PRECONCEPTION

014: How Reproductive Toxins Affect Fertility And Pregnancy w/ Shala Salem, MD

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014: How Reproductive Toxins Affect Fertility And Pregnancy w/ Shala Salem, MD

Welcome to the Hey Mami podcast!

Our guest today is Shala Salem, MD, an Integrative Gynecologist with over a decade of experience.

After completing OBGYN residency in Brooklyn, New York, she completed a fellowship in Integrative Medicine at the University of Arizona under the guidance of Dr. Andrew Weil.

Dr. Salem currently practices in Southern California at a fertility clinic where she helps patients to optimize their fertility through an integrative approach.

She is a mom of three, and a PCOS warrior who has used both conventional and integrative fertility treatments to help her conceive. She is also an expert on environmental toxins and fertility, which is the reason we’re here with her today.

Or listen on Apple Podcasts | Spotify | Stitcher | TuneIn | YouTube

In today’s episode we are talking about environmental toxins and how they impact your fertility and reproductive health. Studies show that a particular group of chemicals called endocrine disrupting chemicals (EDCs) can have negative effects on female and male reproductive health.

Highlights:

  • Dr. Salem’s story
  • What is an Endocrine Disrupting Chemical (EDC)?
  • How to avoid environmental toxins, especially when trying to conceive
  • What chemicals should you try to avoid?
  • Studies on the effects of EDCs on both male and female fertility
  • How are toxins linked to PCOS?
  • How EDCs influence thyroid function

Important Links

Find Dr. Salem online here

Subscribe to Dr. Salem’s newsletter to receive her FREE ebook, Jumpstart Your Fertility: A Complete Guide to Enhancing Your Fertility at Home (scroll about halfway down the page)

Count Down: How Our Modern World Is Threatening Sperm Counts, Altering Male and Female Reproductive Development, and Imperiling the Future of the Human Race

Follow Dr. Salem on Instagram | Facebook

Quotes

“Endocrine disruptors are really compounds that are going to interfere with either the synthesis, the secretion, the transport, binding, any action of the natural hormones in the body.”

“BPA is something that’s considered an ovarian toxicant.”

014: How Reproductive Toxins Affect Fertility And Pregnancy w/ Shala Salem, MD TRANSCRIPT

Dr. Maren:          All right. Welcome back to the Hey Mami Podcast. In today’s episode, we’re talking about environmental toxins and how they impact your fertility and reproductive health. Studies show that a particular group of chemicals, these are called endocrine disrupting chemicals, or EDCs have negative effects on both female and male reproductive health. So in this episode, we’re going to cover common endocrine disrupting chemicals, how they affect both male and female fertility. We’ll also address other hormonal disruptions like PCOS and endometriosis, and then ways to reduce exposure without all the overwhelm.

Dr. Maren:          So I’m super excited about our guest today. This is Shala Salem, MD. She is an integrative gynecologist with over a decade of experience. She completed an OB GYN residency in Brooklyn, New York, and then went on to do a fellowship in integrative medicine at the University of Arizona under the guidance of Dr. Andrew Weil. She currently practices in southern California at a fertility clinic where she helps patients to optimize their fertility through an integrative approach. She’s a mom of three, PCOS warrior herself, and has used both conventional and integrative fertility treatments to help her conceive. She’s also an expert on environmental toxins and fertility, which is the reason we’re here with her today. So welcome and thanks for being here.

Dr. Salem:           Thank you so much, Christine. It’s my pleasure. I’m really excited to be on the show with you today.

Dr. Maren:          Awesome. So we like to just start by, if we can tell our readers or our listeners rather a little bit more about you and why you do what you do. How’d you get into this field?

Dr. Salem:           I’ve always had an interest in women’s health, primarily because I suffered with a lot of issues with my own menstrual cycle, honestly. Ever since I have had a menstrual period, I always had an irregular cycle and so I was always someone who is constantly looking for answers, trying to find answers. And really what I got from doctors when I was young was just be on a birth control pill, which I did and I did that for probably about two decades of my life, because it was the most convenient thing at the time to do when I was going through university and medical school, residency, and all that.

Dr. Salem:           And then never really honestly thought about the possibility of me having PCOS on my own. But that’s what I realized later when I ended up in a residency program and started realizing like, hey, I have a lot of these things. And I suffered with horrible acne, regardless of being on the birth control pill. I had issues with anxiety, which obviously could be part of depression, I mean, part of residency, but that’s something that happens to women with PCOS. And so later on in life, I realized that so long I had not been told about all the things that you could do for PCOS.

