Functional fertility is a systems-based approach to optimize both female and male fertility by addressing nutritional, lifestyle, and psychological components that correct root-cause imbalances in order to prevent or drastically reduce infertility. --Olivia Neely
As a functional AND traditional family medical provider (aka "integrative practitioner"), I work with men and women every day who are struggling with fertility. Many times, they come to see me for headaches, stomach trouble, high blood pressure, or other "typical primary care health needs" and then mention off-handedly that they have been trying to start a family for months or even years.
They are often surprised to find out that we can start the fertility work up right here in primary care without having to immediately jump to a gynecologist or fertility specialist who will cost mucho bucks. Not only can we offer testing, we can offer holistic whole-systems support to their fertility goals, such as nutrient and supplement guidance and adrenal support. In functional primary care, we support male and female reproductive health equally, mindful that up to 40% of infertility issues stem from the male.
Not sure what a functional work up for fertility is? Check out the 12 functional root causes of infertility and the outline of a functional fertility work up in my blog here: https://www.hearthsidemedicine.com/post/why-can-t-we-get-pregnant-root-causes-tests-nutrients-for-male-female-infertility
And read about our favorite nutrient/supplement supports for reproduction here;
In conjunction with a full functional medicine work-up and approach, you may want to consider the following "conventional steps" at some point on your journey if you haven't already (we can order these):
Get a A Semen Analysis is a test to check for male infertility. Thirty-percent (30%) of the time this is the cause of a couple’s fertility problems. A semen analysis checks the number, shape and movement of sperm noted in the sample. If repeat testing is not normal, a urology referral is recommended. A thorough hormone and anatomy exam should be done to uncover the causes of male infertility.
Check the uterus and fallopian tubes — A special X-Ray test, known as a hysterosalpingogram, is done to check that the inner cavity of the uterus is normal and that the fallopian tubes are not blocked. Saline sonography is used to check that the uterine cavity does not contain any polyps, fibroids or scarring that could block implantation.
Check your ovulation — 40% of infertile women and 15% of couples with infertility have problems with ovulation. Causes include PCOS (polycystic ovarian syndrome), thyroid disease, high prolactin levels, and issues with the hypothalamus, the part of the brain that controls hormone regulation. Often these women have irregular periods, however, women with regular periods may have issues with the normal “release” of the egg from the ovary. Noting having regular cycles or sure when you are ovulating? We like the DUTCH test called "Cycle Mapping" to help with this and order it for many of our patients.
Check your ovarian reserve — We can do testing to see if the quality of your eggs is preventing you from getting pregnant. “Ovarian reserve” refers to the remaining egg supply available to make a baby.
Ultrasound ovarian antral follicle count. This checks the number of early follicles present. When only a few follicles are visible, this suggests fewer eggs available to be fertilized. Many believe this to be the best tool available for estimating ovarian reserve. An antral follicle count is performed before ovulation. Fewer than 8 antral follicles may signal a possible poor response to drugs that stimulate ovulation and lower than average pregnancy rates during IVF.
Sample Functional Medicine Lab work-up:
Here is a "SMALL" sampling of the initial labs we may check:
FSH – Follicle Stimulating Hormone
Day 3 FSH can indicate how hard the pituitary is working to stimulate the ovaries.
FSH hormone is the main hormone involved in producing mature eggs in the ovary. Normal FSH levels are generally under 9, but be aware that normal levels do not always correlate with normal ovarian reserve.
FSH Levels (Day 3)
Excellent: less than 6 mIU/mL
Good : 6-9 mIU/mL
Low: 10-13 mIU/mL
Very Low: above 13 mIU/mL
LH – Luteinizing Hormone
Often done on day 3 of the cycle. If higher than FSH, especially > a 2:1 ratio, it can indicate PCOS. High LH levels result in increased ovarian testosterone production, altered estrogen production, and abnormalities with ovulation. Normal day 3 range : <7 mIU/mL
Measured on day 3 of your cycle. If elevated, estradiol can lower FSH, thereby masking elevated fsh levels. This can happen in cases of low ovarian reserve or cysts. Estradiol can also be low in conditions of low ovarian reserve. Those with estradiol over 294 pmol/L (or 80 pg/ml) have a lower chance of success with IVF. The good news is, we can work on lowering estrogen naturally using functional medicine!
