• How did you end up getting into the whole world of functional nutrition, and how did you end up with fertility as one of your focuses?
• For women who are pregnant or trying to get pregnant and having trouble, the extent of the nutrition aspect of that is focused on them to lose weight. How much of a role do you think weight loss really plays when compared to other factors?
• In what ways does a stressful lifestyle, or just being under emotional stress, have an impact on someone’s fertility?
• When we’re talking about stress relief and lowering the stress hormones, do you have any favorite types of mind-body activities?
• What are your thoughts on the prenatal vitamins that are pretty typical to take? Or do you have any recommendations that you like any better?
• You recommend antioxidants for women as well as their male partners. Why are antioxidants important, especially in this sort of scenario?
• If you had to describe the ideal diet to enhance fertility for both men and women, what would that look like?
• Is there anything that we shouldn’t be eating, or restricting a little bit? Or is there anything that’s especially important to stay away from during this time?
• Are there any particular things that you like to recommend to promote good gut health? Or for example if someone has some sort of digestive issue, is there a protocol that you tend to put people through to alleviate some of those symptoms?
• Do you ever deal more specifically with women who have genetic mutations such as MTHFR?
• If somebody needs a more active version of B12, but they’re having a problem with the methylcobalamin, do you have any alternatives? Is there a better version that they do well with?
• Is there testing that you typically recommend for your clients if you end up getting them six or more months ahead of pregnancy? What is kind of the screening process that you go through?
• Is there a biggest misconception you think that people have about fertility and prepping for fertility?

Links Discussed:

• Boston Functional Nutrition
• EatSimply.org
• Ayla’s blog post on how to choose the right prenatal suppplements
• Real Food Radio podcast by Ayla and cohost Diana Rodgers
• Ayla’s webinar: Fueling Fertility: Nutrition Interventions For Men and Women
• WildFoods.co – Use the code WILDRD for a free gift!

TRANSCRIPT

Laura: Hey everyone. Welcome to episode 47 of The Ancestral RDs podcast. My name is Laura Schoenfeld, and with me as always is Kelsey Marksteiner.

Kelsey: Hey everybody.

Laura: How is your weekend, or how was your weekend, Kelsey, since we’re into the week now?

Kelsey: The weekend was good. It was beautiful out, so I spent a lot of time outside. I’m still in Massachusetts so I get to sit outside on my mom’s patio and soak up the sun, which I don’t normally get to do in New York. So it was really great to just relax, get some nice weather, get some sun, some vitamin D. It was great.

Laura: So you don’t go hang out on your balcony in Astoria?

Kelsey: I do, but you’ve been to my apartment so you know you have to climb out the window. We call it our “balcony,” but really that’s in quotes because it’s a fire escape.

Laura: Fire escape, yeah. Well you’ll have to come visit me in Raleigh and lay out on my lounge chairs in my backyard.

Kelsey: Sounds so great.

Laura: Yeah, we have a south facing backyard so it gets sun most of the day actually, which is pretty nice.

Kelsey: That’s awesome. That sounds great. How was your weekend, pretty good?

Laura: Yeah. I’ve been making some changes with my business and some stuff that’s been happening career wise has been kind of…I don’t know, I feel like I’m riding a wave right now and I’m just trying to see where it goes. As I might have mentioned, I’m not even sure if I mentioned this, I did an interview for Steph Gaudreau’s Women’s Strength Summit that was going on. I was really shocked to get a call from my mom on Friday saying that I’d been voted as the top five requested replays for the encore.

Kelsey: Nice!

Laura: Yeah. The first thought that came to my head was wait, what? How‘s that possible? That’s not true. And then so I had this second kind of more metathought that was like, no don’t say that. Say that’s awesome, that’s exciting, I’m so proud, like those kind of don’t stop doubting that it’s possible that people could actually like what I’m saying. And so that was really cool.  I was really excited by that and it kind of gave me a little bit of a nudge as far as feeling like I’m making the correct changes in my business to start getting a more cohesive message.

Kelsey: Like what you want to focus on, you mean?

Laura: Yeah and just really reforming my approach and really figuring out who I want to help and what kind of things I want to help with. So that was really affirming. And then I feel like I just had all this potential energy stored up from all the excitement and I was able to get my first ever chin-up at the gym on Saturday.

Kelsey: Woohoo!

Laura: That was really exciting because I’ve been working on upper body pull-up/chin-up type things consistently for the last ten months and then probably since I don’t even know, probably years ago. It’s been on my mind wanting to get that for a while. Even though some women may be able to do pull-ups really easily, I am totally lower body dominant. I also weight like 160 pounds right now so if I was 140 pounds I’d probably be able to do chin-ups no problem. But since I have this extra weight, and I’m not saying extra weight like fat, I’m just saying higher amount of weight than other women may have, it just felt kind of out of reach for me. And I kept thinking I’m going to have to lose weight if I ever want to do this chin-up. I finally got it and I didn’t have to lose any weight and it was really cool.

Kelsey: That is awesome!

Laura: Yeah. It just feels like, I mean doing a chin-up is whatever. The fact that I can do chin-up doesn’t really mean anything about me from a value perspective.

Kelsey: Right.

