Episode 10 – A Holistic Approach to Improving Fertility in Both Men and Women with The Fertility Expert

Evelyne: I am so excited too. Marc, you and I have known each other for a while now, probably since I started working in supplements almost 12 years ago, or at least a short time after that because we’re both in San Diego. So it’s been a fun ride. I’ve referred friends to you. I’ve referred a lot of practitioners to you also, and you are always top of mind for me when it comes to fertility, so thank you for everything you do.

Dr. Marc Sklar: Yeah, my pleasure. When you asked me to do this, and we’ve known each other for quite some time, I was super excited for it.

Evelyne: So Marc is a natural fertility expert who’s been helping couples get pregnant for 20 years, and his mission is to help couples feel hopeful and confident about their fertility journey. He has an acupuncture clinic with two locations in San Diego called Reproductive Wellness, and for the last eight years has worked with thousands of couples all over the world through his online fertility coaching. He’s the creator of Fertility TV on YouTube, with an incredible amount of content. Marc is a Doctor of Acupuncture and Oriental Medicine. He also trained at the Harvard Medical School, Mind Body Medical Institute and he is a fellow of the Acupuncture and TCM Board of Reproductive Medicine. So Marc, how did you come to specialize in fertility?

Dr. Marc Sklar: The fun question. Really by chance initially, women’s health was always something that interested me and fertility was something that fell into my lap as a result of that. But my career really was decided in a four-month timeframe when I was in my last year of school and I was working in a clinic and seeing patients, and the one patient that came in, or my first patient I should say, with PCOS and after four and a half months she was pregnant and she was shocked, and she delivered a beautiful baby girl named Faith, and I helped her with her second and that really changed… I mean, not that the second was needed, but helping her with her first, with Faith was the thing that really opened the door for me.

To be able to have her come in and find out she was pregnant, and that I played a little role in that was really rewarding, and I don’t feel that there’s anything more rewarding than being able to help a family grow their family, have children pass on their culture, their heritage, to me, it’s just amazing. So that really changed my life as much as I changed her life. I always joke that she probably changed my life more and probably impacted more lives by that moment that she really doesn’t recognize and realize than how much I was able to impact her life, so I was always grateful for that experience and that’s really what pushed me in this direction.

Evelyne: I love that, Marc. Thank you for sharing that. That’s beautiful. So many people are having fertility issues, we hear about this, practitioners are seeing it, what is going on? So what do you see in your practice? What does the latest research say around this topic?

Dr. Marc Sklar: Yeah. Look, I think one aspect of the increased numbers is because we’re talking about it much more. 20 years ago it was still taboo to talk about fertility, and certainly these issues have been going on much longer than that. But 20 years ago when I started, you weren’t really having these conversations, people weren’t openly having these conversations with their family, with their friends, certainly not on social media because all of that just didn’t really exist back then. And I think the creation of social media, the creation of people being able to and feeling comfortable talking about their journeys, expressing more about their life, sharing more about themselves has really led to a bigger, more widespread conversation about fertility issues overall, and I do think that, that has played a role in this. But with that being said, I think some aspect of that has still been around. Just because talking about it more doesn’t mean that it’s more prevalent, it means that we’re just more open about it. So That’s one aspect of it is that we are talking about it and more comfortable talking about it more today than we were before.

But with that being said, I do think that there is a rise in fertility complications with reproductive issues that we haven’t seen in the past. I think some aspect of it and a larger percentage of that and we’re seeing it more and more is really happening because of all the environmental chemicals and toxins that we are exposed to unfortunately on a daily basis. And that is something that definitely is new I’ll say in the last 50 years, but it keeps increasing with each year because we could just keep adding more junk, creating more things, so that piece has definitely played a big role both in male and female fertility issues. I also think stress and the culture that we live in today is really not conducive to proper health overall and proper reproductive function.

We pride ourselves in a culture that is really about doing more and accomplishing more and being more successful. That doesn’t lend itself well to creating a proper and healthy environment for fertility and creating a child. And I just see that becoming worse and worse with technology unfortunately and trying to maintain our cultural status, our financial status, keeping up with the Joneses, whatever we’re trying to attach to that really just doesn’t help anyone create a healthy lifestyle and makes it more challenging. And all those stressors really don’t create a proper environment for fertility and reproductive function, so I think those are the main reasons. We still fundamentally have the same core reproductive issues and fertility issues. It’s that they are impacted in a more negative way today than they were before and thus seeing a higher propensity for those to occur as a result of the environment, the chemicals, the stress, the lifestyle, the culture that we live in today versus in the past.

Evelyne: Yeah. I want to start by talking about female infertility and that is usually where everyone starts, though we will definitely talk about male infertility and the impact there. Where do you start with someone, when a woman first comes to you, which lab tests are you running, what are you assessing, and then do you have a general treatment or is it very individualized for each person?

