Root Cause Infertility: Inflammation, Insulin Resistance & Hormones Explained with Natalie Crawford

Today I'm joined by Dr. Natalie Crawford, one of the leading fertility doctors globally. A double board certified fertility doctor who's also the host of As a woman podcast with more than 5 million downloads. She's the author of her debut book, the fertility Formula and co founder of Fora Fertility, her fertility clinic in Austin, Texas. Today we're covering how to take a root cause approach to your fertility and why inflammation may be impacting your fertility. So, Dr. Crawford, you've said that inflammation is literally at the root of a number of fertility issues. What do you mean by that? And why is this not more commonly known amongst women?

Oh, well, thank you so much for having me here and to talk about this because it is something that so many women just feel like there's nothing they can do to change their fertility, and that's really not the case. And the data supporting the fact that inflammation is so profoundly impacts so many disease states, but especially our fertility, is all over the place. And what I want people to step away from this and think, you know, chapter one of my book is called how inflammation hijacks your fertility because it really is so crucial to how our cells work. And modern medicine has done a disservice in so many different ways. But one thing is that we've segregated all the body organ systems. And we think about your heart over here and your brain and your lungs and, you know, reproduction in its own little bucket. But you've got one body, your cells all work together, and inflammation itself directly impairs how your cells function on a CE level. And that, of course, is going to impact both egg and sperm quality. It's going to impact the brain's ability to interpret and respond to hormones. It is tightly linked with insulin resistance and gut health. And all of these factors actually come together that we have to relearn or learn for the first time how our body actually works. Because we're really not ever told what's normal. We're not taught about our cycles. We're not taught about what happens with our natural fertility as we get older. And we're definitely not told why inflammation plays such a big role. I'll be honest, in medical school and residency, we all learn about inflammation, but we learn about it on a pathway to disease state. And it really is something that we're never thought of as the fact that the world is very inflammatory. We are exposed to things every day that contribute or help our inflammatory burden, and that this alone is the nidus for what actually can lead to disease. One of the stats that I Find so concerning is the fact that if you have infertility, you have a greater risk of a serious health problem or dying earlier. Heart attack, stroke, metabolic disease, cancer. And by no means is it that infertility is contributing to these things directly, but that has to make us step back and say, your fertility is a health marker. There's something underlying at a cellular level that is actually contributing to both your infertility and. And to this later disease risk. So I think for women specifically, often infertility is the very first disease we've ever had. It's the first thing going wrong. It's really a big red flag warning sign that your body is not functioning to its best ability at a cellular level. And it's time that we can pay attention and see what we can do differently.

I love this approach so much because it makes so much intuitive sense, both mechanistically and intuitively. And when you go from doctor to doctor, so many women are faced with these doctors who will say, oh, inflammation has nothing to do with this. Or environmental toxins are something that just Instagram influencers are talking about that play no role in what you're experiencing. So how do you recommend that women who are getting that messaging from their OB GYNs actually, like, figure out what is true?

Oh, you know, I've been that patient. I had multiple pregnancy losses. I had normal evaluation. I was told to just relax, that it was nothing I could do. I couldn't change the outcome. It was just bad luck. Those were words told to me by my own physician. But the truth is, if we step back and we say, well, what is luck? Luck is something that you have 0% control over, but you can control the knowledge you have, the decisions you make, how you advocate for yourself, and how you set yourself up for success, or how perhaps you're holding yourself back and you don't even realize it. The biggest problem I see for women in general is that the health system is not meant to spend time together. And yet we're very bad at advocating for ourselves because we're told to be right. We're told not to be problematic, not to be loud. We dismiss our own symptoms. Then we get gaslit by physicians, and we get into a place where we're not used to being heard, and we wait till we're very sick before we are loud enough to have attention brought to us. A few things I want to say to everybody. Number one, whatever doctor you're seeing right now is not the doctor you have to see. There are great physicians and providers out There. And so please never feel like you're at some point of your journey where you can't go get another opinion. More than that, though, I think we have to start saying what is normal and understanding what normal is so that you have the right language to advocate for when things are abnormal. You should always be advocating for your health or trying to seek answers when things have shifted. And. But a lot of that requires you to really understand what your normal is. And then being a player in a health system that's not meant for your success, but doing so to the best of your ability. So one big thing I see a lot of women do is they say, and my patients tell me this all the time, oh, well, I have an annual exam coming up, so I will just bring it up to my doctor then. But that is not gonna be an opportunity for your doctor to deep dive into whatever your symptom complaint may be. Because an annual exam, maybe they have 15 minutes, they have a list of things they have to get through. It's a preventive care visit. It's not meant to dive into a problem. So I always encourage people schedule a problem focused visit, Say, my cycles are off. That's going to give you some dedicated time to talk about that problem, but then also take a lot of ownership for what you're really experiencing it, how long it's been going on. Have a good story. Because the first question I always ask every patient is, well, tell me what's going on. And there's no reason you should stumble through that because you know it's coming. And I can only work with the data my patients are given me. I love the diagnostic challenge, so I'm gonna pull out every nitty gritty question. But a great example is that many physicians just say, are you having a period? And if you answer yes, they will move on to the next question instead. We know your cycle's a huge vital sign that subtle changes in follicular and luteal phase can represent different hormonal issues. But you only know that if you know when you're ovulating, which you only know if you learn how to track your cycle. And that, you know, having shorter or longer cycles than your normal can reflect different things as well. So there's this balance of the questions your doctor will ask. But bringing information to the table that is really valuable and trying to arm women with the knowledge so that they can do that in a way that's going to be effective for them to get the care that they actually need.

So true. And also I would say that if you are a woman who looks physically healthy from the outside, that it likely increases the bias that your physician has towards you of kind of overlooking a lot of the symptoms that you may be experiencing. And that happened to me in my journey after my miscarriage where she was like, you're generally healthy. This just happened by chance. You should just start trying on your next cycle. And I was like, well, what about some of these other symptoms that I'm telling you about for my cycle? And it was like, you're healthier than most people that I see throughout the day. So you're basically, like, being dramatic about what's happening in your body.

And that's so heartbreaking. And in general, that's not good care. But also for you personally, like, you know, things are not normal, you're getting dismissed, you're then going to be gaslit. And at some point, if somebody keeps telling you it's in your head, often we believe it or we stop bringing it up because that's a really terrible feeling to sit across from somebody who you're going to them for help and to have them essentially say, your complaints aren't valid or you're not sick enough for me to care to look into them more. So, well, one, big hugs that you had to go through that. But I know that's not a unique experience.

Sadly, it's not a unique experience. And I think about even the patients that have endometriosis who, you know, just in order to get an endometriosis diagnosis, it's like you really have to put up a fight in some ways, because the average, you know, to a diagnosis, I believe, is seven years. But you can correct it seven to.

10 years to get an endo diagnosis.

And a lot of them won't want to actually do the laparoscopy unless you have, quote, unquote, enough symptoms. And one of the OB GYN said, if you had endometriosis, you would be in pain 24 7. Now, I have never been diagnosed with it, but it was, you know, one of the things that I was bringing to the table. And it was like just this complete dismissal being like, no, you would have pain 24 7. And so that's how I know that you don't have it.

