If you’re not sure of the reason behind your infertility, it’s a good idea to consider what toxins affect your fertility and how you can limit the ones you can control. We chatted with integrative fertility specialist and clinician Shala Salem, M.D., about all of the must-have info you need to reduce your exposure and simple ways to do it (plus why you should start now!).
Why did you start offering an integrative approach to fertility and what exactly does that mean?
I was trained in conventional medicine. Integrative medicine really came into my life about 5 or 6 years ago. As a physician specializing in fertility, I noticed the number of questions about lifestyle were growing. Women might ask: What can I eat to help my fertility? What else can I do besides these treatments? I always had a passion for complementary therapies, movement, and good nutrition. But, at the same time, it was important to me to be able to offer my patients the sound data and research behind those things. So, I pursued a fellowship in integrative medicine. It really was an eye-opening experience.
In a nutshell, integrative medicine means combining alternative therapies with conventional medicine. You’re not blindly accepting alternative medicine. You’re not throwing away conventional therapies. Really, instead of integrative medicine, it should just be called medicine. We’re looking at the mind, body, spirit, and community of the person. All of these affect health and wellness and fertility and should affect what we do for patients.
What types of lifestyle aspects do you look at and discuss with your patients?
If we think of conventional medicine as the tip of the iceberg, integrative medicine is what’s going on beneath the surface—all of the things that we can’t easily see. Of course, I’m evaluating, diagnosing, and treating conventionally. But I also want to look at how you’re sleeping, your nutrition, what is your environment like, and are there any stressors going on in your life. We’re really weighing what kind of things are going on and how that could be affecting you. When I started to ask those questions and really discuss the answers, I found many women weren’t sleeping well. Many didn’t realize how specific nutrition or lifestyle changes could help. They didn’t know how to reduce exposure to environmental toxins and how that can affect fertility.
Why don’t all physicians dive this deep into a woman’s overall health?
Some conventional providers understand that there’s value in these kinds of questions. But they may not go there as much. It could be that’s just not where there training has taken them. Or, they don’t have enough time. For me, my integrative fellowship really proved the value of investigating. Once I started down that path, I wondered how I ever practiced medicine without this knowledge. With integrative medicine, we know that the patient is the expert on her body. We value what that woman has to say about her experience.
Good examples for this, in the fertility world, are PCOS (polycystic ovarian syndrome) and endometriosis. Typically, with endometriosis, the average wait is 7 to 12 years before a diagnosis. PCOS is usually about three. With both of these conditions, women go through multiple doctors before they get a diagnosis. And, even though endometriosis is a surgical diagnosis, part of that struggle for a diagnosis is providers not really listening or paying attention.
Women often wonder if a specific condition could fit their symptoms. But sometimes they’ll tell me a doctor already said no. Or their ideas got brushed aside. Really taking the time and listening just comes more into play in integrative medicine. That’s true after a diagnosis too. If you receive a diagnosis but didn’t get the time to really dive into it with your provider, you’ll end up on Google. Women want enough information to understand their diagnosis fully and they deserve that.
Fertility gets labeled a lot as a female issue. In your clinical experience, do you find that fertility issues are about equal between males and females?
Yes, it’s about 50/50. We consider fertility to be about 1/3 a female issue, 1/3 a male issue, and 1/3 combined or unexplained. When you think about it, that’s really equal.
However, I’ve specialized in fertility for about 12 years now. Since I’ve been doing this, it’s important to recognize that the World Health Organization has changed the normal parameters for sperm. It used to be that 20 million concentration was normal. Now, it’s 15 million. In a small period of time, that’s a significant drop. And consider this: in the 1970s, the average concentration was about 99 million. So, it’s possible that if sperm parameters hadn’t changed, male infertility could be an even greater share of the issue.
One of the things you’re really passionate about is helping women reduce toxins that affect your fertility. Why is that so important?
Environmental toxins that affect your fertility are really important to look at. We have about 86,000 chemicals in our environment and the majority haven’t been tested. Some of the most toxic chemicals really showed up after World War II. The mindset was that these chemicals were here to make life easier, and that was exciting. There was actually a company slogan that said “Live a better life through chemicals.” But there wasn’t an understanding of what chemicals do before using them in manufacturing processes and products.
Because of the amount of oversight our government has on some things, we take it for granted that if things are for sale, they’re safe. But, with chemicals, America tends to take the approach of “let’s put it out there and see what happens.” Whereas Europe tends to test things first. In the U.S., we’re 70 years into using some of these chemicals, and we’re seeing some huge impacts.
