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!

If you’ve been diagnosed with PCOS (polycystic ovary syndrome), you are likely familiar with at least a few of its hallmark signs. But did you know that up to half of all women with PCOS are at risk of developing a mental health condition? Since so many mental health challenges go undiagnosed, this means that perhaps some of the most devastating effects of PCOS aren’t even being connected to PCOS.

A quick overview of PCOS

Simply put, PCOS is a reproductive hormonal imbalance. This doesn’t always mean that the ovaries have multiple cysts (though its name certainly does seem to suggest this!) More commonly, signs of PCOS include irregular menstrual cycles, thinning of hair on the head, thicker and darker hair growth on the face, acne, and undesired weight gain.

What’s the connection?

The symptoms described above are the ones most frequently discussed with PCOS. But it is just as important that we discuss the mental health implications of PCOS. These conditions span the gamut from mood disorders to eating disorders. Studies have found a significantly increased risk of major depressive disorder, generalized anxiety disorder, binge eating disorder, obsessive compulsive disorder, and bulimia.

Unfortunately hormonal birth control, often prescribed for the control of PCOS symptoms, has also been linked to depression. This can often be a chicken-egg scenario, where it is unclear which factor led to the mood dysregulation. It’s always best to chat with your healthcare provider about your particular situation!

In years past, people believed that the mental health struggles of PCOS patients were caused by poor body image. It was thought that this poor body image resulted from undesired physical changes such as acne or weight gain. Research has since debunked this belief. In reality, PCOS patients deal with depression in similar numbers, regardless of their body weight or skin condition.

Treatment matters!

Unfortunately, patients have sometimes been told that their PCOS doesn’t need treatment if they are not currently trying to get pregnant. This leaves the mental health implications of PCOS ignored and untreated, which is completely unnecessary!

Depression, anxiety, and other mental health challenges can be difficult to deal with. This can be especially true when you’re dealing with infertility, which has emotional challenges of its own.

When you’re dealing with symptoms of depression, anxiety, or any other mental health challenge, it’s important that you focus on the basics of health. Work on developing proper sleep hygiene, including a regular bedtime and wake-up time. Take a walk around the block and stretch on the floor a bit. Self-care during this time is vital, so don’t be afraid to make time to read a novel or just kick your feet up. Work to reduce stress wherever possible.

Avoid overly restrictive diet plans, and concentrate instead on reducing processed foods. Keep quick snacks in your kitchen, like fresh fruits and veggies that are already cut up, string cheese, Greek yogurt, or nuts available. These are easy to grab on-the-go or when you just don’t have the energy to prepare a meal. (Lack of energy and motivation can often be a very real part of mental health challenges!) There is no “correct” way of eating that is perfectly suited to every PCOS patient, but all can benefit from reducing processed foods.

Many antidepressant medications are safe for use during fertility treatments, but be sure that all your healthcare providers are aware that you are currently trying to conceive.

Don’t try to go it alone!

But don’t try to do it all alone! Reach out to a friend or family member who cares about you. There is also a large array of mental health support groups available, both in-person and online. Find a licensed mental health professional who can help you work through some of the challenges in your life. There are even therapists who specialize in mental health and infertility!

If you have been diagnosed with PCOS, it is vital that you collaborate with your healthcare provider to seek optimal physical and mental health. PCOS is not reversible and currently has no known cure. But you can support your body and mind through lifestyle modifications that can make a huge impact on the way you experience PCOS!

Next steps

Have you been diagnosed with PCOS, or do you believe you may have any of the symptoms mentioned above? Dr. Salem’s unique, integrative blend of alternative and conventional medicine is tailored to suit the individual needs of each patient. This holistic view accounts for both physical and mental wellbeing. We understand that each of these aspects impacts the other.

Reach out to us to schedule a consultation to discuss your options. We look forward to meeting with you!

“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!

When you’re going through fertility treatments, there can be many stressors involved. Emotions and tensions can both run high. It’s not uncommon to feel anger, jealousy, hope, anxiety, isolation, optimism, desperation, or heartbreak throughout the course of a menstrual cycle. It’s even normal to feel all these emotions in a single day.

Because of the wide range of emotions, medications, and procedures involved in fertility treatments, it’s natural to stay focused on the end goal of achieving a pregnancy and carrying it to term. It can be easy to hyperfocus on this desired outcome. Resist the temptation to put your head down and “grin and bear it” through the difficulty. Make time for yourself despite the stress.  Self care can involve many aspects of life, and many items on this list may not resonate with you. Don’t let taking care of yourself become just one more thing on your to-do list. Pick out a few of these suggestions to try implementing and see how they work for you!