Dr. Marc Sklar: I’m going to answer the last part first because I think this part is really important and should be the standard, it should be individualized for everybody. I’m not saying that we don’t have some core protocols that we lean on for similar conditions, but no two individuals are the same. No two individuals present the same even if they have PCOS or endometriosis, they have so many other variables that are different from one another. We might see similar things but odds are not the same, and so I’m a big fan of really creating individualized protocols and plans that are unique for those individuals, so I think that’s important to just state off the bat. Again, it doesn’t mean that we all don’t have these tools in our medicine bag that we don’t lean on and rely on and adjust, and you could say, “Oh, I saw a similar case before, so I’m going to start with that as my template and then I’m going to modify,” that’s fine.

But we can’t be just replicating plans for everybody and just assume everybody has the same, and that’s one of the bigger mistakes that I see clinically when I see patients who have already been working with somebody else, that’s one of the bigger things that I see as a problem, is that we end up treating them all the same and they get similar approaches, so I’ll start off there. In terms of lab tests and how I start working up somebody and supporting them, a lot of that just depends on that individual, how they approach me and where they come from. Have they just started trying their six months in, a year in? They’re trying to prepare themselves to be pregnant. That individual is probably going to look a little bit different in terms of how we work them up than someone who’s been trying for three plus years and has already been working with other providers, and has had a fair amount of workup done, then we’re going to approach that a little bit differently.

So on the first scenario, those individuals typically don’t have much that they come with. Maybe they’ve had their annual done and so they have some lab work done that we can start off with but in general, they’re missing quite a bit. So for that new couple on their fertility journey, let’s say starting out wanting to be proactive or within the first year, what I find is that they’re missing quite a bit. And so for those individuals we want all the general lab work that we would normally do for any individual, CBC, lipid panel, metabolic panel, we want to look at vitamin D and inflammatory markers, full thyroid panel. Full thyroid panel that most naturopaths and functional medicine docs would work up, that’s what we’re looking for. And then on top of that, when we’re looking at fertility hormones, we’re going to look at FSH, follicle stimulating hormone, LH, luteinizing hormone, estradiol, AMH, anti-mullerian hormone, testosterone, both free and total, DHEA, prolactin.

We’re going to look at those labs, and so that’s the bare minimum foundational things that I want every woman to have done. In addition, I want them to have their fallopian tubes checked in some form to make sure that they’re open and able to allow for the sperm and egg to fertilize in the fallopian tube, and then for men a semen analysis. And so that’s the bare, bare minimum that I want for anybody who’s just starting off. Can we go beyond that? Sure. There’s all sorts of micronutrients we can test and look at, absolutely that’s important, and there’s all sorts of other layers of labs that I like to look at.

I often use a DUTCH test for many women, and I should say also the other variable regardless of how long they’ve been trying or where they’re on that process is, how old they are. If They’re at a certain age I start to wrap in other labs in as well like the DUTCH test. And we talked earlier about environmental toxins and that’s actually a test that I’m running more and more at the beginning of working with somebody and so I will do environmental toxin panel as well to look at what’s going on there

Evelyne: I’m curious, can I stop you there for a second?

Dr. Marc Sklar: … yeah.

Evelyne: Since you’re running these more and more, what are the most common toxins-

Dr. Marc Sklar: Things to see?

Evelyne: … that you see right now?

Dr. Marc Sklar: Yeah. Glyphosate and other herbicides and pesticides, those tend to be at the top of the list. It varies depending on what country they are but essentially that’s something I absolutely see especially for those individuals in the US. And then BPA actually surprisingly is super common to find, and then different types of phthalates and those are probably the bigger things that I see. We see other things but I would say those are the super common.

What’s really interesting is with the exception of, and I can give you this number because it sticks out for me, with the exception of two individuals who I’ve run this on, everybody has had a minimum of four but usually around six or more toxins that are at least moderately high, so they’re in the yellow, middle or red or extremely high when I find them. Only two people have had only two things, or sorry… Only two people I have found one thing on each one of them. One was just glyphosate, she lives on a farm, has a farm and her husband constantly uses Roundup, so that one was straightforward, and then the other one was BPA as a single. And I didn’t mean a little, they were both off the charts.

Evelyne: Yeah. I remember when glyphosate testing first came out, I did the test, it was quite a few years ago now and I think I was eating mostly organic at the time though I was drinking wine then still, and my glyphosate was high and I was quite surprised but I feel like nobody doesn’t test for it, even if you eat really well we still are exposed to it.

Dr. Marc Sklar: Yeah. There’ve been very few that I’ve seen without it being elevated, which I’ve been pleasantly surprised on, but in general those are the big ones that I’ve been seeing.

Evelyne: Yeah. And so once you’ve done those lab markers, I guess, it would depend on, are you going to give them a treatment plan to reduce those toxins? Are you looking at gut health? How are you addressing everything?