These toxic chemicals affect fertility. We can classify some of these chemicals as endocrine disruptors. Endocrine disruptors mean they impact our endocrine, or hormone, system. Hormones are messengers. They talk to different glands and organs in your body. For example, your pituitary gland (in your brain) speaks to your ovaries (or testes in men). Hormones work at very, very tiny levels–parts per billion or parts per trillion. That means just a small change can really be felt as far as symptoms and effects. These endocrine disruptors mess with our hormone’s production or messaging, and we see these impacts in fertility.
Can you give some examples of changes in fertility that can be due to endocrine disruptors?
In the last 50 years, sperm counts dropped by 50%. If that trend continues, we may hit counts close to 0 by 2045. Research on this has looked at many different factors, but it’s really pointed to the fact that it’s chemicals. We’re also seeing an increase in miscarriage by 1% a year. Endocrine disruptors affect production of progesterone and the receptors progesterone “talks” to. You need the hormone progesterone to become and stay pregnant.
Repeated exposures to endocrine disruptors through life have an impact on fertility. It’s compounding and worse than in previous generations. We’re finding that levels of some of these endocrine disruptors are now 450 times more than they were just in the 1970s. We have much more exposure, and that exposure also impacts the development of fetuses, particularly males.
Are there any specific toxins that affect your fertility that you recommend trying to reduce? Is there a way to keep it simple and doable?
What I always try to focus on with patients is how to reduce the environmental toxins they have control over. One of the concerns when I have this discussion is trying to minimize the overwhelm surrounding toxins that affect fertility. I don’t want anyone to go into this with extra stress and overwhelm. You don’t have to throw away your mattress. You don’t have to live in a bubble. Lots of harmful chemicals exist in our environment. Some we just can’t limit. So let’s focus on the ones we can. Just reducing a few main chemicals you have some control over can make a big difference in a very minimal time. The key ones I look at with my patients look at are:
- Per- and polyfluoroalkyl (PFAS) chemicals
Let’s start with BPA. Why do you want women to be concerned about it?
BPA was discovered just before the 1900s. In the 1930s, scientists wanted to find an estrogen. The idea was: put more estrogen into some situations, like when there were concerns of miscarriage, and it could help prevent it. So, originally BPA was contemplated for pharmaceutical use as an estrogen. However, an alternative, DES was used instead. (Note: About 40 years later, DES was found to cause vaginal cancer in very young women. It also caused malformation of the uterus of the babies of the women who took it. It was also linked to breast cancer in women and taken off the market in the 1970s when the link was finally made.)
How did an estrogen like BPA end up in plastics?
BPA makes plastics really flexible. In the 1950s, this characteristic looked attractive to manufacturers because it let them make plastics into a lot of different shapes. (This goes back to that “make life easier through chemicals” mentality.) So, in went BPA. And the result was that we ended up with an estrogen in our plastic.
Are BPA-free plastic products safe for fertility?
We saw a number of studies on BPA in the early 90s. It became recognized that BPA was bad for babies. A lot of people protested the use of BPA, and it became banned—but only in baby products, like bottles. In order to follow the ban on BPA, two other endocrine disruptors were made: BPS and BPF. They’re basically cousins to BPA and very similar in chemical structure. They’re not safe. There may be less data on these than BPA. But the data we do have says they’re as bad as BPA or even worse. Many of the everyday products labeled as “BPA-free” have one of these other endocrine disruptors in them.
Some of the worst exposure for these is for women who are going to be pregnant. Some of the problems with chemical exposure in utero can cause irreversible damage.
Can you explain how BPA, BPF, and BPS in plastic becomes an issue for our hormones and health?
The chemical BPA is not completely bound to the plastic it’s a part of. It comes out, or “leaks,” with heat, as well as anything acidic, fatty, or abrasive. The chemical simply becomes released into whatever is in your container. It’s easy to think: oh, my plastic water bottle never sits in the heat. But even though you don’t leave your plastic water bottle in the car, it sits out in pallets in the sun and in a hot truck before it gets to you.
Have you ever seen a tupperware that’s orange? A red or orange food went in that tupperware and it was heated up. But once you get your container out of the microwave, you can’t clean it. That’s not a stain. At that point, the line’s blurred between your plastic and the food. You can’t get the orange out of the container because the food is now a part of the plastic. And, the plastic is also a part of the food.
What simple things can reduce exposure to BPA, BPS, and BPF in containers and plastics?