Aim to spend more time outdoors. Besides just helping you get more vitamin D and boosting your immune system, spending time outside can help boost serotonin production and increase your mood. Many people say that spending time in nature helps them to put the stress of their daily life into perspective. Bonus points if you can incorporate exercise into this outside time!

Take time to connect with your significant other. If you are undergoing fertility treatments with a partner, it can feel like infertility has taken over your relationship. This can be especially true of your sex life. Do a check-in to see how he or she is feeling, and be open and honest about what’s going on with you.

Find a therapist. Fertility treatments can be stressful! Having a mental health professional available to help you process your emotions can be a lifesaver. There are even therapists who specialize in infertility topics.

Practice meditation or prayer. Regardless of whether you consider yourself spiritual or religious, implementing a few quiet minutes per day for meditation or prayer can help you feel centered and provide some strength to carry with you throughout the day.

Journal. Whether it’s jotting down a few things you are grateful for at the end of each day or focusing on how you feel about the latest fertility treatment you are trying, journaling can assist you as you process your thoughts. Even if you scribble your thoughts on a napkin that you proceed to throw in the garbage, the process of putting pen to paper (or paper towel?) can help you organize your thoughts.

Make sleep a priority. Sleep can sometimes seem like a waste of time when there is so much to do, but it makes a real difference in our moods and health. Commit to a specific bedtime every night for a week and see what kind of difference it makes!

Connect with friends. Whether it’s reaching out to a friend through a quick text message or meeting for a meal, friendship can be a great source of support during difficult times.

Take time to relax. Relaxation is different for each of us, but some suggestions may include getting a facial or a pedicure, going for a hike, reading a novel, or taking a warm bath.

Seek out healthy snacks. Keeping blood sugar in balance and including plenty of protein and healthy fats can make a world of difference in mood and energy level.

Reach out to others in your community. Pitching in to help with a recycling drive or women’s shelter may not feel like self care, but giving back to the community can be a great way to gain perspective on the world and help someone else when you feel helpless about your own situation.

Be mindful. Take sixty seconds at several points throughout the day to zero in on what you are feeling in that moment. Suspend judgment of your environment or your feelings and just focus on being present in that moment.

Keep yourself hydrated. Even though we know the benefits of hydration for general health, it’s tempting to use caffeinated beverages to give you the energy to power through your day. Make sure to have a water bottle with you at all times, and take sips from it frequently throughout the day.

Give yourself grace. Infertility and some of the medications used during fertility treatments can lead to mood swings. Acknowledging this in advance can help mitigate a little of the frustration you feel if you find yourself being impatient. You’re allowed to be human!

Let it go. We all hold tension in different parts of our bodies. If you know that you tend to furrow your eyebrows, tense your shoulders, or clench your fists when you’re anxious, check in with your body throughout the day. Work to consciously release these muscles.

Go on a social media hiatus. The modern day “miracle” of social media allows us to stay in touch with friends and family all around the world! But it can also lead us to compare our own real lives to the highlight reel that others choose to post. Stepping back from social media (especially when you’ve been dealing with feelings of jealousy or resentment) can be an important part of self care.

Self care doesn’t have to be fun!

When self care is mentioned, many of us immediately think of some of the fun, indulgent activities listed above, like getting a massage. But self care can be anything you do to take care of your future self! If you’re stressed out about what to make for dinner this week, sitting down to make a meal plan can be self care.

Infertility can be stressful, but we are here to help you navigate the process every step of the way. Reach out to see how we can help 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!

Are your health and fertility being affected by something invisible, something that you may not even know how to pronounce? While some of us have heard about BPA, phthalates (pronounced THAL-ates) have been discussed less often. Unfortunately what you don’t know about phthalates may, in fact, be hurting you.

So what are phthalates?

Phthalates are a group of chemicals added to plastics for a variety of reasons. Some phthalates are added to make the plastic more pliant and malleable, while others help scented products to retain their fragrance for a longer period of time. Still others help bright colors retain their vibrancy. Because of the variety of phthalate usages, you may have heard them called “the everywhere chemicals.” Phthalates can be found in a wide variety of items you encounter everyday, from shampoo to nail polish, from vinyl flooring to detergents and fabric softeners.

Just like these “everywhere chemicals” are added to products for various reasons, they can each act on the human body in a variety of ways. All phthalates, however, disrupt the endocrine system, which affects hormone production.

How might phthalates affect fertility?