Dr. Salem:           And that kind of made me open my eyes to integrative medicine, which is what made me look at going to the University of Arizona and really learning about what are the things that you can do through the combination of conventional medicine with alternative therapies. And that’s something was like, really, it changed my life. Not only in a personal, but as a physician, because now I realized like, wow, all those years I had never really talked to patients about exercise, diet, stress, environmental toxins, sleep, all the things that seem so completely obvious, but yet how much time did we spend on that during medical school and residency? Very little. Very little attention is paid to those things. And then suddenly it was like, I couldn’t unsee it. Once I saw all the power, right? The power of all those things, I couldn’t unsee it and people would come into my office and I would ask them these questions and suddenly it was like, I was flooded with so much information that I had never known about before.

Dr. Salem:           I’ve never really asked patients much about their sleep, I never really asked much detail about what they were eating and those things have a tremendous impact because, and I really felt it in my own life and that’s something I was a patient who had to use fertility treatment with my children, because I really had no cycle, regardless of the fact that I thought I was healthy. I was maybe, I had like 10 pounds, I was 10 pounds overweight, but yet before my daughter, I had a hemoglobin A1C of 5.9. So I was a pre-diabetic. And I was, like I said, maybe I had a few extra pounds. And so I didn’t realize that those little small changes actually can be something that can help you, for someone who has PCOS who’s listening, help you to ovulate, help you to have a healthier pregnancy. And I was able, by lifestyle changes, to avoid having gestational diabetes. I was extremely lucky because I really worked on that with lifestyle.

Dr. Maren:          Yeah. I know. It’s so true, you can’t unsee it. And once you learn this stuff, I mean, it’s just, you can’t go back the other direction. It’s kind of hard. So I totally resonate with that. I mean, I love the program. I loved Dr. Weil’s program. And I think that’s awesome that you’re both OB GYN trained and then also have gone on for this additional kind of training because that makes you a really special doctor.

Dr. Salem:           Yeah. Because I wish all doctors had the opportunity and I mean, really, it should be part of all of our medical education. It’s just really being able to teach patients because guess what’s happening, women and men are getting the information on the internet and maybe not from trusted sources about what the real data is showing about things like diet and exercise, sleep. So we are really the ones that should be giving this information to our patients rather than patients having to go get this information outside, from possibly sources that are not really trusted.

Dr. Maren:          I know. There’s just so much to learn in med school, right. Training and we already were working 80 hour weeks, it’s just like, do we make the, I mean, I don’t know what the solution is, but I think when I look around the room at fellow physicians sometimes, I know I’ve been in this position years ago, not in functional medicine, but before I really started my training where I look around the room and see people drinking Diet Coke and eating Goldfish, I’m not joking, like an entire conference room of doctors eating and just not making great lifestyle choices themselves. And so I think we have to kind of start that change with us first and then we can teach other people how to do it, but it’s not an easy change always. And I think you and I, as physicians have experienced our own health journeys, which brought us here, but yeah, it’s a hard one.

Dr. Salem:           Totally. I think we can be the worst ones. I mean, I went through a period of my life, especially during residency where all the Diet Coke, all the junk food, just to keep yourself awake, that’s what you do. And that’s really the time period of my life when I had the worst of my PCOS symptoms was when I was poorly slept, so much stress, the worst possible diet and no exercise, because like you said, you’re working 80 plus hours a week. And so that was really an experiment in life for me to be able to see the extremes of where it can go.

Dr. Salem:           And so, yeah, I think the other thing about being an integrative medicine physician is really looking at your patient as a partner in the journey to health, not as if you’re their doctor and you need to tell them what to do. Because I think patients now are really looking for working with somebody. The days of physician telling you to do X, Y, and Z doesn’t work very well. Because that patient’s coming in and I see it all the time with women who have PCOS or endometriosis who have been told, “Oh no, no, no. That’s not what it is.” And they’ve suffered for years without someone listening to them.

Dr. Salem:           Just go on this birth control pill, which listen, I’m not against the birth control pill, I used it for many years of my life. But the point of it is, is that we need to also really educate the patients on, once you go on the pill and come off the pill, you are still going to have the same condition. It’s not going to erase your PCOS. It’s not erasing your endometriosis, and this is why we’re doing it. And what’s going to happen next? Patients need to be educated appropriately in that, which isn’t happening.

Dr. Maren:          I know. There’s such a misconception around that, well starting a birth control pill will maybe make your cycles more regular but like you said, they don’t erase your PCOS, you’re still going to have the same problem when you get off the birth control pill or maybe worse because it hasn’t been addressed for the last decade because you didn’t know it was a problem or whatever.

Dr. Salem:           Correct.

Dr. Maren:          All right. Well, let’s dive in and talk about EDCs. So if you can just kind of start by telling people what does it mean when we talk about endocrine disrupting chemicals? What are what’s an EDC?

