- I mean, are there things that people should eat and not eat, things that people should supplement and not supplement in order to optimize their fertility? - I mean, this is definitely an interest of mine, right? All my fellowship research cycles around fecundability and natural fertility. And I think we really do a disservice by how medicine really is categorized by organ systems because we act like things in one place don't impact the other.

- As if. - Right, but it's, you have a body and your body and especially your hormones change and fluctuate and they're meant to. They are meant to be a dynamic system, but the world and the environment of which you are subjecting your body to has proven changes on both hormonal function and also when it comes to egg and sperm quality.

And so if you are somebody who just wants to live your healthiest life and have your most regular periods and have your hormones as well balanced as they can be for a lack of a better word, we'll just say that that means that they're functioning normally, then paying attention to the things that you do are really important.

And so I know this is a big one for you. Sleep is probably the number one thing that people don't do that does impact their reproductive hormone system and therefore can impact egg and sperm quality because sleep is when you have cellular repair and when you can drop your inflammation levels.

We know that inflammation is just toxic to eggs and sperm. It is. The inflammatory environment is not ideal for conception. And then for a female, you have to deal with the fact that you have your egg quality, but you also have how inflammation or what you're exposed to impacts your uterine environment.

So you have a two-fold situation here. So none of this should be shocking news when it comes to nutrition, but it is not talked about enough. You're right. Decreasing inflammation by the foods that we put in our body is consistently shown with an improvement in fecundability, an improvement in ovulation, and an improvement in success with IVF, and a decrease in miscarriage, right?

Huge studies have looked at these. Now, the big caveat is that nutrition studies are super hard because people who consume flax, for example, tend to have other good health behaviors that sometimes make it hard to identify what flax did versus their general health versus somebody who eats fast food every day.

So nutrition studies tend to be observational, and fertility studies are really hard too because what endpoint are you using? Is it getting pregnant? Is it live birth? Are you looking at IVF? Are you looking at natural fertility? And we have a lot of different overlap that makes both of these a little bit difficult.

And so they're all cohort-based or population-based studies where you analyze how people perform when it comes to fertility treatments or getting pregnant naturally based on their exposures to certain things. Diets high in fruits and vegetables are good for you, right, fiber, antioxidants. Fruit is not bad. Fruit got this really bad reputation.

- Really? I love fruit. - I love fruit too, but people think that it has sugar and that it's bad for you. - Well, it has fructose, but, you know. - No, it's not. That type of sugar is not bad for you, if we can just agree on the fact that fruit has a lot of nutritional benefit, especially when it comes to vitamins and antioxidants that can be extremely beneficial in decreasing inflammation.

Grains, so whole grains, especially that your body, you know, provide a lot of great fiber. So, of course, if you have celiac or you're gluten intolerant, you're a different category. But there was so much focus on keto and people eliminating grains as a food group overall. And even though that might be utilized in a dietary strategy to lose weight and losing weight can improve fertility, likely because of inflammation being the primary driver.

Because we know that even in studies where I take donor eggs and I transfer that embryo into somebody who's overweight, they have lower odds of success than if they were a normal BMI. So we can't act like that causation is just on egg quality from obesity, right? There's also some inflammation, some inflammatory changes that impact the body's ability or desire to allow an embryo to implant.

So fruits, veggies, whole grains are all good. Interestingly, you know, dairy. Dairy tends to be okay in most studies, but what we do see is that if you're gonna have dairy, have the real thing, the processed dairy, the skim milk, that actually decreases your fertility. And likely because the processing to make it still look like milk when you take out the fat is adding in things that are unnatural, potentially impacting your fertility.

- I don't drink milk anymore, but when I was a teenager, I drank half and half. I'm not recommending anyone do that. Remember, I was a skiing teenager. - You were trying to bulk up. - Well, no, I just could afford to. I wasn't trying, at that age, I wasn't trying to at all, but it was just delicious.

But so cheeses, whole, full fat milk. - Yogurt, yeah. - Half and half yogurt, okay. Yeah, but don't choose the skim one. Choose the actual one that comes with some of the milk fat. Fat is not bad for you. There's also this, right, hopefully we're getting away from it, but there's been such a low-fat craze or this real attention that fat is so bad, but fat comes in so many important forms.