Laura: It’s not like suddenly I’m like the most awesome person in the world since I can do a chin-up. But what I will say is that just being able to accomplish something that for a really long time I just didn’t think I was going to be able to accomplish, and kind of felt discouraged about, and was practicing and training and all this stuff, it just felt it was never going to come. So suddenly to be able to do it just makes it feel like it was all worth the effort and that I can do things that take a lot of practice and take a lot of training. I don’ know. It just like this kind of grander metaphor for life in general where it’s like I can do things that I put my mind to even if they don’t happen right away. Just being confident and having faith that I will be able to at some point, I think is just really a cool experience and a cool thing to do just in general to get myself feeling more confident in my abilities to make changes in my life or do thing that I’m either afraid of or do things that I feel like I can’t do.

Kelsey: Right. I think that’s awesome. I would love to be able to do a chin-up. Someday for me.

Laura: Yeah. It’s hard. I have some shoulder stability issues and my lats are super weak probably from the amount of sitting, and typing, and computer work that I do. Then also just recovering from my car accident last year, I just feel like my back and neck really were kind of weak for a while there.

Kelsey: Right.

Laura: So we’ll see. Now have to do more than one and I have to be able to do one consistently because I feel like that was just a unicorn chin-up that I’m never going to get again.

Kelsey: New goal.

Laura: New goal is that I can do one on command. So if I go to the gym and my coach Matt says, okay chin-up, now! I can actually pull one out and not just be like, no I swear I did it one time!

Kelsey: Well that’s really cool, Laura. Congratulations! That’s awesome!

Laura: Thanks, I’m stoked. And like I said, it’s one of these things that it just feels like I’m riding this weird wave of energy and positivity. And I’m like okay, I’m going to stay on this thing as long as I can.

Kelsey: Right. Let’s keep going with this, this is great.

Laura: Yeah, just keep paddling, keep paddling!

Kelsey: That’s awesome.

Laura: Great. Well we have a really cool interview today. It’s going to be all about, well I shouldn’t say all about fertility, but the majority of what we discuss with this particular guest is all about fertility. And Kelsey is going to introduce our guest in just a second. But before she introduces her, let’s hear a quick work from our sponsor.

Kelsey: Alright. Welcome back. Today we have a wonderful guest. Ayla Withee is a Registered Dietician and Nutritionist, and Certified LEAP Therapist, and owner of a successful private practice, Boston Functional Nutrition. She has trained for years with experts in the field of functional medicine and embraces a whole body approach to addressing the root cause of health issues. Her specialties include women’s health, gastrointestinal disorders, and nutrigenomics. Often sought after for her passion and expertise for various media and speaking opportunities, Ayla has consulted with a wide range of organizations and health professionals from Fortune 500 companies to Olympic athletes. She’s also a preceptor for several dietetic internship programs. You can find Ayla blogging about real food at EatSimply.org, subscribe to her and cohost Diana Rodgers podcast Real Food Radio, or learn more about her practice at BostonFunctionalNutrition.com.

Welcome Ayla.

Ayla: Oh thank you so much for having me, Kelsey. I’m happy to be here. I’m a big fan of your podcast.

Kelsey: Awesome. We’re very excited to have you as well. Why don’t you start by telling us a little bit about you. How did you end up getting into the whole world of functional nutrition?

Ayla: Yeah, sure. I have had a very diverse career in the field of nutrition, one that almost took me right out of the field. I did the coordinated program, dietetic internship program through the University of Connecticut and graduated. And there was that really strong push that I bet you both can relate to, to get into clinical dietetics and kind of work in the hospital setting. I resisted that. I knew it wasn’t quite right for me and I was trying to find my way for many years. I did community nutrition, taught quite a bit, I always enjoyed teaching. And then I found my way into corporate wellness and enjoyed that quite a bit, but found myself doing more benefits management administration kind of work and got a little frustrated feeling like I wasn’t really using my nutrition degree. So I started mentoring with Susan Allen, actually. She’s a Dietician who does a lot of mentorship in integrative and functional medicine and researching that, and I just fell in love with it. So that’s how I wound up doing that. And then the private practice launched shortly after that, so I feel like I’m where I’m supposed to be now.

Kelsey: A long path, but you finally got there. That’s great.

Ayla: Yeah.

Kelsey: Cool. Today we’re talking about fertility. So this is a topic that I find really fascinating. I’m just wondering how you ended up focusing…of course functional nutrition is wide, you can deal with a wide array of things. How did you end up with fertility as one of your focuses?

Ayla: It started by I had a couple of women come to see my in private practice who were struggling with fertility and their physicians had sent them to me to lose weight. That was the instruction that they had. They came like many women, actually, undergoing fertility treatment. That can be the extent oftentimes of the advice that they’re getting nutrition wise from their physicians or healthcare practitioners. They come and they’re panicked and they want to do something fast. So at any rate, I have a couple women who came to me. I started working with them, and just like any other patient when you’re looking at it with a functional medicine lens, you’re always going to kind of the root cause of what going on. I found that there was always these underlying factors, and there’s a number of them with fertility that we could address to really influence.

Kelsey: Right.

Ayla: I also realized there is very little out there for the nutrition and fertility connection. Not a whole lot of dieticians in our field or other practitioners are really doing counseling in that area and there’s so much that can be done from just nutrition and lifestyle wise to influence fertility.

