This month, we spoke with Dr. Kalea Wattles, a naturopathic physician specializing in fertility and functional medicine. We talked with Dr. Wattles about how functional medicine, including a whole-systems approach, can improve fertility and what steps clinicians can take to proactively address issues like hormonal imbalance and the gut-fertility connection.
Dr. Kalea Wattles is a Naturopathic Physician specializing in fertility and Functional Medicine. She earned her doctorate from Bastyr University and is certified as a Functional Medicine Practitioner by the Institute for Functional Medicine.
Dr. Wattles combines her Naturopathic and Functional Medicine training to treat patients with a “Functional Fertility” perspective, using a root-cause, science-based, body-systems approach to cultivating a fertile body. She is dedicated to using this patient-centered method to support patients anywhere on their fertility journey – whether they are thinking about getting pregnant for the first time or exploring advanced fertility treatments. Dr. Wattles can be found at drkaleawattles.com and on Instagram @functionalfertility.
SHWI: How did you become interested in women’s sexual health, and what inspired you to focus on fertility?
My journey really started with a great interest in fertility, and women’s sexual health was inherently part of that. I was so inspired by the birth of my first daughter and knew I desperately wanted to help make motherhood a reality for those who wanted to have a baby. I spent time rotating with the reproductive endocrinologists at my local fertility clinics and learning everything I could about a functional medicine approach to optimizing fertility outcomes. In the fertility clinics, and later in my fertility practice, there was something I heard over and over–when you start thinking about having a baby, sexual health suddenly takes center stage. Sometimes it’s fun, but other times it feels very pressured. Sexuality and fertility are intricately tied together and it’s important that I can have an open dialogue with patients about it.
SHWI: As a functional medicine doctor, you use a whole-systems approach to address fertility health. What protocol do you take women through who are in the preconception phase or those who are struggling with fertility?
When I’m supporting patients in the preconception phase, my goal is to fully assess their body systems. I am certified as a functional medicine practitioner, and the functional medicine model taught me how to assess some important areas where we can see clinical imbalances: assimilation/digestion, our immune system and inflammatory response, cellular energy production, biotransformation capabilities, circulation and lymphatic systems, hormones, and the structural integrity of our body. All these areas have important implications for fertility, so I really seek to ensure we are supporting health and fertility in a well-rounded way.
SHWI: What are the most important health and lifestyle practices for women who are trying-to-conceive, and how can these practices increase their chances for conception?
I love this question, because optimizing fertility is really about cultivating resilience as a human and ensuring you are healthy as an entire organism. Nutrition and lifestyle practices are foundational to a great preconception plan. Here are my top 5 suggestions:
1. Starting a high-quality prenatal vitamin six to twelve months prior to trying to conceive. We want to start from a place of fullness!
2. Ensuring screening lab work is up-to-date. This allows us to swiftly act on some of the most common lab findings I see in my patients who are struggling with fertility – elevated inflammation, insulin resistance, thyroid dysfunction, and iron insufficiency, for example.
3. Cycle tracking is important, whether we are using basal body temperature, ovulation predictor kits, or technology-based methods. Understanding patterns in menses is extremely helpful information as we zone in on the “fertile window” where ovulation occurs and pregnancy is possible.
4. I recommend a Mediterranean-style diet for most of my preconception patients. This food plan emphasizes healthy fats, adequate dietary fiber, and fresh fruits and vegetables full of vitamins and antioxidants.
5. A regular bedtime! Both reproductive hormones and sexual function have a connection with circadian rhythm, our relationship with light and darkness cues. Having a regular bedtime can help to encourage appropriate cyclicity to the hormones of the menstrual cycle, and can also encourage melatonin production, an important antioxidant which protects both eggs cells and a developing placenta.
SHWI: Studies show that hormonal imbalances are the leading cause of infertility in women, and can be the result of disorders like PCOS and endometriosis. What do women need to know about the causes of hormonal imbalances, and what steps can they take to proactively address these?
When it comes to reproductive disorders like PCOS and endometriosis, we want to think globally about what is driving hormonal imbalance. For example, insulin resistance is a major contributor to the androgen excess that is characteristic of PCOS–high levels of insulin causes the ovary to produce more testosterone. It’s very important for me as a functional medicine doctor to look “upstream” – what is really at the root of this dysfunction? Rather than give a medication that lowers testosterone, it’s often very effective to address insulin resistance. As insulin lowers, testosterone also lowers, and ovulation becomes more regular.
Even further, endometriosis is certainly hormonally influenced, but I tend to classify this as a condition of excess inflammation as well. We see that the fluid in the pelvis/abdomen of women with endometriosis has a higher concentration of inflammatory compounds, and lower levels of antioxidants. Many women with endometriosis are also “progesterone resistant,” meaning their tissue doesn’t soak up progesterone in a normal way. This is important because progesterone tends to be an anti-inflammatory hormone, so resistance to its effects means more inflammation. Similarly, women with PCOS also tend to have lower progesterone levels (because they are not ovulating, the only way you make significant amounts of progesterone), lower antioxidant capacity and higher levels of oxidative stress (compounds that can damage cells and DNA).
In both conditions, there is a real opportunity to address sources of inflammation and to improve antioxidant status. In my practice, I am often recommending an antioxidant-rich diet, stress management strategies, and ensuring healthy sleep. I also use targeted supplementation with nutraceuticals such as curcumin, omega-3 fatty acids, resveratrol, and glutathione.
SHWI: You talk extensively about the gut-fertility connection. Yet, surprisingly, many patients and healthcare professionals are unaware this can be a cause of infertility. How does GI tract health affect reproductive health and what are specific things to look for?