First, we should say that endo is an inflammatory disease. It has an autoimmune component, but that people present across the pain spectrum and certainly patients can have no symptoms and have endo. Some people have terrible symptoms. It doesn't even correlate with stage of disease. But that. How terrible to say you're not in enough pain, essentially, for me to take your complaint seriously. And that's why women suffer for so many years. And one out of ten women have endo. That would never be the case if 10% of men had a condition that caused chronic pain to the point where it impacts their daily living. I can't even imagine a world where it would take seven to 10 years to get to that diagnosis.

I completely agree. It's so wrong. So you've been extremely open about your own fertility journey. I'd love for you to open up and share what that process was like for you as a fertility doctor, struggling with it, and how it changed how you care for your patients.

It was terrible, right? It changed everything of how I approach medicine. I'd been with my husband for a long time and in my last year of OBGYN residency. So to be a fertility doctor, it's four years of OBGYN training and then three years of reproductive endocrinology fellowship. And we started trying and started experiencing miscarriage after miscarriage. And I was very pragmatic at first. Oh, this happens. This many people lose a pregnancy, it's better that it didn't get further along. And then when it happened again, I went to the doctor and was told, well, we don't even work up pregnancy loss till you've had three of them. I thought, how terrible. Like, two can't be normal. I'm young. Had a third, finally get an evaluation and told everything's normal, just to relax. Bad luck. And I knew that something wasn't normal. Said, like, I have these other symptoms that are not the pregnancy loss, but this just doesn't make sense why I'm going through this. Ended up having a fourth pregnancy loss that was an ectopic pregnancy, and that one overlapped with, I was now moving into fellowship. So now I was a fertility doctor. I'm training to be a fertility doctor, and I'm thinking, I'm going to be somebody who helps everybody else get pregnant except myself. And I realized at the time all the questions I really had, you know, I was the classic person. I was on birth control up until we decided to start trying for a family. I had never learned to track a cycle. I had no idea what we really needed to do to try to get pregnant. And when we started to lose pregnancies, all the questions I had, nobody had the answers, and they were not taught to me in my training. And it got to the point where, as a fellow, you do a year and A half of research and a year and a half of clinical work. And research is typically an IVF project. Most fellows across the country study ivf. And it's a very controlled environment because you have to publish on it. You have to go sit for your thesis and defend it as part of your oral boards. And I remember going to my program director and said, I don't want to study ivf. Like, I love ivf, but I want to study natural fertility. I want to understand the factors that influence some people having a harder time and having infertility. I want to understand cycle abnormalities. And they said, that's not something somebody does. That's too hard. But essentially they made me agree that if I wanted to do that, I'd have to get a master's in clinical research. And I was, sign me up. I am here for it. I want the answers, because these are the answers I felt like real life women had. And I. I'm old. So I was on, like, forums and, like, old. Like, I was deep in the Internet trying to figure out, like, what I should be doing because it wasn't in any book. And during that time, I studied the luteal phase, I studied AMH or ovarian reserve, I studied vitamin D, I studied environmental toxins. And what my big moment during this was, I started realizing that all these different things that were related because people had infertility, but they weren't the same. Inflammation was in all the research about on the disease pathway, this caused inflammation. This group had more inflammation. And I started to say, we only learn about inflammation right in this late stage form. But it seems like if the toxins we're exposed to cause inflammation or if our dietary pattern can be inflammatory, that makes sense that it's impacting our cells. And I really started to take this deep dive approach to it. And I was my own N of one experiment, which does not is not data. But I said, if my medical community is telling me that my only option is to do IVF for my pregnancy loss, they said, there's nothing else I can do. Then I know that in IVF they can only work with the eggs and sperm we have. So I'm gonna make sure we go into that with the best eggs and possible and started really paying attention to what inflammation felt like, what the symptoms were, what in my world caused it, and just trying to take those things out. And I actually got pregnant during that time frame with both my children and stayed pregnant after years of infertility and pregnancy loss. And it turns out a decade later, That I ended up having celiac disease that got diagnosed much later, that was never diagnosed. Then when I was told everything was normal and. And when I was starting to learn to listen to what my optimal was. Right. Like, normal aside. But what is optimal? How should I be feeling? And what is inflammation? I cut out gluten. And at the time, everybody was in the camp of like, don't cut out food groups, don't do this. And I cut it out just to. Because I was experimenting. How would I feel better? And I felt better. So I cut it out and got pregnant and stayed pregnant. And that makes a lot of sense with the fact that I now have a celiac diagnosis that got diagnosed so much later on the other end of it. What I really learned was to believe women and medicine teaches you to be efficient, to be a good purveyor of how you use resources, to be very judicial. Because when you're going through training, a lot of your patients do have really limited resources and you are trying to be very mindful about what you're doing. But in the real world, for the individual experience, having the approach that this was my fertility journey and nobody else's, why did I not have a greater say in what tests were ordered or what happened or what I got to do? Why was I so dismissed? And really having that approach with the idea that if I educate people and they are now brought their knowledge base up so that they can understand why we may recommend this or why we may not some tests, I say maybe it's not worth doing because we're going to make this change anyway. Right. So there's always pros and cons, but allowing the person whose story it is to be at the center of making the decisions instead of it being such a paternalistic field of medicine, is really core to how I practice now and what I think all patients deserve.

All patients deserve. Oh, my gosh. I could not agree more. And I'm so sorry that you went through that journey, but I feel like in so many practitioners that I meet, and this is my own case as well, that it makes you such a better practitioner because you understand the human side of how we're not necessarily trained to practice.

Yeah, it's definitely not how we're trained. And I wouldn't wish it on anybody. I will say that along the way, you know, not all my doctors were bad, nor do I want to say that they were. You know, I did have somebody who was so helpful, and she did say, you know, there's nothing here that's, you know, abnormal. But I believe you will be pregnant one day. And, you know, maybe there's things we can't control. I mean, she didn't give me an answer, but she gave me this nugget of hope that really latched on to that, like the child that's meant to be mine, it will all come together. And that it was my responsibility to make sure. I was doing everything I could to make that happen. But that was helpful too, because it is so isolating. I felt so left behind. My friends, my, you know, my family. As everybody was getting to this having kids stage, the holidays were so triggering that it really makes me approach them all now on this side with a deep understanding. I was just thinking how 12 years ago, like this month, I saw my fifth, you know, positive pregnancy test and I was just certain it would be another pregnancy I would lose. I was, wasn't even excited. And that's my daughter, you know, and so how sometimes it's like you can make a difference in your health even when you're being told the opposite, and that we should really help encourage more health autonomy. And when somebody tells you there's nothing you can do to change it, that's not very motivating to make any change. Like, why change if you can't change anything? But the data doesn't support that. The data actually supports the sum of all these choices make a huge impact on your health and your fertility. And yes, there may be no one thing that causes infertility or cures it, but that doesn't mean that we shouldn't really take a holistic approach to your fertility and your hormones. Because there are so many different working parts that have to go into getting pregnant and having a healthy pregnancy that it makes sense that your cells need to be really functioning at their best in order for that to happen.

Yes, it's so true. So with you having celiac disease, you removed gluten and you experienced benefits. I do want to touch on because I feel that so many women feel so much better on a gluten free diet. I've been Gluten free for 20 years. In the times that obviously everyone said, like, don't go gluten free unless you have celiac disease. And I have non celiac gluten sensitivity. What is your stance on gluten? Obviously, being an individualized approach. I'm sure. But overall, like, can you explain what your approach would be for someone that doesn't have celiac disease?