This is often measured on day 21. to determine whether ovulation has occurred as a healthy corpus luteum produces progesterone. It is important to measure progesterone 7 days after your ovulation, measuring on day 21 only applies to women who ovulate on day 14. Levels higher than 16 nmol/L strongly suggest an ovulatory cycle. If progesterone is too low, it can really impact the ability to conceive, thus sometimes it is necessary to give someone progesterone and support their overall diet and health to increase their progesterone.
Elevated cortisol can affect ovarian circulation and function. In FM, we prefer to test between 6-8 am (blood levels) and check a 24 hour urine level as well as salivary level. We also run a full adrenal analysis over 24 hours to understand how one's adrenal health is impacting their reproductive health.
Understanding where your stress hormones lie can give you insight on how that affects estrogen, progesterone, testosterone. Remember, your sex hormones are usually the last dominos to fall, so abnormal levels are just a downstream effect of something happening further upstream that needs to be corrected (aka ROOT CAUSE!).
High cortisol impedes fertility for many people by generating systemic inflammation, insulin resistance, nutrient deficiency, and sometime, progesterone insufficiency.
Causes of high cortisol include pituitary tumors in the brain, sleep apnea, poor blood sugar balance, nutrient-depleted diet, high inflammatory diet, stress, chronic depression or anxiety, sleeping problems, and more! In functional medicine, if we identify high cortisol as causative towards infertility, we have many tools to support our patients in lowering their cortisol levels.
We think of testosterone as a "male hormone", but it is present in females too. If elevated this can indicate PCOS. High testosterone interferes with normal ovulation often causing delayed ovulation or anovulation. Levels can also be low around which can negatively affect ovarian function. We like to test this via blood in conjunction with the DUTCH hormone test.
Why would testosterone be high in a female? This is often due to systemic inflammation and insulin resistance--also known as metabolic syndrome--the good news here? There is SO much we can do to successfully lower testosterone, inflammation and insulin resistance using functional medicine!
The amount of testosterone that is not bound to carriers and is available to stimulate tissues. The higher this is, the more androgenic effect on the tissues. This can be elevated in PCOS and specific adrenal conditions..
Normally elevated in nursing and pregnancy, but If elevated in other situations, it can interfere with ovulation and fertility. Stress, medications such as antidepressants or painkillers, thyroid disease, or pituitary conditions such as microadenomas can cause elevated levels.
DHT – Dihydrotestosterone
A form of testosterone which is very potent. DHT Can be elevated in pcos or enzyme conversion disorders resulting in androgen excess signs and symptoms. Serum testing for DHT is often unreliable.
Sex hormone binding globulin Can be low in patients with androgen excess conditions such as pcos or in hypothyroidism (too little thyroid). Can be high in adrenal problems and hyperthyroidism (too much thyroid).
An average marker of insulin resistance and blood sugar levels. Can be elevated in pcos. Marks the previous 3 months of blood sugar levels.
DHEA – S A precursor to hormones, most especially androgens (testosterone). DHEA is made by the adrenal gland. Levels tend to reduce with age, reduce in low ovarian reserve and be elevated in PCOS.
Ferritin A marker for stored iron. Levels can be low in patients with infertility. I recommend patients to achieve ferritin levels of above 50. High ferritin can indicate inflammation.