Kelsey: Yeah, absolutely. Actually that brings me to one of my questions that I had for you, which is exactly what you said that women who are pregnant or trying to get pregnant and having trouble, a lot of the extent of the nutrition aspect of that is focused on them to lose weight. I think it probably does play some degree of a role, but how much of a role do you think that really plays when compared to these other factors that you’ve just mentioned?

Ayla: It’s been interesting because most of the research with nutrition fertility has focused around the weight piece. I think that’s where a lot of physicians have gotten this recommendation where that’s what they feel comfortable saying. Being at a healthy body weight definitely helps. The research points to that. But it’s always a question of the whole context. And when the woman is coming to you…and men, men play a big role in their weight as well…as to when is it appropriate to lose weight, how much weight, do they need to gain weight? That I’m seeing more and more of with women, for sure.

Kelsey: Yeah.

Ayla: Weight absolutely influences it. It’s actually a little more about body fat percentage though then overall weight. That seems to play a bigger role.

Kelsey: When you say body fat percentage, what are we talking here? Is there a minimum? Is there a maximum where you start to kind of have trouble in either end of the spectrum?

Ayla: In terms of exact numbers, it’s a little bit tough. But I will say that as body fat percentage increases outside of a healthy range for that individual, and it is very individual based, that’s when the estrogen metabolism cycle start to change. Similarly, as body fat increases, the estrogen metabolism cycle is affected as well as when body fat decreases too significantly. It’s also affected in those cases. It can turn on or off the cycle in this sense in both directions. So there’s sort of a happy place.

Kelsey: Yeah. I mean, that makes perfect sense. Completely. Laura and I often talk about on our podcast, and in our blogs, and everything about how being underweight or under eating and kind of stressing out your body in that capacity has a host of ill effects on your body. I think for fertility is probably one of those big ones. Tell us a little bit more about the people that you’ve worked with that seem to not have enough body fat or are under eating. How do you kind of deal with those types of clients?

Ayla: It is a challenge because what I’m seeing more and more of actually is diagnoses with women with hypothalamic amenorrhea, which is how this can at one extreme manifest. Hypothalamic amenorrhea is when the hypothalamus slows or stops releasing the gonadotropin releasing hormone, which is the hormone that affects and starts the menstrual cycle. It doesn’t necessarily take a lot, but it does happen when low body weights, low percentage of body fat, very low intake of calories or fat or inadequate intake, emotional stress, very strenuous exercise with inadequate calories. I’m seeing more and more of this and it’s something that when women come in, I think the stress of trying to get pregnant and not being able to actually can push some women to restrict further and exercise more and actually further exacerbate the issue. It does become kind of a counseling issue. I’ve got to really work with women to get them to understand metabolism and how physiologically their healthy lifestyle has gone a little too far.

Kelsey: Right.

Ayla: Their body is sending them cues and giving them signals that it’s time to back off. When you’re trying to get pregnant, backing off a bit on exercise and making sure that you’re eating enough is just so critical. Your body wants to know that it’s safe to bring a baby into the world, that it’s likely be a successful pregnancy, and you’ve got to give it those signals.

Kelsey: Yeah. Absolutely. Luckily I think with fertility, at least in my experience, I think that’s one of the great places where this educational piece actually works a lot of the time because women who are trying to get pregnant are obviously very concerned about actually making this happen. So they’re a least, like I said in my experience, they’re a little bit more likely understand and implement this sort of less exercise, more calories approach. Whereas if I have someone coming to me for just maybe another health issue, or they may even come to me wanting to lose weight and I end up finding out that they’re really still not eating enough or they’re over exercising, it’s kind of a more difficult situation to help that person understand that what they’re doing is having a negative impact versus fertility. Do you find that’s true?

Ayla: I do, absolutely. It’s definitely a very highly motivated group of individuals. There’s a very clear goal in mind. But I also find that exercise and sometimes that tight control over diet can be an anxiety or stress management tool, or it becomes that way for a lot of women. The one thing that became very clear to me when I was working with this population is that I needed to be knowledgeable and have some really good extra tools on the integrative side of other ways to manage stress and anxiety so that you’ve got some other tools in your toolbox.

Kelsey: Yeah. Speaking of stress, I think that that is huge and I’m sure you do to when it comes to fertility. In what ways does a stressful lifestyle, or just being under emotional stress, or anything like that have an impact on someone’s fertility?

Ayla: Absolutely. Stress hormones, your cortisol, epinephrine, norepinephrine, they interact with the HPA axis, the hypothalamic pituitary adrenal axis, which I know you and Laura know quite a bit about. It can modify levels of the follicle stimulating hormone: FSH and LH: luteinizing hormone, which those two are critical because they directly affect the synthesis of estrogen and progesterone. An elevated cortisol in men, too, can inhibit the conversion of androstenedione (I think I’m saying that right) into testosterone. It affects testosterone essentially.

Kelsey: Right.

Ayla: And then there’s a number of other ways. I mean these stress hormones kind of pumping through your body on a regular basis, I would say the reproductive system is probably one of the very first systems that is impacted, and it’s significant.

Kelsey: Right. Which makes sense because if you think about it just in how our ancestors would have been affected by this fight or flight kind of feeling, of course if you’re actively being chased by a wild animal in the wilderness or something, or you don’t have enough food in an acute period of time, of course reproductive stuff is just not on the body’s mind at the point. It doesn’t feel safe. Those sort of hormones, to me at least, it makes sense that it would kind of shut down reproduction as one of the first things that gets shut down.

