Tabitha: Well, that’s very close to the truth. So, you know, female infertility, or infertility, is defined as an inability to sort of generating and maintain a pregnancy after a timed trying for up to 12 months. And the burden of infertility has tended to rest on women’s shoulders for such a long period of time. But as we learn more and more, the research is kind of highlighting that of those infertility cases that present to us, about 20% to 30% of the causes are solely female-driven. But, again, very close to that, about 27% of the cases are solely male-driven causes towards that infertility. And so, the tables are starting to sort of square up. And then a proportion, again, maybe 20% or more of both contributing to the burden of infertility in the same couple.

But, yes, it’s traditionally been a very female-focused issue, and perhaps that’s because women have more…they feel more in tune with their bodies, or they’re more aware of the cyclic nature of, you know, when their fertile window is and things like that. But we are learning so much more about the compromise, you know, in male infertility components contributing to increased pregnancy loss and things like that. So, really, it’s something that’s distressing. It’s obviously very, very complex. It’s hard to be in private clinical practice without having a couple present to you on their fertility journey, whether they’ve just started trying or they have been trying for a number of months and it hasn’t been working for them. But, yes, it’s something we see all the time and something that I think it’s critical for clinicians to feel confident in addressing.

Andrew: Can you help me with my vernacular that I use. I use the word infertility. Should we be changing that to say fertility issues or fertility support, whatever, so that it doesn’t have a negative twang?

Tabitha: I agree with you because the word I choose to use or the expression I choose to use in practice is subfertility. Because quite often, infertility, it’s negatively framed, obviously, but we can usually, with good detective work, figure out what the driver is or what the cause of the problem is. So I prefer the language subfertility, but a lot of the published literature uses infertility when talking about population-based studies, epidemiology, and statistics.

Andrew: Okay. So, obviously, as you said, like, you know, it can be an extremely complex issue when we’re dealing with this physical, emotional, psychosocial, financial, hormonal, nutritional issues that we’ve gotta sort of delve into, or you do. So can I just go straight into the sort of practicalities of it? What are you seeing in clinic as the major hurdles that face…let’s start with women, and their fertility these days?

Tabitha: Yes. The focus of today is absolutely the micronutrients, the women. And even though, like, one of my major interests is in male fertility and how it’s impacted by the environment, I wanna focus on female subfertility and infertility today. But, yes, I can think of probably four, if I was to think of four prongs or four major compromises to this multifaceted kind of complex subfertility presentation, the four most common drivers of subfertility in women, we’ve got the environmental factors. And you know how passionate I am about this with the publication of “One Bite at a Time” all those years ago. The influence of endocrine-disrupting chemicals or environmental contaminants that, you know, may be toxins of choice, they may be in plastic chemicals, food packaging, pesticides on our food.

Or they may be larger exposures, you know, in our water or air pollutants that we’re less, you know, unbeknownst to some of these women, they’re exposing themselves to regularly. But endocrine-disrupting chemicals and environmental exposures are something that really have to be highlighted in a preconception or antenatal appointment because they are, for the most part, a modifiable risk factor. And they’re costly nutritionally. So exposure to some of these chemicals can not only have neurohormonal influences that impact our capacity to produce hormones like progesterone that maintain pregnancy, but they can also disturb thyroid function or interfere with ovulation, which is obviously critical to conception, timely ovulation and predictable windows of fertility for intimacy.

So there’s that environmental prong or component that I think needs to be managed. If I was to extend on from that environmental component too, and I’m still talking about female fertility here, but, actually, some of the published research talks about how sperm parameters or semen analyses, sperm parameters, are a reflector of environmental exposures. So when I meet with a woman who’s had recurrent miscarriage or early pregnancy loss, she really takes that on as something that she may have done wrong. “Maybe I wasn’t getting enough folate, or maybe I was too stressed or not eating well enough,” whereas we have so much data showing that DNA fragmentation in sperm contributes to early pregnancy loss.

So, there’s often quite a lot of education, and I think I’ve become over the years, pretty proficient at getting my male patients on board with how critical their role is to successful pregnancy outcomes with their partners when I’m working with a heterosexual couple. So there’s environmental exposures at large. There’s the significant role that the men play in taking some pressure off the women and reducing their risk of pregnancy loss. And that’s something that I have to sort of sensitively navigate. But, you know, there’s so much potential for the men to make a difference here. I would also like to mention age. You know, there really is a bit of a timeline with women. And with industrialization and, you know, more education, I see so many women trying for their first baby in their mid to late 30s, sometimes even early 40s.

And I wouldn’t go strongly as to say that that’s a barrier to fertility, but it does create a great deal extra work, and statistically significantly increases risk of pregnancy loss. So that would be a third barrier. But truly, and I don’t think it’s just the last two years, the fourth prong that I have to address quite often as a bit of a hurdle or a barrier is the hurdle of stress, you know? These couples, they are usually, you know, enormously stressed because of work commitments, maybe elderly or aging parents, lockdowns, work responsibilities. Some of the women I’m working with don’t have partners so they’re going ahead in an IVF setting with sperm donations. So stress is a major piece of the infertility or subfertility puzzle that needs… I’m constantly reminding women to prioritize sleep, spend more time in nature, you know, do breathing exercises, you know, a good quality magnesium goes a very long way with some of these women whose nerves are frazzled and adrenal reserves or DHEA-S levels are really low.

Andrew: What do you find useful in supporting DHEA-S levels?