Dr. Salem:           So endocrine disruptors are really compounds that are going to interfere with either the synthesis, the secretion, the transport, binding, any action of the natural hormones in the body. And so that can affect male reproduction, female reproduction, it’s actually even causes, it potentially increased rates of cancer, it impacts your thyroid, obesity rates, diabetes. So it’s so many things because our hormones impact so many things in our body. And when you have these chemicals that really are sort of mimics of your body’s own hormones, then they can have a long reaching effects.

Dr. Maren:          Yeah. That’s a great explanation. Makes it just more simple. And I think importantly, and what’s crazy is how ubiquitous these things are. We all get exposed to environmental, or why do I keep calling it, to endocrine-disrupting chemicals every day. They’re all over. So we don’t have to be perfect, but we got to do something to decrease our exposure. So can you talk about some of the specific environmental toxins and then maybe some ways that we can avoid them or why we should be avoiding them when trying to conceive?

Dr. Salem:           So like you were saying, we can’t get away. We have tons of chemicals in our environment. We say there’s probably over 85,000 chemicals in the environment. And the key thing to note there is that really these are not tested chemicals. So I think sometimes people expect that because it’s released or because it’s out, that means that the government said it’s safe or it must be safe. They must’ve done testing on these things, right. I mean, they test our medications. Why wouldn’t they be testing these chemicals that we’re exposed to? But really in reality, very few have been tested and only a small handful of them have been banned. So it’s almost like we were in this large human experiment in real time.

Dr. Salem:           And then the other thing is to note is that the preconception and very early pregnancy period is very critical point in time. There’s no time that’s more fragile than that development stage of egg, sperm, embryo, and the fetus. And so, when you go back the egg and sperm go through development for about three months before they come together to form the embryo. So it’s not, I know a lot of times I think we think, okay, now I’m pregnant. What do I need to do? What should I avoid? But there’s already a lot of things that happened before you’re pregnant. Now, one thing I would say is that at any point that you are doing this, it’s good. So you shouldn’t feel like, oh my gosh, I didn’t do this at preconception or, oh my gosh, I didn’t do this in pregnancy. These things can always help along the stages. So if you’re someone who’s already had a child, there’s still benefits of doing these things now.

Dr. Salem:           And the other thing about toxins is that sometimes we think, well, they’re so small, it can’t be that big of a deal. But the fact of the matter is that hormones are released in tiny, tiny, tiny amounts. So it’s like parts per trillion. And so it shouldn’t be a surprise that these chemicals, even though they’re at small amounts, they’re affecting things like egg or sperm development.

Dr. Salem:           And so, there was a study that was done by the Environmental Working Group and they looked at cord blood of 10 babies. And this was back in 2005 and they found that an average of 200 chemicals are found in the cord blood of the baby. So indeed babies are born pre polluted already. So again, we can’t get away and no one is going to have zero chemical exposure, let’s just say that. But I think what we’re trying to go for in all of this is not be the upper quartile. So that top quarter, top 25%, that’s really where most of the reproductive impacts happen. So that’s where you want to try to reduce your exposure. You’re not going to get to zero. Nobody will. You want to try to just get it down because that’s really where we see that the highest effects.

Dr. Maren:          Yeah, for sure. Do you do any testing in your clinical practice for chemicals?

Dr. Salem:           I personally don’t, I know that there’s a company out there, a few companies that do urine testing for chemicals. I kind of take an approach of everybody has them and so let’s try to do these things to reduce. I mean, there are certain patients that are, if they want to, I will do it if they’re interested, but at the same time, cost is always an issue. A lot of things are not covered by insurance, surely these tests aren’t and so it can be costly so some patients may not be able to, or interested in doing that. So I try to really assume that has them.

Dr. Maren:          Sometimes it’s more like spend the money on your water filter versus the test. We already know you need the water filter.

Dr. Salem:           Yeah. And sometimes I imagine that tests could be scary for somebody to realize like, oh my gosh, how bad it is. I think it could be somewhat overwhelming. For some people I think would be motivating to do it and see the changes.

Dr. Maren:          Yeah. I mean, what you said about the upper quartiles, just interesting, because I’ll do the Great Plains test. They have an envirotox test where, this one’s actually just the GPL tox, but the envirotox also looks at glyphosate and mycotoxins, but there’s always stuff. Everybody’s got chemicals, nobody’s ever like really, really low for everything. Everybody’s got some exposure that’s a little high and it’s sometimes it’s a hard one because it’s stuff you can’t do anything about because it’s just in your air, because you live in an area where there’s a lot of industry and I suppose you could move, but most people aren’t going to do that.

