In the absence of clear diagnostic reasons for not being able to conceive a child, and after trying for a year unsuccessfully, a diagnosis of “unexplained infertility” is commonly passed out. This diagnosis of exclusion leaves two people in a state of uncertainty and can be very frustrating. It is not really unexplained though, if all of the possibilities have not been explored. Last year, 16 couples labeled with “Unexplained Infertility” who came to my office were able to conceive naturally by digging deeper with Functional Medicine. If you have available eggs and your partner has viable sperm, you are not infertile. There is a reason that this very natural process isn’t working. Finding that reason and addressing the root cause is often corrective.
Medical Infertility Overview:
According to Mayo Clinic, 10% to 15% of couples in the U.S. are infertile. Infertility is defined as not being able to get pregnant despite having frequent, unprotected intercourse for at least a year. Infertility may result from an issue with either you or your partner, or a combination of factors that prevent pregnancy. The statistics show that 33% of the time there is a problem with the man or woman, the other 34% of the time both parties have a factor that contributes to the fertility challenge.
Medically identifiable causes of male infertility:
• Abnormal sperm production or function from diabetes or genetics.
• Problems with the delivery of sperm like premature ejaculation or sperm blockage.
• Overexposure environmental factors like pesticides, chemicals, radiation, Cigarette smoke, alcohol, marijuana, anabolic steroids, and taking medications to treat bacterial infections.
• Sperm Damage related to cancer treatment, including radiation or chemotherapy.
Medically identifiable causes of female infertility may include:
• Ovulation disorders such as polycystic ovary syndrome, hyper or hypo-thyroid, over-exercising, low body fat and eating disorders.
• Uterine or cervical abnormalities that can block the fallopian tubes or stop a fertilized egg from implanting in the uterus.
• Fallopian tube damage or blockage from pelvic inflammatory disease, endometriosis or adhesions.
• Endometriosis, which occurs when endometrial tissue grows outside of the uterus, may affect the function of the ovaries, uterus and fallopian tubes.
• Primary ovarian insufficiency (early menopause), when the ovaries stop working and menstruation ends before age 40.
• History of Cancer treatment. Certain cancers, particularly reproductive cancers often impair female fertility. Both radiation and chemotherapy may affect fertility.
If you have consulted with a reproductive endocrinologist and the list of known fertility factors have been ruled out, couples are usually offered fertility drugs to stimulate release of eggs. If follicle or egg stimulation does not yield pregnancy, options like IUI or IVF are brought to the table. I have had success with patients both before and after IUI and IVF.
IUI stands for intrauterine insemination. IUI works by putting sperm cells directly into your uterus around the time you’re ovulating, helping the sperm get closer to your egg. This cuts down on the time and distance sperm has to travel, making it easier to fertilize your egg.
IVF stands for In Vitro Fertilization. IVF is often brought to the table as the “last chance to conceive” for couples. This is the process of fertilization by extracting eggs, retrieving a sperm sample, and then manually combining an egg and sperm in a laboratory dish. The embryo is then transferred to the uterus for implantation.
Many couples are open to the idea of taking a medication to stimulate release of the eggs to increase odds. This openness tends to dwindle when the idea of manual manipulation of the process, like IUI or IVF is suggested. The most common time I will meet a couple with fertility goals is after medications that stimulate egg release fail and before the discussion of IUI or IVF are entertained.
Functional Medicine Evaluation of Infertility.
Medical diagnostics for infertility are fundamental. I always like to know what tests have been performed to gain valuable insight into “things that we know are working”. With that basic respect for the rather advanced level of diagnostics available, there are a list of things that I have observed that are overlooked or interpreted differently from my Functional Medicine scope. Here is a list of common reasons that I find with couples who have fertility related issues. I will also provide a very brief commentary of each issue.