This is a really exciting topic, and emerging evidence continues to show us that the gut microbiome (the composition of bacteria in the gut) can influence reproductive success. This makes sense, as we know our gut bacteria can contribute to other conditions affecting fertility, things like chronic inflammation, immune dysfunction, and insulin resistance.
In instances of intestinal permeability (or leaky gut), endotoxins can traverse the intestinal wall and enter systemic circulation where they can activate alarm signals and trigger an inflammatory cascade in the endometrium (the innermost layer of the uterus where an embryo will implant). In animal studies, researchers have observed a negative effect on implantation rates and placental development in the setting of leaky gut.
Beta-glucuronidase, an enzyme involved in the recycling of estrogen, is produced by bacteria in the gut. When there is lower diversity of microbes in the gut, we can see more estrogen recycling than ideal – contributing to conditions of estrogen excess like endometriosis and uterine fibroids. I measure beta glucuronidase activity using comprehensive stool analysis in my practice.
We also know how important nutrient absorption is for fertility, which requires adequate stomach acid. Stomach acid (hydrochloric acid, or HCl) is important for the absorption of many nutrients – protein, B12, vitamin C, iron, calcium, magnesium, and zinc. These are heavy hitters in the fertility world! When I see patients with bloating, nausea after taking vitamins, acne, or many food allergies, this is one area I want to explore.
SHWI: What are some practices you recommend to your patients struggling with infertility? What can they do for their emotional and physical wellbeing, and how can healthcare providers support them in what can often be a difficult time?
I encourage many of my patients to establish care with a licensed mental health care provider for counseling services. I work with a counseling referral service to help match my patients with a provider who meets their needs. One of my mentors taught me that hormones are really the transducers that allow our thoughts and feelings to manifest in a physical way. Our mental-emotional-spiritual wellness is at the center of our health, so this is an essential component of a treatment plan!
I also find that patients can feel disconnected from their partner when struggling with fertility concerns, so I’m a big believer in date night. Finding time to anchor into your relationship and fortify your connection is a huge help when things get stressful.
On a practical note, I’m a big fan of using mindfulness apps to help with guided imagery, deep breathing, and meditation. I also love for patients to explore mantras that they can repeat when needed, things like, “I am nourished enough to give to another” or, “I am open to possibilities that are beyond my expectations.”
SHWI: What do you believe is the most research that needs to be done over the next five years to advance women's reproductive health?
One of the most frustrating diagnoses, something that I see often, is “unexplained infertility.” As research continues to emerge, it looks unexplained infertility could result from a combination of poor gut health, inadequate nutrition, altered immune activity, thyroid or adrenal dysfunction, oxidative stress, chronic inflammation, and toxic exposures.
I am very excited about the emerging field of reproductive immunology, and I think research in this area will help to shed light on contributions of immune dysfunction to fertility outcomes.
To read more interviews with leading women’s healthcare practitioners, as well as the latest on women's health clinical trials and research, check out The Biome Blog.
Endometriosis, Inflammation, and Oxidative Stress
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Da Broi MG, Navarro PA. Oxidative stress and oocyte quality: ethiopathogenic mechanisms of minimal/mild endometriosis-related infertility. Cell Tissue Res. 2016 Apr;364(1):1-7. doi: 10.1007/s00441-015-2339-9.
Dull AM, Moga MA, Dimienescu OG, Sechel G, Burtea V, Anastasiu CV. Therapeutic Approaches of Resveratrol on Endometriosis via Anti-Inflammatory and Anti-Angiogenic Pathways. Molecules. 2019 Feb 13;24(4):667. doi: 10.3390/molecules24040667.
PCOS and Oxidative Stress
Mohammadi M. Oxidative Stress and Polycystic Ovary Syndrome: A Brief Review. Int J Prev Med. 2019 May 17;10:86. doi: 10.4103/ijpvm.IJPVM_576_17.
Murri M, Luque-Ramírez M, Insenser M, Ojeda-Ojeda M, Escobar-Morreale HF. Circulating markers of oxidative stress and polycystic ovary syndrome (PCOS): a systematic review and meta-analysis. Hum Reprod Update. 2013 May-Jun;19(3):268-88. doi: 10.1093/humupd/dms059.
Thakker D, Raval A, Patel I, Walia R. N-acetylcysteine for polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled clinical trials. Obstet Gynecol Int. 2015;2015:817849. doi: 10.1155/2015/817849.
Günalan E, Yaba A, Yılmaz B. The effect of nutrient supplementation in the management of polycystic ovary syndrome-associated metabolic dysfunctions: A critical review. J Turk Ger Gynecol Assoc. 2018 Nov 15;19(4):220-232. doi: 10.4274/jtgga.2018.0077.
Gut Health and Fertility
Tremellen K, Syedi N, Tan S, Pearce K. Metabolic endotoxaemia--a potential novel link between ovarian inflammation and impaired progesterone production. Gynecol Endocrinol. 2015 Apr;31(4):309-12. doi: 10.3109/09513590.2014.994602.
Sirota I, Zarek SM, Segars JH. Potential influence of the microbiome on infertility and assisted reproductive technology. Semin Reprod Med. 2014 Jan;32(1):35-42. doi: 10.1055/s-0033-1361821.
Silva MSB, Giacobini P. Don't Trust Your Gut: When Gut Microbiota Disrupt Fertility. Cell Metab. 2019 Oct 1;30(4):616-618. doi: 10.1016/j.cmet.2019.09.005.
Reid G, Brigidi P, Burton JP, Contractor N, Duncan S, Fargier E, Hill C, Lebeer S, Martín R, McBain AJ, Mor G, O'Neill C, Rodríguez JM, Swann J, van Hemert S, Ansell J. Microbes central to human reproduction. Am J Reprod Immunol. 2015 Jan;73(1):1-11. doi: 10.1111/aji.12319.