Research indicates that women tend to have more side effects from phthalate exposure, possibly because they tend to use more phthalate-containing products on a daily basis. In fact, the average American woman uses 10-12 beauty and personal care products throughout the course of her day! Some sources have estimated that the average woman is exposed to over 150 hormone disrupting chemicals over the course of one day! Several studies have also shown that women living with endometriosis have higher levels of certain phthalates in their bloodstream than their peers without this condition. Other phthalates are known to interfere with egg development and cause genital malformations in fetuses of women who have exposure.

Although males may experience less exposure to phthalates through personal care products, they are still exposed to these chemicals many times over the course of a day. These exposures are not without their negative effects on men either: higher phthalate levels have been linked to diminished sperm count, poor sperm quality, and even an increase in the incidence of prostate cancer.

Phthalate exposure during conception and pregnancy

One convincing argument for decreasing your exposure to phthalates, particularly while trying to conceive, is the association between high levels of phthalate and pregnancy loss and preterm births. Phthalate exposure seems to be most risky for male fetuses, who cazz4n be born with malformations in the genital tract after in-utero exposure to phthalates. Children exposed to these high levels in the womb may also be more likely to experience congenital defects, slow growth, and a late onset of puberty.

How to reduce phthalate exposure

With all these risks and very little benefit to the consumer, you may find yourself wanting to decrease your phthalate exposure but feeling a little overwhelmed by all the changes you’d need to make. It’s usually not feasible (or financially prudent!) to replace every product at once. Baby steps are the way to go.

Get in the habit of reading labels on the products before you buy them. Phthalates can be listed as an abbreviation like DnOP or BBzP, or the ingredients may simply list “parfum” or “fragrance.” The easiest way to identify whether a product uses phthalates or not is to look it up on the Environmental Working Group’s “Skin Deep” database. The EWG is a nonprofit, nonpartisan group that helps consumers make informed decisions about a product’s ingredients before purchase. You can easily search the Skin Deep database by ingredient, brand, or product, and they even have apps for iPhone and Android for clean shopping on the go! 

Another baby step you can take is reducing the phthalates in your period products, like pads and tampons. The vagina and vulva are extremely permeable, and using chemical-laden products in this area of the body means phthalates are absorbed more quickly and easily. When looking for feminine hygiene products, then, it’s important to avoid any scented products on this sensitive part of the body. You can also spring for a menstrual cup, cloth pads, or “period panties,” which require more of an investment up front but can be reused cycle after cycle.

One very easy way to avoid unnecessary phthalate exposure is to stop using vaginal washes or douches. The vagina is a self-cleaning body part, and there is no need to wash it with soap or any other product. In fact, women who use these rinses just twice a month were found to have 152 percent higher levels of certain phthalates present in their urine!

Another area to examine is the health and beauty products you use that are applied to a very large portion of the body, such as lotions. Products like these also are not rinsed off of the skin after use, so there is more of an opportunity for phthalates to continue accumulating in the body throughout the day. Examining your hairspray ingredients might also be a small change with a big payoff, since this product is absorbed through the skin but also inhaled in fairly large quantities while it is being applied.

Replacing your scented household cleaning products can be cost effective too: you can use inexpensive castile soap, vinegar, baking soda, water, and a little elbow grease in place of those pricey, heavily scented cleaners.

Avoiding fast food and eating primarily whole foods can cut phthalate intake significantly, as well as adding many other benefits for your fertility! Dairy and meat are known to contain high levels of phthalates, so try to choose other sources of nutrition when possible. When preparing meals at home, focus on using glass or stainless steel food storage containers, particularly when dealing with foods with high fat or high oil content. You can also swap out your plastic water bottle for stainless steel while you’re at it!

Attempting to make all these changes at once can very quickly lead to overwhelm and burnout, but if you can replace items with phthalate-free alternatives when you need to replace them anyway, cleaning up your routine can be simple!

Do you have more questions about how phthalates and other environmental toxins might be affecting your health and fertility? Get in touch with us today!

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!

If you have struggled to conceive despite regularly engaging in unprotected sex, one of the many possible medical interventions that your doctor discusses with you might be intrauterine insemination, or IUI.

What is IUI?

IUI allows the sperm to bypass the vaginal canal and cervix by placing the sperm directly into the uterine cavity. The procedure is timed to happen as close to ovulation as possible to maximize your chances of conception. During intercourse, it is not uncommon for some sperm to be left in the folds of the vaginal wall, never quite completing its journey to meet the egg. Sperm can also encounter problems penetrating a tightly closed or scarred cervix or surviving a vaginal pH that may be slightly too acidic.

Why might I need IUI?

