liver function, especially in someone if there is already a predisposition to any type of liver issues, whether it be fatty liver, or PCOS, or whatever the case may be – high alcohol and smoking consumption. Those will all factor into it.

[10:32] Now, as far as abortions go and different types of procedures that we have on the female reproductive system, even something like DNCs, leak procedures that women have for cervical dysplasia. Anything that’s going to cause a physical trauma to the endometrium or the cervix, both, can impact fertility.

[10:56] In our practice, what we do is we actually have cervical healing protocols that we put into place to help to regenerate and help the healing and decrease the inflammation of the cervix and the uterus. Could these affect implantations? Absolutely. If you have scar tissue from a DNC, that’s going to affect implantation. If you have fibroids or polyps, anything that’s physically there – cysts, can all affect fertility. It just depends on their size and their location.

[11:32] You could have a cyst on your ovary and not have it impact fertility, or you could have a cyst compressing your fallopian tube, and now you can’t ovulate from that side as well. It’s all very situationally specific, but all of these will contribute to fertility. That’s what we do here and fertility clinics across the country, as we’re looking at and investigating why isn’t someone getting pregnant? 

• Is it a problem with fertilization? 
• Is it a problem with the implantation? 
• Is it hormonal? 
• Is it immune-related? 
• Is it all of the above?

So all the investigations that we do are trying to decode that and re-explain unexplained fertility.

[12:26] Cassy Price: If you get a scar on your skin, things like vitamin E can help reduce that. Are there certain things you can do to reduce scar tissue if you have had some of these procedures that could help improve that possibility of proper implantation or reduce the issues?

[12:43] Dr. Sarah Zadek: Yeah. It really depends on the location of the tissue and what we’re trying to do. If you had abdominal surgery or any type of pelvic-type of surgery, there could be scar tissue there. In some cases, again, depending on the location, you might be able to reach it as far as doing a physical therapy, like acupuncture or a physiotherapy, where you can break up that tissue. Pelvic floor physiotherapy is great for that as well.

[13:19] As far as supplements go, we use different types of anti-inflammatories. Vitamin C, bioflavonoids are both good ones as well. Certain types of dietary oils like Omega-3s can help as well. Zinc is a nice immune supporter as well. You mentioned vitamin E. It really depends on where the damage is and what we can do to resolve it.

[13:51] Cassy Price: Then jumping back to the conversation about the hormonal contraceptives, I know you mentioned that people have stayed on for as long as a decade or maybe even more, so how long on average does it take for a woman who has been on these hormonal contraceptives for a significant amount of time to return to her natural cycles that you can start seeing any issues that may exist?

[14:13] Dr. Sarah Zadek: That’s a great question because it does vary. A lot of my patients get their periods back pretty much right away. We always get that first period after you stop birth control; I’m always wary of it. It’s always – I don’t know that you would call it a true period. I like to wait for the next one after that as a better sense of what your body is doing with its own internal endogenous hormones.

[14:39] In other cases, for example, for myself personally, when I came off birth control, it took me six months to get my period back. So I had no idea what was going on. I just wasn’t getting a period, and I kept waiting for it to show up again. Eventually, after six months, it did happen, but I use that almost as a cautionary tale as far as if you’re unsure what your body is going to do after you stop these hormones, which are synthetic hormones, plan earlier.

[15:13] If you want to get pregnant this year, but you’re coming off of the birth control pill, give yourself those extra few months just in case because you don’t know how your body is going to react. You could get a normal period back right away and get pregnant the next month, and I’ve seen that happen very often. But, again, I look at myself and say, “Well, it’s also possible that you might not get a period for months at a time, and you just don’t know when it’s going to come back.”

[15:40] I always say, “Plan and plan ahead. The earlier you can start, the better.”

[15:44] Cassy Price: Oftentimes, when people speak about infertility, it’s in the vein of women’s health and women’s hormones and more on the female side of it. How common is male infertility?

[15:57] Dr. Sarah Zadek: It’s actually more common than we think. It takes two. When we’re looking at embryo quality, an embryo is half the DNA from sperm and half the DNA from an egg. I would probably estimate about 30% or so of cases are usually a male factor. That’s the average that I see, and I think that number is pretty close to what’s been reported in the literature. 

[16:27] I think there’s a good 10% to 20% wiggle room because some cases are just not reported, or we don’t know the reason. I’d say approximately 30% are male-related, and it is usually lifestyle or dietary-related. It’s all very easily fixable things. It’s usually a male who is smoking or drinking a lot or using marijuana or someone who’s just not keeping up a healthy body composition. It’s all the dietary and lifestyle things that I see.