Tabitha: Well, today is about micronutrients, but do you know, Andrew, I can’t really go past looking at adaptogens like ashwagandha would be one of my favorites. So, Withania somnifera, botanical name, is a herbal medicine that I use in moderate amounts with these couples walking through my door, who may be stressed by their fertility journey, or may be stressed by other, you know, the demands of modern living and daily life. Ashwagandha, I actually love that I learned more about the name. I’ve traveled to Sri Lanka and been under the care of an ayurvedic doctor before, even though we use ashwagandha in Western herbal medicine as well.

And what I didn’t realize until I was in Sri Lanka on this camp is that ashwa means horse and gandha means smell because the root of ashwagandha has a bit of an earthy smell, so horse smell. But it’s, you know, traditionally was thought to give the strength of a horse and really support resistance to stress. And research has since shown on some of those extracts that have been studied or some of those trademarked extracts of ashwagandha like Shoden, for example, that actually, they do protect the HPA access. And they also, you know, ashwagandha can protect the immune system and the reproductive system, the endocrine system when under stress. It kind of protects and maintains homeostasis regardless of the stress or allostatic load around.

So some of the studies show DHEA-S to come up and cortisol to come down after eight weeks of use of ashwagandha. And another thing I really love about using it in these couples is that it has such a brilliant safety profile and doesn’t interfere with a number of medications. So if a client is on an SSRI anxiolytic medication, or is going through some IVF processes, we’ve got some wonderful… When we do the interactions databases, the ashwagandha is really well-tolerated, but also safe for use concurrently with most of these medications.

Andrew: Right. Because that was gonna be my next question is, with regards to herbal medicine, obviously, you being a naturopath and nutritionist, you’re keenly aware of this, particularly working in a Masters in, you know, the School of Medicine, there’s a heavy responsibility there. So are they open, in that school, if you like to talk about this or is it like, “I’ll learn my specialty from you and then I’ll go and do my own thing?” Is there a bipartisanship there or is it still pretty closed doors?

Tabitha: Well, I’m by no means the first naturopath to embark on the reproductive Masters. A number of my colleagues have already finished their Masters, and there are acupuncturists, other naturopaths doing the same study. So the course content doesn’t cover topics like herbal medicine. It certainly covers nutrition.

Andrew: No.

Tabitha: But the assessments and submitting of the essays and final exams does allow us to be able to integrate our prior learning with our, you know, module content. So I am able to discuss things like this in my assessments that I hand in, and I get marked well for them. And actually, that brings me back to the environmental medicine component because I’ve quite often brought in my prior understanding of environmental influences on things like PCOS, endometriosis, breast cancer, male infertility to the assessments. And it is well received because it shows a thinking outside of the box. So it’s not an integrative course, but because of the nature of the students, yes, bringing in your prior knowledge is acknowledged and rewarded.

I was thinking though, that your question could have also been to me about how receptive other clinicians are. So when I’m working alongside someone, I think you might know this already, but I take referrals each week from some of the breast cancer oncologists at St. Vincent’s working with women with breast cancer or other reproductive cancers. And I actually think communication is the most important thing that we can do. So I have access to an interactions database on a paid subscription. And sitting with clients, I will plug in their pharmaceutical medications and then I will plug in my proposed prescriptions.

And I will show them if, you know, if there are any possible or likely interactions, what they involve. There are a number of herbal medicines I can’t employ often because they might impact the CYP 450 enzyme system. So that might increase or slow the breakdown of a drug that they’re on, or it might interfere with the efficacy of a medication they’re taking. So communication, first with the patient, but also with their primary carer, like a fertility specialist, is really important. And please don’t get me wrong. I’m not suggesting that there are zero interactions reported or recorded with ashwagandha.

We have to be careful with some thyroid conditions, and I would never prescribe ashwagandha in a patient who had a hyperactive thyroid or was taking Neomercazole for Grave’s disease or something like that. So it does take some extra time to look into all of these things and interactions and get a good feel for them. But ultimately, it’s our responsibility as clinicians to be savvy and to be on the front foot and to also be communicating so no one’s left in the dark.

Andrew: Yeah. You said words earlier and you said toxins of choice. Just going through a few of those, so it’s things like, you know, I mean, Australia’s the biggest drinkers in the world. I don’t know where we sit with trans-fat. I think we’ve made huge headways, but there’s still trans fats in our diet. Salt, smoking… smoking, thankfully is declining in our age group. Unfortunately then very craftily targeting the younger generations, and then there’s vaping, don’t get me started on that. But what other sort of modifiable risk factors do you coach women on?

Tabitha: Okay, well, when I think about toxins of choice, I’m definitely mostly thinking about alcohol, recreational drug use, and caffeine even. You know, caffeine as well. I also counsel clients around the fact that caffeine’s quite a heavily sprayed crop, coffee beans are a heavily sprayed crop, so women can be buying Fairtrade, certified organic. I get asked often about methods of decaffeination. So rather than sort of a chemical decaf…if someone’s wanting to reduce their caffeine load, rather than a standard decaffeination process which employs chemicals like chlorine and there’s residue on those coffee beans, we talk about the Swiss Water decaf method and how that doesn’t remove all caffeine, but just maybe two thirds. But it doesn’t leave that same chemical residue.

I would agree with you in terms of, not just the food packaging I mentioned earlier, but food additives and processed foods. And I’m talking about things like sulfite preservatives, nitrates, I’m talking about food colors. And you’d be surprised at how people have a real disconnect between their daily habits and their health outcomes. You know, maybe they’re just used to getting a Coke Zero every lunch break, maybe their family always used margarine so that’s just what they do. And maybe they’re using Teflon fry pans, and maybe they’re not aware that there’s a great deal of dust in the home, or, you know, there’s a damp problem in the home.