• Highly Inflammatory Diet (Male or Female)
• Functional P.C.O.S. (Female)
• Estrogen Dominance (M or F)
• Functional Thyroid Issues (M or F)
• Toxic Metal Syndrome (M or F)
• Methylation Disorders (M or F)
• Systemic Inflammation (M or F)
• Stress Hormone Imbalances (M or F)
• Poor Body Composition (M or F)
• Vitamin Deficiency Status (M or F)
• A Highly Inflammatory Diet is suspect as a driver for any negative condition in the body. Fertility issues are no different. A 2018 Harvard study even includes healthy diet as part of the list of suggestions to increase odds of conceiving. What is the best diet for fertility? The best diet for your individual system is the best diet. How do you determine what diet is best for you? Hire a Board-Certified Clinical Nutritionist. The answer is unique to the individual.
• Functional P.C.O.S. (poly cystic ovarian syndrome) in a woman is where hormone levels are just out of balance enough to interfere with optimal egg release but do not show up as a diagnosable medical condition. You do not need to have facial hair, high body temperature, lack of ovulation, abnormal cycle length, cysts on the ovaries and obesity to have compromised egg release. Many women float just below the diagnostic radar with high androgen hormones. With the right diet, exercise modification and nutritional therapy, they can usually regulate their systems in a few months. P.C.O.S. is misunderstood by many. Testosterone tends to have a stronger ability to bind to the estrogen receptor than estrogen does. If testosterone levels are high, estrogen can be displaced leaving a large amount of free form estrogen dominance. This leads to multiple levels of systemic inflammation and poor ovulation at the same time. This is a very common infertility driver.
• Estrogen Dominance can show up as either too much estrogen or an unbalanced ratio of estrogen to other hormones. Men or Women can have sub-optimal fertility potential due to this imbalance. In men, estrogen dominance can interfere with sperm production and lowers testosterone levels. In women, estrogen dominance causes many PMS symptoms as well as driving an inflammatory state that can create endometriosis, uterine fibroids, or the inability to ovulate.
• Functional thyroid imbalances are very common drivers of fertility issues. The medical reference ranges to evaluate the thyroid are established to determine if there is a detrimental lack of, or over-stimulated level of thyroid function. To reach the medical “disease” ranges you have gone well out of a normal functional range. For example, a TSH (Thyroid Stimulating Hormone) level above 2.0 ng/ml can lower basal body temperature and interfere with ovulation or sperm production. A blood level of 4.5 ng/ml or above is required for a medical diagnosis of HypoThyroidism. There are many patients who fall between the cracks on this one and with a thyroid friendly diet and some basic thyroid support find themselves ovulating and self-regulating within three menstrual cycles. Is there a family history of thyroid issues? It is worth asking!
• Toxic Metals are ubiquitous. They are in the air, food, water, soil, under-arm anti-perspirants, pots and pans and even in your brown rice. Some of us have an efficient detoxification system that allows us to remove these toxins at the speed we are exposed to them. There are others of us who have a genetically compromised detox system where we are more likely to accumulate toxic metals. Certain levels of aluminum, mercury, cadmium, lead, arsenic and antimony in our body can interfere with optimal sperm production or implantation of the embryo in the uterus. A non-invasive, inexpensive toxic metal screen can be used from hair or urine to determine if toxic metals could be behind your fertility issues.
• Methylation disorders refer to genetic variants in one of the bodies five detoxification pathways called methylation. The MTHFR gene is the most studied of the 32 genes in this pathway and plays a strong role in converting B vitamins 2, 6, 9 and 12 into their active form. If a woman has one of two combinations of variants in the MTHFR gene, the folic acid (Vitamin B-9) in her prenatal is not supportive of sustaining pregnancy and chemical miscarriages are common. Many times, couples are conceiving but the uterus will not allow implantation and it just looks like the woman’s menstrual cycle started a few days late. A simple blood test can determine the MTHFR status. The problematic combinations in the MTHFR gene are one copy of the A1298C together with one copy of the C677t gene, called compound heterozygous, or two copies of the C677t gene called Homozygous. Both of these variants require a specific form of active folic acid to support sustaining pregnancy. It is important to note that recurring miscarriages fall under the infertility umbrella. There are a hand-full of relevant genes in the methylation pathway that can contribute to miscarriage and assessing just MTHFR is considered limited information.