Dr. Maren:          But it’s just the stuff that we can change, like what’s under your control, under your house, under your roof. What can you do there? So yeah. It’s all super interesting. Well, let’s talk, can you talk specifically about what chemicals are we talking about? What are these things called? If you look on a label, what are you trying to avoid?

Dr. Salem:           So there’s obviously a long list of chemicals that we want to avoid. Some of the top ones that I talk to patients about are bisphenols, so BPA, that includes the other parts of the family of bisphenols. So it could be like, S, F, Z, there’s so many different bisphenols, really that’s kind of the company getting smart about, oh, nobody wants BPA. Everybody wants BPA free. Which by the way, doesn’t mean it’s safe. I think that’s obviously honestly the assumption sometimes, but they have just gone on to then use other sister chemicals, which really are the same thing and are finding they’re having the same effects on health and fertility in particular. So that, bisphenols is something you find in plastics or cans, receipts, concert tickets, boarding passes, all that.

Dr. Salem:           Phthalates, that’s another one I really look for. And when I tell patients really to look, the biggest thing is fragrance, that’s kind of the easiest thing to find. So any of your sprays or any of your body products, if it says fragrance, hair products, fragrance, perfume, parfum, any of that, try to avoid it. It’s also in soft plastic toys or you can find it in food packaging a lot. So a lot of times in processing of the food, it can come in there as well.

Dr. Salem:           Parabens, those are preservatives that you find in food or personal care products is sometimes you’ll find it like methylparaben or something in a beauty product. And things we would call like persistent, organic pollutants. An example of that would be like flame retardants, so you’d find that in couch or your mattresses. I know that it’s kind of changing now, but if you have an older piece of furniture, more than likely that’s in there. Which flame retardants, unfortunately, haven’t been proven to really be helpful for actually what they were designed for. That’s when they started for people who were smoking on their couch to stop flames. But unfortunately it’s just something that will stick around in the environment.

Dr. Maren:          Created another problem.

Dr. Salem:           Yep, created another problem for us. And then of course, we have pesticides, which includes also herbicides, insecticides. And that’s from food, air, water, household dust. If you live potentially close to a park, a farm, a golf course that’s spraying, that’s super important. If you go on a golf course often, and then you come inside with your shoes in the house, then you’re going to have that inside the house.

Dr. Salem:           And then things like heavy metals. So aluminum, lead, mercury might get that through contaminated food or water, again, air pollution, certain dental fillings, things like that we can get all of those.

Dr. Maren:          Yeah. That’s a good list. And I think that last one, I mean, we’ve known for such a long time, like when you’re pregnant, you shouldn’t eat canned tuna or you should limit it. But then just in September of 2020, the FDA, I’m sure you saw it, but the FDA came out and they said, “Okay, so maybe amalgam fillings, which are the silver fillings, might be problematic for certain high risk populations and those include women who are pregnant, women who are trying to conceive and women who are breastfeeding.” I’d like to just put this caveat out there for anybody who’s listening, what they didn’t say is have them removed by somebody who does it safely, and also maybe just leave them put when you’re pregnant or breastfeeding.

Dr. Salem:           Yes.

Dr. Maren:          But nonetheless, I appreciate that they acknowledged that there is some mercury vapor that can influence our health because I think a lot of times we know, we know now lead’s not a good thing. Everybody knows lead’s not great. Leads can children’s IQ and all sorts of other things, but if we went back to the seventies, nobody thought that was a bad thing really.

Dr. Salem:           Exactly.

Dr. Maren:          That was like in the early eighties that we started thinking about that. So I think now we’re really starting to think like, oh, and mercury. The other thing I do see high in a lot of patients is arsenic, which I think is really just related to pesticide use because there’s a ton of arsenic in Roundup. It’s like glyphosate and arsenic. And we see it a lot in groundwater and stuff. So yeah, it’s crazy. But these things are definitely around and pretty ubiquitous.

Dr. Maren:          So let’s talk about specific research or studies on how they actually impact female fertility. What happens?

Dr. Salem:           So I wanted to give a little bit of background just on BPA because I always find it, patients and other practitioners find it so interesting when you learn about really where BPA came from. And then you’re like, oh, actually that should be bad. BPA is something that they discovered in the late 1800s. And then in the 1930s, they were looking for a pharmaceutical estrogen. And then they thought, well, we have this chemical called BPA, we can actually use that as a pharmaceutical estrogen. And then they found a different chemical, which then ended up taking over for BPA and BPA was shelved. That chemical that was used was called DES or diethylstilbestrol, which later on, 40 years later, we found out that it caused malformation of the uterus of babies of the women who took it. It’s linked to breast cancer and vaginal clear cell carcinoma in younger women.