Yeah, I actually feel quite strongly about this. Right. Because I, I didn't have celiac disease either for a while.

Right.

You have to be quite sick to get a diagnosis. It's another thing that's actually quite hard to diagnose. One thing that I think is important is that when it comes to your inflammatory burden, it doesn't really matter if you have celiac or if you have a sensitivity. It's the inflammatory response that is problematic for your cellular health. So I think it's very important for people to do an elimination diet and then add back. Especially if you're in the camp of having an unexplained whatever. If you're in a position and you know, you're not feeling well or your cycles are off, you're having pregnancy loss or unexplained infertility. We are, I am assuming that is chronic inflammation until proven otherwise. So let's see how we can target that. So I have everybody eliminate gluten from their diet. You know, really go on a very, you know, no processed foods, no added sugar, no alcohol, no gluten, no dairy for four weeks. So at least a little bit of time to kind of simplify things out. And then the first thing I let them add back in if they want to, is going to be gluten for a couple weeks and see how they feel. And many people are very sensitive when they incorporate it back in. It's almost like that chronic low level inflammation you get so used to over time because they always tell me, oh, there's no way I have any sensitivity to glutenite bread all the time. You know, there's zero percent chance. And it's not until you experience what maybe your optimal gut health feels like, that then when you have it again, you can say, oh, never mind, I actually don't feel great this way. And I do a similar thing, you know, with dairy. It's important if you are looking at your diet and trying to tailor your inflammation symptoms, which largely can be fatigue, brain fog, difficulty concentrating, headache, bloating, GI distress, there's literally hundreds of symptoms, but those are gonna be some of the top frequent ones that you're trying to take out. Everything you know, can cause those and then just, you know, evaluating one thing at a time so you can pinpoint what that thing is that's really making an impact. What I find is that so often people have been avoiding dairy because it's kind of societally okay to avoid dairy. They maybe they had some low level inflammation, but a lot of times when they go through this process, it's actually gluten that they're more sensitive to. And, you know, we eat dairy and gluten so often, but I think give ourselves room to say, sometimes the diagnosis doesn't matter, but it's what it's doing to your body that really matters the most. And when we look at the age of autoimmune disease, diagnosis, how sick you have to get to get a diagnosis for a lot of these things to be taken seriously. It makes sense that in this age range, when, you know, maybe you are trying for your family or you start to experience these things, that you're, quote, not sick enough to get that true diagnosis, but it doesn't mean something's not happening in your body. So the longest answer ever to say, I'm a fan of removing it and seeing how you feel. If it doesn't make any change to you eat all the gluten in the world and I'll be jealous of you. But if you notice that it's an inflammatory, you know, factor for you, then you should avoid it, especially if you're trying to get pregnant or optimize your health.

Yes. And in circling, I take a very similar approach in circling back to the fact that these symptoms are warning signs. They're warning signs of something that is off underneath the surface. And like you said, they're a manifestation of inflammation.

Yes, yes.

So when it comes to toxins and environmental toxins, this is another thing that a lot of doctors will say, don't matter. Can you explain the connection between toxins and fertility?

Yes. And I did research on this back in fellowship. I remember my husband still laughs at me. This was the start to completely changing our health. But he came home one day from work and I was in our kitchen, and all the Teflon, all the plastic was getting piled up because I was doing research at the time on PFCs, which are perforinated chemicals, also known as forever chemicals, and how they impacted your steroid hormone levels and your ovarian reserve. And the data was just profound that the. So many different chemicals change how your body works on a multitude of different levels, but they can contribute to a direct inflammatory response. They can damage your gut and cause increased gut permeability. They can directly change your hormone system. That's why they're called endocrine disruptors, because they either bind or mimic hormones, which, if we think about your brain, I often say it's air traffic control, it's your hypothalamus is responsible for interpreting signals and then responding appropriately. And so if something's coming in and mimicking or Blocking, it's like static. It can't hear the right signal. It's not going to be able to respond appropriately. And that right away is going to interfere with your ovulation, your hormone production, and the quality of your luteal phase. Very often that's kind of the first sign of ovulation dysfunction, is you are still ovulating, but your luteal phase isn't lasting as long as it should. And what's so frustrating for me that so many physicians, their first or only question about a period is just, are you having periods or are you having regular periods? And then they move on. And that's the whole first stage of ovulatory dysfunction. But to answer the question is that there's so many different endocrine disruptors or environmental toxins that we are exposed to every single day that directly can cause inflammation, insulin resistance, harm our gut and our hormonal health. Yet it's really impractical to envision that we could live in a world that we could get rid of all of them. And many providers therefore just dismiss this altogether and think that it's not even worth discussing. And I like to start by saying, hey, let's change the things that we're exposed to. The most things that you are exposed to every single day are gonna have the biggest bang for their buck and they're easier and you don't have to make every single change at once. But, but factors that I don't think we give enough metric or attention to is going to be, number one, your air and water quality. So, you know, air filtration systems. A great, some great research was presented at the American Society for Reproductive Medicine just this month showing that, you know, look at the California wildfires and how that changed fertility levels and hormone levels. And of course, that's an extreme example, but many people live in places where air quality is not ideal. So consider getting air filtration for your home water as well. You can go to, you know, ewgthe environmentalworkinggroup.org and you can put in your zip code and see what is in your own tap water. And it'll actually help you find a filtration system that will remove what is problematic because many of us do need to filter our water so that we can have clean drinking water. And there's this kind of false idea that, oh, bottled water is good, and I'll just have bottled water. But not all bottled water is created equal. And some studies have shown that it's actually can have more chemicals, especially if it's In a plastic bottle. Think about it on the truck getting hot, right? So I think, you know, air and water are one secondarily for environmental chemicals. A lot of them reside in the kitchen. And that's gonna be because we use these things to prepare our food or to store our food. And that's an easy place to say plastic should never be heated or come in contact with hot foods. Most plastic you just do not need in your kitchen and you should get rid of it and think about stirring utensils, think about, you know, storage containers or Tupperware and change that over. You know, get glass, get stainless steel, get things that are not going to leach and be as contaminating. A big one that I see right now is processed food is coming in, you know, wrappers that has a lot of toxins in it. But probably the biggest nidus for a lot of families is that they were ordering so much food online. And I'm guilty of this too, right? I'm busy. Sometimes it's great to doordash food and it can come to my house if I don't have time to go pick it up. But these restaurants are, are not typically putting food in containers that are really great and safe because the food's often warm. Many of these containers are plastic or have other toxins in them and yet we're saving it in them or we're eating out of them to not do dishes. So I would say if you're ordering food, please remove it from the to go container. You know, when it gets to your house, whether that's putting it in glass, if you're going to keep it warm, or just eating it off of plates instead of that container itself can be really easy. So none of those are like huge behavior changes, but they're just starting to notice that the world around you is not meant for your optimal health and that these different things do cause inflammation inside your body, which we all have some baseline inflammation. People who have endo people have celiac disease, we have disease related inflammation as well. But then there's so much that we're exposed to from our habits of sleep, stress and exercise, from the foods we eat, and from the toxins in the world that we need to actively look at how we mitigate that inflammation because we can control it. And then I'll also just say beauty products, especially those you use every day. I'm less worried about the perfume you're putting on for date night, you know, once a month. And I'm much more worried about the laundry detergent you're using the shampoo and conditioner, the things that are going directly on your skin every single day are the ones that we should pay a closer concern to.