So my intake form even includes a whole lot of environmental-related questions and obviously diet questions. And then it gives me, I find it very difficult to do an initial consult less than 90 minutes actually. And we are working hard in that 90 minutes because there’s so much to cover about their home environment, or bedroom environment, home environment, and work environment before we even get to a systems review and a diet review.

Andrew: Right. I can totally imagine you being the ultimate detective here because of your passion for looking further than what we just take as a thing like caffeine, with coffee, but you go, “No, how’s it extracted?” So how do we prepare those foods? And this is the funny thing, I’ve never thought of coffee, I’ve never contemplated the pesticide issues of coffee extraction. But I’ve commonly commented on, well, you know, is it the wheat that we’re eating or is it the pesticides with the wheat?

Tabitha: The glyco…

Andrew: Is it the beer you’re drinking, or is it the preservatives? How do you tease all of that apart? It’s really hard. Talk about detective work. I’d hate to do one of your intake forms, it’d be embarrassing.

Tabitha: No, no, not at all. But, like, to translate all of that into a really practical setting, I actually have…on my desktop in the office, I’ve got screenshots or visuals of grocery items. So I say, like, “Here are a couple of brands. These ones are from Harris Farm. These ones are from your local health food store, but here are some coffee bean brands you might wish to buy. What almond milk are you putting in your coffee or oat milk?” We’ll have a look at the ingredients of that. Here’s one that has better ingredients. It doesn’t have a vegetable oil, doesn’t have any sugar added. So in a practical setting, I’m giving people grocery items lists and including things like the Tupperware they might be using, good deodorants, and good personal care products, so they can see visually what the products look like. And slowly, slowly, we do a transition. That’s why it’s so critical and pivotal to catch people early, if I can. Any woman of reproductive age, I open this conversation with.

Andrew: I also noted when you were talking about using the Teflon-type fry pans. And isn’t it interesting that we’ve seen this change from, it’s actually a marketing term now, BPA-free? Well, which BPA?

Tabitha: With the plastics. Yeah, that’s right.

Andrew: And then you get told, “Now we’re seeing in fry pans…” what is it, PFOE free?

Tabitha: That’s right. That’s right.

Andrew: But what about the other chemicals?

Tabitha: And they’ve got similar pharmacokinetic sort of profiles or similar toxicity profiles. So I talk about sort of glass, steel, ceramic, maybe cast iron, and just about those inert substances. And just to be a little bit label savvy, and to kind of look at how our grandparents did it without, you know, without being too cliché, but just to go back to basics. Like, even ice cube trays that are made out of steel rather than plastic, especially for those young parents that are making, you know, purees and freezing them and the purees might be warm when they put them in. So, yeah, it’s a captive audience. Working in reproductive medicine is an emotionally fraught area. I know I’ve got some colleagues that just don’t work in that area because, you know, you have to be present and hold space for pregnancy losses, early and late gestation.

And, you know, it’s really emotionally fraught. But the upside of that is it’s really meaningful work. And, you know, I’ll often say to a couple that are having struggles early in the piece, you know, “One day you will be here with me sitting on the couch breastfeeding, and we’ll be talking about timely introduction of solids. So you just have to have your eyes on the outcome and we’ll get to the root of what the compromise is, and we’ll get you there.” The other upside is they’re a very captive audience, so they’re ready to make these changes and they just need the inspiration and the practical steps to help them and support them. In fact, I’m in the process of writing a fertility, it’s called “Awaken Your Fertility” eBook.

But I wrote last year, a pregnancy guide called, “Your Empowered Pregnancy” because I feel like my role as clinician is not just to educate and to inspire, but to really empower these women. And that’s why when we get into some of the micronutrients, of course, I can talk adequate intakes and recommended daily intakes, but actually, my passion is inspiring these couples on feeling confident to get some of these nutrients from their diet as well. Choline, iodine, how can I get more folate? So, you know, I love teaching them so they effectively don’t need me anymore.

Andrew: Well, let’s dive into this. So where do you start with, you know, your nutritional prescriptions and education about their importance?

Tabitha: Well, I think, you know, with some of those toxins of choice and, you know, I will actually discuss the impact of caffeine and alcohol as depleting nutrients, and depleting nutrients that are specifically important for methylation. So we’ll talk about the importance of a good, obviously, foundational antenatal supplement. I prefer a vegan capsule rather than a hard tablet, especially when my women are in their first trimester. If there’s a bit of nausea or reflux, they don’t want a hard, big tablet. They want something that’s gonna break down nice and easily in their tummy. So, obviously, we cover a lot of the foundations with an excellent quality, one or two a day antenatal vegan capsule that covers their folate, choline, iodine, zinc.

But I start by talking about the importance of methylation, and the research also points to a Mediterranean approach to eating. So in doing a diet review, we ensure there’s adequate protein at every meal. But we also ensure that there’s a great deal of phytochemical protection or in-season colorful produce on the other side of the plate because of the synergy of all of those phytonutrients working together to protect and stabilize DNA, which is really critical for the process of reproduction. So, yeah, I counsel around diet, first and foremost.

Andrew: And I noticed, you said folate there. We could go off on a whole podcast with Carolyn Ledowsky and her work on unmetabolized folic acid. It’s so important. And I’ve gotta say, I’m a changed man with this subject.

Tabitha: Yeah. Well, it’s a really big subject and it’s kind of, you know, I studied 15, 20 years ago. I think I graduated from the medical science degree in 2000 and then maybe 2006 from the naturopathy or 2005. So, you know, this has all been published since then, but obviously, single nutrient synthetic high dose prescriptions are a pretty outdated approach. So a high dose of synthetic folic acid without a balanced amount of other methylating Bs is absolutely not on the cards in my clinical practice. I’m constantly teaching people about taking 5-methylfolate alongside methyl B12s and also choline, which I’d love to discuss with you today. We’re learning more about choline with each year.