Although in-vitro fertilization may be the most well-known type of fertility treatment, IUI is both less invasive and less expensive. (Many insurance companies that cover IVF even require the patient to attempt a certain number of IUI cycles before they will cover any of the more invasive procedures involved in IVF.)

IUI may be recommended as a first line of treatment for patients trying to conceive using sperm from a donor. IUI may also be an option for couples who are unable to have sexual intercourse during the fertile period, either due to sexual dysfunction or a partner who travels frequently or is deployed. In cases of separation or donation, sperm can be frozen for use in future IUI cycles. IUI may also be a good option for couples dealing with sperm motility that falls in the borderline-low to normal range. Some cases of unexplained infertility, especially in females under the age of 38, may also benefit from IUI.

To be a candidate for IUI, patients need to have at least one open fallopian tube and a sufficient number of motile sperm.

What is involved in the IUI process?

Medications: IUI can be completed with or without medications to induce the growth of one or more eggs. Your doctor may recommend that you take letrozole or Clomid for five days, usually early in your cycle. Injectable medications can sometimes be used as well. Injectable prescriptions are typically a bit more powerful than oral medications, which is why most physicians prefer to try IUI with an oral medication first. You may also be prescribed a one-time hormone injection to trigger the release of one or more of the mature eggs.

Monitoring. Depending on whether a cycle is medicated or unmedicated, your provider will discuss ways to monitor your hormone levels. In a natural cycle, you will time your IUI or trigger shot with your natural ovulation. During a medicated cycle, this may include urine ovulation tests, bloodwork, or pelvic ultrasound. (Ultrasound is more commonly used when medications are prescribed along with the IUI cycle.)

Sperm collection and processing. A semen specimen is provided either by your partner or a sperm donor. The semen then undergoes a process called sperm-washing in a lab. Fresh or frozen semen can both undergo the sperm washing procedure. During this process, the sperm is separated from the rest of the seminal fluid.

Insemination procedure. The insemination itself is a fairly simple process. Once you and your physician have identified that you are ovulating, the washed sperm is placed into a very thin cannula with a syringe at the end. Most patients describe this procedure as causing minimal discomfort, and it might feel similar to a pap smear. Anesthesia is not required, and the insemination itself takes less than five minutes. You may be asked to remain on your back for several minutes after the insemination. There are no activity restrictions or bedrest requirements after IUI.

What is the success rate of IUI?

The overall success rate of each IUI cycle is between 10 and 20 percent, but much of this depends on the reasons for IUI being performed and the age of the female. Chances may be higher in patients with no known fertility challenges, such as couples unable to have intercourse due to travel or sexual dysfunction and patients using donor sperm. The age of the female is one of the most important determining factors to success rates of IUI cycles.

When do I find out if I am pregnant?

After undergoing a procedure like IUI, you will likely be anxious to find out whether or not it has resulted in a pregnancy.  Bloodwork or a urine pregnancy test should be accurate about 14 days after the IUI procedure. If you attempt a home pregnancy test before this time, you may receive a false positive result because of the hormones in the trigger shot.

If you are having difficulty conceiving, contact us today to discuss whether IUI could be an appropriate option for you!

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.  

Trying to conceive can be a stressful process for many women, especially those who may be experiencing difficulty resulting from infertility. Patients who achieve pregnancy but then experience a pregnancy loss may feel even more frustrated. Recurrent pregnancy loss is defined as having two or more pregnancy losses following a documented gestational sac in the uterus.  Causes of recurrent loss can be related to uterine anomalies, immune issues, chromosomal imbalances in either the male or female partner, hormone issues, and most common, chromosomal imbalances in the embryo. 


Uterine Anomalies:


One of the most common uterine anomalies contributing to recurrent pregnancy loss is called a uterine septum.   A uterine septum results from failure of the uterus to develop normally in a female fetus in utero.  A septum acts like a dividing wall in the middle of the uterine cavity. . The septum itself is composed of fibrous tissue that does not have much blood supply on its own. Therefore, if a fertilized egg implants on the septum, it may not receive adequate nutrients during the pregnancy resulting in the possibility of loss. Most physicians agree that a uterine septum increases the risk of a pregnancy loss and should be removed if found. 


Fibroids, or benign fibrous tissue  of the uterus, are another anomaly responsible for some pregnancy loss or difficulty conceiving. There are different types of fibroids, depending on their location within the uterus. Fibroids located within the uterine cavity where the embryo implants and grows are linked to pregnancy loss.  There is also an increased risk for miscarriage in women with very large fibroids. 