TSH - thyroid stimulating hormone
Optimal levels for conception are approximately 2 – 2.5. Higher levels can increase risk for early miscarriage. "Normal Ranges" are : 0.4 – 4 mIU/L, but normal doesn't always equal optimal. If levels are above 3, and especially if thyroid antibodies such as antithyroglobulin and anti-thyroid peroxidase are present with signs and symptoms of hypothyroidism, this and may present risks for fertility. We run a very thorough thyroid panel in FM, unlike most standard work-ups.
Marker of inflammation and circulatory health. This test is only recently being found to be important for ovarian health. Elevated levels can be found in autoimmune conditions, ovarian aging and endometriosis. High levels can indicate inflammation as well as poor B12 absorption.
One of the most important labs to investigate infertility and yet rarely checked in conventional medicine. High levels are correlated with difficulty conceiving. This can be corrected often with diet changes and exercise alone.
INR A measure of blood clotting. Blood which clots excessively may interfere with implantation. Can also elevated in endometriosis or fibroids.
Anti sperm antibodies
The presence of anti- sperm antibodies in women can destroy or damage the sperm before they have the chance to fertilize the egg. Around 5% of infertile women have these antibodies in their bloodstreams.
Anti thyroid antibodies
These antibodies, if present will reduce fertility by 13%, even if thyroid function is normal. These antibodies can cause alterations in thyroid function and also can be cross reactive with ovarian tissue. Women with PCOS who don’t respond to clomid have a higher likelihood of having antithyroid antibodies. You may have been told your thyroid hormones are in range, but they may in fact not be optimal. In FM, we can help you optimize these.
Anti nuclear antibodies (ANA)
These antibodies are present in autoimmune disease such as Lupus and Sjogrens syndrome and other autoimmune conditions that can be related to infertility.
Special Ovarian Reserve Markers:
Ovarian follicles are small sacs filled with fluid that are found inside a woman’s ovaries. They secrete hormones which influence stages of the menstrual cycle and women. Each follicle has the potential to release an egg for fertilization. Follicles and their size and status are a vital part of assessing fertility and fertility treatment. Evaluation of follicles involves a pelvic ultrasound of your uterus and ovaries as well as an Anti-Mullerian Hormone (AMH) blood test. The ultrasound will assess the size and number of follicles present on your ovaries called an " Antral Follicle Count."
AMH is produced by growing follicles . This value generally correlates with the number of functional follicles remaining in the ovary. Generally, the higher the AMH, the more healthy follicles are in the ovary. AMH can predict the age of onset of menopause with some degree of accuracy. Low AMH often does not give a good prognosis for IVF because IVF is based on the stimulation of multiple follicles – women with lower AMH tend to get fewer follicles during IVF stimulation. However, even if AMH is low, conception is possible. Even if there are not many follicles remaining in the ovary, their quality can be improved with treatments including antioxidants and circulatory enhancing therapies. Natural conception with low AMH can and does happen.
Optimal Fertility:28.6 pmol/L – 48.5 pmol/L or over 1.0 ng/ml
Satisfactory Fertility:15.7 pmol/L – 28.6 pmol/L or over 1.0 ng/ml
Low Fertility:2.2 pmol/L – 15.7 pmol/L or 0.3 – 0.9 ng/ml
Very Low/Undetectable:0.0 pmol/L – 2.2 pmol/L or less than 0.3 ng/ml
**High Level found in PCOS> 48.5 pmol/L or over 3 ng/ml
AMH can show if the eggs are of poorer quality. Levels are lower when follicles stop growing. Levels below 1 ng/ml are associated with decreased fertility.
Inhibin b--checked on day 3 of cycle A marker of ovarian function and reserve, the protein is secreted by the follicles and can indicate quantity /function of the remaining follicles. This test is not widely available. Normal = above 45 pg/ml Low = below 45 pg/mL . Like with AMH even if inhibin B is low, conception is possible if the health of the remaining follicles is enhanced.
