Researchers estimate that the human body contains approximately seven quadrillion bacterial cells! Most of us hadn’t even heard the word “microbiome” until just a few years ago. But now the concept of gut health and gut flora are all over the news! It seems like every week a new connection is made between gut health and some other facet of wellness.

Research has recently shown that the balance of bacteria in our guts affects not only our gastrointestinal systems, but our hearts, kidneys, and even our brains and mental health! The microbiota of the skin has gotten some media attention as well.

The uterine microbiome, though, hasn’t received as much press time as it deserves! In fact, until quite recently scientists believed that the uterine environment was sterile (meaning there were no microorganisms present in it at all.)

Flora and microbiome and endometrium, oh my!

Let’s start by defining some of these words! Just as you’ve likely heard the plant life in a certain area referred to as the area’s flora and fauna, the term “flora” simply refers to the normal, beneficial bacteria that resides in or on the human body. “Microbiome” is just another way of referring to this healthy bacteria.

In this article, we’ll be discussing the unique microbiome of the uterus, which is contained in the endometrium. The endometrium is the lining of the uterus. This is the cushioning where a fertilized egg implants at the beginning of a pregnancy. In a normal menstrual cycle, the endometrium becomes thicker after ovulation in order to prepare for a potential pregnancy. It is then shed during menstruation if no pregnancy occurs.

Learning more about the unique microbiome of the uterus

Advances in modern medicine have allowed physicians to study the endometrium’s microbial environment with more precision than ever before. Early studies suggest that the most common bacterium in the uterus are called Bacteroides and Lactobacillus.

One study compared samples from the endometrium and vaginas of 35 infertile women undergoing in-vitro fertilization treatment. The results of this study revealed an important discovery: the women with more non-Lactobacillus bacteria in their microbiomes had decreased likelihood of implantation, pregnancy, and live birth.

Currently there are limited studies about the impact of the endometrial microbiome on fertility levels and success with IUI, IVF, and other fertility treatments. However, testing has recently become available to assess the endometrial lining for various types of bacterial flora. Hopefully this will open doors in the future for the ability to treat a uterine microbiome that is not ideal for conception.

Where does this beneficial bacteria come from?

Currently the most common theory is that the flora that populate the uterus ascend from the vaginal canal. The vagina has its own microbiome, and it can fluctuate frequently. Immediately prior to ovulation, for example, Lactobacillus levels tend to stabilize, then these levels drop during menstruation.

But are there other external and lifestyle factors that affect the balance of bacteria in the vagina (and thus the uterus)? Studies suggest that this may be the case! Menstruation, sexual activity, and use of period products like pads, tampons, and menstrual cups. There is also some evidence that the use of a copper IUD can increase an imbalance in the vaginal flora. Some other studies, however, suggest that the flora of the vagina are only affected by ethnicity and number of sexual partners. Clearly there is much we have yet to learn on this subject!

Another microbiome?

No discussion of bacteria’s influence on reproduction would be complete without a brief mention of yet another microbiome: the placental microbiome. After a pregnancy is achieved, any elements that interfere with the communication between the embryo and the uterine lining can interfere with the pregnancy. An imbalance in the uterine or placental microbiome, then, might set off an inflammatory response that can be possibly linked to a poor outcome and loss of the pregnancy.

You might be aware that the immune system becomes slightly suppressed during pregnancy in order to protect the developing embryo. This happens so that a woman’s body doesn’t recognize the developing embryo as an intruder and thus attacks it as a foreign object. If there is a severe imbalance in the flora of the uterus and placenta, then, it makes sense that the body would attempt to eliminate this.  However, this attempt to exterminate the flora imbalance could lead to devastating consequences for a pregnancy.

You don’t have to struggle alone

These issues can be isolating and confusing, but we are committed to walking this journey alongside you and explaining all the nuances. Testing is now available to evaluate your uterine microbiome. Speak with your fertility doctor to see if you are a candidate for this testing based on your case!

To connect with Dr. Salem and her team, contact us today to arrange a consultation!

“How do our ages affect our chances of conception?” This is one of the top questions that patients ask each day in fertility clinics around the world, and it is becoming more and more relevant. More individuals than ever are choosing to delay their attempts to conceive due to educational choices, career opportunities, or personal decisions. (In the United States, the average first time mother gives birth around five years later than she would have in 1972.)

Fortunately, there is fairly clear data to answer this question! A woman’s age is one of the most reliable factors in predicting natural conception and her success with various fertility treatments. The quality of a woman’s eggs as she ages is the main concern.

How does aging affect a woman’s eggs?