Totally. And I would also add the soap that you're putting in your dishwasher.

Oh, yes.

Because when you're washing all of your plates and things with the traditional dishwashing detergent, I can. When we eat at other people's houses, I can literally taste it. It's crazy how much you can taste it. And another change that we recently made was switching from the plastic SodaStream bottles to a glass company where, you know, you're not just keeping the water in because a lot of the. So all the soda streams are plastic bottles if you're doing soda water at home. And another one that I see a lot of people with are like K cups and coffee filters, where not only is like the mold accumulation something that you want to be watching for environmentally, but also the plastics that are being heated in those coffee containers, let's just.

Say coffee, even brewing coffee too, as well, because there's so much plastic involved in most coffee makers. I mean, how many people get their coffee brewed at home, even if they're doing traditional methods? And they might even have like a plastic kind of coffee pot at the bottom of it or all the plastic that the water is getting heated up through. So looking for options that have, you know, glass reservoirs for water or glass coffee pot, or even doing a pour over is a fabulous option. I know it takes a little bit longer, but that's my absolute favorite. Just pour it over, do something, and have like a nice fresh, hot cup of coffee. No toxins involved. Just. Just these are choices we make. And just because we have to do something differently or maybe it seems foreign to us, doesn't mean that you're not worth making proactive choices to improve your health. Not just if you're wanting to get pregnant, but just for your longevity as well.

For your longevity. In addition to making these changes helps to support fertility, but it's also one of the most important changes that you can start to make when you become a parent, to prepare yourself for being a parent so that for your kids, you're not exposing them to these things so that you're decreasing their rates of asthma and allergies and so many other conditions that we just normalize. That so many kids are experiencing that stems from the health of the mother, what the mother is exposed to, and then what these kids are exposed to with the dishwasher, with the detergents, and so many Other environmental exposures that their little bodies can't properly detox from.

You're so right. When, when you are pregnant, we often don't talk about. We starting to see more of a focus on it that the things you do during pregnancy, you know, influence the epigenetics of your child. Right. They get a genetic code. But your behaviors, your exposures are going to determine which genes are turned on and off and set them up for what they're going to experience for their life. One thing we are seeing clinically is an increased rate of low ovarian reserve in younger patients. Meaning women are born with all the eggs that they're ever going to have. Yes, they run out of them over time, but more women are experiencing low ovarian reserve earlier. And I think this is a direct cause to think about the world we grew up in and the foods we ate and the chemicals that were around in the world and things that were very normalized without second thought. There are consequences to some of these exposures when they add up over time. And that's why it's not too late to make a change right now for you. And yes, when you do become a parent or if you are, I just think about how much better off my kids are going to be. Right. I mean, we have stainless steel plates for them. They have glass bottles. And you have to sometimes say, this is the best I can do. You don't have to do everything at once. But the sum of all these little decisions add up and you can control that. So that should be really empowering because there's so much about our health risk that is genetic and we can't control. We should control these factors that we can and I will say in the book, I often say not just fertility, but hormonal health. Like if we can go through menopause later, if we can understand our body better, if we can have better hormone balance, which I know gets a bad reputation. But to me, your hormones are a dynamic system. They are meant to change moment to moment. Yet hormone balance is real. That means your brain and ovary are properly communicating and can respond. And we already talked about how inflammation comes in and can interfere with that system. So balance is a proper response and stimulus pathway. And that is what we should all seek, that our body can respond appropriately to the world around us.

So what are the key nutrition recommendations, just generally speaking, that you recommend for supporting hormone balance?

Okay. The number one thing that most people are not doing well, we'll use the. The ads is going to be fiber, having more Fiber in your diet, higher variety of fruits and vegetables. Your gut is so integral to your hormonal health and your levels of insulin resistance, your levels of inflammation, how your hormones are even going to function. Yet so few fertility doctors are even talking about gut health or gut permeability and your gut microbiome. But it's the first layer of exposure. When I try to break this down for patients because there's always nutritional pushback or fear or hesitation because it feels really scary to sometimes change our food. I always say, look inside your gut. You've got your gut microbiome. They do so many incredible things for your health. They even, you know, help metabolize estrogen and other hormones, but they are fed only by fiber. So we've got to start looking at the fact that the standard American diet, a lot of, you know, animal protein, and not saying that that's bad, but that doesn't have fiber in it. Very few vegetable servings. You know, we are not really exposing our gut microbiome to diverse nutrients, nor are we feeding them best. So starting by giving good nutritional backbones with lots of vitamins and nutrients, 2 to 3 servings of fruits and vegetables at every meal, trying to get at least 30 grams of fiber a day, most people are not getting that. That's gonna be the number one start. And the number one take out is we just do not need ultra processed foods. We do not need those added and artificial sugars. You many times we reach for something out of convenience and it is not providing nourishment for our body and it's hurting us on multiple levels. So it's not even providing nourishment, but it's causing inflammation and harming our gut microbiome and worsening the permeability of our gut. So remove and then add some fiber. When it comes to some of the other variables, I think it is important to say that cholesterol is the backbone of all steroid hormones. So progesterone, right? So we. I'm older than you, but like I grew up definitely in this era of like, if there is a low fat and a full fat option, like I should choose the low fat or the no fat. And so many people are just hardwired that way because of prior food marketing, which is an entirely different conversation we can have. But cholesterol is really good for you. It's necessary for hormone production. So this means making sure you're taking, you know, take in full fat. When you're taking in things that have fat in them, those healthy fats you know, the olives, oils, the nuts, the avocados. You should not be fearful of the fat content in your diet, especially from those healthy based sources that is a backbone of nutrients for steroid hormone production. And then I think for animal meat, there is some data that not all animal meat's created equal. So if you do not eat animal based meat, you do not have to. I, I will have patients ask that question all the time. Oh, I'm vegetarian. Do I need to incorporate meat into my diet to get pregnant? The answer is no. On the other hand, we do have literature showing that more servings of certain types of things, so red meat, for example. Increased servings of red meat per week can be associated with worsening egg quality, worsening IVF outcomes, and probably advancing disease states like endometriosis. Not all red meat's created equal. And probably looking at somebody who's taking in the highest quartile because that's how food studies do. They look at, you know, this, but for your audience, they look at a population of people and they say, these people ate none. These people ate the next group, then more and then more. And so they compared the group who ate the most to the group who didn't eat any. And yet there's a lot of gray zone in there for what most people should have. So it's for a lot of those things, it's about limiting. And when you do limit, you're going to be able to be exposed to different types of meat if you eat them. Of course, we know that fish have a lot of great added benefit when it comes to a protein source. So do many plant based proteins that people are very fearful of. Tofu is great that soy is not problematic. In fact, it's been shown to have higher fertility parameters for both men and women. And then, you know, other sources where you can get protein from plants, you should feel free to incorporate those to have greater diversity of the foods that you're exposing your gut microbiome to. And then dairy is another one that has mixed data, meaning it can sometimes be inflammatory in certain people. It can sometimes be really advantageous, probably because of some of the vitamins and nutrients that are in it. And it also can be, you know, a great source of fat intake as well. So it's one of those, I say that's where you gotta pay attention to your individualized response. But the scientific studies support that if you consume dairy, a full fat based option is going to be more advantageous than a low fat or a no fat. So if you know don't choose skim milk, don't get the no fat yogurt. If you're going to eat dairy products, eat those that have their full architecture and that they're not modified or processed, for lack of a better word. And then complex carbohydrates and, you know, whole grains when you can. You and I feel similarly about gluten. I think a trial to see if you're sensitive is really helpful for people. If you are not sensitive, good for you. But again, the complexity of the carbohydrate is going to have better fiber content, it's going to have a lower glycemic load. And I can't believe we're this far in the show and we haven't even talked really about insulin resistance and how harmful it is to your health.