Avocados and oils and nuts, dairy, meat. Fat and cholesterol are the backbone for all hormones, right, so you need that in order for your body to make the estrogen and progesterone that it needs to allow this whole process to happen. And so there's this idea that those are bad for you.

That's just really not. So healthy fats, whole grains, fruits, veggies. - And what about proteins and meats? Because I think within those categories, I'm a big fan of sustainably raised meats, if possible. Some people choose not to eat meat, but fish, eggs. - Love it all. Okay, so let's just go through the meats and the myth and the fact.

So we'll do tofu. So there's this big issue that tofu has soy and that too much soy can be bad because soy can be a phytoestrogen. Tofu does not negatively impact fertility, even in men. In fact, it can improve it because it does have some antioxidant-like properties, lots of iron.

When it comes to fish, fish are fantastic sources of healthy fats and omega-3 fatty acids, which are very crucial in the reproductive process. We do worry about, if you're pregnant, having too much fish and overexposure to mercury and how that can impact fetal brain development. So the general recommendation is three servings per week.

That doesn't-- - Let me guess, a serving is like four to six ounces, as opposed to like a real human that eats, you know. - A real human. - Yeah, that eats, you know, six to eight ounces of fish. - And I think it's important to say, even though people will tell you that when you're trying to get pregnant with the idea of we don't know when you're going to be pregnant, if you're going through things like egg freezing or IVF and you know when you're going to be pregnant, I wouldn't feel like you have to restrict yourself on the consumption of seafood during those time periods when you know you're not pregnant yet, because really the concern is about that mercury and what it could potentially do to a fetal brain.

- And raw seafood, correct? No sushi, no sashimi. - Well, when you're pregnant, correct. And that's mostly because of the risk of infectious disease that can cause severe brain development and other issues. - What do they do in Japan? - I don't know, I don't live there. - They probably laugh at this.

- They probably do laugh at us. They probably do laugh at us a lot. - Someone who's been pregnant in Japan. - Yeah, reach out, tell us. - Yeah, or conceived in Japan. Tell us, don't tell us the story of the conception, but tell us, did you have sashimi?

- Overall, meat is a really broad category and studies study it differently. Like, is it all meat? Are you distinguishing now red meat and chicken? Are you putting it all together? I mean, obviously I think we can all come to the agreement that processed meats are not good for a variety of different reasons.

In addition to being carcinogenic, those toxins do negatively impact fertility. Now-- - So deli meat, no bueno. - So yeah, but in specifically those things like the bacon and like the things that are really highly processed, hot dogs, sorry, the 4th of July hot dog picnic. But those things really do not provide nutritional advantages and only harm.

Especially then when we have red meat. For the most part, red meat when isolated individually in most circumstances in moderation tends to be fine. I usually tell my patients, I want them to eat a plant forward diet. But that doesn't mean no meat. But I say, look at your meat servings, I don't want it red meat every single day.

Because there was a study looking at IVF and looking at embryos and the more servings, a lot of nutritional studies based things on quartile. So who eats the lowest and the second most and the third most and the top most. And people who ate in that top quartile of red meat had lower progression of embryos through the culture.

So less embryos that developed, less normal embryos and lower success rates. - Do we know anything about how that meat was arriving? - No, unfortunately we don't. - Are we talking about like hoagie sandwiches? - We don't know it. - Or are we talking about like grass fed steaks?

- Right, these studies are not wonderful, but that doesn't mean that they don't hold merit in helping us guide counseling. But no, that one was how many servings of red meat do you eat in a week, right? So we don't really know. Does the really ethically sourced, the grass fed, this environment which we feel like is much less toxic than potentially, let's say like a cattle factory where the cows are injected with all sorts of things.

Is there a difference in how those impact your reproduction? Probably, right? If this cow is getting injected with a lot of hormones, why are we thinking that it's not impacting the meat that you're then ingesting into your body? - No, I think our audience will certainly subscribe to that idea.

I think most of them will. I mean, the notion that like the pollutants you breathe in the air somehow are not the air that you breathe into your lungs is just like completely naive. - Wild. - And the idea-- - But people feel that way and they hold strongly to this idea that it can't be this thing that I love that is causing this problem, right?