Ayla: Yeah, absolutely. Again, our body is looking for those external cues, those environmental cues, and signals that it’s a safe time, that it’s likely that this will be a successful pregnancy. So if we look at it from purely a biological and even historical perspective, that plays a big influence.

Kelsey: Right. Now when we’re talking about stress relief and kind of lowering the stress hormones, do you have any favorite types of mind-body activities, or anything like that?

Ayla: Yeah. There was actually an interesting study. It was actually done out of Massachusetts Fertility Clinic that they showed actually significant improvements in pregnancy rates…this is a group undergoing IVF…when they went through a mind-body intervention called letting go counseling. It essentially was a cognitive behavioral therapy kind of approach. That’s a more comprehensive total body, I would refer out to another practitioner to really work on that.

But some of my favorite tools to use are simple progressive relaxation techniques. I’ll definitely work with clients on simple apps that help them to focus on breathing, which I mean it’s so basic, but just good breathing exercises for five or ten minutes can totally rest the parasympathetic nervous system.

Kelsey: Right.

Ayla: We oftentimes just work there because if I send people out saying, okay now go mediate for an hour a day, that oftentimes causes mores stress than it helps.

Kelsey: Yeah. I think some of the research too has shown that it’s kind of better to do little bits of mind body activities on a daily basis versus doing an hour or two of mediation one day a week or something like that.

Ayla: Yeah. Absolutely. That’s the feedback that I’ve gotten too from people. It can be really profound just five or ten minutes, and it’s doable.

Kelsey: Right.

Ayla: So that’s one of my favorites. But I also work with women and men on focusing more on more restorative gentle types of exercise like yoga, things that will get them more focused on their body. That’s meditative in itself, I find anyway.

Kelsey: Yeah.

Ayla: We do that, a little bit of journaling, and sometimes some visualization techniques as well.

Kelsey: Cool. That sounds awesome. I can imagine that would more than anything just sort of reduce that pressure to get pregnant too, and really feel like its restorative for the person themselves regardless of the outcome.

Ayla: Exactly.

Laura: I think these practices, I know it sounds like, oh just do this and then you’ll get pregnant or whatever. I think these practices actually can come in handy for people after they get pregnant. I think a lot of women, especially if they haven’t had children, and I’m not trying to pretend I know what it’s like to have children. But when you have your first child, I feel like your life gets turned upside down, and new stressors come that you didn’t have before, and there’s lots of things that are potentially overwhelming. If you build these practices before you get pregnant and maybe even practice them while you’re pregnant, then when you have that first child you’ll be more ready to deal with the stressors that come from having a baby for the first time.

Ayla: Absolutely. Even during labor and delivery there’s been some good research around just having the tools to really understand breathing and being mindful. It’s something that I’m personally going through. I’m actually pregnant myself.

Kelsey: Oh, congrats!

Ayla: It’s coming up pretty quickly for me and I’ve been practicing a little bit of hypno-birthing, and just finding whenever its right in your life to start practicing some of these exercises, the applications I think are applicable everywhere.

Kelsey: Right. With stress management, of course at any point starting some sort of practice including these activities is going to be great. But is there a, I don’t want to say cut off time, but is there an ideal time if you’ve never even thought about doing these things before but you’re like I’m starting to think about getting pregnant. Is there any time that you would say is really great to start these things? Or basically just as early as possible?

Ayla: I mean broadly speaking, definitely as early as possible. The more you practice lifestyle behavior changes, the better off you’ll be. Obviously there’s certain eating behaviors, coping mechanisms that we’ve practiced for years and years, maybe our whole life. So it takes a while to reroute those pathways in the brain and learn new behaviors. But I would say I really love it when I can get someone six months at least beforehand. That’s really nice. It’s not that often. But if I can, that’s something that I’ll screen for and I’ll ask for in an initial assessment, are you thinking about getting pregnant? Is that a goal of yours? Then we’ll start to put everything we do in context of that and I’ll relate back to that goal. But yeah, six months is ideal, even just for trying to address nutrient deficiencies and try to replenish those.

Kelsey: Yeah. Makes sense. Speaking of nutrient deficiencies, one of the first things that I think women start to think about or are told when they’re either thinking about becoming pregnant or are pregnant is to take a prenatal vitamin. What are your thoughts on the prenatal vitamins that are pretty typical to take? Or do you have any recommendations that you like any better?

Ayla: Yes. I actually blogged about this a little bit. And I would love it if collectively we could get some better information out there about prenatals because what I’ve found is that most women are just recommended by their health care practitioner just to go find something at the pharmacy. Maybe they’re given a prescription, which are honestly little better than what you’re finding over the counter at the pharmacy. It just has low quality vitamins and minerals, lots of synthetic stuff, things that are not absorbed particularly well, not in great ratios or balance to each other. That’s really critical. Again, nutrient deficiencies can be a real root cause to infertility.

Kelsey: Yeah.

Ayla: So from my perspective, it’s really important to get with a health care practitioner who understands quality supplements and can make a personalized recommendation. I think at the very least, you want to look for a multivitamin that is going to cover a broad spectrum of vitamins and minerals.