We'll go there next. I know.

So I think that that's a healthy dietary pattern that is not shocking headline front news. And yet it is really not what the majority of people are consuming on a day to day basis.

Yeah, it's the. I mean, you just spoke to so many of the pillars in my nutrition programs because I'm completely on the same page with everything that you just said. And I think that in addition to that, which gets into the blood sugar piece, that we have a lot of people who self identify as eating very healthy because they're eating things like, like oatmeal and avocado toast and other things that are quote unquote healthy. But it's not until you have like the right structure in place that actually helps with optimizing those results. So can you speak to the role of blood sugar and how blood sugar impacts fertility and our overall hormones and what your recommendations are around that?

All right, there's so I love this question, so thank you. Because too often patients dismiss me when I start talking about blood sugar and they say, I'm not diabetic. This doesn't apply to me. Or I don't have pcos. It doesn't matter. Yet it matters for all of us because we live in a very inflammatory world and we live in a world that's gonna cause what's known as insulin resistance. So I love analogies. So here's my simple analogy for this. When you eat food, the food is broken down into glucose, which is the food for your cell. That's what a cell needs to function. And when this glucose is in your bloodstream, your pancreas is gonna release insulin, which is a hormone that lets glucose into the cell. And I like to think of Insulin, like a salesman, like knocking on the door, your cell opens the door and glucose can enter the cell. Well, what starts to happen is that there's many things that cause us to have higher glucose in our bloodstream. So eating foods with a high glycemic index, meaning they cause a higher blood sugar response. A lot of these are simple carbohydrates or those ultra processed foods eating really frequently. So we're snacking a lot of times, so we're having a constant glucose exposure. Chronic stress. Because stress is releasing glucose from your liver into your bloodstream. Because. Because your body doesn't know the difference in needing to run away from a bear or getting a bad email, not getting enough sleep. Because your sleep is when you know your glucose naturally can lower down. So there's a lot of different variables that go in to what your circulating blood glucose is. But what we can say is that when you start to have higher glucose levels in your blood, your body has to release more insulin. And it's like if the salesman comes to your door every single day, you're gonna stop answering it. You know what's happening, and that is what? Insulin resistance. The cell is no longer opening the door for the salesman. And it takes a higher insulin level to get the glucose in the cell. The salesman has to pound on the door really hard to let insulin get into the cell. Well, this is problematic on a couple levels because insulin's known as a growth hormone, and high insulin levels are then causing you to store visceral fat. Your cells are actually nutritionally starved, but there's so much glucose in your bloodstream, this is extremely inflammatory. Impacts how your brain interprets hormones. Changes your ovarian function directly and makes androgens. More male hormones start to be produced right at the ovarian level. In addition, changes how the ovary response, changes egg quality, the mitochondrial health right inside the egg. So right away we can see that this high insulin level, our bodies are meant to adapt. And if this is your new norm, your cells are going to start to adapt to it and not in a positive way. The thing that we have to start doing is really breaking, like break this chain in multiple levels. That changes the food that comes into our body. Right. Healing our gut, microbiome, improving our gut. So it's not leaky. Putting better, you know, kind of the backbone for what our body's trying to do, giving us better context to work with. That's a piece of it. We also need to kind of look at the other ends of the spectrum as well, which is going to mean, you know, limit those environmental toxins and endocrine disruptors that contribute to this pathway. Way getting more sleep, at least seven hours of sleep a night is crucial to really achieve a good foundation for your day and to fight insulin resistance. Managing stress and exercise, I'm going to hit them really fast. But one of the most fascinating things that I think most women do not know is that building and using skeletal muscle is one of the top things you can do to have your optimal hormonal health. Health. Your skeletal muscle has a transporter it called glute 4, which helps glucose get into the cell without needing insulin. So if you have this high glucose level and we're trying to fight against insulin resistance, if you can build more and use more skeletal muscle, it's like giving that glucose a key to the cell. It doesn't need insulin anymore. And this will lower levels, lower that insulin down and eventually will make the cell more sensitive so it can start to respond appropriately, starts to break the chain. This is an, of course skeletal muscle is important in hormone health, fertility, long term health outcomes on so many different metrics. But I also want to take this concept into the stress, because chronic stress directly contributes to insulin resistance. Because that stress mechanism again says, oh my gosh, Natalie has to run from a bear and frees up glucose from the liver, even though I didn't need it. And most of us though do not go run from the bear and use up that glucose. The things that cause us stress in the modern world do not require physical exertion. The majority of the time it's a bad appointment, a bad email, a bad encounter.

It's a meeting that happens to whole pregnancy losses.

Yeah, it's, there's kind of this chronic stress, there's direct stress, but none of that is countering the fact that all these little stressful things that daily anxiety is just raising glucose in our bloodstream and we're giving it no outlet. So one thing I always say is be mindful of this to the point that daily exercise can be helpful for this. Yes. But so can in an acute stress moment. So let's say you get out of the doctor's appointment and it was bad. You had one of these terrible encounters that you and I talked about earlier where you got dismissed and you feel crappy leaving it. That's a stressful experience. Go for a five minute walk, do, do something, move your body. You know that glucose has just been freed up and so leverage your physiology to benefit. You say, okay, I know this is happening. This is gonna add this problem I'm having. So I'm going to counter that. I'm going to go for a walk. It'll help lower your cortisol, clear your mind, but also very physically will help get some glucose into your muscle cells and lower it from your blood and help you start to fight inflammation directly.

So good. So good. So you're speaking to everything that I am always talking about, which is the intersection really between blood sugar inflammation in your hormonal health and your gut health, really. I mean, you can't leave that part out, but absolutely. There is so much interconnection between this, exactly what you're talking about. So if we switch gears and talk about tracking your cycle, which you identified as being such an important way to do so, how do you recommend that women track their cycle if they're trying to learn more about this as a vital sign, do you recommend is wearing an OURA ring with the natural cycles integration? Is that enough? What else should women be doing outside of that? That.