Many people are surprised to learn that a woman’s body doesn’t continue creating eggs throughout her lifetime. Female infants are born with all the eggs they will ever have. (This number is usually around one million eggs!) This number declines to about 300,000 by the time she begins menstruating. Eggs continue to decline in both quantity and quality throughout a woman’s lifetime until she reaches menopause. This decline unfortunately means that the rate of fertility declines with age as well.

This decline in egg count and egg quality continues regardless of whether or not a woman is ovulating regularly or at all. Women who don’t menstruate regularly due to hormonal birth control, reproductive hormonal imbalances, pregnancies, or lactation still see a steady decline in their egg quality and number of remaining eggs. Modern medicine hasn’t yet found a way to slow this process.

Now, this decline in fertility can be very different from female to female. (Average age at menopause is 51, but this can be affected by a broad range of factors including hormonal contraceptive use, smoking history, childbearing, and physical activity level.) This fertility decrease generally coincides with the timing of a woman’s menopause, so women who enter menopause earlier will likely see their egg counts decreasing earlier as well. 

Why do eggs decline in quality with age?

After being released from the ovary, eggs divide their genetic material. When a mistake happens during this division process, the egg will contain an abnormal number of chromosomes, which can lead to congenital anomalies, high risk pregnancies, and pregnancy loss. This division of genetic material becomes more difficult with age, and it becomes more likely that these chromosomal abnormalities will occur.

While a woman attempting to conceive in her twenties may have a one-in-four chance of conceiving in any given month, someone who is over forty has around a 3 percent chance of natural conception during each menstrual cycle. Sadly, pregnancy loss is also much more common as maternal age increases.

What about male partners? 

Is sperm quality affected by age as much as egg quality? While age does impact male fertility, the impact does not seem to be quite as large, and the correlations are not as clear. Male aging is associated with some decline in level of sexual health, but it is important to keep in mind that these correlations don’t necessarily mean that age is their cause.

As a man’s age advances beyond about 40, he can see an increased risk of genetic damage to the sperm. This can lead to chromosomal abnormalities in his offspring, such as Down syndrome or XYY syndrome. Sperm morphology (size and shape) and motility (ability to swim) decrease as age progresses. Older men are more likely to produce offspring with autism and schizophrenia, and the partners of these men more commonly experience miscarriage and pregnancy complications such as preeclampsia. These female partners are also more likely to require a cesarean birth due to higher risk pregnancies.

Sexual dysfunction can also lead to fertility concerns, as issues like erectile dysfunction and reduced libido may affect his ability or desire for intercourse, further reducing the chance of conception with his partner.

There is hope!

The information above might seem a bit overwhelming, but our intent at The Integrative Fertility M.D. is to arm you with the data you need to make informed decisions about your care. Due to the potential concerns mentioned here, we recommend seeking help in conceiving after six months of unprotected sex if you are over the age of 35, right away if you are over age 40, or whenever you have any concern about your age.

Dr. Salem has personally worked with hundreds of couples where one or both partners were in their forties who have gone on to have successful pregnancies and healthy births. Our unique combination of traditional medicine and natural lifestyle modifications can help optimize your fertility regardless of your age.

Do you have more questions about your age and fertility? Connect with us to consult with Dr. Salem about how to maximize your chances of conceiving regardless of your age. We look forward to hearing from you!

We all need it to survive, but very few of us feel that we get enough of it on a consistent basis. What are we talking about? Sleep.

You know you feel more alert, energetic, and ready to take on the day ahead after a good night’s rest. But a solid 8 hours of sleep may feel like a pipedream in our hectic, fast-paced society. We know we should aim for 7 to 9 hours of quality sleep per night, but it can be difficult to make rest be a priority when there’s so much else to be done. Particularly when you’re undergoing fertility treatments, getting enough sleep can feel like just one more item on the “to do” list.

Why sleep matters

Beyond the advantage of waking up feeling refreshed and motivated to take on the day, research has shown that a lack of sleep is linked to health problems like heart disease, high blood pressure, and diabetes. Part of this may be due to the fact that sleep-deprived people also tend to have less energy to make health-conscious decisions, and exhaustion may lead to seeking out simple carbohydrates like candy for a quick energy boost.

Sometimes the insomnia-stress cycle can seem endless: when you’re experiencing stress, anxiety can keep you staring at the ceiling for hours. But being deprived of sleep can also cause higher levels of stress, which can lead to more sleeplessness!

Experiencing stress is very common when you’re facing the challenges that come with infertility, and it can be difficult to make sleep a priority when you have so much on your mind. While current research is inconclusive about a connection between stress and fertility, we do know that anything you can do to boost your general wellbeing can also help your fertility.

Here are a few things you can do to get more rest despite the uncertainty of infertility.