[16:58] Cassy Price: How is the health of semen evaluated?

[17:03] Dr. Sarah Zadek: It’s called a sperm analysis. The male usually abstains from ejaculating for two days or so. Then they’ll bring in a sperm sample, and I get this looked at under a microscope by the nurses. They will do a sperm count. They look at the motility of sperm, so how well sperm can swim. 

[17:26] They also look at sperm morphology. This means the shape of sperm. So you can have defects in the head, the body, and the tail. You can have two heads on a sperm; you can have a short tail, where it can’t swim as well; you can have all these different morphological changes that affect the quality and the function of sperm.

[17:50] Then, as far as the actual quality of the fluid goes, like I mentioned earlier, we’re also looking at viscosity. How thick is the fluid? Does it look like it’s coagulating? Is it sticky and all stuck together? Is there debris there? Or is it fluid where sperm can easily swim within that fluid?

[18:12] Cassy Price: So, for men who have a low sperm count or slower swimmers, I know you’ve mentioned a few things, but are there specific steps they can take to improve this?

[18:23] Dr. Sarah Zadek: Yeah. Absolutely. When it comes to treatment, a lot of it is diet and lifestyle, but also supplementation. We take a similar approach when it comes to protecting the DNA of sperm. The first thing is, again, looking at overall diet & lifestyle: quitting smoking, stop drinking, no recreational drug use.

[18:48] Then, from there, we want to make sure that the sperm have all the necessary nutrients that they need. That’s everything from zinc and carnitine and arginine to B vitamins, folic acid or B-12, omegas, CoQ10 as well. Everything that a sperm needs to get enough energy to function and to protect its DNA.

[19:20] Cassy Price: Okay. So you had previously mentioned how immune factors can play into fertility as well. Do you mind elaborating on that a bit?

[19:29] Dr. Sarah Zadek: Sure. When I talk about immune factors, one of the relatively recent reasons that we’re finding for unexplained fertility is autoimmune conditions. Most commonly, I’m finding patients presenting with antithyroid antibodies. Basically, your body is attacking its own thyroid gland and causing dysfunction. That seems to be one of the more common ones.

[19:52] But, I also have seen some cases of what we call antiphospholipid antibodies. This increases the risk of blood clotting and having miscarriages. The immune system and autoimmune conditions play a huge role in fertility. We don’t want the body attacking itself, especially when you’re trying to conceive, and you’re going to be carrying a pregnancy, those have to be controlled. It’s one of the causes of second-trimester miscarriages is autoimmune conditions.

[20:30] Cassy Price: That’s interesting. I didn’t realize that. What are some of the signs that make you question if it’s an autoimmune issue?

[20:41] Dr. Sarah Zadek: Usually, if I see repeated miscarriages, especially if they’re later than 12 weeks, then we look to consider them. But to be honest, we’re screening most patients now for the antithyroid antibodies because it’s something that can be remedied pretty quickly. It’s pretty easy to treat. Even dietary changes can make a big impact on antibodies. Studies are showing a gluten-free diet can decrease antibodies. We’re basically screening patients for the thyroid antibodies, but anything additional to that, you’re looking at someone who has had repeated miscarriages, especially if they’re later in the pregnancy or second trimester. 

[21:27] Cassy Price: Does inflammation or CRP levels ever play into people’s ability to conceive?

[21:35] Dr. Sarah Zadek: Inflammation, yes. CRP, I find, is too general a marker. I actually don’t even use it anymore. It gives you an idea of what’s going on, but it doesn’t tell you where the inflammation is or how bad it is. Inflammation, I’m looking at what kind of problems are coming up because of inflammation – for example, someone with incredibly heavy periods, painful periods, endometriosis. Anytime there’s another presentation of inflammation in the body, we’re looking at that for sure. 

[22:16] Not all inflammation is bad, though. I think that’s really important to note. This comes down to the lifestyle things that we can modify for fertility is the anti-inflammatory use that we have. For example, your body actually needs a very small but very specific inflammatory signal to tell your body to allow the pocket that’s holding your egg to release to ovulate it.

[22:43] So, without that little bit of inflammation, your body doesn’t release an egg, so you need that signal there. For this reason, we recommend avoiding NSAID medications, those that are non-steroidal anti-inflammatory drugs like Naproxen, Ibuprofen. We want to avoid those around ovulation because they could interfere with the release of an egg.