So I think we all have to know what's going to work for us. But I want to say number one, just using an app by itself, only about 20% of the apps actually detect when ovulation's happening correctly. Apps are all based on a calendar method. They're presuming your luteal length is going to be 14 days. Yes, it will adjust month to month based on total cycle length, but it gets it wrong the majority of the time. Now, apps that integrate with wearables is completely different. When we use what we call fertility awareness methods. These are your body actual physical signs that ovulation is happening. And these. There's three main ones that I like to leverage for women. The first one is going to be basal body temperature. So what the wearables are checking basal body temperature is the premise that after you ovulate, your body's going to make progesterone and progesterone raises your core body temperature by at least 0.4 degrees Fahrenheit. Well, back when I was trying, I was OCD obsessed with this because you had to have like a special mercury based thermometer that measured to 0.41 degree and this fancy graph paper. And it's very complicated and I would say for me, in fact it was quite stressful. So that for years I told women, I don't think you should do that. It's, it's hard to interpret. You'll overanalyze it. Not great. And I love to say this is where tech And AI has really changed the game. These wearables, so like Oura Ring, Apple Watch, integration with Natural Cycles, for example, they are getting temperature based measurements, you know, multiple times, you know, every few minutes. They're able to really have a much more accurate representation of when your temperature is getting low. It actually gets low with ovulation and then it raises and predict when ovulation is happening to such a higher sensitivity. And I think that's a really easy way for a lot of women. The app is doing the hard part. If you like, if you wear an Oura ring or an Apple watch already I know Whoop is integrating some of this. So it's leveraging something that you might already be doing with getting the dash up. I'm a huge fan of that. Other ways include urinary based hormone monitoring. And this one is on the idea that your body's going to send out a surge of LH before the follicle ruptures to release the egg. And if you detect when that LH is highest, you're then going to be able to know ovulation is imminent, typically the next day. OPK stand for Ovulation Predictor kits. And these are urinary based tests you pee on like a pregnancy test and they're checking for lh. And these are simple enough. These are going to be not very expensive. And once you see your first positive, you don't need to use any more. You know, ovulation happens the next day. There are many more hormone based testing systems, urinary based testing that are much more complex and expensive. They give a wealth of data. I love data. But for the average person, you don't need to feel like you have to buy one of those expensive systems in order to really track your cycle. It can be.

Is that like mirror.

They're like Mira anito. I think they're, they're great technology and I really do love them. But it depends on what your goal is. And I don't want anybody to feel like they have to spend that level of money, you know, over and over again buying more test strips if that data is not that helpful to them or if they're just trying to know exactly when they're ovulating.

Yeah, I actually did Miro with the LH and the pregnenolone and more so because I was trying to just understand my cycle better and my ob GYN that I went to once, I tried to show him the data on my phone, he completely dismissed me, like, this is so silly that you're doing this.

So well, you know, those tests give you these beautiful graphs and the one thing I will say about them is that these hormones are pulsatile. Fsh, lh, progesterone are released in pulses. Yet you can remember from your mirror, it probably showed this pretty progesterone line. And so it's not reflecting what's actually happening on a moment to moment basis. It is kind of making some leaps. We could have a whole discussion about progesterone limitations in the, you know, ludal phase in general. But so I do like, it's like.

If you test cortisol one time in a lab.

Exactly. Like that's your cortisol level when you.

Walk in and it's not your overall daily rhythm that could be impacting why you're not able to fall asleep or other things.

Yes, exactly. Wonderful analogy to think about it. So I always say these urinary based tests are helpful, they're giving you data, but they're not diagnostic, you know, And I think that that's a really important limitation. The last thing on these kind of cycle tracking based methods. Because I think it's more important than to just say, say, this is when my period starts. I think you really need to know when you ovulate to know your luteal phase. And your follicular phase is not enough. Women use cervical mucus monitoring because it is free. It is easy. Here. Your cervical mucus, your cervix is the entry point to your uterus and your cervical mucus is kind of protecting so that nothing kind of gets into the uterus and it's usually thicker or creamier until you have high estrogen levels seen with ovulation. At peak estrogen levels, that cervical mucus is going to change and be sticky and stretchy and egg white. And that is consistent with ovulation. So if you're trying to get pregnant or detect your ovulation day, that type 4 cervical mucus, the first time you see it is your ovulation day. You don't have to put any like fingers inside or do anything weird. I recommend that if you want to check cervical mucus when you go to the restroom, wipe first, which is not what most people do because that type 4 might just fall into the toilet and you might miss it. So just wipe first. Look at it. If it's like slimy, sticky, egg whitey, you'll see it right away. It's definitely not creamy. Then you say, hey, this is my type 4. And many times people will use that and maybe they do Other methods of fertility awareness too, and they realize they're in sync and then they're able to just do cervical mucus. Because it really is nice to do something that's, you know, free and simple and easy. And so I think everybody should do that, even if they're doing other methods, just to see if they correspond.

Yeah, it's actually so helpful. I, I had my son, I got pregnant with my son 3 months postpartum with my daughter, and I was still breastfeeding and hadn't had a cycle back. But I feel like had I just been paying closer attention to that, that you might have known, done myself a favor of not having my son before my daughter turned one.

See, you would have known that you were ovulating before you had that first period. Had we been paying a little bit of attention. Of, of course, the postpartum period is so much change in transition. Nobody can blame you for not even picking up on that. But I think that's an under leveraged tool that our body is giving us naturally to tell us that ovulation is happening.

Yeah, that's such a good one. And for women to really say like, this is a vital sign in addition to more information about your body. So do you recommend that for most women, like my stance has always been, Even if you're 30 years old, like, you should know what your HSCRP levels are. You should know what your fasting insulin levels are. Some of these markers, your full thyroid panel, not just your tsh. And so is that your stance as well?

It is. You know, you can't make decisions on data you don't know. And there's no reason why in today's world we have more things that we're able to test. We should be waiting until you get really sick or have a major health problem before we're able to start to detect some of these abnormalities. That's not every doctor's approach. I understand. Like, you know, we are providers in like a unique space. You know, our, our view on health is always shaped by our own experience as well and our own knowledge fund. But this idea that, you know, just because something's been done one way or the bigger one is. I have a master's in clinical research. I love scientific studies. But just because a study hasn't been done doesn't mean that something's not impactful. And we always have to leverage scientific data that exists yet with hypothesis and plausibility to make the best decisions we can for the people who sit in front of us and empowering Women to be in a position to know what to ask for. Because I think that's one of the things we find is somebody goes to doctors, I think my hormones are off. They get this very dismissive response because that is a very vague question. And what does that mean versus saying for, you know, three months I've been having brain fog, my cycle is shorter. I'm. You know, when you can really more eloquently arm yourself with what's going on, you have a higher likelihood of getting the test done that you need. And it's never wrong to ask for them. You know, they may say no, but what's the old quote? You get 0% of the things you don't ask for. So if you want to have this proactive approach to your health, and there's now, you know, more companies and more access to these things, if you have the resources that I think are really opening our eyes to, you know, our cellular health, health and how that impacts our whole body, including our hormonal health and our fertility.

Totally agree. Okay. When it comes to supplements, let's talk about supplements. What's your go to prenatal recommendation? And then beyond that, are there two to three supplements that you're. You're seeing yourself recommend for the majority of your clients or patients who are trying to get pregnant?

You know, that is a great question that I never thought when I entered this field that that would be controversial. Like. Like, like it is now. Right. I think for the prenatal vitamin LB have gotten themselves into a trouble because we've kind of gotten ourselves in a position where we're like, oh, any prenatal is fine. And now I know. Right? And now that kills me.

That kills me.