But absolutely, the B vitamins work synergistically as a team and they’re absolutely involved in the production and formation and replication of DNA. So there’s no more critical time making sure you’ve got your methylating factors coming in than in the antenatal period, preconception and early pregnancy and beyond. But I think that these are essential co-factors also for keeping homocysteine low. We know when homocysteine is elevated, that’s been associated with increased pregnancy loss because of the hypercoagulability of the blood when homocysteine is elevated.

And, you know, I will comment that I have clients’ folate and methyl B12, and active B6 requirements and other methylating factors like B10 and choline covered in their antenatal capsule so that I’ve always got their back. But I spend quite a decent proportion of time teaching them about foods that also support methylation. And, you know, you can pull research like this from all sorts of various papers, but one pivotal paper for me that I think I’d love to make sure you’ve got as a part of this podcast so we can share it with all of your guests is a paper published by Deanna Minich, who you might know, in 2015.

Andrew: Yep. Yep.

Tabitha: She published a paper. I think I’ve got it on the table here. I’ll find it. It’s called “Modulation of Metabolic Detox Pathways Using Foods and Food-Derived Components.” It’s very clinically applicable, and she’s just got this, you know, it highlights the potential, obviously, for foods and herbs and food components to support and modulate detox pathways. And methylation is not just involved in DNA replication, it’s also an important part of our detox pathways. But she’s got a wonderful table on page 13 of the paper that I actually screenshot and give to my clients, because it has foods that are rich in B12, foods that are rich in folate, magnesium, betaine, choline, methionine.

So I talk to my patients and they usually go, “Ah, that makes sense, that folate gets its name from foliage.” So we look at things like green leafy vegetables and asparagus and parsley. But we can also extend the folate foods list of things like beetroot and lentils, peanuts, some seeds, mung beans chickpeas. So I do make sure that clients have a good understanding of which foods contain folate so that they can increase those. And it always backs up the Mediterranean approach to each meal anyway. Because you look at a list like this and you think, “That looks like a naturopathic whole foods diet.” So it just enhances probably their compliance, teaching them about this.

Andrew: Yeah. Yeah. We’ll definitely put that paper up if it’s free. We’ll put that up on…

Tabitha: Yes, it is.

Andrew: … the show notes for everybody to access. Yeah, definitely. Can I ask you, Tabitha, with regards to, now, we’re talking about mainly fertility, so the preconceptual phase. But obviously you’re dealing with, hopefully, a woman who will eventually become pregnant. When they’re taking their pregnancy multi, you know how women’s sense of smell and taste becomes so finely attuned, they’re so sensitive to, you know, like, a tinny taste in a cup of tea and they, you know, taste like metal, that sort of thing, their senses of taste and smell heightened. How do you get over that B vitamin smell with regards to nausea and stuff? You got any hints and tips for us?

Tabitha: Look, I do have a couple of tips up my sleeve, and it probably is relevant to mention anyway. So there is a number of differences between folic acid and 5-methylfolate, but something we know about 5-methylfolate is that it is less stable. Okay? So it’s not necessarily a label requirement that we keep our capsules containing 5-methylfolate in the fridge, but this is how I counsel my patients. I say, “I’d actually like you to keep it with your probiotic in the refrigerator door so that every morning you go and grab out your, you know, lemon to make your lemon water or your breakfast, you just grab it out of the door.” And absolutely, our feedback is when the capsules are kept cool and swallowed straight from the fridge, they have far less of a kind of B vitamin smell or flavor. That’s what I do.

Andrew: Why didn’t I think of that with my wife Lee? Anyway.

Tabitha: Yeah, they can be a bit smelly. But, you know, even just taking them in the evening is another little trick. So often women go to bed and then they’re still… Motion can also augment that nausea, burpy kind of feeling. So just with a meal right before bed is something I’ve kept up my sleeve if someone’s very nauseous in the morning as well.

Andrew: That’s what I used to do with my wife, is just have a little tiny snack just prior to bed and maybe take the multi around that time, or whatever. Can I ask with regards to other nutrients? So things like, you know, we’ve gone into choline. Let’s, actually, can we just cover off exactly what choline achieves?

Tabitha: I think it’s really important. I think, actually, so, you know, when we’re talking essentials, I wanted to run through folate, choline, and iodine, and then we’ll talk about some extras. So choline being number two, I just think the research on choline, you know, is pouring out and it’s probably more important than we’ve ever realized. And you’d see this reflected in the number of the formulas out there. Like, I don’t believe there’s any choline in the old kind of pharmaceutically-derived element. Choline is a pseudo B vitamin and it basically is a brain builder. That’s the way I think of it. And there are a number of ways that it works, but it contributes literally to the morphology or the scaffolding of the brain.

And we don’t work with recommended daily intakes with choline because there hasn’t been one set, we work with adequate intakes. And the adequate intake for choline in Australia is something like, I’ve got it written down, it’s 425 milligrams a day for reproductive women, but that increases to 440 milligrams a day for pregnant women, and up to 550 milligrams a day in lactating women. But there is actually some American data showing that when we double that… The adequate intake is 480 milligrams in America. So in the American research, when they double that to 930 milligrams or so a day, there are favorable outcomes for that infant’s, that offspring’s attention, stress response, recall and memory behavior.