Dr. Marc Sklar: Right. So the other part of that is just taking a proper history for somebody and then running appropriate labs outside of what I just mentioned, so those are just basic foundational ones that everybody should have. But then you’ve got to take a proper history, so if anyone has any signs of digestive issues, I definitely run a stool tests and gut labs to make sure and rule out anything. And so anything that I have to do to clean up the digestive system or to clean up environmental toxins jumps to the top of the list of things of places we start. So we always start there and maybe we’re going from one to the other depending on what our findings are, and then we’re slowly progressing over to something else, so much so I have couples that I’ve been working with for six to nine months and we still have not even added in any specific plan that is focused purely on their fertility. We’ve been working through all these areas and now we’re about to do that, so that is not uncommon to see.

And we will get couples who will be a little bit frustrated like, “I thought we were going to be focusing on my fertility, I thought…” And I have to remind them that, “All of this is focusing on your fertility.” For me, creating a healthy environment and getting everyone to be as healthy as they can in every aspect is creating a healthy environment and focusing on fertility. It might not always be exactly like, “Oh, I’m going to give you some hormones or something to regulate your menstrual cycle,” or whatever it might be, but all of these things absolutely impact your fertility and your hormones, and so we need to start there because if we don’t start there, it’s really hard to do the other things that we want to do, so I always start in those areas.

And that kind of brings me, I laid out two different types of couples that will approach us, if someone’s been trying for three plus years, they’ve been through, let’s say, multiple providers in some fashion, multiple, let’s say, IUIs or IVF cycles or whatever it might be, my assumption is they’ve had a lot of these workups done. Sometimes they haven’t so we do have to fill in the missing pieces but more and more, I’m finding couples who are coming to me who have been working with either a naturopath or a functional medicine provider who has already started to do a lot of these other additional tests, and so I’m bringing those things together and then starting to fill in the missing pieces because one of the things that I find with NDs and functional docs is that they do a great job on the functional testing so there’s very little for me to fill in there, but they don’t do a lot on the just general fertility testing, so that’s where I’m filling in a lot of missing pieces there.

And then also we need to start talking about labs and tests that we can’t run but I know that they need that we need to work in collaboration with their either gynecologist or fertility clinic to run, and these are all different types of biopsies or labs to look inside the uterus, what’s going on inside the endometrium or with the endometrium that might be causing an issue. Is the microbiome poor? Is there an infection, some sort of bacteria, is there inflammation with endometriosis or endometritis, what’s the reason we’re not having implantation. And so those are some of the more advanced tests, the different layers of things that we’re looking at that start to come down the road later on if someone’s already started to have those other labs and they’ve made progress in those other areas.

Evelyne: Yeah. Thank you for sharing that. And I know that we hear stories, I’m sure you’ve had these as well with your patients where you’re working on the gut or you do a detox program with someone and then they get pregnant after that and you don’t have to even do any of the fertility nutrients.

Dr. Marc Sklar: Yep. I see that very often and they’re always very grateful. I actually just had one this week. We have a process that we work couples through in my program that they have to start with before they even have a private call to review their case, and she had done all those things and she was on her detox and we were cleaning up, I think she was on a candida detox if I’m not mistaken, and she had just had her private one-on-one to review her whole history and we were getting ready to start to create her fertility plan for her and three days after her call she reaches out to us to tell us that she’s pregnant.

Evelyne: Wow. That’s awesome.

Dr. Marc Sklar: That’s a perfect example as to why we start where we start because it lays this foundation, it changes someone’s environment, the environment of the body that leads them to be able to create a safe and healthy place to conceive and so much so that they do before we ever do anything else, and that’s not uncommon for us to see. I get messages literally every day from the members of my program who will say, “I’ve been doing this for five days a week, three weeks, a month,” whatever it is, “and I can’t believe how good I feel and how much better I feel. And these things are changing and these things are changing, and these things are changing and I can’t believe it.” I got one this morning and it’s the same sort of thing, so there’s a reason why we do these things. There’s a method to the madness even though sometimes patients can’t always see it and they get a little bit frustrated with like, “Hey I’m not doing my fertility thing, why not?”

Evelyne: Yeah. And you mentioned that when couples come to you and you mentioned you do sperm analysis off the bat, so I want to talk about male factor in fertility. I was reading some interesting statistics and I think most people have heard based on that study, I think it was published in 2017 but the analysis from 1973 to 2011, the total sperm count of men in western countries dropped by 59%. Quality also went down, so it was motility, morphology and DNA damage and count were all affected. So at that point it was going down, sperm concentration was going down by 1.6% per year. Then the latest study there was an even steeper decline to 2.64% and overall 62.3% reduction, and this is just crazy. And then the analysis was updated it’s not just in Western men anymore, this is a problem worldwide.

Dr. Marc Sklar: Correct.

Evelyne: So do you always start with both the man and the woman? Do women come to you first and you’re like, “Nope, I need to see both of you.” How do you work around that?

Dr. Marc Sklar: You’re correct. Usually the person who reaches out first usually, and I would say by usually 98, 99% of the time is going to be the woman in the relationship and she is going to reach out, but just because she reaches out it doesn’t mean that we ignore the man. It takes two parts to conceive, we need egg and sperm and so as a result we can’t ignore that. 50% of all fertility issues are male factor related. If we just focus on one side of the equation because they’re more complicated, because it takes more effort because there’s more information out there than we are ignoring the other 50% and invariably you’re going to run into blockages if that’s the way you approach things. So we absolutely always want to work or at least evaluate the man. For instance, this morning I’ve been going back and forth with someone about getting a new semen analysis.