Dr. Salem:           And so you can see something how that really kind of shows us how a chemical can potentially cause problems for generations to come. It’s not something that’s just the here and now, it continues on, in fact there’s potentially some links coming up for multiple generations after the use of DES. So I always find that story kind of really, oh, okay. Wow. There’s BPA, which is a potential estrogen in my water bottle. It’s something good to tell men who don’t want to stop drinking water bottles.

Dr. Maren:          Agreed, totally. Testosterone and estrogen are always great things for men to test When a man sees low testosterone and high estrogen, he usually is going to make some changes.

Dr. Salem:           Yeah. And BPA is something that’s considered an ovarian toxicant. And they did studies on women that are going through IVF and they found that women who had the higher levels of BPA, they retrieved fewer eggs, fewer quality eggs, and then had fewer embryos that made it to blastocyst stage development, which is usually when you get to about 150 cells of development. And they also had a link to a lower ovarian reserve in the women who had the highest levels of BPA. So now again, just because you have BPA exposure doesn’t mean all of those things are going to happen to you. We’re talking about again, the highest quartile, so you want to try to just get out of that. And BPA is not only limited to the ovaries, it’s actually something that has potentially shown to cause decreased uterine receptivity and increase implantation failure. So it’s something that you could see it in both the ovaries and the uterus.

Dr. Maren:          That’s interesting.

Dr. Salem:           And they also even have it linked to recurrent pregnancy loss. So they did studies on women who had the highest levels of BPA, they were times as likely to have pregnancy loss than women with the lower levels.

Dr. Maren:          Wow.

Dr. Salem:           And one of the things that takes back to the studies done by Patricia Hunt, that was in the late nineties, that’s kind of how we discovered that BPA was problematic. And she was doing studies on mice and she discovered that her control group of mice, which typically had very few what we call aneuploid or abnormal eggs, they actually had 40% of them were genetically abnormal. And they were like, what’s going on here? We don’t know what’s going on. And it took them months and they did all these things and they changed labs and they changed all these different parts of the labs to try to figure out what was happening to the mice. And what they found was actually that there was a new janitor that was cleaning the water bottles in cages with a new detergent that was allowing the BPA to get in the mice’s water. And so that kind of uncovered this, here’s this chemical BPA that’s causing all these things to the eggs. Oh my goodness, what’s going on here? This is probably important with human health.

Dr. Salem:           Now it’s harder obviously in humans to see this. And that’s why a lot of the studies are done in IVF because it allows us to look, or in vitro fertilization, excuse me, allow us to see the eggs and see the embryo development. But in her studies, she’s able to look at multiple generations of mice and see that actually from the first generation, they can see it as many as four generations later that it’s still negatively impacting eggs.

Dr. Salem:           And so I know that sometimes people don’t really care for animal studies, but to me, I would want to pay attention. I would want to pay attention to anything that might be negatively impacting, because this is something that you have to understand when you’re pregnant, it’s impacting you and potentially then also impacting your fetus and then their germ cells, so you have the potential of impacting three generations once during a pregnancy. And so that’s why it’s super important to pay attention to that because it’s something that doesn’t just end with you.

Dr. Maren:          Yeah, it’s hard to wrap your head around that, but I like the example you gave with DES. I mean, we know that’s a thing for women who used that 50 years ago or whatever. Yeah, that’s super interesting. And again, like you said, just because it’s BPA free, it’s got BPS, it’s just marketing. What about male fertility? What kind of studies do we have looking at male fertility and these endocrine disrupting chemicals?

Dr. Salem:           So with male fertility, we know that BPA, pesticides and phthalates, they all can negatively impact sperm. With BPA we saw that it can cause lower sperm counts, lower poor motility, poor morphology, or the shape, and actually cause DNA damage of the sperm. And there was studies that looked at pesticides that found that men who ate fruits and vegetables with the highest levels of pesticides actually had a significant reduction in sperm counts and fewer normally shaped sperms.

Dr. Salem:           And one of the most interesting, which is something that maybe you have seen in the last few months, and some of the listeners may have seen is the work of Dr. Shanna Swan. And she released a book called Count Down, which talked about the idea that sperm counts have dropped by over 50% in the last 50 years. And if we continue on this approach that it will near zero by the year 2045. She’s been studying it for over two decades and she said she really didn’t think it was environment, but they’ve done all these different things and really everything points back to the environment.

Dr. Salem:           And one of the greatest things was phthalates. And that phthalates are things that we know that can reduce sperm quality. It causes DNA damage to the sperm. And it’s also linked to genital malformations in utero in boys. And that comes from lower testosterone, which then causes, prevents full masculine realization of the male fetus. So some of the headlines that you may have seen is shrinking penises, dropping sperm counts, all of that can be linked to phthalates. And phthalates, as we talked about again, are things we see in fragrances and plastics and soft toys. And then this is compacting, right? So you have generation one, which is exposed and then that he has his germ cells. And then later on, he has a child and then that child already has germ cells that were exposed. And then it’s compacting every generation.