Not all prenatals are created equal. Here's the thing I'm going to say, and I do feel strongly about this one. Right. Is that you need to be taking folic acid in its folic acid form. Does that mean you're not going to benefit from methylated folate or that a subset of the population doesn't need both? I think there's a large argument that methylated folate can be helpful. But what Natalie needs when she's not pregnant and what Natalie needs when she's pregnant and what's been proven to cross a placenta and protect my baby. We have to sometimes frame nutritional advice and pregnancy advice in the right mindset set. Folic acid in its folic acid form is the only thing proven to prevent a neural tube defect like anencephaly or spina bifida which is failure of the brain to form. I will say that without any studies sitting in front of me, I have clinically seen more patients who have neural tube defects in well off populations that should not, who are taking prenatals that do not include folic acid. I think that there's many lovely prenatals on the market that have methylated folate. I think many people, people do digest methylated folate. It's a further down the stream metabolite. It has been shown in studies to have the same or higher blood levels, but it's never been shown to prevent neural tube defects. But nor will it ever. Nobody's ever going to approve that study because in order to do so you'd have to risk exposing a group to non standard care. So we have to say which they.

Used in the old folic acid studies is what they used to, is what they did.

Right. But nowadays that would never be acceptable. So we're at a place where we have a newer option yet. There's not gonna be research that ex that exists ever to say that it's okay to take a prenatal with an only a methylated option. However, I love a lot of the prenatals with methylated folate because they have so many other added nutrients that some prenatals are lacking. So my sense here is that we know that you need 400 micrograms to prevent a neural tube defect. These are devastating. If you have a prenatal that has methylated folate, just add on an additional folic acid pill to it. Those are small, easy and expensive and can be a way that you can cover both of your basis. There are some prenatals now that have both, which I think is excellent. Kind of just alleviates worry from all ends.

And you would recommend that even for a woman that has an mthfr?

I do. I recommend that even for my patients with mthfr because at the end of the day we might know how your body metabolizes one thing, but we don't have great data showing what's crossing the placenta in its best form. Right. So we're kind of sitting here. It's like thyroid in a lot of ways. Right. Like we know that somebody with thyroid can often benefit from T3 replacement, but we know when you're pregnant you need a greater preponderance of T4 as well. So we have to kind of say pregnancy and the placenta. I mean the placenta truly is the most fascinating organ in your whole body that you're ever going to have and acknowledging that that state is a unique state. So my patients with mthfr, I have them on methylated folate throughout their life, when they're having their normal life. But when they want to get pregnant, I want them on folic acid in addition. And I know that that causes a lot of confusion for a lot of patients, you know, which is sad. I mean, I wish prenatal vitamins were not something that would cause so much confusion because there's already so much information out there, you know, a lot of other things that are really important in prenatal vitamins. I think that, you know, choline's really important for brain health. We have lots of great data for that. Omega 3 fatty acids are absolutely fabulous. I did, I did. I'm so old. I did omega 3 fatty acid research in college in mice. I was a nutrition major. And we looked at their brain function and the mice who were exposed to it when their moms were pregnant with them. It's fascinating, right, and how they. How they worked, but just kind of thinking about the things that you also need. I would love it if we lived in a world where everybody could get, you know, every micronutrient and vitamin through their diet, but that's just not reality for the majority of people. And that's where we really kind of see prenatal vitamins being helpful for us, because we can make sure that we are getting some of the different things that we do need when it comes to. I like vitamin D, calcium, omega 3s, choline, your B vitamins, like folic acid and folic acid form, and iodine, when it comes outside of a prenatal, like fertility in general. You know, most prenatals don't have enough vitamin D. So I'm always telling my patients to take an additional vitamin D supplement if they.

To aim for, what, 4,000 IUs at.

Least to get 2,000 IUs a day. So most prenatals usually have between 600 to 800 IUs, so typically not quite enough for the average person. Of course, I'm in a unique space because I check vitamin D levels, and then if you're even lower, you know, we'll take higher doses to try to get that up. Omega 3s, if your prenatal doesn't have them, is something you should take. In addition, Coq 10, you know, is an antioxidant that's wonderful for mitochondrial health health and is one of the supplements that has been shown advantageous for egg health and for fertility outcomes. But we really like it to be at higher doses than most people take. So some prenatals have COQ now, which is great, but the dose for fertility is 600 milligrams a day. So that's usually higher than most prenatals have in them. And so it's something that I think is important to probably take. In addition, melatonin is probably one of the things that I add on for my patients. Obviously it's not going to be in a prenatal melatonin most people think of as a sleep aid, but it can be very helpful because it is an antioxidant and it has been shown to improve egg quality to be helpful with women who have infertility. One of the biggest things here, though, is that melatonin doses and many over the counter supplements is way too high and that can have long term negative consequences. Kind of suppresses the brain too much, to put it simply. So I recommend 3mg is the very highest dose of melatonin that you take. Many would benefit from 1 milligram, which is more of a pediatric dose. So you can even find like a kid's chewable melatonin and take that at night if it's something that you're wanting to try.

I also love the liquid droppers of melatonin that I'll recommend to clients because then they can control like there's just a lot more control over the exact dose. If you're not using the entire dropper and you're just doing a few drops, it will significantly lower the dose, which is sometimes hard to find in capsule form.

I think the other thing here, since we're chatting about supplements really quickly, is that a lot of modern supplements or greens powders or these other things, they actually have a ton of biotin in them. And biotin is in a lot of hair, skin and nails, vitamins as well. Biotin, however, is actually known to bind to the sex steroid hormone assay in the lab, so it's not harming your body. But if you are taking high doses of biotin and you're doing ivf, I can no longer trust your estrogen levels. They're all going to be abnormal. And so I frequently have to take people off of a high dose of biotin before we can do testing to get accurate hormone levels. And it's just one thing to keep in mind, especially if you get test values that come back wonky or don't really make sense, is that if you are taking a lot of biotin, that is something that we want you to kind of stop Any of that additional level, there's usually a tiny bit in a prenatal vitamin and that's going to be fine. But again, it's 300 mcgs or micrograms for biotin is typically the max we want you to take.

So helpful. And then when it comes to AMH levels and testing amh, do you recommend AMH testing and can you change your AMH levels? Because I know there's a lot of controversy around this.

Yeah, I mean, I'm going against your medical society advice by saying that I think all women should have an AMH tested. Especially if you fall into the camp where you want children one day and not yet. The argument against it by ACOG is that it's going to cause undue stress on you, it's not associated with your fertility and there's nothing you can do about about it. My argument is that if you find out you might have a less time to grow your family, you definitely might start trying sooner, you might freeze your eggs, you might start to look at underlying causes. And I believe it's a false narrative to just blanket say that yes, if you have a low amh, you don't have infertility per se, you could still get pregnant. But there are so many factors, we'll use endometriosis or smoking cigarettes that can cause both a low AMH and can cause in infertility that we definitely have to start changing our approach to this. Your eggs are kept in a vault inside your ovary. You're born with all the eggs you're ever going to have. Every month you have a group of eggs available to you and the size of that group is a reflection of how many are on the inside. So when you have more eggs remaining, more come out every month. When you have fewer eggs, fewer come out. The cells that surround each follicle and egg grows in a follicle are called granulosa cells and they make amh. So the more eggs and cells inside, more come out, higher AMH levels, fewer eggs inside, fewer come out lower. Your body's not perfect and there's month to month variability even when you're functioning normally. So already your AMH levels are going to hop around to a large extent. It shouldn't vary tons, but studies have shown up to 30% change month to month. So we automatically should know that it's absolutely possible that you get an AMH at one time period and then later on it could be higher or it could be lower and it's not linear. Right. It's doing these Minor fluctuations between. I always tell patients it's unrealistic that we're going to make major changes in your AMH value. With a few exceptions, periods of prolonged ovarian suppression when you're not ovulating absolutely can lower your amh. We see this in pregnancy, postpartum or contraceptive use when you're not ovulating with it. And so checking an AMH in those circumstances, it absolutely might be suppressed, doesn't mean you have less eggs, but the cells are not as active as they could be. And, and two to three months after whatever that exposure was, you will start to see kind of the real value reflect itself. I still check AMH and young women who are on contraceptive options and I say, hey, if it comes back low, we'll have to make a decision if we're going to stop this or we'll have to do ultrasound and, you know, dig in a little bit more. Most of the time it's normal and fine, but if it is low, it can kind of be a leading place to see, was it the contraceptive or is this a real value? You women who have low ovarian reserve tend to have a reason why. And I think that's the biggest thing that AMH testing is going to tell you is that before you're struggling with infertility, having that foresight that something's not functioning appropriately in your body gives you more of an opportunity to change, to know about your body. If you got diagnosed with endo or autoimmune thyroid disease, the earlier we get those diseases under control, the better for you. So I'm in complete disagreement that we shouldn't check AMH unless you have infertility. I actually think it's a highly valuable tool fuel. It can fluctuate month to month, and based on certain circumstances, it's unrealistic that you're going to really cause more eggs to come out of the vault substantially. But you might on a month to month basis, like if you're doing IVF or egg freezing by trying to decrease other factors that influence egg release like inflammation and insulin resistance.