She said, “Well, all the doctors say that my husband’s semen analysis looks fine, and the last one he did was in 2021.” I’m like, “That was two years ago.” I mean, so much can change in two months for sperm quality, that in two years I can’t trust something that was from 2021. I want to see the report but I want him to do a new one, and I can’t tell you how often fertility clinics dismiss the male side of things as not being important, and it’s not because they don’t think it’s important it’s because they assume that the couple is doing IVF and if they’re doing IVF, “It doesn’t matter, I just need one good sperm to match the amount of eggs that I have.”

Evelyne: Wow.

Dr. Marc Sklar: “So if I retrieve eight eggs or 10 eggs I only need eight or 10 sperm, so I don’t care I’ll typically find that.” So they dismiss it quite a bit and as a result what they say is they’re fine. And I’m not saying that he’s not fine, he might be, I like to see it for myself but what I typically see is that he was fine enough for IVF but not fine enough for natural fertility, and that’s when you talk about the numbers that you just shared and this steep decline in male fertility. First and foremost I think it’s a direct byproduct of all the environmental chemicals and toxins that we’ve been exposed to. And we do know if you look at the graphs, the increase of environmental toxins is directly correlated to the decrease in sperm quality in all parameters, and we see that worldwide. So no one can tell me that, that’s not a variable and that’s not impacting things, and so that also means that it’s harder to get pregnant naturally if we don’t support male fertility properly.

And when we look at the current numbers and parameters that are considered normal for men, I think there’s a big misunderstanding here. So I want to paint a picture, and the easiest way to paint this picture is if we talk about sperm count. What used to be considered normal for sperm count years ago was a hundred million sperm per ejaculate was considered normal. So that every time a man ejaculates during intercourse that they should be producing a hundred million sperm and that’s considered normal. Over the years that number has gone down to what’s considered normal so much so that the most recent parameters have lowered the normal range to at least 15 million.

Evelyne: What?

Dr. Marc Sklar: So we’ve gone from a number-

Evelyne: Oh my gosh.

Dr. Marc Sklar: … that used to be considered normal, a hundred million to now 15 million.

Evelyne: Wow.

Dr. Marc Sklar: So all the other numbers, motility and morphology are percentages off of count and concentration. So if we don’t change any other parameter in terms of percentages and what’s considered normal in terms of motility is 40% of the sperms swim in a strong forward progression, that’s considered healthy and normal, although I’d like to see that closer to 50% if we can, 40% of a hundred million is very different than 40% of 15 million, right?

Evelyne: Yeah.

Dr. Marc Sklar: So I want everyone to understand that that’s a big change and that’s because they changed those numbers because what they’re seeing is that they can’t find enough men that have a hundred million or 50 million, or 40 million to make that a normal range, so what’s considered normal now is 15 million. I also think that number has come down because of IVF and IUI. If you only need a lower number to inseminate someone or for IVF to choose enough healthy sperm for IVF, then who caress if you have more because if you’re just trying to promote IUI and IVF, and there’s a place for those, so I’m not saying there’s not a place for those procedures, I’m just saying I think those numbers are skewed as a result of that. So my feeling is we really need to work on improving count across the board for everybody, for all men, even if we can’t change the percentages, invariably those numbers will go up.

But to that point we are seeing, you mentioned DNA fragmentation which is a test that doesn’t get talked about enough and something that I definitely would always like to run and work up on men, especially if we see morphology be an issue because DNA fragmentation and morphology are extensions of one another. So we want to see that if we have reoccurring pregnancy loss, 50% of all miscarriages are due to male factor, you definitely need to run DNA fragmentation for those individuals, and the older a man is the more likely that there is fragmentation, so you want to rule that out as well. I just spoke to a woman who’s 38, her husband is 50 and I said, “Okay, we’re going to run labs but we need to run a DNA fragmentation as well to rule that out.” And so these are all numbers that we’re seeing become more and more prominent or issues in those areas, more and more prominent as a result of environmental toxins, and sperm are really sensitive and volatile both on a good and bad side.

We can make huge impacts to see change in a very short timeframe because men reproduce sperm every 24 hours, so we can monitor things a little bit more closely. But also as a result because of where they’re produced and they’re so much so exposed by that being housed in the testes that they’re more easily exposed to chemicals and toxins, and can be damaged much faster, so as a result we have to be more careful with that both on the good and the bad side of how we manage sperm quality. But even with that 24 hour number that I just said, we really need to give spermatogenesis enough time, which is about a hundred days to see sperm really repair. So we’re talking about count we can see a little bit faster, but if we’re looking at motility and morphology and the quality of sperm, it really takes about a hundred days.

Evelyne: Wow. This is fascinating and really great information you’re sharing. It’s so crazy to me that everything usually falls on the woman, and women have to go through the pain of miscarriages or failed treatments, and especially in IVF that it doesn’t change the treatment, it’s just mind-blowing to me.