Folate is key, but not just any folate. You typically see folic acid, which is the synthetic version of folate found in pretty much all I’d say over the counter kinds of prenatals and multivitamins. I work a lot with nutrigenomics and that sort of thing. A lot of people have problems converting that folic acid. That could be a whole other topic of discussion, but non-converted or un-metabolized folic can be really problematic for the body because being a source of inflammation in itself. Having real folate, or folinic acid, or what’s called the L-5 methyltetrahydrofolate, those are the active forms of folate and that’s a really good thing to look for.

I’d say also EPA/DHA is really important, fish oil and an algae based option, DHA being the most important of the two there. It’s nice to kind of get that in context, get it in a nicely balanced product.

In terms of prenatals, people always ask me very specifically what I think are the best and I have sort of a favorite protocol. I don’t know if you want me to share that.

Kelsey: Yeah, go for it.

Ayla: Okay. I’d say for preconception, if I can get someone just taking a basic prenatal that’s like a two or perhaps three a day…and I should mention that a good sign of not a great multivitamin, in my opinion, is one that’s just a one a day giant dose tablet.

Kelsey: Right.

Ayla: The chances are, and Kelsey, I know you do a lot with gut heath, but unless you’ve got the most stellar GI system, it’s unlikely that you’re going to really absorb and breakdown that whole tablet. The better options really are the ones that are divided doses. It could be a little tough to take, but if you can get in the habit, that’s good.

Kelsey: Right.

Ayla: I really like the Thorne Basic Prenatal for that option, for that reason. Then the first trimester, what I’ve found is a lot of women start to then resort back to the over the counter gummy prenatals because they have a lot of nausea and they just can’t tolerate a lot.  I love Seeking Health has an Optimal Protein Powder version that has some nice extra compounds in there, some antioxidants and things. It’s iron free, so it’s very gentle.

Kelsey: Good.

Kelsey: You don’t really need a whole lot of iron in the first trimester. That really comes into play more second and third.

Kelsey: And you said it’s a protein powder?

Ayla: It is. Yeah. It’s a pea protein based power.

Kelsey: Interesting.

Ayla: Yeah. It’s pretty good quality. I don’t love protein powders to be honest. But that one I think is a nice option for smoothies to sip on when you’re not feeling great.

Kelsey: Yeah, not feeling great. That makes perfect sense because I mean honestly, you think about all these ideal nutrients and foods to eat, and then comes the first trimester and that can all go out the window very, very quickly depending on how someone’s feeling.

Ayla: Yeah. I often hear women say they had every intention of creating this temple for their body. But it’s difficult when you’re not feeling well. Anyway, that can help. Then in the second and third trimester, that’s when you really start to need the iron, the extra iron, a little more calcium, magnesium.  I really like, Metagenics has a Wellness Essentials Prenatal and it’s kind of a pack of everything you need. I find that’s really well tolerated. People do awesome on that. Then also I should mention too, that’s kind of the prenatal protocol I like for women, but when I can get the male partners in the picture as well when it comes to fertility, I’m definitely recommending antioxidants and things like that for them.

Kelsey: Awesome. Why are antioxidants important, especially in this sort of scenario?

Ayla: Spermatozoa, sperm are actually really highly sensitive to oxidative stress. That’s because they have a high concentration of polyunsaturated fatty acids and they also cannot repair their membranes. It’s really critical for men to increase their antioxidant and nutrient rich foods. I think zinc, vitamin E, coenzyme Q10, vitamin C, those are all really good, your phytonutrients. It’s an important part of it and a lot of men are not thinking that they’re really playing a significant role or part of the picture, but that’s huge, sperm quality.

Kelsey: Very interesting. Yeah. You never really hear much about the men in this stuff. But I think it’s really important because I totally agree. Even from a stress standpoint too, I think it makes a lot of sense for the men to get involved in that process for reasons like Laura mentioned before, even just to cope after the fact. But also the HPA axis, and your stress hormones, and everything have an effect on pretty much every aspect of your body like we were talking about before. I would imagine that even for men, that’s going to improve sperm quality and pretty much just make them healthier overall, which of course is going to end up leading to a healthier baby.

Ayla: Yes, absolutely.

Kelsey: Cool. Let’s talk diet a little bit because we jumped into there a little bit with talking about the nutrients, and antioxidants, and kind of increasing your intake of antioxidants through food, but also supplementation if it makes sense. If you had to describe sort of the ideal diet to enhance fertility for both men and women, and it can be different sorts of diet if that makes sense. What would that look like?

Ayla: Actually it would pretty much mirror the Mediterranean style diet. Some of the best research around fertility has really shown that women and men, but women who follow a Mediterranean style diet pattern really increase their chances of pregnancy. So they found a direct connection. I think it’s because it’s obviously a diet that’s very rich in fruits and vegetables, it’s rich in good loads of extra virgin olive oil, so good fat. This is kind of what we can take from this diet I think is lots of produce, lots of extra virgin olive oil. In some Mediterranean diets there’s also nuts and seeds, but not all of them. But that’s the foundation of that diet. It tends to be higher in fiber, so anti-inflammatory. But it does end up being rather low in red meat and rich in fish and seafood.

Kelsey: Right. Okay. Do you think it’s important to restrict red meat or anything like that? Is there anything that we shouldn’t be eating, or restricting a little bit? Laura and I sort of focus on a real food “Paleo” sort of diet sometimes. I think we’re moving away from calling it that or whatever, but that’s a whole other big story. But is there anything that’s especially important to stay away from during this time?