[23:06] So, again, not all inflammation is bad. It’s when it becomes out of control and becomes very symptomatic that we want to get control of it. So what can do this? Like over-exercising can cause inflammation of the body. You’re feeling sorer. You’re not recovering as well. That can definitely be it. Gut inflammation, when we’re having loose stools. If there’s inflammation in the gut, we’re not absorbing nutrients as efficiently. That’s going to affect fertility.

[23:37] Cassy Price: How would a woman know she’s in ovulation because not everyone has the same 28-day cycle. Everybody can vary from that. Some have slightly shorter; some have slightly longer. And even if you do have a perfect 28-day cycle, it doesn’t mean your ovulation days are perfectly at day 14, 15, 16. Right?

[23:57] Dr. Sarah Zadek: Yeah. Some women will opt for using ovulation predictor kits, which are test strips that detect the luteinizing hormone, which peaks right before you ovulate. I find that they’re not always reliable, though. Women don’t always get the readout that they’re expecting. So the line will be too faint or too dark, or it just will be wonky. They’ll get different answers on different days, and things get a little bit messed up.

[24:26] These kits are really expensive. For my patients, I usually say if you don’t have any LH strips or ovulation predictor strips at home, don’t worry about it. There are other ways you can tell if and when you’re ovulating. One of the at-home ways that I teach patients to identify this is a combination. 

[24:48] The first thing I do is get them to take their temperatures. It’s called basal body temperature. I have women, as soon as you wake up in the morning, but before you get out of bed, take your temperature. Log into your cycle tracker app, or if you’re just using paper and pen, you can do that too. But cycle tracking apps are awesome for this. Basically, you’re looking at the pattern of when your temperatures rise and fall.

[25:14] What we’re looking for is that in the first half of your cycle, before you ovulate, your temperatures are going to be at their lowest. Then you’re going to have between a .4 and a .6-degree difference when you ovulate. That temperature is going to rise a little bit, and it’s going to stay elevated. The reason for this is because of the progesterone. It’s keeping that body temperature higher for you in hopes that you’re pregnant.

[25:43] Then, when your temperature falls back down again, it’s usually when you get your period because you’re not pregnant. So, tracking temperatures is one way that we can get an idea of when you might be ovulating, but that, on its own, isn’t always accurate. And like the LH strips, you can get variations on what that chart might look like. I pair that with visual and physical inspection of the actual cervical mucus.

[26:12] It’s not as complicated as it sounds. Just pay attention when you’re wiping. Approximately six days before you ovulate, you might start to notice changes in your cervical discharge or vaginal discharge. As we get closer to ovulation, it will become almost like egg whites. It will be clear and slick, very slippery, and if you were to hold it with a tissue or between your thumb and forefinger, you should be able to let it stretch, and it should stretch like a good inch or so. It’s really neat to see the first time you do it, but I find tracking your cervical mucus quality with temperatures together is a pretty good indicator of approximately when you’re ovulating.

[26:57] Cassy Price: That’s very cool. So if people have been following a lot of these preconception steps: nutrition, lifestyle changes, etc. and they’re still struggling with fertility, what are some of the options available to them?

[27:14] Dr. Sarah Zadek: First of all, I would go in to see a fertility specialist right away. The big take-home here is that not all OB-GYNs are the same. Some have their own specialties and little niches that they like to work in. So make sure you’re seeing a reproductive endocrinologist or a proper OB-GYN at a fertility clinic. I think that’s really important.

[27:40] Patients also have the option of doing something like acupuncture. The research with acupuncture and fertility is growing very strong. It already is strong, but we’re getting more and more studies as time goes on. Seeing someone like a traditional Chinese medicine doctor or a registered acupuncturist, or an ND who does specific fertility acupuncture is also a great way to help to support fertility throughout this journey.

[28:11] Cassy Price: Cool. If any of our listeners wanted to get ahold of you directly to work with you or learn more from your expertise, how could they go about doing that?

[28:20] Dr. Sarah Zadek: You can use our website: conceivehealth.com. Our main location is in Toronto, but we have clinics embedded throughout Ontario from Kitchener, Waterloo, Barrie, Whitby, Thornhill – I believe as well is opened – and a few others. Conceivehealth.com has all of our information there, and you can find out more about preconception healthcare. You can learn more about our individual practitioners and find the treatment plan that’s right for you.

[28:52] Cassy Price: Awesome. This has been amazing. There’s so much information here, so thank you so much for joining me today, and thank you to the listeners for hopping on as well.

[29:02] Dr. Sarah Zadek: Great. Thank you.

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