Dr. Marc Sklar: Yeah. It’s unfortunate, so much so that it really makes men apathetic and really not want to give samples or be involved. I see all too often it’s really unfortunate that it takes me quite some time to get somebody to get a test done. Couples have been trying for years and years without their partner ever having a semen analysis done, it’s beyond me. And they actually put up a big fuss about it like, “Oh no, I don’t want to do it. I’m fine. Why do I have to give a sperm sample?” For all the things that women have to do to be tested and to be poked and prodded and manage because everything really is managed on the female side of things. It’s really so little to ask their partners to give a sperm sample. I mean, it’s ridiculous that they don’t do it. And by the way, for all the men listening, there’s no test your partners will ever do where they get to orgasm at the same time. So I mean, it’s not that big of a deal to give a sperm sample really.

Evelyne: Well, we as practitioners need to spread the word on this because this really needs to be talked about more, so thank you for everything that you’re doing. So I want to talk more about how sperm can change in that a hundred-day period. I know that sauna and heat in general can negatively impact sperm. Does that impact count or morphology or motility? Do you tell people not to do hot tubs, saunas, et cetera?

Dr. Marc Sklar: Yeah. Hot tubs are more of an issue just because of how hot they get and it’s much more difficult to control that environment. I do in general will say no heat in that area, no saunas, no hot tubs, no tight underwear, no bike riding, things of that nature, I will absolutely do that. There is an exception to the sauna piece for me. If we’ve done an environmental toxin panel and we see that they have a lot of chemicals and toxin exposure, then I will ask them to do saunas but that’s for a specific purpose. And usually I just ask them to do two or three times a week in that regard, but I will then also ask them to ice their testes afterwards for 15 minutes-

Evelyne: Interesting.

Dr. Marc Sklar: … trying to combat that heat. But yes, the heat will impact, for sure, count, really all those parameters. But for one individual more it will impact one thing more than another, but in general it can impact all aspects of those parameters.

Evelyne: And if you’re working with someone over a period of say a few months, will you tell them to… Well, maybe they’re using the sauna to detox initially, but then will you ask them to stop for maybe a period of time prior or are you doing this all in conjunction?

Dr. Marc Sklar: Each circumstance is a little bit different, so yes, I’ll ask them to either stop or reduce, but we’ll manage it in some way.

Evelyne: Okay, interesting. And how quickly do you see changes or do you generally wait about three months to retest?

Dr. Marc Sklar: I mean, I don’t like to test much sooner than three months unless… So the rule of thumb with testing men is to say, you do your first semen analysis, if it comes back, we basically want two semen analysis let’s just say within a month or two even if those are two weeks apart. If we see consistency in both of those, then we’re fine. We can be like, “Okay, we can trust that number.” If we see inconsistencies one was good, the next one was bad, the first one was bad, the next one was good, then we say, “Well, let’s do a third to see what’s going on,” so that’s how we look at that. And then after that then I just say, “Let’s work the plan for at least a hundred days before we retest and see what’s going on,” and typically we’ll see good results.

There are few exceptions to that and I do have one specific individual that comes to mind right now that we’re working with and I’ve been working with him for close to nine months and I just can’t get numbers to change and budge. And so now we just ran a toxin panel for him. There was a lot that came up, so now We’re going to treat that and I’m going to see if that changes things. If that doesn’t change things then I’m not sure we can get results with him, and that happens. We don’t get results with a hundred percent of the people we work with. I wish we did, but that comes back to the individuality and uniqueness of each person. I don’t know what’s causing this and as a result they might need to take other steps if we can’t make real significant headway for him in these areas.

Evelyne: Staying on the topic of male fertility, sperm, what are some of the nutrients that you use in your practice with men specifically to boost these numbers?

Dr. Marc Sklar: Yeah. CoQ10 is huge. That’s a big one that I like to use.

Evelyne: Can you talk about how CoQ10 works specifically for that?

Dr. Marc Sklar: Yeah. It’s working on the health and function of the mitochondria, and so if we’re looking at DNA, cellular issues, we have to use it. Not to mention, by the way, that it’s probably one of the best researched nutrients for both women and male fertility issues because beneficial for both. So we use it across the board, higher dosaging is great for CoQ10. I Don’t think there’s really any concern there. You can dose lower if you have a form of CoQ10 that is more absorbable and that they can absorb better. If it’s not a form that they absorb efficiently enough, then you need to dose higher with it.

Evelyne: Yeah. So with say ubiquinol, how much generally are you dosing it at for males and for females?

Dr. Marc Sklar: Somewhere between two and 400.

Evelyne: Okay.

Dr. Marc Sklar: But you could go higher with ubiquinone six, 800 plus.

Evelyne: And then in females for ubiquinone, how much are you-

Dr. Marc Sklar: Same.

Evelyne: … okay, great.

Dr. Marc Sklar: Yeah.

Evelyne: And then what are some of the other nutrients for men that you’re using?