And so, we know that it’s literally contributing to the scaffolding of the brain. It up-regulates or enhances ability to take DHA into the brain. Some parts of choline, the fat-soluble cholines, contribute to the myelin sheath. So there’s so much research now, and a lot of the supplements really only contain 100 or so milligrams per daily serve. So this is an area where I’m actually really specific in counseling patients with their diet. So for example, in one egg yolk, there’s about 150 milligrams of choline. So in a woman taking her quality antenatal and having two eggs a day, she’s really just at baseline. And most of the choline is unfortunately found in the animal kingdom. So we have choline in pork and chicken and cod and fish, eggs, mince beef. There’s far less found in the plant kingdom for our vegetarians or vegans, so I’m likely to supplement a little bit more in my vegetarians or predominantly plant-based clients.

But we do have choline in some plant foods like peanuts or good quality peanut butter that doesn’t have a vegetable oil, and the Brasica family. So cauliflower has a little bit, broccolini, Brussels sprouts. But, yeah, choline, I feel like there’s been a gap in our knowledge. And even though the research is there, it’s really taking a long time to kind of filter down into clinical practice. And I think this is something that rather than just putting on an antenatal, having a folate discussion but also having a choline dietary discussion and an iodine dietary discussion is really pivotal and empowering for these women.

Andrew: Well, there’s eggs as well with iodine.

Tabitha: A little bit, yeah, that’s right.

Andrew: It stunts me that, you know, even Professor Creswell Eastman was frustrated by the lack of uptake of the National Health and Medical Research Council guidelines, the NHMRC guidelines, from January, 2010. And I think he wrote a paper in… not a paper. It was a news article, in I think it was 2014. It was years later. And he was frustrated by the lack of uptake of these guidelines that women receive 150 micrograms as a supplement, extra, on top of dietary recommendations during pregnancy.

Tabitha: Well, you know, you were talking about the heightened sense of smell and taste. I can vouch for the fact that a lot of clients, even if they’ve previously enjoyed seafood, don’t feel like salmon or fish or seaweed or trout in the first-trimester pregnancy. So the iodine requirements increase, you know, progressively through, you know, you’re right that reproductive women need 150 micrograms a day, but the requirement increases to 220 micrograms in pregnancy and 270 micrograms in lactation. So I actually start off in the antenatal or preconception time with 270 micrograms if I can because I just wanna prepare their thyroid for the extra demands placed on it by the pregnancy hormones and the placental transfer of iodine and the placental transfer of T4 to the growing baby. Because the baby in utero doesn’t actually even have a thyroid gland until about 14 weeks.

So brain development and brain cell migration relies entirely on maternal transfer through the placenta of T4. So mum’s thyroid is effectively making thyroid hormone for two. And then once the baby’s thyroid gland is morphologically being made and then starts to work well, it’s really close to mid-gestation. But that bub still relies on maternal transfer of iodine to make its T4. And we know that deficiencies in iodine and T4, if prolonged, can result in cretinism. So I don’t usually get too dark and heavy with my clients, but the iodine conversation does speak to the fact that, actually, this is a really important nutrient or trace mineral for your baby’s mental acuity and IQ outcomes, and we need to make sure it’s coming in every day.

Andrew: Can I ask then, just moving along into other nutrients, CoQ10. I’ll always remember years ago, Ruth Trickey advocated the use of 100 milligrams of CoQ10, not because of the evidence at that stage, it was based on her positive outcomes. So she was, I think the words she used was she was encouraged by the results. And so, she just routinely used to add in 100 milligrams of CoQ10. Now we have ubiquinol, the active form of CoQ10. Is that something that you use regularly? Do you choose the women you use it with?

Tabitha: It is. I’d consider it an extra. So it does depend on the age of my clients and, you know, but we do know with age. And actually, with stress and obesity and a whole lot of lifestyle choices, etc., that increased reactive oxygen species contributes to DNA damage. And we can do what we can from a diet, but also an antioxidant potential to preserve a DNA quality and to sort of stabilize that reactive oxygen or oxygen damage. And I found, you know I had a real interest, I’m just about to get to CoQ10 and ubiquinol, but I have a real interest in male reproductive parameters. We know quite a lot about the seminal fluid and the antioxidants and toxins, but particularly the antioxidants in seminal fluid, having a real protective impact on the DNA quality of the sperm.

Well, there’s some wonderful published research that it’s the same deal for female reproductive fluids, whether it be cervical fluid or follicular fluid or fluids in the uterus. You know, the antioxidant potential in those fluids also has an outcome on egg quality and the successful implantation and, or fertilization and then implantation. So antioxidants are part of my extras discussion, and we can satisfy some of those antioxidants with that Mediterranean approach to eating and adding value to every meal by adding spices or herbs and certified organic, if we can, for increased phytochemical content. But CoQ10 is always a consideration. A lot of the published data we have has been done using Coenzyme Q10 rather than its reduced form, ubiquinol, which is more bioavailable.

So the theory is we need to use lower amounts of ubiquinol rather than the ubiquinone or CoQ10. But because it enhances mitochondrial energy and it’s thought to improve egg quality, particularly in mature women, it’s front of mind for me when a woman’s trying to conceive or planning to conceive in her mid-30s or beyond. And, again, a lot of the data we have is done in an IVF setting because it’s easier to control. And it certainly, you know, it does depend on what outcomes we’re measuring in the different published papers as well, but a meta-analysis I’ve actually got in front of me talks about how pre-treatment with co-enzyme Q10 for 60 days prior to egg collection improves egg quality, improves fertilization rates, reduce the number of times that cycles were canceled because fetal embryo transfer couldn’t go ahead, and reduced early embryo loss, so helped with pregnancy outcomes.

And this meta-analysis talks about how it increases clinical pregnancy rates when compared to placebo, without actually, in this meta-analysis, having an effect on live birth rates or miscarriage rates. But it certainly increases pregnancy rates. So, again, it always depends…I think that’s why some of the research is really challenging to pull together because different researchers are looking at different outcomes. Are they looking at fecundity or pregnancy rates or live birth rates, etc.?