There are a lot of simple switches you can make that can have an impact on your fertility and health. You don’t have to change up your whole lifestyle or spend a lot of money to reduce your exposure to BPAs and other BPA-like chemicals.
1. Reduce plastics whenever you can
Plastics are my first go-to. Reduce single-use water bottles, plastic drink containers, and plastic tupperware. If you do have plastics and still need to use them, don’t heat them. That includes the dishwasher. Also, try not to put fatty things, like oil, in plastic. Avoid putting foods like tomatoes in plastic containers because they’re acidic. Storing foods like these in plastic can unbind BPA. If your product is BPA-free, it will still unbind the BPS or BPF.
2. Limit how many canned goods you purchase
Minimize how much of your foods come in cans. You don’t have to eliminate canned food all together. I buy cans occasionally. But many of the aluminum cans come with a BPA lining on the inside. People aren’t always aware of this. The lining prevents the food and aluminum from mixing over the long shelf-life of the can. A study done on this found people who ate one canned food per week had a 1,000% higher level of chemical exposure than those who didn’t. You can reduce your BPA exposure by almost 60% by limiting canned foods and plastic. If cans are really convenient for you, there are certain companies who use safer linings in their cans.
3. Make coffee out a treat or bring your own cup
Some of us really love our morning or afternoon coffee run, but getting your coffee that way every day might not be a good idea. You’re handed your nice hot drink in a paper cup. But it’s not really just paper. A paper cup wouldn’t hold coffee. There’s plastic inside the cup, coating the paper. When the hot coffee gets poured over it, the chemicals unbind and end up in the liquid. Right now, using reusable cups anywhere is hard. If you can, I’d say make your coffee at home most of the time and use a stainless steel cup.
4. Skip the receipt or have it emailed to you
An area that gets overlooked is receipts. The ones that have that silky, soft feel have a film that uses BPA. Don’t get a receipt you don’t need. But where this one really has an impact is if you’re employed in an industry that handles receipts all day long. These women are going to have a much higher exposure to BPA. So, ask your employer if you can wear gloves. That will help reduce your exposure. Also, if you work with receipts, wash your hands with soap and water as much as possible over using hand sanitizer. Hand sanitizer increases your absorption of BPA by almost 1,000%.
5. Make small changes to food prep and how you heat things
Food and drink are two of the big ways we’re exposed to BPAs, like we saw with cans and drinks. But eating out is another big source of plastics. If you’re someone who’s trying to conceive, maybe don’t eat out every day. If you do, take it out of the takeout containers as quickly as you can. Move it to glass, and never use those takeout containers to reheat–even if they say they’re microwave-safe. Even the ones that are paper have a liner made with plastic.
Processed foods are another big one. A packaged dinner has a plastic container. Plus, dinner itself goes through a lot of components in order to be prepared. That includes plastic tubing and various containers that are mostly plastic. We know that processed foods have higher chemical levels than foods that are not. That doesn’t mean you can’t enjoy a dinner out here and there. But when you can, eat fresh, whole foods at home, especially if you’re trying to conceive.
One thing you talk about with your patients is pesticide exposure. Why is this important to fertility and what can we do to limit the risk?
A lot of our information on chemicals come from studying in-vitro fertilization. That’s how we really get to look at eggs and embryos and see the effects. Many studies have looked at how pesticides impact reduced number of eggs, reduced hormone levels, and reduced number of embryos that make it to the final stage, and lower pregnancy rates. There are a couple of important, easy things to control some of your pesticide exposure.
1. Think before you garden
You don’t want to be handling yard or gardening chemicals without the right protection. Also, if you have your yard sprayed, stay off the grass afterward. And if you like working with plants, don’t garden with your hands in the soil without gloves. Many endocrine disruptors last in soil for a long time. You don’t want them to come in contact with your skin.
2. Go to ewg.org to find the dirty dozen
If you are able, eating organic does reduce our exposure to pesticides. One great website is ewg.org. Every year, they look at the fruits and vegetables that have the highest levels of pesticides or the lowest. They list them as the “clean 15” and “dirty dozen.”
You don’t have to eat 100% organic. But you want to try to shop with those lists in mind. If something is on the dirty dozen, like strawberries or kale, you might buy organic. However, with produce like pineapples and onions, you could purchase conventional. Purchasing frozen organic fruits and vegetables can also be a great way to save money versus opting for those as fresh food.
Is it possible for our drinking water to impact fertility?