Dr. Marc Sklar: So for men, one of my favorite things which was often overlooked is essential fatty acids. Fish oils really important for sperm count and concentration, and I talked about how important that number specifically is for men and improving that number, which is why I routinely work that in for everybody, but we’re really also just looking at antioxidants overall. So one of the things I really want to do for most men is increase their antioxidant load. Especially if we’re talking about DNA fragmentation or morphology, we want to definitely do that piece. We can do that in a lot of different ways. Resveratrol is one way that you can do that, you can do that with NAD as well for men. I don’t tend to use NAD too much for women but more for men, and I use NMN more for women, and I don’t really use it for men because the research is just not there.

Evelyne: Interesting.

Dr. Marc Sklar: So that’s something that I play around with. Pycnogenol is great for men as well, long history of being used for male fertility with some good research around it. I think of it in the same way as I would think of resveratrol. And then if you’re working on specifically motility or morphology, then I start to work in carnitine and arginine as well as nutrients into the fold.

Evelyne: And I think well, antioxidants diet, of course, is going to be very important.

Dr. Marc Sklar: A hundred percent. I don’t like to talk about supplements with anybody unless we’ve also talked about diet and lifestyle for that matter. For me those foundational pieces of diet and lifestyle, exercise and sleep are all core pieces that need to be worked into any plan, male or female, and quite frankly it’s actually harder to change some of those things in men. They’re more stubborn about diet or alcohol, or working out or whatever it might be, so those have to be worked in to the puzzle because if we don’t see those things change, then you’ve got an uphill battle with everything else that you’re trying to do.

Evelyne: Yeah. I want to go back to something you said about the NAD. So you’re saying that in men you’re using actual NAD as injections, but then in women you’re using NMN?

Dr. Marc Sklar: NMN.

Evelyne: Okay.

Dr. Marc Sklar: Because the research is not there for women with NAD, it’s there with NMN, although small but it’s still there specifically with NMN, so that’s how I differentiate the two. And I should actually clarify as well, the research with NMN and women is more specifically for older women, not younger women as well.

Evelyne: Interesting. What does the research say, and NMN by the way, for anyone who isn’t familiar is nicotinamide mononucleotide, what does it say?

Dr. Marc Sklar: You could say that way better than I can. It just rolled off your tongue.

Evelyne: Thanks.

Dr. Marc Sklar: The research shows that with older women who use it with a moderate dose, it doesn’t need to be even really high dose, obviously that changes based on height and weight and so forth, that it increases follicular development and quality. And these studies were done on mice, so I should be clear about that, but it’s promising, so we are recommending that we’re appropriate.

Evelyne: Yeah…

Dr. Marc Sklar: And they also need to have low, I should say, the other variables that the research pointed out was their AMH levels were low as well for their age. If someone has good healthy AMH levels, then it’s not something I typically consider.

Evelyne: … yeah, thank you. I need to start adding NMN to my regimen in my advanced age according to-

Dr. Marc Sklar: You probably do a ton of right things, I doubt that that’s something that you need to worry about.

Evelyne: … I do a lot of right things, but I know that there are additional things that I could be doing. And as I was researching for the show, I was reminded of some of these that I should be doing that I’m not currently doing. Actually, I want to talk about AMH for a moment. I did have my AMH tested just one time, so I don’t know what it was prior, but it was actually shockingly low and I was actually quite upset because I just didn’t expect that. And so somebody put me at ease at one point and said, “Oh, we call it the anxiety making hormone,” and so I’m curious what your thoughts are in someone in their late 30s or early 40s, and I have many friends who’ve gotten pregnant in late 30s, 40s and I want to talk about this and I’m putting this in quotes, “advanced paternal age.” You have a lot of success stories, but how much does AMH play a role?

Dr. Marc Sklar: Yeah. So I think we need to take all our labs with a grain of salt, and I’m, not saying to ignore them, but I’m also saying to just take everything with a grain of salt with balance. AMH is an indicator for ovarian reserve, how many eggs we theoretically have left. FSH is an indicator for egg quality, how good are the eggs that we are producing? We can’t look at each one of those as a standalone hormone test and say all of our fertility is riding on this one hormone. It’s just a piece of the puzzle. But what we do know pretty clearly is that your FSH and your AMH are not good predictors of your ability to conceive and have a healthy pregnancy. They are valuable in the IVF world because they will help them dictate the type of protocol they want to use and how much medication they want to use.

But from a standpoint of being able to conceive and have a child they’re not as valuable as we are led to believe. So if you are trying naturally the most important thing that we need to focus on is, are you menstruating regularly and are you ovulating regularly? Those are the two most important things. And then if I add to that it’s like, “Do you know when you’re ovulating?” And have you timed in, of course, appropriately, so outside of that it doesn’t really matter. On a regular cycle, whether your AMH level is high or low or your antral follicle count is high or low, doesn’t really make a difference. Theoretically in most circumstances, you’re only going to ovulate and release one egg. So does it matter if you’ve got 10 or 20 follicles that are maturing? Does it matter if you have eight or six?