Dr. Maren:          And then they play with soft toys?

Dr. Salem:           Correct. And children are known to have higher-

Dr. Maren:          Stick them in their mouth.

Dr. Salem:           Correct. Higher, they have higher levels of all these toxins because they’re on the floor, in more dust, putting everything in their mouth. And so they have the highest levels. And that’s why it’s, if you have children, all this stuff is important, even though you’ve already had your kids, it’s still important to continue doing these things at home because it impacts children’s health even more than our own.

Dr. Maren:          Yeah, totally. Yeah, that’s wild. Okay. Well, let’s talk PCOS. How are toxins linked to PCOS? Because it’s so common, I think what’s the statistic with PCOS, one in?

Dr. Salem:           One in 10.

Dr. Maren:          10. Okay. I was going to say one in 10, but that sounds dang high. That’s crazy.

Dr. Salem:           Yeah. And PCOS, it’s important for women, we’re talking about getting pregnant. So someone listening might be thinking, well, I’m not really trying to get pregnant so does this really apply to me? But these toxins again, can cause things like PCOS, endometriosis, thyroid dysfunction, we talked about insulin resistance, obesity, all of those things are linked to chemical exposure. And when it comes to PCOS we don’t know that this is the cause, right? So we think that there’s potentially an impact of the in utero exposure of mom to certain chemicals, that’s one potential. And there’s also a link later on between BPA levels and insulin resistance. So they show that women who had the highest levels of BPA were twice as likely to have insulin resistance than those who had the lowest levels. So the correlation between BPA and PCOS or insulin resistance doesn’t mean that’s cause, but it’s definitely, I think, super important if you’re somebody who has PCOS to eliminate endocrine disrupting chemicals.

Dr. Salem:           I mean, I think for me, it was a huge, it was something that greatly impact my own fertility, along with all the other things that I was doing for lifestyle, which then allowed me to have normal ovulation later in life, which before I had never paid attention to endocrine disrupting chemicals. I mean, at all. I mean, you learn in medical school, like we said, lead, smoking, we don’t learn about plastics. I mean, perhaps, maybe now they’re doing a little bit of it, but I definitely didn’t know anything about that. So with that, with endometriosis, we know that endometriosis again, is something that can impact one in every 10 women. And we know that we’ve seen higher levels of phthalate metabolites in women with endometriosis. Again, just because of that correlation that doesn’t mean that that’s the cause, but there’s definitely a potential link there with environmental toxins. And again, it could also be, there is some evidence that talks about in utero exposure for the fetus and potentially links to endometriosis as well.

Dr. Maren:          Yeah. And then thyroid, I talk about thyroid all day every day. So tell us about how chemicals influence thyroid function.

Dr. Salem:           So, like I said, chemicals are, it doesn’t just impact, it disrupts all of our hormones. And so then it’s important for thyroid function because that is when you have a fetus, it’s something that if it’s impacting your thyroid, it’s impacting the fetus development too. So it’s really super important to, and as you know, we’re seeing tons of patients now with thyroid dysfunction and we don’t even pay to it until they’re in full Hashimoto’s. Then you’re like, oh, now there’s a problem. Now let’s pay attention. As opposed to looking at the tiny little incremental changes in the antibodies or TSH levels and the full thyroid panel to see whether we should maybe look at some of these things now, as opposed to waiting until it’s a real problem.

Dr. Maren:          Totally. Yeah. I mean, I see a decent number of patients with thyroid problems who don’t have Hashimoto’s, which is somewhat surprising to me because we know the most common cause of hypothyroidism is Hashimoto’s disease, which is this autoimmune problem. But then yeah, just the amount of women who have Hashimoto’s disease and have known for 10 years that’s something’s wrong, but just nobody checks their antibodies. So if you’re listening and you think something’s wrong with your thyroid, ask to check your antibodies, if nothing else. Check for Hashimoto’s.

Dr. Salem:           Yeah, I see them so often.

Dr. Maren:          So common.

Dr. Salem:           Little tiny of a like, and I’ll usually tip off patients like, oh, something’s barely. I do the same thing with diabetes, because for some reason, nobody wants to tell patients when they have a little bit of elevated fasting glucose until they’re full diabetics. So I usually say like, okay, well it’s not even pre-diabetes, but you’re really getting close to it. So let’s try to work on it now.