• Systemic inflammation, as touched on with the inflammatory diet discussion, can interfere with all aspects of fertility. Sed rate and CRP blood tests can determine if there is an underlying level of inflammation that needs to be corrected to support fertility outcomes. Headaches, joint pain, inflammatory bowel, pronounced muscle stiffness, swelling or water retention are all symptoms of underlying inflammation. Infertility does not necessarily have a symptom associated with it other than not achieving pregnancy, but the system imbalances that challenge fertility do. Listen to your body, the answer might be right there linked to how you are feeling day to day.
• Stress hormone imbalances or states of chronic high stress can create sex hormone imbalances that pull the human body away from the hormone regularity required to conceive. Too much stress can cause a shift in men that lowers testosterone levels. The brain will allow sex hormones to be used to make more stress hormones when required. In this case low testosterone will be secondary in nature. Optimal total testosterone blood levels for males is 650ng/ml. An FSH and LH level can determine if the low hormone is primary (testicular issue) or secondary (often stress issue). With secondary low testosterone, repair of the adrenal system and stress/behavior modification will usually be restorative of optimal testosterone levels and sperm production will improve.
• Too much stress in a woman carries a different mechanism than men. 25% of a woman’s testosterone is made from the adrenals, so if high stress is causing high testosterone levels ovulation can be compromised. Total Testosterone levels above a 32ng/ml in a woman can be problematic. The other side of the female stress sword can lower progesterone and interfere with implantation.
• Poor body composition is often overlooked in the pursuit of fertility. Increased body weight, over-weight or obese, can shift hormones into a sub-optimal state. Belly fat is a very big reason for estrogen dominance and low testosterone in men. Mid-section weight gain in both men and women will increase the levels of aromatase, the hormone that increases system estrogen levels. Estrogens are also stored in body fat, so the larger the storage tank of body fat, the more likely there will be a hormone imbalance. One of the best indicators that fertility is improving with over-weight couples is weight loss.
• Vitamin Deficiencies can also complicate fertility issues. In humans, the vitamin D receptor is found in the ovary, uterus, and placenta. The active form of vitamin D, when bound to its receptor, can control the genes involved in making estrogen. The uterine lining produces calcitriol in response to the and controls several genes involved in embryo implantation. Optimal vitamin D levels are 65-75 ng/dl. Lab reference ranges are 30-100 allowing many women to fall through the cracks.
One of the side effects of vitamin B12 deficiency is infertility, optimal serum B12 levels are around 750 where lab reference ranges are 200-1100. Clinically low levels of B vitamins can affect both sperm production in men and compromise implantation in women.
Folic acid levels are required to sustain a healthy pregnancy. This is the vitamin that is most focused on with the Pre-Natal vitamin. The methylation pathways described above play a huge role in optimizing the form of folic acid your body requires for both achieving and sustaining pregnancy.
If you have been trying to conceive for over a year with no success, and you have ruled out all of the common medical causes for infertility, do not stop looking for answers if it is “unexplained”. It is very common to find a combination of the factors discussed above, that when put together create the environment less likely to support conception. An overweight man with mid-section weight gain and moderately low testosterone combined with a highly stressed and estrogen dominant woman who has clinical vitamin deficiencies is enough to lower the odds of conceiving. These shifts are not difficult to correct with the right motivation and commitment to health.
It is common to take around 3 months, or 3 menstrual cycles, to optimize hormone metabolism, treat vitamin deficiencies and allow a corrective diet to control inflammation at the cellular level. From this point, the odds of fertility start to spin in the favor of the well-prepared couple.
Regarding motivation, an average IVF cycle, with 50% success rate, will cost a couple $17,000-$20,000 out of pocket. This is not to ignore the daily injections of hormone stimulants, egg retrieval, fertilization and transfer, and the increased odds of twins or triplets. The medication Clomid, (clomiphene citrate) that is used to stimulate the ovaries can cause nausea, headache, flushing, diarrhea, shortness of breath, chest pain, seizures or stroke.
It is no surprise that many couples are looking to find the root cause and pursue getting healthy first, before making that kind of commitment.