The denial of the association between what we put in and on our body and how it impacts our body's function is really strong in some people. And I think it's really just lack of education and awareness because the medical community for so long did not address these factors, right?

Your doctor never talks to you about nutrition. And so it just became this idea that it must not matter, otherwise your doctor would talk to you about it. I think sugar is the last thing I just didn't mention, but added sugar and artificial sugars are bad for you. - Artificial sugars.

- Artificial sugars too. - Including stevia, so plant-based low-calorie sweeteners. - Stevia itself hasn't been studied as much as the other ones, things like sweet and low and all of those. But what we do know is that they interfere, they cause inflammation inside the body. And then they also can cause a stress reaction and they can cause higher rates of miscarriage when you intake more sugar and artificial sugar.

So that's a lot to wrap your head around. And I say the same thing to every patient. One cake, one this, one hot dog. I mean, those things individually are not gonna make a difference, right? It's the choices that you make every single day that are going to set you up to be your healthy self or not.

And so you should make choices in line with how you wanna treat yourself. You want to be in your best health. You want your hormones functioning the best. And if that added helps you get pregnant when you want to, helps you have a better chance of success with IVF, oh my gosh, what a fantastic benefit.

But that doesn't mean you can't enjoy some of these bad things here and there, as long as you've set yourself up on the day-to-day where you're giving your body lots of nutritious food that it needs to make hormones. Similarly, being very underweight and calorie restricting, we all know is really terrible for your reproductive system and can cause the brain to totally shut down ovulation because it senses that you can't have a pregnancy.

- If people miscarry, excuse me, by virtue of being underweight, does the body, like I learned some years ago, I think this is still true, that one of the signals for the onset of puberty in females is that leptin hormone is secreted from body fat that then signals to the brain, to the hypothalamus, like, okay, there's enough reserves to create environment.

It's a signal about environmental-- - Yeah, there's enough extra fat to have a baby. - Yeah, and there's presumably enough food around to sustain that baby, right. Are miscarriages and lack of body fat correlated? - On both ends of the spectrum, yes. So lack of body fat and being overweight, we see decrease in getting pregnant per month and we see increase in losing pregnancies.

So certainly, there is a healthy medium where your body has what it needs. And that makes sense because if you have, I like to even say hypothalamic dysfunction. So maybe your brain's not totally shut off where it's sending out no hormones and you're not ovulating 'cause you're not getting pregnant in that circumstance.

But certainly, ovulation disorders are on a spectrum where you go from a perfectly synchronized cycle to one that prolongs it, gets shorter together, then prolongs, and then you have nothing. There's this spectrum of dysfunction which is representing your hormones not being necessarily perfect. And that can have impacts on the placenta trying to grow into that uterus.

I mean, the placenta is fascinating, right? An entire talk just on the placenta. But it does this incredible job where your body has to not reject it, yet allow it to eat away at the side of your uterus and grow into your blood vessels. But that requires a very specific hormonal environment for it to be done and to be done right.

I think in the same breath of all this, what you're also asking is, yeah, okay, so that's eating healthy. None of that's really new news for most people. A lot of those things I just said. - Well, I think some, but I do wanna thank you 'cause I think rarely, if ever, do we hear somebody, a physician, be really direct about like, hey, listen, some red meat, yes, not excessive amounts of red meat.

Ideally from sustainable sources, whole fat milk products, grains, fruits, vegetables. I mean, those kind of straight, what to you seem like straightforward directives are actually pretty rare in the landscape of public health discussion. Because more often than not, people talk about nutrition in these kind of elimination diet type things.

Like eliminate all the grains or eliminate all the meat or eliminate all the milk fats. When in reality, I think people forget that like most people out there are omnivores and they can make better choices about not deli meat. You know, less bacon, if any bacon, right? - Have some veggies with your lunch, right?

Like you can make better choices on the day to day. I think that is a great point. I think there's a place for supplements. I think the big disclaimer that everybody's gonna say with supplements is that they are not regulated like the way medications are, right? And I will say supplements and herbs are different things.