Full nutrient panel (all your vital minerals, vitamins, proteins and enzymes needed for a healthy reproductive system and conception
Comprehensive gut health and microbiome testing
Food Intolerance Testing
Heavy metal and chemical toxicity panel
Blood, urine, and salivary hormones
In Summary: Creating a fertile landscape in the body
We know that a full cycle of egg development takes 4 months, and several cycles are sometimes needed to prepare our bodies for conception if we have recently been on hormonal birth control or are trying to re-balance our body from a condition like PCOS.
Things you can do right now to increase fertility include Eliminate/avoiding toxins which can impair fertility such as Alcohol ¡ Caffeine ¡ Cigarettes ¡ Pesticides ¡ Pollutants ¡ Endocrine-disrupting compounds ÷ Environmental estrogens
Here are I seven foundational strategies inspired by FM guru Dr. Mark Hyman that can help anyone (female and male) balance hormones, reverse infertility, and create abundant health.
Go low-glycemic. Take away processed and sugary foods and replace them with a low-sugar diet rich in good fats, plants, and lean animal protein. A high HEALTHY fat, low-sugar diet may help reverse infertility. To detox from sugar, gluten, dairy, and other inflammatory foods, try The Blood Sugar Solution 10-Day Detox Diet, which provides a comprehensive, easy-to-follow plan in just 10 days. The most studied diet showing overall best health outcomes is the Mediterranean diet with modified carb intake. We can help you with a lifestyle diet plan.
Implement supplements. The right nutrients benefit both men and women by increasing sperm count and otherwise decreasing infertility risk. One study found nutrients like L-carnitine, vitamins C and E, N-acetylcysteine, zinc, and coenzyme Q10 could increase male fertility four-fold. Other good nutrients to reduce infertility include vitamin D, fish oil, and B vitamins.
Exercise regularly. Studies show increased physical activity and other lifestyle modifications become a first-line approach to managing PCOS. Consistent exercise can have profound effects on balancing hormones, reducing sugar cravings, and otherwise improving fertility. Just don't over exercise and cause other fertility problems!
Get sufficient sleep. Studies show sleep disturbances diminish women’s health and wellbeing and can contribute to infertility. Those are among the reasons why you want to aim for eight hours of quality, uninterrupted sleep every night. Many people don't know they have sleep apnea, so it may be worthwhile getting tested.
Reduce your environmental toxin exposure. Environmental chemicals can knock hormones out of balance and contribute to infertility. Become more aware about how these chemicals impact you. For instance, if you drink bottled water, choose glass or clear, hard, durable plastic containers (versus soft, opaque, thin, easily bendable plastic). Soft plastics tend to release toxic chemicals, including phythalates and bisphenol A, which have been linked to hormonal disorders and infertility. Visit the Environmental Working Group’s page to learn more about reducing chemical exposure.
I encourage you to work with a Functional Medicine provider in conjunction with a gynecologist or fertility specialist to identify, address and correct and underlying root causes. Havilah Brodhead, FNP, CMO, CEO of Hearthside Medicine Family Care offers virtual visits to residents of Washington and Oregon, as well as in-person visits at her clinic in Bend, Oregon.
About the Author:
Havilah Brodhead, FNP, CEO, CMO
Hearthside Medicine Family Care
Havilah is an integrative, functional medicine nurse practitioner with a solid background in conventional medicine, including women's health, maternal-child health, mental health, gut health, hormones, family medicine, urgent care, men's health. She is passionate about helping patients find root causes to their health concerns and treating naturally whenever possible. She is accepting new patients for functional medicine consultations and care in both Washington and Oregon and accepts most insurances.
Havilah resides in Bend, Oregon and co-owns Hearthside Medicine Family Care with her husband Jeremy Brodhead, NP, who specializes in men's health. Hearthside is an integrative and primary care practice for all ages. She is mom to little girls and loves to mountain bike and practice yoga in addition to being a mommy and medical provider.
Appointment requests can be made easily online here: https://www.hearthsidemedicine.com/schedule-appointment