Dr. Maren:          Right. It’s like, what’s the difference between a hemoglobin A1C of 5.5 and 5.6? One gives you a diagnosis of pre-diabetes and one does not, but you’re 0.1. As we know, it’s a spectrum, like all of these things are a spectrum and if you’re somewhere on that spectrum, often it doesn’t get acknowledged until you’re too far down the path. Which I mean.

Dr. Salem:           Yeah. And people fall through the cracks all the time, PCOS patients, especially they could be thin. And then they’re like, they probably don’t have diabetes. They probably don’t have anything.

Dr. Maren:          Same with tyroid, just because you’re not overweight doesn’t mean you don’t have hypothyroidism.

Dr. Salem:           Correct.

Dr. Maren:          So, yeah. And then obesity, how are these things, why are they linked to obesity? Just because the insulin resistance piece?

Dr. Salem:           It’s kind of the new, insulin resistance, for sure, there’s also links to adiponectin and other hormone, but that’s something new that’s been kind of coined obesogens in the last 20 years I think. We’re kind of seeing these chemicals as obesogens. And so it’s important if maybe you’ve been trying to lose weight and you haven’t really seen impacts with the things you’re doing, I think you should look at environmental toxins because sometimes I think that those are things that may impact. And I think one of the main things is just really not, sometimes other thing I wanted to actually point out, which I haven’t yet is that we need to understand that also a lot of these chemicals there’s a huge impact on the underserved population.

Dr. Maren:          Totally.

Dr. Salem:           So why? It’s because less access to clean water, food, living near certain industrial areas, freeways. And also the products that are-

Dr. Maren:          And jobs too, right?

Dr. Salem:           Correct, right, jobs.

Dr. Maren:          If they’re working toxic jobs, laying, whatever, doing construction with chemicals or whatever it might be.

Dr. Salem:           Yeah, I actually have a story about that. I had a patient that came in a while ago to see me and her husband worked in a pest control. And so she came in because of pregnancy loss and then I asked him what he did. And then he said, oh, he was in pest control. And it was interesting that the timing of his job with pest control kind of really coincided with the timing of her losses, as well as her development of thyroid dysfunction. And so then I started asking more about his protection, his gear. Are you using protective gear? Well, yes I do. Okay, then tell me a little bit about how, what do you do with your gear after you’re done for the day? He said, “Oh, I wear my uniform home.” And I said, “Then what? Do you take it off and you put it into the wash?” And he said, “No.” And literally I was like, “Oh my gosh, you have to take it off. You can’t have that uniform that’s been around chemicals all day in your home.”

Dr. Salem:           And that’s the same thing with shoes, we have to think about, so if you’re in a certain industry, you have to make sure you take your uniforms off, your shoes off at the door, because you’re bringing in chemicals into the home, which then can impact your pets, your kids, your wife, and all of that. Of course, do I know a hundred percent that that was the cause of her pregnancy loss or thyroid dysfunction? I don’t. But it’s definitely something to address to try that exposure.

Dr. Maren:          Totally. We see those patterns. I mean, I trained in San Antonio and my residency director used to say like, “There’s something about like this population, the underserved population really gets some really terrible disease.” And I’m like, “Isn’t it obvious?” Their jobs often are working in a dry cleaning facility or in a nail salon or something like that. And then you don’t have the access, like you mentioned. And so it seems like a really clear issue. I mean it’s sad.

Dr. Salem:           Yeah. And they have looked at those higher rates of breast cancer amongst black women and they know that they market, the majority of the products that are marketed to black women, very few of them are safe in terms of toxins. They have very high levels of toxins in the products that are marketed to them. And often they have, in terms of food, you have more fast food that’s available in the neighborhood and fewer grocery stores, fewer farmer’s markets, that doesn’t exist for a lot of people out there. So they then have, one of the things that could get you increased risk exposure to chemicals is more processed food, more eating out. And so they’re going to also have high levels because of that.

Dr. Maren:          Totally. All right. So I know both of us talked about this before we started recording, but it’s like often women who are trying to conceive are already, or women’s especially struggling with infertility, it’s stressful and so we don’t really want to pile that on, but we also know that knowledge is power. So how do you help? I think that the quartile thing is super helpful, but how do you help women kind of get a handle on this in a sort of simple, practical way without the overwhelm?

Dr. Salem:           Yeah, I think that’s one of my struggles always is that I want to, as you said, empower them, give them the knowledge, give them the tools to do things, but at the same time, it’s not overwhelming them and making them feel like, forget it, it’s too much. Everybody has chemicals, so nevermind. Because yes, you want to try to get out of that top quartile and then we’re going to see the benefits of that. So I think starting with one thing at a time. So I usually tell patients if it’s feels overwhelming, start with one thing at a time, and perhaps, it’s this week, I’m going to just get the plastic out of my kitchen. I am going to get glass Tupperware for my food and I’m going to not use single use plastic water bottles and not going to put my plastic in the dishwasher.