Right, a supplement, but many companies are adding herbs to their supplements and that can get into really murky territory, especially when it comes to how some of these herbs do have estrogen and progestin like properties and can impact reproduction and hormones. - And perhaps even androgenic properties too. - Yes, so we can't act like everything's created equal.

So I always tell people, if I recommend you take a supplement or your doctor does, your due diligence is to look at what is also included and make sure it doesn't have these extra added things that they're unaware of, because sometimes they can have negative impact at one stage of your life or another, depending on where you are.

Certainly, a prenatal vitamin, which has folic acid, we all know that folic acid is really important to prevent neural tube defects, but it's also important in cell division and how the ovary is growing follicles and growing eggs. - So should people, women, but also men, be taking a vitamin with folic acid even when they're not trying to conceive?

- There's no harm in having it, but very often pregnancies occur when you're not trying to conceive, and that is a store that needs to be built up three months ahead of time. So we really need you to be taking that ahead of getting pregnant. So not just, let's get pregnant right now, I'm going to start this prenatal vitamin.

So I recommend anybody who's in their reproductive years, take a prenatal vitamin. We also know that many, many people are vitamin D deficient and vitamin D does impact reproduction. And so I usually say 1,000 international units of vitamin D is not going to be harmful in anybody. It's going to be helpful for most people.

Some people definitely need higher levels. So we screen everybody with a vitamin D to see who needs to have extra, but a blanket statement that extra vitamin D is going to be helpful. Omega-3 fatty acids, also extremely important in one, being anti-inflammatory, but two, brain development of a fetus.

So most prenatals now actually do have those omega-3 fatty acids in them, but if they don't, I recommend a patient take those. - Just a brief question/insertion there. There's a laboratory up at the University of California, Santa Barbara, that's published some really interesting data showing that essentially brain weight, which is just about one indirect measure of brain health, but brain weight at birth seems to be correlated, at least in some positive way, with the amount of essential fatty acids that mom consumed during pregnancy.

Does that sound, does that hold? - Yeah, I mean, that does hold. And there's mice studies about that mice are smarter when they have diets with omega-3 fatty acids when they're in utero, right? So the exposure and the time period is really important. And omega-3s have a lot of health benefits when it comes to their antioxidant properties, especially in endometriosis, diseases that are very highly inflammatory.

They can be very beneficial. - We're definitely gonna talk about your work after baby has arrived and impact of essential fatty acids, but what would you say is the dosage cutoff? On this podcast before, I've sort of thrown out numbers, like one to two grams per day of the EPA form of essential fatty acids.

And then we could have a whole discussion about omega-3, omega-6 ratios. But do you think there's a upper limit? Is it truly that, let's say up to four grams per day of EPA, would that be advantageous? Is it better than one gram? - I tell people a gram. - A gram, okay.

That's in alignment with pretty much what we've talked about before. - So that's what I recommend. You know, when I give my handout to my patients and they're trying to get pregnant, it's gonna have a prenatal, 1,000 IUs of vitamin D, a gram of omega-3s, and then CoQ10. So CoQ10, which essentially, in general, is trying to help the mitochondria.

That's the whole idea here, that it is helping provide support across the body in a lot of different ways, right? Like CoQ10 is used in a lot of different areas of the body. But when it comes to reproduction, when it comes to meiosis and cell division and ovulation and egg quality and even sperm quality, there's a place for CoQ10 showing benefit without harm, right?

And so no, like I said earlier, nothing's without any harm or any risk of harm, but very, very little. So I usually recommend if you're trying to get pregnant and you take CoQ10, a dose of 200 milligrams three times a day. So there's kind of a higher dose than sometimes people are on.

Often prenatals now have just like 200 total in it. And so- - The expensive ingredients are usually the lower concentrations in blends. - Just enough so they can put it on the label. - Right, which includes CoQ10. Does the form of CoQ10 matter? 'Cause you'll find them in gel capsules.

You'll also find them in powdered capsules. - I always say, I mean, there might be for the individual person. I mean, absorption of medication is really depending a lot on gut health and other factors. But the number one issue with supplementation is that people don't stick to it. So I always say whichever one you're going to consistently take is going to be the better form.

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