Ayla: I was actually presenting on this topic exactly to other health care practitioners and I found it a little difficult to…in the research, they’re saying across the board no red meat or reduce it, even animal products. I think Walter Willett, him and Chavarro are big researchers that look at the Nurses’ Health Study often very specifically looking for information on fertility, and they do seem to consistently be promoting a plant based diet. But when you really look at it, it’s a matter of quality protein. They’re not really sifting that out in the research. From my perspective, its quality sources of protein where you’re getting that nice broad spectrum of amino acids that are important for the reproductive system if you look at it psychologically.

Kelsey: Right.

Ayla: I think that that does include meat from quality sources, for sure.

Kelsey: Yeah.

Ayla: One thing they found definitely, which I find really fascinating, is that low fat dairy is not supportive for fertility, but full fat dairy is.

Kelsey: Yeah. I’ve seen that too. It’s so funny because we see things like that where in the context of fertility it’s really useful, and then still all of these “healthy diets” tend to promote the low fat dairy. It’s like to me that doesn’t make any sense. I’m like wouldn’t a fertility diet be pretty much the healthiest diet you could have to basically promote your body feeling safe and full of nutrition? It’s just funny that there still seems to be some disconnect there.

Ayla: I completely agree. Fat is a key part of it. I think most women I venture to say, most woman are not eating enough protein or fat. That’s something that I focus on.

Kelsey: Not to go back to numbers again, but I do think that it can be helpful for people to hear some sort of quantified explanation of what you’re talking about here. Would you say there’s any sort of minimum amount of protein, or minimum amount of fat that a woman or a man should focus on when they’re trying to get pregnant?

Ayla: Yeah. I was looking at some research that was looking at athletes and fertility and it was really showing that going less than 20 percent fat in the diet was problematic.

Kelsey: Okay.

Ayla: I think it probably should be quite a bit higher than that. But that does seem to be one point at which it’s problematic. And then for protein, I think you can get upwards of thirty plus percent as well.

Kelsey: Yeah.

Ayla: For sure. I always focus on listening to the body, the individual needs, and trying to think about quality first and foremost.

Kelsey: Yeah. Perfect. I think that makes sense, too. From my perspective, I really also start to think about gut health when I think about fertility. Not necessarily fertility, but just if someone is preparing to get pregnant, that’s another place that my mind sort of immediately goes. Do you focus on gut health at all maybe as someone gets pregnant? Or is there at point at which you start to really think about that?

Ayla: Definitely. Yeah, defiantly because when the gut is not in good shape we are not extracting the nutrients from our food the way we ought to. We’re not digesting properly. It’s certainly causes inflammation in a wide variety of ways, right?

Kelsey: Mm hmm.

Ayla: So inflammation and nutrient deficiencies are truly the enemy when it comes to fertility.

Kelsey: Yeah.

Ayla: We’re just going to struggle until that’s corrected, so balance is key. And then even if you take into consideration the microbiome and all of the influences that has on healthy pregnancy outcomes, even down the road to the health of the baby once delivered, that’s something to think about as well.

Kelsey: Yeah. Are there any particular things that you like to recommend to promote good gut health? Or for example, if someone has some sort of digestive issue, is there kind of a simple protocol that you tend to put people through to alleviate some of those symptoms?

Ayla: Yeah. We’re definitely dealing with if there’s bacterial imbalances, gut flora imbalances, that something that needs to be addressed, I think. It definitely extends that timeline. So if I have the time to work with someone if they’re not immediately and currently undergoing IVF for instance, which I get plenty of those individuals who have not really sought the nutrition piece first. They’re doing the IVF now and the timeline is a little different. But definitely working on that microbial balancing is important.

More simply and broadly, a couple of things I love recommending are…I said before I don’t love protein products, but I’m going to mention one more. I do love the collagen protein products. I think that that’s so beneficial for gut health, but overall for tissue repair and balancing and just a great way get in some quality protein as well. So I might incorporate something like that, make sure there’s plenty of good prebiotics and probiotics in the diet. I find most people that come to see me, I’m not sure if you both feel this way as well, but most people that see me are eating virtually no fermented foods.

Kelsey: Yes, right. It’s certainly not something that’s overwhelmingly popular in diets so far.

Ayla: Yeah. Maybe a little yogurt, but that about it.

Kelsey: Right.

Ayla: We’d probably focus on that. I get a lot of people that are coming in to see me on a low FODMAP diet and have been for quite a while. I actually have some strong opinions about the low FODMAP diet.

Kelsey: Yes. Well, yeah, certainly if you’re trying to improve gut heath and get a healthy microbiome, it’s probably not the best thing to be on, for sure.

Ayla: Exactly. So, looking at all those things. Then I would also say, this is a little bit separate from gut health, but one of the other big screening things that I’ll do is look at the environmental factors as well. Toxins and different things that are coming in that can be endocrine disrupting, that’s important too.

Kelsey: Yeah, absolutely. Cool. I mean, it sounds like your approach kind of covers all the bases, which is really important when I think you’re dealing with fertility issues because oftentimes its never one thing in particular. Unless like you were talking about before, someone has just simply too low body fat or they’re amenorrheic, of course that’s going to be sort of the bigger thing that you’re going to focus on. But I think in a lot of cases, and this goes beyond just fertility in general, but any sort of health issue, I mean it’s never one thing in particular that directly causing that health issue to be present. It’s usually many, many factors working together to just disrupt the normal functioning of the body. Would you agree with that?