Fortunately, treatment for both uterine septum and fibroids within the uterine cavity is available. Both can be removed surgically through minor, outpatient surgery in a minimally invasive procedure called Hysteroscopy.  Sometimes a larger procedure called a Myomectomy is needed for the removal of larger fibroids. 


Immune issues:  


Immune issues can involve either overactivity or low activity. With overactivity, the body responds by attacking and damaging its own tissues. In low activity cases, the body has difficulty fighting off infections and is, therefore, more vulnerable to disease. Two conditions seen in patients with recurrent pregnancy loss that fall under immune causes are Antiphospholipid syndrome and 


Antiphospholipid syndrome,  is an immune disorder where the body makes antibodies that attack phospholipids. Phospholipids are major components of plasma membranes and the structural component of cells. In antiphospholipid syndrome, blood clots can form within arteries, veins, and other organs. Recurrent pregnancy loss or stillbirth may be an effect of aPL as the clots may affect normal placental function. . 


This disorder is believed to be genetic and rare, found to be present in less than 200,000 cases each year. Medical professionals can prescribe blood-thinning medications to reduce the risk of blood clots.


Inherited thrombophilias is an inherited DNA mutation which results in the body producing too much or too little of a blood-clotting protein. The relationship between inherited thrombophilias and pregnancy loss remains controversial amongst doctors. They have reported evidence suggests treatment with an anticoagulant does not improve pregnancy outcomes. 

Hormone issues:


While there are several examples of hormone disruptions that could affect infertility and pregnancy loss, some examples are abnormal thyroid levels, elevated prolactin, and polycystic ovary syndrome (PCOS).


Abnormal thyroid function, both hyperthyroid and hypothyroid, appear to correlate to pregnancy loss. Hyperthyroidism produces too much thyroid hormone and can cause body processes to speed up, as in an elevated heart rate and metabolism.


On the other hand, hypothyroidism is the effect of too little or no thyroid hormone being produced. Most of the time thyroid conditions may be treated with medications. 


Prolactin is a hormone secreted after childbirth which aids in breastmilk production. In some cases, elevated prolactin in a woman before pregnancy may lead to infertility and or pregnancy loss as hormone production affects the estrogen and progesterone levels. However, high levels of prolactin may signal hypothyroidism or pituitary tumors and should be examined further. Sometimes there is no cause for the elevated levels of prolactin, and it may be treated with medication. 


Hypothyroidism is usually managed with medications, and tumors may be removed surgically. Other causes of elevated prolactin may be medications or stress. 


PCOS is common within the United States, with over 200,000 diagnosed cases each year. There is some evidence that women with PCOS have higher rates of pregnancy loss. This may be due to elevated male hormones, and elevated insulin levels. 


One resolution may be maintaining stable blood sugar levels. Some medical professionals might prescribe medications such as Metformin. Diet is another method that can manage PCOS symptoms and may help reduce pregnancy loss.



Insulin resistance is similar to hormone issues listed above. When the body does not respond to insulin, glucose cannot be absorbed from the blood. The result can be prediabetes or diabetes.  There is currently evidence demonstrating that elevated blood glucose can be associated with increase first-trimester loss [R]. 


Within my clinic, I often screen patients with a fasting blood glucose test as well as screenings for insulin levels and HgbA1C. The results will provide a snapshot of what blood glucose has looked like over a 3-month period. 


Diet and lifestyle changes are usually recommended; however, medications such as Metformin may also be prescribed.

Chromosomal imbalances 

Balanced Translocation refers to a condition in which part of the chromosome has broken off and reattached to another location. Depending on the circumstances, a chromosomal translocation may be harmless, or it may cause serious health problems. 


In the case of balanced, or reciprocal, translocation many individuals are unaware they are affected until pregnancy. If an affected person’s cells attempt to divide to create egg or sperm cells, the irregular chromosome would contain extra or missing genetic material. It could lead to pregnancy loss, depending on the gene affected. 


The translocation can be diagnosed through a test called a karyotype; however, there is no treatment. 


Chromosomal abnormalities of the embryo account for the most common cause of first-trimester pregnancy loss. Unfortunately, there is no simple test, such as a blood draw, to determine the cause. Genetic testing after a pregnancy loss can be performed if pregnancy tissue can be collected and sent to the lab.  Pregnancy tissue can be collected in cases where a woman miscarries at home or if the patient has a procedure called a Dilatation and Curettage ( D&C ) .  If available the pregnancy can be tested genetically to confirm the presence of an abnormal number of chromosomes. 


If you’d like support with pregnancy loss, or you are experiencing difficulty conceiving, contact me and we can help you get tested and decide if treatment is right for you.