Ways to optimize your sleep and care for your health

Here are a few steps you can implement to make your sleep as restful and rejuvenating as possible.

• Wake up at the same time each day. Though it may seem counterintuitive, waking up at the same time each morning (yes, even on weekends!) can help “reset” your internal clock so that you know you’ll be tired when bedtime arrives.

• • Incorporate regular movement into your day. One of the many benefits of exercise is that it can lead to more restful sleep. It’s ideal if you can schedule your workout earlier in the day so that your body has time to wind down a bit before bed, though.

• Limit caffeine. Caffeine, while safe in moderation while trying to conceive, can keep you awake much later than intended if you consume it too late in the day. If you find yourself having difficulty sleeping after drinking coffee, tea, or eating chocolate, try to limit these treats to earlier in the day. (Limiting caffeine consumption to before lunchtime or early afternoon is usually sufficient.)

• Cut back on the bedtime snacks. Try to stop eating about 2 hours before you’d like to go to sleep. This gives your digestive system a chance to settle down for the evening and can also cut back on heartburn or indigestion that can keep you awake.

• • Limit screens before bed. Make it a goal to unplug from your devices about an hour before lights out. Artificial blue light inhibits the production of melatonin, an important sleep hormone, which can keep you awake much longer than you had planned!

• Find a calming evening ritual. Since you’re not checking social media or reading one last chapter on your e-reader, find some activities that you find relaxing to help you settle in for the night. This could include journaling, a warm bubble bath, some gentle stretching, or meditation.

• Keep your bedroom cool and dark. You can hang room darkening blinds in your windows if street lights keep you awake. A little bit of ambient noise such as a fan can help to cover up any sounds from traffic and other disturbances outside. Keeping your bedroom at a cool, comfortable temperature is also more conducive to sleep. (Most experts recommend a temperature between 60 and 68 degrees.)

• Make your bed your “sacred space.” As tempting as it may be to try to catch up on email or take business calls from the comfort of your bed, this can form an association in your mind between your bed and your work. Find another place to check your laptop, even if it’s just a chair beside the bed, and try to limit your in-bed activities to sleep and sex.

Do you struggle with keeping a regular sleep routine due to stress from your busy life, anxiety related to fertility treatments, or any other roadblocks to healthy sleep? Contact us today to set up a consultation with Dr. Salem to discuss how we can help you!

Polycystic ovarian syndrome, or PCOS, is a collection of symptoms associated with an imbalance in reproductive hormones. This hormonal imbalance can lead to symptoms like weight gain, thinning of the hair on the head, heavier growth of hair on the face and torso, acne, and irregular menstrual cycles. Although PCOS is frequently discussed in relation to fertility, lots of inaccurate information about PCOS is conveyed as fact. Below we will take a look at some of the most common misconceptions about polycystic ovarian syndrome.

PCOS Myth #1: PCOS is rare.

Actually, it is estimated that about ten percent of women of childbearing age in the United States meet the diagnostic criteria for PCOS! Many of these women haven’t even been diagnosed. Personal health is a sensitive topic, and a diagnosis of PCOS may be difficult or painful for a woman to share, particularly if she is struggling to conceive. Thus many women are not comfortable talking about their diagnosis openly. But odds are that you know more than one person who is affected by PCOS.

PCOS Myth #2: Patients with PCOS have lots of cysts on their ovaries.

It would be easy to draw the conclusion that with a name like “polycystic ovarian syndrome,” PCOS would involve lots of cysts on the ovaries. In reality, PCOS is poorly named. The hormone imbalances involved in PCOS can cause changes in the ovaries, typically women with PCOS have a greater number of ovarian follicles than their age matched counterparts. Ovarian follicles are normal, and no treatment or surgery is needed.  Women with PCOS are not at greater risk of developing cysts. 

PCOS Myth #3: All women with PCOS are overweight. You can’t have PCOS if you are thin.

Although undesired weight gain is one of the hallmark symptoms of PCOS, nearly one third of women with PCOS are not considered overweight or obese. Lab work should be performed to assess for hormonal imbalances if other symptoms are present, because PCOS patients in a healthy weight range can still have other difficulties. And regardless of a patient’s body size, PCOS patients can benefit from healthy eating practices and adding more movement to their routines.

PCOS Myth #4: PCOS can be diagnosed through blood testing alone.

Because PCOS is caused by an imbalance in reproductive hormones, many patients believe that blood tests Unfortunately nothing about medical diagnosis is that simple. Although bloodwork is a vital part of the PCOS diagnosis, the process is much more thorough than that. Diagnosing PCOS involves a comprehensive physical examination which includes laboratory testing and pelvic ultrasound. Your provider will also take a detailed medical and menstrual history.

