Q&A: Early Interventions to Prevent Subfertility and Promote Longevity

According to Kalea Wattles, ND, IFMCP, and Monique Class, MS, APRN-BC, clinicians should be screening girls as early as their teen years for biomarkers related to subfertility.

In an Integrative Practitioner Podcast episode, Dr. Wattles, a naturopathic and functional physician with a specialization in fertility and Class, a functional family nurse practitioner, discussed early interventions for subfertility, specific biomarkers related to fertility and biological age, as well as when to address fertility with patients. 

Avery St. Onge: What is the clinical definition of subfertility, and what are the health risks associated with it? 

Kalea Wattles: Subfertility is a term I've been using for years. I think about fertility, in many ways, as a spectrum. Even with each cycle, we might be tending towards the more fertile end or the less fertile end of that spectrum. This depends on so many things: our hormones, our stress level, perceived safety, trauma, history, circadian rhythm, and nutrition; there are just so many players. 

Subfertility describes a scenario where it might take longer to conceive than what we would typically expect. Most sources agree that with appropriately timed intercourse, healthy couples should be able to conceive within about 12 months. And oftentimes, we see subfertility and infertility used interchangeably, but they're not the same. In subfertility, there is a delay in conception for some reason, but conception without assisted reproductive technologies is still possible. There's still hope there, and that's what language instills: it's still possible. It's just taking a long time for some reason. 

Something like subfertility is where functional medicine really shines. The functional medicine operating system and the model of care are oriented towards this body systems approach that's going to pick up on some of those more nuanced factors that affect fertility. We're going to ask questions about how hormones are behaving, how activated the immune system is, inflammation, and any environmental exposures occurring. So, I really prefer the term subfertility for most of my patients. 

In terms of the health risks you asked about, that really depends on what's driving the subfertility in the first place. So, I think a great example is insulin resistance. We know that insulin resistance is really common in terms of contributing to ovulatory dysfunction and, therefore, subfertility. There’s so much that we can and should do to improve insulin sensitivity and glucose control when we catch this pattern during our preconception workup because later, it can contribute to things like an increased risk of breast cancer, heart disease, metabolic syndrome, type two diabetes, and Alzheimer's disease. Other things I see a lot in my patients struggling to get pregnant are low thyroid function, lots of inflammation, and adrenal dysfunction, all of which can contribute to chronic disease over time. So that's the background on why we use the term subfertility. 

Avery St. Onge: Monique, could you tell me how fertility issues are related to aging?

Monique Class: So, biological age looks at the impact of nutrition, lifestyle, illness, and genetics on the body. It's basically how old the body thinks it is, whereas our chronological age is how old you actually are. So, with biological aging and subfertility, what we're looking to catch early is something we call the senescence process, which is the gradual deterioration of function at the molecular level. 

Like Kalea was saying, we want to look out for things like inflammation, oxidative stress, and glycation because they damage molecular structure and function. You can pick these early biomarkers up in young women if you're paying attention. I've done women's health for 30 years; there's no better opportunity to begin to address these early changes in inflammation and oxidative stress than when we have these young women coming in who are either trying to conceive or even earlier than that. When they start coming in for their pap smears and birth control, we can easily do a lot of these tests that give us an early heads up on inflammation, oxidative stress, insulin resistance, glucose levels, thyroid problems, and genetics. These are problems we need to reroute early on before the shoe is dropped, to not only enhance their fertility years but to decrease long-term consequences with complex chronic diseases in the future. There are the genes that they’re born with, and then there's the lifestyle they're playing out, which is going to turn those genes on or off, and those genes are going to directly impact fertility and complex chronic disease in the future.

Avery St. Onge: With a functional medicine approach, how do you begin to reverse or change those factors and help someone become more fertile while also helping with the biological aging process?

Monique Class: That’s the question, right? It's one thing to know that it's happening and to see it on bloodwork; it's another thing to figure out how to change it. And that's where the collaborative care team is really important because you can't do it all as the clinician. So, in addition to identifying the biomarkers early, you need to engage the client in lifestyle changes that are going to put them on the road to well-being instead of on the road to complex chronic disease. 

Depending on what you find when you do your deeper investigation, and depending on what the client is actually able to do, you're looking to make changes with lifestyle and reorganize the body. For instance, Kalea was talking about insulin levels. Well, the first change in insulin isn't your fasting insulin. Fasting insulin can look normal, but you can still have insulin resistance. So, it’s really about looking two hours after the meal, understanding the genetics, looking at their food plan, and understanding how the foods that they're eating are impacting their glucose and insulin levels. That's going to add to the etiology of PCOS and sub-ovulation, even if they're getting a couple of periods, and impact fertility. So that's just one example. 

You have to work with nutritionists and coaches to help people change what they're eating, how they’re moving, and their stress levels, which I think is under appreciated. Long-term chronic stress is going to directly impact ovulation because when you think about it mechanistically, if you're in times of feast or famine, or your body feels it’s threatened, then it’s going to behave as if it’s unnecessary to reproduce. The pituitary is going to shut down the ovary and not waste energy on ovulation. 

What we need to do is take a deep dive into the hormonal changes happening caused by ongoing chronic stress, this sympathetic overdrive or sympathetic Olympic hijack, whatever language you want to use to describe it, and then begin to work with mindset. Mindfulness practices, or any type of practice that can begin to self-regulate the body and balance out the nervous system, will help decrease stress. So, depending on where the bigger issues are, there are often multiple leverage points. You’ll want to co-create these care plans and bring in a collaborative care team because, as a clinician, you can't do it all. You can't be their therapist, you can't be their mind-body practitioner, you can't be their coach, but you should understand that they all need that. So, you're working together with the patient in the middle and really looking at this in a holistic, integrative way. It’s about identifying things early but also having the support team around them to make the type of lifestyle changes that are going to reverse engineer that process.

Kalea Wattles: I'll chime in and just revisit something that Monique said that I thought was so important; we should really start having these conversations when our female patients first enter the healthcare system as adults when they're presenting to have their pap or get their birth control for the first time. I am seeing younger and younger women in my practice who are dealing with fertility struggles, even in their late 20s or early 30s. Something I hear all the time is, “If someone had taught me early on when I was in my teens how all of these modifiable lifestyle factors were going to impact my reproductive potential later, I would have made different choices.” Knowing that, as healthcare providers, we have the power to give that education early on feels really important. And I think that's at the root of our mission.

Editor's Note: This interview was edited and condensed. Listen to the full podcast episode here.