Andrew: Yeah. It’s always a conundrum when you’re trying to pull, you know, research that asks that question, try and tie it in with research that asks this question, and try and meet in the middle. Tabitha, what other essentials do you use, before we move on to sort of optional things that you might include in certain challenging cases?

Tabitha: Well, if we go back to those foundations or those, you know, I wanted to talk about three, the folate and methylating factors, including choline there. Because, you know, even some of those, you know, a large proportion of clients actually, even up towards a third, have these metabolic inefficiencies with how they break down a lot of B vitamins in the diet or in certain supplements. So choline, actually, they can also be genetic snips that influence how well we use choline. So the folate choline and iodine conversation is always had in a consultation with a preconception or early pregnancy couple in my clinic, because they’re just critical. But vitamin D is also something that I’ll be checking in with, whether I’m just, you know, thinking about it seasonally, I’m thinking about what their postcode is, what their day looks like or their week looks like, and then what season it is.

Maybe also skin color or skin tone, things like that. But we know that vitamin D status, because vitamin D has such an immune modulating role in the body, we know that with vitamin D deficiencies, again, the studies have been done in IVF settings because it’s easier to control for, but we know that there’s reduced implantation with vitamin D deficiency. But with replete vitamin D levels, we know that the immune cells lining the uterus or the endometrium are more likely to make a sensible decision and allow for healthy implantation when vitamin D levels are sufficient or robust. There can actually also be, you know, vitamin D works a bit like a hormone as well. And some research points to the fact that low vitamin D will also show a low AMH, low anti-mullerian hormone.

Andrew: Oh, anti-mullerian. Yeah.

Tabitha: That’s right. So I’m keeping an eye on vitamin D levels, and we’ll usually supplement to someone’s blood levels. So rather than just taking, it’s a very safe vitamin, obviously, and I always communicate and teach my clients. There’s a wonderful MJA article published years ago in 2009 that was very practical because it basically said based on what capital city you live in, what season it is and what time of the day it is, how many minutes you need to spend in the sun to make your recommended daily intake. So I will say to my clients, this 1000 IU capsule that you are already taking or that I’d like to prescribe to you is equivalent to about 8 to 10 minutes of sunshine between 11:00 and 3:00 on a spring day in Sydney. I’m based in Sydney. So, you know, if you’re not getting that, I’d like you to take that and also we can do a baseline vitamin D blood test and see where you’re sitting.

Andrew: Thank you so much for putting the time in there. People go for their morning walk and think they’re getting vitamin D because it’s a beautiful sunrise. You’re not making any. It only makes vitamin D when the sun is above you. And that’s got to do with how…

Tabitha: Yeah, and UVB rays.

Andrew: …UVB rays bounce off the atmosphere at a lower angle.

Tabitha: That’s right.

Andrew: Well done. Well done, Madam. And yet, I keep on preaching. I say, you can take a supplement if you like, or you can get out for 5 or 10 minutes in the midday sun. Just 5 or 10 minutes, you know? Maybe 15 in winter…

Tabitha: Yeah. This paper was so clever. Maybe I should attach it because it’s a free paper too. Even though it’s old, 2009, I still think it’s really relevant. Because it actually says there were two tables. This is if you’re exposing 10% of your body surface area, with no SPF. And this is if you’re exposing 20% of your skin. So I talk about it as nude skin to the nude sun, arms and legs out, so about 20% of the body is exposed. And we have to be creative if someone’s very hairy on their legs, like a man, or hairy on the chest or something, we have to be creative and find an area where there’s not a lot of hair. But, yes, we talk about, is there an opportunity for you to eat your Mediterranean salad or your Sardinian Longevity Minestrone in the sunshine at your lunch break around about this time and get your shirt off? And quite often that’s not possible. But we really wanna translate it into practice.

Andrew: Yes. Can I ask the author of that paper? It wasn’t Ingrid Van Der Mei, was it?

Tabitha: I’d have to look. I’ve got it saved on my desktop. I could find it. But I’ll make sure you’ve got access to it.

Andrew: No, that’s all right, we’ll put it up on the show notes for everybody.

Tabitha: Yes.

Andrew: Yeah, yeah. That’d be great. All right. So let’s move on to nutrients that you might choose for, say, more challenging cases or in certain aspects.

Tabitha: Yeah. Well, the CoQ10 or ubiquinol we’ve touched on, and it is a winner of mine. Important to mention, actually, that with vitamin D and with ubiquinol, I always am reminding clients that they’re fat soluble. So to take them with a meal to get the most out of them or their DHA or their fish oil. So really making sure they’re getting the bang for their buck with their supplements. But, yes, ubiquinol is something that’s on my radar when there’s been a lot of oxidative stress. There’s an age factor and obviously very applicable to our male clients as well. I had an interesting case a long while ago where a woman had had an osteoarthritis of the hip because of her posture. She had scoliosis. And during her teens and 20s, she’d had a real high number of hip x-rays where her ovaries weren’t protected with a lead apron.

So even though she hadn’t hit 35, her mid-30s yet, it was absolutely on my radar to be giving her mitochondrial energy support for her ovaries. And that was of major help to her and her fertility. She’s now a mom, for example, with two kids. They’d be primary school age. That was a long time ago. But, yes, in addition to ubiquinol, I always have an inositol up my sleeve because obviously when it comes to trying to conceive, if a woman is experiencing a mild insulin resistance picture or has some other form of polycystic ovarian syndrome and is experiencing oligomenorrhea, we’ve got some beautiful data on inositol as being involved in insulin response and actually really supporting more regular ovulation. So I’ve had some great success in PCOS clients using around about 2 grams twice a day of Myo-inositol, or even 3 grams once a day into magnesium.