Ayla: I absolutely agree.  Definitely multi-factorial and very much why I kind of moved into more of a holistic kind of a practice. It can be a challenge because I think the way that we’re taught, and I think a lot of health practitioners are taught at least in initially, is that you look at each individual issue, and you address that, and you have evidence based guidelines. I think you can still do that at a holistic level. But things tend to get so just let’s treat the symptoms, lets again just prescribe weight loss without looking at all the different factors that influence weight and whether or not that’s actually appropriate.

Kelsey: Right. Yeah. Absolutely. I wanted to ask one more thing. I’m kind of jumping back a little bit here because you had mentioned the MTHFR genetic mutations and kind of what goes along with that. One thing that I find personally sometimes with people, if women are having trouble with fertility that they will tend to have some of these genetic mutations that can cause multiple miscarriages, things like that. Do you ever deal more specifically with women who have these genetic mutations and work pretty much…I mean not solely I guess because like we were just taking about, there’s multiple factors that we have to take into consideration. But is that ever a really big focus for you when you’re working with someone?

Ayla: It is and it’s interesting because it’s such a relatively new kind of conversation, I think, that so many people are not familiar with that. I do find some clients that I work with can start to get a little uncomfortable. It’s a matter of communicating it all properly, but they start to get a little overwhelmed.

Kelsey: Right.

Ayla: It’s so many things to focus on. But I love it when I can get a genetic picture on somebody because that just helps tremendously with understanding so many things that are going on with their metabolic processes and methylation, and that’s what the MTHFR really comes into play. There’s quite a few people that do have either somewhat compromised or really nearly completely compromised ability to really take folate and turn it into its active form that we really need.

Kelsey: Right.

Ayla: That causes a lot of problems. Folate is so critical for reproduction and reproductive health. Actually, trouble with just doing that can then trickle into trouble with accessing a lot other vitamins and minerals. So kind of see it a little more clearly. I mean that process requires methylation. So a basic cellular process really requires so many different nutrients as cofactors that people can become very deficient in different things that can then bubble up into oxidative stress, and inflammation, and reproductive issues just simply because of that one mutation.

Kelsey: Right. I know, I find that fascinating. But you’re right. It’s sort of this whole new world I guess that we’re learning more and more about every day. So it can be a little difficult to translate that into what should we actually do about it? But I definitely think that the folate piece is huge, at least in this capacity for sure.

Ayla: Yeah. And just one note, too. This is always in the back of my mind when I’m recommending prenatal supplements, or supplements in general, or trying to broadly communicate a recommendation because its actually one consideration. One thing that can be difficult is that there’s across the board now because of all the talk around MTHFR, a lot of at least the professional pharmaceutical grade kind of supplement companies are doing the methyltetrahydrofolate, the type of folic acid or folate that is ideal. But they’re also doing methylcobalamin, so B12. The problem with just blindly supplementing with that without having a little more insight on your genetics is it can actually really exacerbate and contribute to anxiety and sleep issues. That’s something I see, I wouldn’t say often, but it comes up and it can be really, really significant for people.

Kelsey: Interesting.

Ayla: Actually, I should just say I think the way to approach that then is with any new supplement, even prenatal, and this is another reason why it’s ideal to address your needs and start things six months or more prior to trying to get pregnant, is to go slowly. You never start at the full dose. You consider that. Also maybe your just starting with natural sources of these, just food based sources, and more of them like rich leafy greens and your good quality meat.

Kelsey: Right. With the methylcobalamin, if somebody needs a more active version of B12, but they’re having a problem with the methylcobalamin, do you have any alternatives? Is there a better version that they do well with?

Ayla: Yea. I would say either andenosyl or hydroxycobalamin.

Kelsey: Okay.

Ayla: Those are two other non-synthetic versions of cobalamin, B12, that are better absorbed, better utilized that they won’t quite feed the neurotransmitter production pathway quite as quickly. So it slows things down a little bit. That’s’ what kind of what we are trying to do with those folks who are having anxiety and sleep disturbances.

Kelsey: Right. That’s cool. I think that’s really useful for people. I’ve had some people with that sort of reaction to the methylcobalamin and that’s usually what I do, is change them to one of those. So it’s just interesting to hear you kind of say the same thing because I feel like I’ve definitely seen that before as well.

Laura: Yeah. That’s been my experience too.

Kelsey: Yeah. Especially when you’re probably under a significant of stress in this sort of situation, any extra is certainly unwelcome.

Ayla: Yeah. Absolutely. That’s a good way to lose somebody from working with you.

Kelsey: Totally.

Ayla: I wouldn’t blame them.

Kelsey: Right. They’re like, I feel so much worse, this is terrible.

Well, speaking of the MTHFR testing, is there any other testing that you typically recommend for your clients if you end up getting them six or more months ahead of time? What is kind of the screening process that you go through?

Ayla: If I have plenty amount of time working with somebody, I really love to get just conventional lab wise, I’ll send them to their physician and tell them, okay get vitamin D, and multiple versions of that. So vitamin D, get your serum levels of B12 and also MMA, or methylmalonic acid, because that can actually tell us a little bit if we are unable to get MTHFR. That can give me a little information on how to work with it. Folate levels, your cholesterol, triglycerides, I think it’s fantastic to get a baseline fasting blood glucose, hemoglobin A1C, which is really good to get even in the first trimester, too, actually. On our podcast, Real Food Radio, we talked to Lily Nichols, who is an expert in gestational diabetes. We were talking about the problems around the gestational diabetes screening process.