So helpful. And I've also heard you say talk about how knowing low amh, even if you're not trying to get pregnant, can be helpful because it impacts then how early you go into menopause, which then the earlier they go into menopause, the higher the risk of pretty much every single chronic disease.

Absolutely. And everybody's talking about menopause saying there's no test for menopause. And I always push back A little, because I was like, I check AMH all the time and I diagnose women with low ovarian reserve, which is by definition perimenopause. I know that you are now in the 4 to 10 year window before you're going to go into menopause if your egg count is, you know, substantially low for your egg age. And to me, that knowledge is extremely insightful. You know, have limited time in your life where you can build bone, you can build up muscle, you can start to learn about how you're going to mitigate some of these chronic health risks, be more aware of your cycle, detect earlier cycle abnormalities, research hormone replacement. Like, why enter a huge life transition like menopause without knowledge? Especially if you're going to go through it before your other friends. You might not be able to change the trajectory. You might actually. But you should absolutely understand your body and what you should be doing during that.

And I strongly believe in, like, working with as many women as I've worked with in the last 10 years that you can delay the age that you go into perimenopause to menopause with addressing some of the things that we've discussed today, like increasing your insulin sensitivity and improving blood sugar and decreasing chronic inflammation and, and those sorts of things because of the direct impact that they have on your hormones.

We know that chronic inflammation and insulin resistance result in a lower egg count for your age, proportionally. So it only makes sense, sense that if you control those factors earlier in your life, you're going to have an increase in your ovarian longevity and go into menopause later. You and I are in agreement. Yes. There's no study that's going to directly prove that. But if we look at the research that exists with ovarian reserve and inflammation, it's not a hard conclusion to say that you probably can modify this for yourself.

So true. Okay, we need to wrap up. And I want to end with beyond what we eat and the supplements that we're taking, what are other, other sneaky, sneaky factors that impact overall fertility?

Oh, I would say, you know, for women, a lot of them aren't that sneaky. But I think the, the big ones, the ones that we ever address, I always say this is the first thing that I want patients to do, is to get more sleep. Sleep is when your body is going to heal from these different things, set off that foundation of the day and actively manage stress. Those two factors are really the things people don't think about. Right. They want an easy fix. They Want or we glamorize the hustle culture of I only need five hours of sleep. Instead of really prioritizing that, you will be exposed to inflammation. You will have insulin resistance throughout the day. Sleep is when your body's gonna clear that reset, improve your insulin sensitivity. And if you don't give your body enough time to accomplish those tasks, they're not doing them faster. You're starting the day in a deficit. And then you can do all the good choices that you want, and you're not gonna be able to catch up. So we have to start at the very beginning and set our for success. I will say, for men, there are sneaky ones. And I know that's not exactly what we're talking about, but men are 50% of the equation here. So testes are out of the body for a reason. Increased heat is bad for sperm production. Saunas are huge right now. Love, personally, but if you're trying to get pregnant, keep your guy out of the sauna, out of the hot tub. The testes do not need to be exposed to that additional heat. Same with laptop in lap. Also, you know, supplemental testosterone use is very common that can directly impair spermatogenesis or the production of sperm. Sperm, it often works like male birth control. The body sees their testosterone, therefore doesn't send out FSH and LH to make any additional testosterone. But that's also how it makes sperm. There are things, though, low T is real, that if your male partner has low T or low libido or difficulty with erection or ejaculation, there are other medical options that can be used that will more increase FSH and LH release, therefore improving testosterone from the testes and improving sperm, and then also toxins, which we really didn't touch on too much. I mean, we know alcohol is inflammatory, as is cannabis and smoking. It appears of the three of them, cannabis is so detrimental to sperm, it changes the production, changes male hormone levels, changes their motility and their shape. It's also directly damaging the DNA inside the sperm. And we know that female partners who do not use cannabis, whose male partners do have a higher risk of a miscarriage. So just to really wrap in that we should not be ignoring the male side of things. I would say fertility is a team sport, and we both really need to come to the table to get together.

I'm so glad that you addressed that. Yes, I could not agree more. Dr. Natalie Crawford, thank you so much for being here. Knowing that one in five couples struggles with infertility and the enormous infertility crisis that we're in and also just how beautiful of a gift these children in our lives can be. The work that you're doing is so important and I'm so excited about your new book that's coming out in April. Can you share how people can pre order now? Because you guys, pre ordering is so important for helping authors to really get to that New York Times bestsellers list, which I have no doubt you're going to achieve. But can you tell us how people can pre order the book and then what they get from doing that?

Thank you so much. This book is a book is a labor of love, you know. And the truth is this is the book that I wish I had had back when I was asking the question, when I said I wanted kids one day but not yet, or when I was struggling or even in the depths of it because I didn't have the knowledge of the answers to the questions I wanted to. And it's divided into all the fertility facts I wish you could have known or I want you to know, understanding how to track your cycles. Know when things are off, but also what you should do if you try to get pregnant or have infertility. But then half the book is all about the data between inflammation, fertility hormones and tangible changes you can start making and a plan to do so that doesn't feel really overwhelming. The book's called the Fertility Formula. You can get@natalie crawfordmd.com book or anywhere where books are sold. But we do have pre order bonuses so you'll get a hormone reset guide if you fill out the pre order form on my website. You also get access to a pre order webpage which includes an IVF course. If you're going through ivf, you need this. It goes into details about protocols, questions to ask, nitty gritty. But we also have a pre release book club where every month we have a module from the book contents. We're having a live Q and A call that's being recorded and it's really just such a fun opportunity to connect with everybody. And I love seeing this increased awareness and focus on something as important as our fertility and our hormones. And I'm just really happy that everybody's showing up and supporting. And thank you so much for having me on this show.

Oh, of course. And then also share where people can find you.

Absolutely. So I'm on instagram @natalie crawfordmd. I host the As a Woman podcast and I practice clinically in Austin, Texas at Fora Fertility.

Amazing. Thank you so much for being here. And we'll see you next time.

Thank you so much.