In the end, no. You just need one good healthy follicle to mature an egg and release it during ovulation to give you a chance, so in the end that doesn’t really matter in the grand scheme of things. Now, it doesn’t mean we don’t test it. It doesn’t mean that we don’t support it, we do those things, but I don’t like to have all of our focus dependent on those specific numbers. It’s the same thing as someone saying to me, “All my numbers look good but I’m 41 and my doctor told me I’m too old.” Well, I mean, that’s just focusing on your age, the only thing you actually have zero control over and can’t change. So why are we going to just focus on the one thing that we can’t control or do anything about as opposed to focusing on the things that are good and working well and the things we can improve and change to give you the best chance to conceive?

So AMH is a number and it’s valuable. I don’t think it’s a super reliable number by the way. That is something I have routinely seen over the years. So for me, it’s just another piece of information that we need to gather and have. But It’s not the only thing that should dictate all of our fertility, and I do see this as a major problem in the fertility world right now because they get this number and then they think the world is ending, and it’s really not necessarily the case. And so I really want everyone here who’s listening to just use that as information but really to broaden our perspective and our mindset when it comes to looking at our fertility and how fertile we are because our fertility is so much more than that one number.

Evelyne: Yeah. This is great information. And on your YouTube channel you share stories of hope. There’s one section where you have stories of pregnancy at 41, at 45 after trying for seven years. Do you have any favorite stories you can share? I’m sure you have so many but just one that comes to mind, maybe a recent one. And also you mentioned that your treatment might change a little bit when someone is older. You already mentioned the NMN, but what else is different?

Dr. Marc Sklar: For me, every story of hope, every story of success is super important to me. All the stories that I see that are really impactful that bring a huge smile to my day are the ones of women who were told they can’t, they won’t, it’s not possible, do IVF use donor egg, just give up, adopt, whatever it is that they’ve been told, and they’ve been told all these things and much worse and they conceive. I just got a post a message from a member of my program who was told all those things and she had lost hope before she joined the program. She just delivered 10 days ago, just delivered her little baby and she was told all those things like, “It’s not going to happen. It’s not possible. Look at donor,” and I’m not saying there’s not a place for all of these things. There is certainly a place for donor and I’m a big proponent for that for those individuals who need it. There’s a big place for IVF and I’m a big proponent of that for those who need it, but to be told these blanket things is really just really doing a disservice to couples. What should really be said by those fertility doctors who are making these statements to these individuals is, “I don’t believe that I can help you conceive with the treatments that I offer.” Or, “I don’t believe that we can support you to reach your goal based on what I can do for you or the services or the technology that we have.” As opposed to saying, and then they could say, “I think some options you can consider are these things if that’s something you want to do.” But to constantly be putting down women and couples, and putting these negative thoughts in is just a huge detriment to society.

It’s all negative, it’s all fear-based, “You can’t, you won’t, it’s not going to happen,” so much so because they’re doing this because it impacts their success rates. So they’re really worried about their marketing and their success rates, so they want to improve those so that’s why they use that terminology because they want them to have better success rates, so they want them to use methods that have higher success rates. So it’s really unfortunate. With the couples who are older, I think I can get into all sorts of supplements, but I think that the most important thing that I want to share when it comes to older couples it’s more about time than anything. What ends up happening in situations like this is, if you have a woman who’s 42 and older, we have to start considering time as a variable. So as much as I don’t pay attention to age, I think it has to be something we consider in the way we manage patients, in the way we manage couples to get them to their end goal.

This might mean that I actually do have less time to support them in the way that I want because I don’t want them to lose their opportunity to also potentially use IVF or something else. So that has to be part of the conversation now to a couple who says, “I never want to do IVF,” that approach is very different. Okay, great. Fine, let’s approach it the way we would normally do. But to someone who says, “I want to use every means possible to have a family,” then those individuals need to be managed differently. Maybe our timeframe instead of six months or a year is going to be in half, what can we do in three months? What can we do in six months before they consider IVF?

And then we also do need to consider donor eggs in these situations if those individuals are open to it because that definitely increases their odds and can be a potential for them, assuming that’s the right path for them and assuming we’ve already done all the things that we feel like we can to support them, but that’s where age really comes in, I think we need to look at timing, how much time are they willing to put in and give, how can we manage that better for them and how can we support them through that process to get them to the end result.

Evelyne: Yeah. Thank you for sharing that. Since we talked about supplements that you use in males, I’d love to talk a little bit more about what you like using in females for egg quality and all the other parameters supporting hormones.

Dr. Marc Sklar: Yeah. So we mentioned some of them already. I should say, and I want to be clear. Just because someone is going through fertility issues, it doesn’t mean that all fertility related female issues are egg quality related, so I just want to be clear about that. Assuming that someone does truly have an egg quality issue, that’s where we would incorporate NMN and CoQ10, that’s where we would still also look at adding in some other micronutrients. I do like to use inositol, quite a bit.