Kelsey: Yeah.

Ayla: There could be a lot of things you can do early on to help just make sure that you’re getting an accurate diagnosis. That’s one thing. Get that baseline. I love defiantly a full thyroid panel, which is extremely difficult to get through conventional routes. All they’re measuring is TSH typically. So you have to do a little bit of pushing perhaps, or maybe work with a functional medicine practitioner, which is always tough to get a full thyroid panel. Iron, ferritin, so looking at those stores to start because that would change how you supplement from the get-go. I mean, if you’re starting out iron deficient, then you defiantly want to address that because that will definitely get worse with pregnancy.

Kelsey: Right.

Ayla: Yeah. And then I love it when I can do some functional labs, too. Like really run a full micronutrient panel with somebody, look at even environment toxins if we think that that’s playing a role. Heavy metals or other chemicals solvents, that sort of thing. Sometimes hormones, that can be appropriate as well to look at what’s going on hormonally. And then like we were just discussing, I mean it’s fantastic to get a nice big genetic panel.

Kelsey: Right. Yeah. Awesome. I would probably add to that too, at least once you maybe are pregnant or are getting closer to that goal, the gut health stuff. If they can afford or want to do some of those panels, especially, well its interesting because if you do the stool panel which is looking at what’s going on in the large intestine, really I just want to be screening them for anything really not good going on there and see how their balance is of good and bad bacteria. But I guess at the end of the day, what I would recommend that they do if it is off balance is pretty much exactly what you’d recommend anyway. So that would be loads of prebiotics, lots of probiotics, fiber, all that kind of stuff. I wouldn’t worry too much if they couldn’t get one of those panels done because at the end of the day, the recommendation is often going to be the same. But especially if they’re having gut symptoms, and I’m sure you’d do this if someone came to you with gut symptoms, figuring out what’s going on there too, if only to help the absorption that you were talking about before, making sure they’re getting all of their nutrients from the food and supplements that they are eating and taking. That can be huge because you want to make sure that they’re getting those nutrients and oftentimes that digestive stuff can stand in the way of that, unfortunately.

Ayla: Yeah, I agree with all of that. Defiantly. Even just one more kind of consideration that isn’t talked about very much, it’s something that being in this stage of pregnancy I’m in right now I’m thinking a lot about, is they do test for the Group B Strep later on in pregnancy towards the end. That obviously is a microorganism that lives normally usually in most people’s vaginal and gastrointestinal tract. So they’ll swab for that and it can be influenced ahead of time….you can really reduce the numbers of that because it can be problematic for the baby once born. You can reduce the numbers of that if you got good gut health and maybe are doing plenty of probiotics, prebiotics. The reason you probably want to do that that is because if they do find it, you’re going to be kind of pumped with some antibiotics.

Kelsey: Right.

Ayla: Yeah, and that’s tough for you, I think that’s tough for babies. It’s something to think about, too.

Kelsey: Well, awesome. Before we wrap up, I just want to ask if there is any biggest misconception you think that people have about fertility and sort of prepping for fertility? I know kind of a tough question.

Ayla: Yeah. Well I would say really broadly, I think the biggest misconception is that nutrition and lifestyle don’t really have anything to do with it, that its genetics, that it’s that you are left with only assisted reproductive technology as your tools in your toolbox, when in reality there’s so much that could be done. Sometimes it’s really amazing and very rewarding. I love it when I can work with people and just make some basic tweaks, and that is literally all they need to get pregnant.

Kelsey: Yeah.

Ayla: What we do has such a huge influence, not only actually conceiving, but on healthy pregnancy outcomes. And just finally too, that it’s not just women that play the role. Men’s health comes into the picture as well when it comes to fertility.

Kelsey: Yeah. Love that. This is great, Ayla. I think this is so helpful because I think you’re absolutely right. There does seem to be this big misconception that you’re kind of just stuck with your genetics, especially when it comes to fertility and you kind of just have to deal with it if you want to get pregnant. But I think that there’s so much that can be done. And not to discount, there certainly are people who will do all of this and they’ll still have trouble. Those people are certainly out there. But it’s just, I think to me, it’s sad to kind see so many people thinking that they’re only option is to kind of go through these really intense treatments and all this stuff and thinking that they have to fight against their genetics when they can be doing a lot of things that are not only healthy for potentially their future baby, but really healthy for themselves, too.

Ayla: Yes. I agree. Just to reemphasize, I know there definitely are medical conditions I didn’t touch on here like PCOS and a lot of other things can influence fertility that need to be looked at kind of separately. But as a whole, I think exactly what we’ve said.

Kelsey: Awesome. Well, thank you so much for being on our podcast today, Ayla. We will link to your blog, your practice, and actually if you want to send us that link for your prenatal post on your website, we can link to that as well so people can kind of get a little more information about what to look for in a prenatal vitamin and all of that great information.

Ayla: Great. Thank you, Kelsey and Laura, for having me. It was wonderful.

Laura: Thanks for being with us.

Kelsey: Alright. Take care, Ayla.

Ayla: Thanks.