PCOS Myth #5: Irregular periods mean that you have PCOS.

PCOS can, and often does, cause irregular menstrual cycles due to problems with ovulation. But there are lots of other things that could be causing irregular cycles as well, so consultation with a medical professional is essential! If your menstrual cycles are longer than about 35 days, bleeding is significantly lighter or heavier than normal, or you experience spotting between periods, talk to your healthcare provider to determine the cause.

PCOS Myth #6: Oral contraceptives cure PCOS.

Oral contraceptives are frequently prescribed for PCOS, and they can help control symptoms and regulate your cycle. Birth control pills can play a role in the treatment of PCOS. However, these are not a cure. If you are trying to conceive, however, other options that are more in line with your goals can be utilized. Work together with your doctor to make a plan that is right for you.

PCOS Myth #7: A diagnosis of PCOS means I need to follow a specific diet.

Despite the popularity of the gluten-free and keto diet plans, you don’t need to try these diets to control PCOS symptoms. The Mediterranean diet is a balanced eating approach that is commonly used for PCOS, and includes foods that are rich in antioxidants, folate, and vitamin D. (These nutrients can all positively contribute to hormone regulation.) A Mediterranean diet includes minimally processed, whole foods. This means choosing fresh fruits and vegetables, fish, nuts, and including healthy fats such as avocados and olive oil. Limiting simple carbohydrates, as well as including lots of leafy greens, is also an integral part of the Mediterranean diet.

PCOS Myth #8: PCOS makes it impossible to get pregnant.

A large percentage of women diagnosed with PCOS may seek assistance to conceive with a medication like Clomid or letrozole. If you are attempting to conceive with a partner, both of you should be evaluated despite your PCOS diagnosis. The lifestyle modifications mentioned above may also help alleviate unwanted symptoms and gently encourage your body toward hormone regulation, which can lead to a higher chance of conception. Our integrative fertility practices combine traditional medicine, alternative therapies, and lifestyle practices, giving you access to the “best of both worlds” in your journey.

Do you have any of the signs and symptoms of PCOS, such as irregular menstruation, thinning hair, acne, or weight that can be difficult to regulate? Contact us today to schedule a consultation with Dr. Salem to discuss your options!

Sexual intercourse, for the purpose of conception, can leave you with many questions you wouldn’t have otherwise thought about.  These questions are normal, common, and important. 

Let’s dive right into the top 5 questions people have about intercourse when trying to conceive.

1. When are the best days to have sex when trying to conceive? 

Having sex every day of the month will not increase your chances of pregnancy. In fact, there is a small window of time each month that a woman’s body is able – often referred to as the fertile window. The fertile window is about 5 days prior to ovulation, but the highest chances occur when intercourse occurs on the day before ovulation and/or the day of ovulation. This is why it’s important to know how to detect your ovulation, or find out if you have any ovulatory problems.

 Click here to learn more about ovulation detection.

2. How often should I have sex during the fertile window, when trying to conceive?

It’s easy to suddenly question how often you should be having sex. Daily or every other day within your fertile window is perfect. Your fertile window is the few days leading up to ovulation, plus the day of ovulation. 

While there is physically nothing wrong with having sex at different times of the month, those times won’t end in a pregnancy and some couples begin to experience sexual “burnout”. It has been shown that for some couples, trying to have sex every day and/or multiple times a day can cause excessive stress. If daily intercourse is not natural to you and your partner, it can lead to performance anxiety and sexual dysfunction. 

3. Does position matter?

There is no evidence that sexual position makes any difference in chances of pregnancy or fertility. Choose what is best for you and your partner. 

4. How long should I wait to get up after sex?

While there’s no harm in remaining flat after intercourse, there is also no evidence to suggest that it will help. It takes only seconds for sperm to enter the cervical canal. Healthy sperm swim, regardless of the position of your body. There’s no benefit to remaining flat so choose what is comfortable for you. 

5. Should I use a lubricant?

Let’s bust a myth. Using lubricant does not improve chances of conception. However, there are some lubricants that can actually harm your chances. Both water and oil-based lubricants have been found to interfere with sperm motility. There are some “fertility-friendly” lubricants on the market. Visit our Resource Page for a fertility-friendly option. These will not help increase your chances, but rather, it will have minimal interference. 

When in Doubt

Asking questions about sex can feel a bit embarassing for some. Especially if it’s a question they feel they “should” know.  As you enter your fertility journey, there truly are no bad questions. Your doctors have heard them all. So if questions pop up, be sure to contact your doctor. They understand how overwhelming and confusing trying to conceive can actually be and they will guide you in the right direction. 

If you’ve been having difficulty trying to conceive and want to explore treatment options, contact me to schedule a consult.