I think that’s super helpful both for managing blood sugar because we know how impactful blood sugar management can be both positive and negative for fertility and reproductive health, but also because inositol also has been shown to improve some egg quality as well. Melatonin is a good one to support egg quality, we have a lot of new research around that, which is great. So in terms of egg quality, those are the sorts of things. I’m just trying to think on top of my head about what we do. I incorporate vitamin D almost with everybody unless their vitamin D levels are super high, that’s a huge variable, especially for supporting AMH levels.

Evelyne: Where do you like to see vitamin D in females?

Dr. Marc Sklar: Between 60 and 80. Those are the big ones, unless we’re talking about specific issues and conditions, and then we can get a little bit more granular with that.

Evelyne: Yeah. I want to talk about… Because you mentioned the blood sugar, so how does glucose metabolism specifically impact fertility? We know that obesity is an issue and then PCOS is also a common reason for fertility issues. Can you tell us a little bit more about that?

Dr. Marc Sklar: Yeah. Well one, it causes a huge inflammatory issue and that’s a huge problem. Also, I think there’s a slight, depending the severity of the blood sugar issue, we could maybe even take that to an immune level, and so those are two issues that are huge. You mentioned PCOS has to be considered and managed with all women with PCOS and can throw off their ovulation otherwise, so it’s huge and something that I’m seeing more and more of and really have to factor in more and more. Sometimes their A1C and glucose look just fine, but we can still see in just their diet.

I just make an assumption because I’m looking at their diet, I’m like, “There’s no way their blood sugar could be healthy with what I’m seeing, how they eat and what they eat,” so I have to factor that in as well. But I don’t routinely just throw in inositol with everybody, but I do think that in some way or another, whether you’re just focused on managing it through diet or through other means, we have to manage blood sugar. And one of the things I’m recommending more and more is actually exercise because people aren’t moving enough, especially after a big meal.

Evelyne: Yeah. That’s great. Marc, I could ask you so many more questions, but we do have to wrap up. There are three questions though that we ask every guest on Conversations for Health. The first one is, what are your three favorite supplements just for yourself?

Dr. Marc Sklar: My three favorite supplements for myself right now, I am taking a vitamin E, annatto-E. I always like to take a mushroom blend, so I always add that in, and I think all of us should be on some form of a probiotic in some varying degree. So those three things are probably at the top of my list currently that I like to take.

Evelyne: Nice. And we had Barrie Tan on the podcast talking about the vitamin E tocotrienols.

Dr. Marc Sklar: Oh, nice.

Evelyne: The next question is, what are your favorite health practices that keep you healthy and resilient and balanced. And you’re seeing, you’re holding a lot, supporting all these patients?

Dr. Marc Sklar: Yeah. The two things that I think are really important for me personally is one, unplugging on the weekend. I am juggling a lot during the week and it’s really, really important for me to just unplug on the weekend and do as little as possible when it comes to work and computer work, so that’s huge for me. And two is just making sure I go to bed on time. It’s not always possible, but that’s a huge thing. My wife knows it. I’ve got put the kids to bed, I’ve got to get in bed, I’ve got to get my sleep, or else I’m just not functional the next day.

Evelyne: Yeah.

Dr. Marc Sklar: It’s difficult for me. So those are probably the two biggest things.

Evelyne: Yeah. Such important pillars. And what is something that you’ve changed your mind about through your years in practice?

Dr. Marc Sklar: When I started practice and was very, very new, just graduated, I had a lot of misconceptions, misunderstandings and preconceived notions about conventional medicine and integrating with Western medicine. And I think for me, what I have learned is the best path forward, the best way to get success long-term with anyone we’re working with is to work as a team with their conventional or Western provider. And if we can’t have an integrative approach the likelihood of us getting the long-term results that we’re looking for are pretty low. Unfortunately, we can’t do everything we want naturally without medication and we can’t do everything we want with medication without some natural functional interventions to contribute to that process. And I think that’s probably one of the bigger things that surprises couples that I work with when I say, “Okay, we need to get you on some medication, or we need to collaborate with your doctor a little bit more to get these results better for you.” That’s probably the biggest thing that has made the biggest change for me over the course of the Last 20 years.

Evelyne: That’s great. Thank you for sharing that. Thank you so much. Where can practitioners learn more about you?

Dr. Marc Sklar: My favorite thing is my YouTube channel, so Fertility TV. Outside of that I’m on Instagram, Facebook and TikTok as the Fertility Expert. Or you can just go to my website, marcsklar.com.

Evelyne: Wonderful. Thank you so much, Marc. This has been hugely informative and I’m so in awe of everything that you’re doing for the San Diego community, for couples worldwide, so thank you.

Dr. Marc Sklar: Thanks so much for having me. This was awesome.

Evelyne: Thank you. Thank you for tuning into Conversations for Health. Check out the show notes for any of the resources from our conversation today, and please share this podcast with your colleagues. Follow, rate, leave a review wherever you listen. And thank you for designing a well world with us.

Voiceover: This is Conversations for Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence-based cutting edge research and practical tips.