And, you know, they may be having menstrual cycles that are sort of 40-something days long, or even up to 60 days. But when we get some dietary support with very structured eating times and we give them an exercise plan that’s manageable and practical, and I teach them how to formulate a meal and we make that Mediterranean approach and then we add in the inositol, quite often their menstrual cycle length will normalize. And they’ll be getting clearer ideas of their cervical fluid or their sort of body barometers of when they might be ovulating, which just makes timing for intimacy a little bit easier to manage in these PCOS clients. So inositol is something that I think we have a really nice body of literature on. And all clinicians, if you’re not familiar with the use of inositol in PCOS for supporting ovulation, should really become… Inositol is cost-effective, it tastes fine. It’s just a really easy thing and very safe, a good safety profile again.

Andrew: Yeah. What else?

Tabitha: I can’t go past vitamin E quite often as well. Vitamin E is something that I think of, you know, actually when vitamin E was discovered in the early 1900s, 1920s, I think it was…

Andrew: ’26.

Tabitha: …actually, yeah, called in some of the published literature from back then, an anti-sterility factor. So we know that it’s got some… It’s obviously a fat-soluble antioxidant. We know that it’s got some really wonderful properties in thinning blood and acting as an antioxidant, but it actually can increase blood flow to the endometrium. We also know, and I actually am really fascinated by some of the work that Dr. Barrie Tan has done with the tocotrienols.

Andrew: I love that guy.

Tabitha: Yeah. Isn’t he enthusiastic? Isn’t he gorgeous?

Andrew: He’s a lovely man.

Tabitha: Yeah. Well, I haven’t met him. I’ve just heard his podcast and I’ve read his book. I think it’s over on the table somewhere. But we know that we’ve got, in the vitamin E family, the tocopherols, which everyone, actually, the bulk of the research, has been done on. But then we’ve also got the tocotrienols, which structurally, are just a little bit smaller with a slightly smaller head and as a result can penetrate membranes a little bit more easily and have a more robust and a stronger antioxidant protective effect. So when I think about the oxidative stress that we are under, because of, you know, whether it be lifestyle factors, you know, emotional stress or perceived stress or being overweight, or being exposed to environmental contaminants or toxins of choice, or just infections even, we know that the…

Andrew: Oh, sorry, forgive me for interjecting. I await with bated breath. Speaking with Barrie Tan, I’m aware of the metabolic aspects, the usage of tocotrienols, but I’m very interested in Lise Alschuler’s use with delta tocotrienols with cancer. I know this is getting off-topic, but I’m really interested in the future and I’d be very interested to see what research comes out to see if it has a mechanism working as an anti-inflammatory somehow. I don’t know, I haven’t looked into this research if it’s there at all, but I’d just be very interested to see how it’s achieving these results.

Tabitha: A lot of our antioxidants have a dual anti-inflammatory action or a secondary anti-inflammatory action. And I think of the high delta tocotrienol and annatto extract as being useful in metabolic disorders like hypercholesterolemia or family, familial hypercholesterolemia, because of the way that the vitamin E can reduce the oxidation of the LDL. So I’m certain that we are going to find anti-inflammatory actions as well.  So, you know, possibly indicated in conditions like endometriosis where there’s more reactive oxygen species.

Andrew: That’d be so interesting to find out. Anyway, that’s for the future. We wait with bated breath with so, sorry, Tabitha. I interjected there. What else? What else do you…?

Tabitha: No, not at all. But, you know, because of the way that vitamin E increases blood flow to the endometrial lining, sometimes, again, working with couples going through an IVF process, the endometrial lining has to reach a certain thickness before a fetal embryo transfer can go ahead. And there is some human published data on the use of vitamin E in gently thickening the endometrial lining and sort of reducing the number of cycles canceled because the lining of the uterus is too thin for the procedure to go ahead. So I keep it up my sleeve also for things like that. But what else might I consider? Gosh, it’s a really big question. I guess I think the master of antioxidants when it comes to fertility, reproduction, and I guess, gametes, is glutathione.

Glutathione can obviously be produced endogenously, but, you know, things like N-acetylcysteine or taking glutathione in a liposomal pump under the tongue can be wonderful for, again, a first-line defence of dampening that oxidative damage to the gametes. Again, we know that the male sperm can be like a barometer for how much oxidation’s going on, and toxic exposure. But we do have glutathione around the oocytes as well, and glutathione’s on my radar for the antenatal or preconception time. But we don’t have a lot of safety data for glutathione during pregnancy.

So it’s something on my radar preconception, but I’d be more inclined to use N-acetylcysteine as a precursor to glutathione if I needed to during pregnancy. And, in fact, I have done that, Andrew. I’ve had scores and scores, maybe because I work in the Eastern suburbs, but I’ve had scores and scores of pregnant clients who’ve tested positive for COVID. And I have used things like N-acetylcysteine, vitamin C, vitamin D as a precursor glutathione to dampen the cytokine storm and protect the developing baby.

Andrew: Yeah. And of course, NAC is a mucolytic as well.

Tabitha: Great for the…

Andrew: Yeah. I wonder how all of these, I’m not a fan of the term antioxidant, but how have these, let’s say, antioxidative stress nutrients, are used in helping the woman choose the right sperm.

Tabitha: Oh, you mean at the moment of conception, you mean?

Andrew: Yeah.