Dr. Salem:           If I have any, listen, you can still use plastic, okay. Because I think sometimes people are like, oh my God, I can’t have plastic, but use plastic to store toys or store certain things that are not going to eat. You’re not going to eat them because most of the way we get exposure is through food and water. So I usually say, start with one thing. And then just say, just knowing, just knowing that there’s issues with certain things is a win, that’s step one. Just the knowledge already is the first step, you’ve already done that. And then just go little by little.

Dr. Salem:           I’m still working on this today. Okay. So this is for always. Is everything in my home completely safe? No, it’s not. Do I always eat a hundred percent organic? No, I don’t. Do I avoid going to a certain place because it may be like golf course, no. So it’s just as much as you can. We’re not asking you to live a life that’s not reasonable, right?

Dr. Maren:          Right.

Dr. Salem:           It’s just trying to reduce as best you can. And again, not feeling worried about the past and what happened and I didn’t do that in my pregnancy or I didn’t do that with my children when they were growing up. There’s always room to start along the way.

Dr. Maren:          That’s progress over perfection.

Dr. Salem:           Totally.

Dr. Maren:          And I always tell people like the 80 20 rule, 80% of the time if you can choose the best option, great. You don’t have to be perfect. If you’re at the airport and all you have is a plastic water bottle, drink the plastic water bottle. But if it’s the daily thing that you’re doing and you’re packing water, whatever, you’re carrying a water bottle when you go to the gym, use the stainless steel one, just as your daily habit, it’s the daily habits where I just think that’s what makes the biggest dent. And like you said, it doesn’t have to be perfect.

Dr. Salem:           I totally agree.

Dr. Maren:          Any hints on how to get spouse on board?

Dr. Salem:           Yeah, spouse is a hard one.

Dr. Maren:          Or your partner or whatever?

Dr. Salem:           Because it’s hard, if you have a male partner, sometimes it can be really difficult. Men sometimes are used to certain things, don’t see it as a big deal. They don’t understand. One of the biggest protests I think sometimes I can get is, well, I know lots of people who don’t do these things and they have children, they seem fine. So why does that affect me? I think one of the important things to understand is that it impacts everybody differently. Just because you could have someone in your home that is impacted greater by toxins than you are. So with men, I think little by little, little changes, women are usually the purchasers in the home, so trying to purchase things and swap them out for them, making slow changes. If there’s a certain product that he wants to hang on to then I think it’s okay, but understand that those things, they impact men too, because men are half of the equation.

Dr. Salem:           I know lots of times it’s like, oh, it’s all women’s problem. Oh, you need to eat healthy. You need to exercise. You need to do all of that. But it’s men too, so it impacts sperm DNA as we talked about, it impacts the movement of the sperm, the health of the sperm. So we really need to pay attention to men as well. But it is hard. I will totally give you that. That sometimes it’s difficult to change, little by little, slow changes as I said, I think is the key with making them not get overwhelmed and discouraged about what you’re doing.

Dr. Maren:          Yep. Agreed. Well, thank you so much for your expertise. We love having experts, especially OB-GYNs on the podcast.

Dr. Salem:           Yeah, thank you.

Dr. Maren:          So we really appreciate your time. Can you tell people where they can find you?

Dr. Salem:           Yeah, sure. Thank you so much for having me on. I really appreciate it. I’d love to discuss this and get this information out and I love what you’re doing with your podcast. I think it’s super important. So you can find me at, on Instagram at integrativefertilitymd. And I have a website www.theintegratedfertilitymd.com. On my website I have a free ebook that you can get when you sign up for my mailing list. The ebook has a lot of information on things that you can do to support your fertility at home.

Dr. Maren:          That’s awesome. And I got to say plug to your Instagram page because it’s awesome. So if you’re not following her already, you should, she’s got so much good information, not just about fertility, but just reproductive health and hormones in general.

Dr. Salem:           Thank you. Appreciate it.

Dr. Maren:          So thank you. Thank you for the work you do. And thanks for being here again and stay in touch. We’ll see you on Instagram, if nothing less, right?

Dr. Salem:           Thank you so much.

Dr. Maren:          All right. Thanks so much.

Dr. Salem:           Take care. Bye.

Alejandra Carrasco M.D. and Christine Maren D.O.

Hello! We are Alejandra Carrasco M.D. and Christine Maren D.O. We founded Hey Mami because we felt a lack of support for fellow mamis. As physicians, we see women every day who struggle with fertility, are forgotten about postpartum, and have put their health on hold for years while they raise a family. We’re here to change that.

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