Water is really important to think about. It can be a way that we get exposure to certain pesticides, pharmaceuticals, and heavy metals–and those can affect fertility. First, you need to know what’s in your water. You can learn that by going to the Environmental Working Group’s Tap Water Database. Put in your zip code. See what your water has in it in your area that’s problematic compared to their recommendations. Depending on your area, you might see higher than optimal levels of arsenic, radium, fluoride, PFAs, aluminum, and other contaminants.
With that information, you can determine what kind of filter you need. Filters are important but the right one for your water is especially important. On the page with your zip code’s water results, there’s information on recommended filters for different contaminants. You can also send a sample of your water to some companies, and they’ll help you figure out what you need.
You mentioned patients should consider phthalates exposure. How can we easily limit this toxin?
Women tend to use about 12 to 15 products on their body a day. Each of which can have their own laundry list of chemicals and toxins that affect your fertility. Keep in mind the beauty/personal care industry has not been regulated since 1938. They have a lot of latitude to put whatever they want into their products. Even though I would list food and drink as a higher priority, what we put on our skin matters a lot. And when you think about it, with lipstick and lipgloss, we actually consume some of the product.
With cosmetics, your main concern is phthalates. Think of phthalates as a form of plastic. They help colors stay. They make products long-lasting. A good example is nail polish. Phthalates are helping to keep that polish looking smooth and from chipping. They’re also keeping a 12-hour foundation and lip stain in place. And then there’s fragrance. Phthalates help fragrances cling—to your skin, to your fabric, and so on. Parabens are also important. Look for products that are specifically labeled paraben-free.
1. Do away with unnecessary fragrance
If you do one thing with personal care products, I recommend doing away with fragrance. Fragrance ingredients don’t have to be released by companies. Sometimes 300 chemicals go into one fragrance, and we have no way of knowing what they are. When I say fragrance, I mean perfumes, laundry detergents, plug-ins, and other scented products. We’ve come to associate scented with clean. But that’s not really true. Going without scented products can be hard at first. Smell plays a big role in nostalgia and our memories. However, you do get used to it.
You also have concerns about PFAs. How do these toxins affect your fertility?
Per- and polyfluoroalkyl substances, or PFAs, end up in our environment. There are several different types of PFAs. One of those is PTFE. Generally, PTFE isn’t indicated as being harmful to people when it’s bound in a product. We often see PTFE used in nonstick cookware. Nonstick cookware has a coating that we know as teflon. Teflon is a PTFE, and it can become problematic when your pans begin to show wear and tear.
1. Switch your cookware next time you need to replace it
If you need to replace your cookware, stainless steel, cast iron, or glass are the best options.
Any other top ways to reduce harmful chemicals in our lives?
There are some other really simple ways you can lower your toxin exposure.
- Vacuum thoroughly. Vacuuming isn’t just for cleaning or sweeping up dirt. With a high-quality vacuum and filter, you can help your home have fewer toxic chemicals in it. It’s important to use a HEPA filter and have good suction, so your vacuum doesn’t release particles back out into your home.
- Dust well. Everyday dust doesn’t look great and is bad for allergies. But there are also toxins that affect your fertility that can hang onto that dust. One great way to dust is to use the vacuum attachment on your vacuum cleaner. Or, use a wet cloth to trap dust.
We’ve talked about how toxins affect your fertility. But do you think everyone should be aware of endocrine disruptors?
In my opinion, endocrine disruptors have an impact on everyone. Whether that’s fertility or issues with fetal development or a child’s life later on. There’s no one that goes unscathed by these chemicals. But it’s not as obvious. It’s not like thalidomide, where we see the effects right in front of our eyes. It’s tiny incremental exposures that add up.
You have to assume that you have had exposure to these chemicals. The CDC did a study and found that 95% of patients they studied had been exposed. But how much is it impacting your fertility? That’s difficult to determine. Women get pregnant without making any changes. But it’s important to consider how to eliminate toxins because it could affect your long-term fertility.
And for women and men who maybe never want to have children, it’s still important. It’s not just about how toxins affect your fertility. It impacts things like endometriosis, and studies testing urine levels of phthalates show women with endometriosis have higher levels. Toxins have an impact on everyone and are a health issue.
What do I do if I am trying to conceive but haven’t had success?
Your first step is to get evaluated and see what the issue is. If you’re dealing with unexplained fertility, I think looking at environmental toxins that affect your fertility are even more important. Is it a sole factor in unexplained fertility? No. But because there’s no answer in this form of infertility, all of these changes can help.