Tabitha: I talk through that, actually. So I run a little bit of a skit with my couples when I have them in front of me. I run a little bit of a skit. I talk about the size difference between the sperm and the oocyte, 10,000-fold different size. So I say, you know, if the sperm was the size of my pen tip and the egg was the size of this room, there are obviously millions of sperm swimming towards the goal, and quite a number of them will fatigue early or some of them will start to contribute to fertilization, but might actually fatigue and die halfway through. But finally, that successful sperm, before DNA merges, the female DNA scans the male DNA for damage and offers up her antioxidant potential to patchwork fix any fragmented DNA before she allows

And this, you know when we were talking earlier on full circle about how there’s this pivotal role that the male takes in the three months leading into conception, because he can take so much pressure off the oocyte because the oocyte can keep her antioxidant potential for herself rather than contribute some of hers to correct his damage. So just in that three-month spermatogenesis, it’s actually a bit shorter than that, but the three-month preconception plan, getting the right antioxidants and the right methylation support and a really nice diet with very little insult from alcohol and recreational stuff and smoking and obesity and over exercise, I forgot to mention.

But, you know, the antioxidant discussion, I think of them as kind of like a first line of defense. They obviously work synergistically together. You know, I think of C and zinc and selenium and vitamin E and then glutathione as well. But, you know, we’ve got this increase in reactive oxygen species being produced because of modern living and stress and infection. And we’ve got this diminished antioxidant reserves that happens with aging and that happens with diet quality, processed foods and that standard Western diet that I hear about all the time in clinic, when I’m doing a diet review. You think, I think, where are the antioxidants coming from: Weetabix for breakfast, ham and cheese toastie? I’ve gotta get those up.

Andrew: But, like, you’re obviously an expert, you’ve researched this, you’ve written a book “One Bite at a Time,” is it eating your way to… what’s the subtitle?

Tabitha: “Eating the World That You Want.” “Eating the World That You Want.”

Andrew: That’s the one, “Eating the World That You Want.” So, you know, you’ve obviously delved really heavily into this with Sarah Lantz and you now practice this day to day. But there’s so much for all of us to learn. So are there any short, additional considerations that we need to be aware of for female fertility? Not the least is, of course, that once again, with the ovum and the sperm, women, are helping men to do their job, but anyway. Are there any other major nutritional considerations we must be aware of?

Tabitha: Look, I will share, Andrew, that this is not my area of clinical expertise at all, but I’m fascinated by the research coming out on the vaginal microbiome and the microbiome shared between the male and the female with intimacy. And how infections introduced to the female ecosystem from male semen can obviously contribute to early pregnancy loss. This is an area that, I think the research is still at its infancy, but I find it absolutely fascinating. And for me, it’s a watch this space and refer to the experts. I think of people like Leah Hechtman as an expert or someone I would look up to in this area. But I think that that’s worth considering if, from an environmental perspective, I’m checking in with my women that are of reproductive age and menstruating that they’re not using commercial tampon brands that have been bleached and might have residual dioxin left in them.

And that they’re not using soaps and perfumes and lubricants for intimacy that might be impacting the pH of their vagina and, therefore the microbiota in there. So I think that is an area that I’m really interested in and needs to be touched on in clinical practice. But I still don’t feel confident enough with myself because I probably need to do more reading. But it’s on my radar.

Andrew: You’ll be doing the reading, I’m sure. When you mentioned microbiota, I was gonna ask a quick question: Do you routinely advocate the use of probiotics? Like most of the work is Lactobacillus rhamnosus GG, there’s also some work on Lactobacillus rhamnosus HN001, I understand, on preventing atopic dermatitis in a child, but only if you give it certainly in the last trimester of pregnancy. If you give it too late, there’s no point. Is that right?

Tabitha: It’s not uncommon for me to make a probiotic prescription, and I am focused on the LGG strain. And I often refer to Professor Mimi Tang’s work, and I believe it is sort of mid-gestation prescription, or maybe clicking over to the third trimester, 26 to 28 weeks. And the use of about 50 billion a day also through the first 3 months of life. So I call that the third and fourth trimester. And the significantly reduced incidents of atopic presentation, whether that be eczema, asthma, later on, hay fever or food intolerance or food allergy in the offspring… It is a personalized thing, though. When I’m taking that medical history in the preconception phase, I’m asking both partners if, as infants, they experienced atopy or it runs in the family.

And atopy is not a very consultation-friendly word, so I have to spell it out and say, did you have any eczema, asthma, or hay fever? Does anyone else in the family food allergies? But if one parent has, I’m inclined, and if both parents have experienced that in their medical history or a strong family medical history, I’m very inclined to prescribe something like LGG mid-gestation and beyond as an oral supplement.

Andrew: Gotcha. Yeah, yeah. Tabitha, there’s so much to talk into. We could talk all day. I’ll just go, “But what about, but what about…?” There’s obviously so much that we could delve into. We’re certainly gonna be podcasting again, definitely. But I thank you so much for sharing your absolute wealth of expertise and your warmth as well. You have such a caring nature…

Tabitha: Aww, thanks, Andrew.

Andrew: …in, not just with how, you know, I remember how you helped me before a talk once with a sore throat, you know, you were just this beautiful mother helping me so much.  But how you give this care to obviously every one of your patients. Thank you so much for sharing this expertise with us today on the essentials of how we can help people with fertility.

Tabitha: It’s my pleasure. And I’d love to follow through with those papers so that the audience can access them as well. It’d be no problem.

Andrew: That’d be wonderful. Thank you, everybody, as well, for joining us today. You can catch up on all of these show notes. There’s gonna be a lot. And, of course, all the other podcasts on the Designs for Health website. I’m Andrew Whitfield-Cook. This is “Wellness by Designs.”