The Microbiome: How it Affects Our Fertility Journey and Our Lives with Dr. Katrina Coulter
If you're like me, you didn't learn about the microbiome in medical school. Or if you did, perhaps it was a cursory review, and nobody ever discussed how it could affect the Gyn tract and fertility. And yet, in 2025 we know it's real, and the data about the many ways in which it affects our lives are humbling.
Today's episode is filled with pathophysiology and the latest science. I promise--you will learn a lot when you listen, and my hope is that it will influence your fertility journey in a positive way.
We discuss the following:
the gut microbiome
dietary effects on the gut microbiome
neurotransmitters and brain chemistry
the gynecological microbiome
what we know and don't know about the effect on fertility
long term IUD use and potential mechanisms for altered endometrial function
antibiotic stewardship and vaginal probiotics
bonus: our favorite power foods!
This episode is not just high level, but it's relatable and practical. Even more than the proverbial CME, my intention is that you come away with a renewed sense of authentic hope (you know how much I adore hope grounded in science).
Guest Details:
Dr. Katrina Coulter is a physician, regenerative rancher, content creator, and public health educator. She is board certified in Internal Medicine and Infectious Diseases. She completed her medical school, residency, and fellowship training all at the University of Arkansas for Medical Sciences in Little Rock.
Dr. Coulter strives to be the premier authority on microbiome health and its relationship to infectious disease occurrence, treatment, and prevention. She focuses on restoring health and well-being by promoting balance in both our internal and external ecosystems.
You can follow her on YouTube @KatrinaCoulterMD and Instagram: FarmhouseMD
As always, please keep in mind that this is my perspective and nothing in this podcast is medical advice.
If you found this conversation valuable, book a consult call with me using this link:
https://calendly.com/loveandsciencefertility/discovery-call
Also, be sure to check out our website: loveandsciencefertility.com
Follow us on social media:
IG: www.instagram.com/loveandsciencefertility
FB: www.facebook.com/profile.php?id=61553692167183
Please don’t let infertility have the final word. We are here to take the burden from you so that you can achieve your goal of building your family with confidence and compassion. I’m rooting for you always.
In Gratitude,
Dr. Erica Bove
Transcript:
Hello, my loves and welcome back to the Love and Science podcast.
I am so excited for this episode.
We've been waiting for this to happen for a while.
I have Dr. Katrina Coulter with me.
She is an infectious disease specialist.
And so all these questions that we have about the uterine microbiome, the vaginal microbiome, how all these different Emma Alice endometrial results, influence fertility, recurrent implantation failure, recurrent pregnancy loss, all the things we're going to talk about it all.
So let me introduce her.
She's an amazing human and she's also a friend.
She Dr. Katrina Coulter.
She is a physician, wife, regenerative rancher, content creator, and a public health educator.
She's board certified in internal medicine and infectious diseases.
She did her training in Arkansas, Arkansas, which is amazing.
And now she's in Colorado.
So she's currently in private practice and it's super exciting.
She is about to launch infinity ID and wellness.
This has been building for a long time.
This is her own practice for infectious disease concerns.
And I'm so super thrilled that she's doing this.
I've been honored to have a front seat to the journey.
And also if you live outside of Colorado, she is a coach and is open to hear about your infectious disease concerns and provide her perspective.
So please do take her up on that.
She's amazing.
So I am so, so excited to have her here.
She's at premier authority on microbiome health and its relationship to infectious disease concerns occurrence, treatment, and prevention.
So let's talk about how we can restore our health, restore our fertility, restore even our wellbeing by what we can learn about the GYN microbiome.
Dr. Katrina, it's so nice to have you here.
Oh, thank you.
That was an amazing intro.
So thank you, Dr. Bove.
And I am so excited to be here and have this high level conversation with you and your audience, and I really hope they get some good takeaways from it.
Absolutely.
So this, this podcast actually came out of a conversation we were having around a table about these concerns about fertility and the microbiome.
And it's so fascinating because I feel like we're both mid-career at this point.
When I was in medical school, what I knew about infertility and infectious disease was like, it's not good if you have a TOA, don't get a TOA.
If you get a tubal-bearing abscess, you know, you're probably going to have tubal factor and all those associated issues.
So it was a very dramatic, like, you know, you have to ask about pelvic inflammatory disease and TOA.
And, you know, yes, if they've had chlamydia once, it's a risk factor.
So keep that in mind.
But it's really kind of these larger things to think about where we really, you know, our eyebrows go up, we start writing our notes and we start to think, oh my goodness, this might be a clue to what's going on.
But I think, I mean, certainly that is still true.
Somebody has that history, we need to be concerned and mindful and do the full evaluation.
But I think that there's all these other more subtle infectious disease concerns that are just starting to come to our attention.
And that's what I really want to talk about today because, you know, if somebody is trying to get pregnant, even despite IVF and the treatments are working, how can we help them finally get to their goal?
Right?
So let's talk about that.
What have you learned, you know, I will say recently, because the data is somewhat recent, in terms of the relationship between the GYN microbiome and fertility?
Yeah. And I just want to mention, when we were in medical school, these topics almost didn't even exist, really.
And so both the microbiome and the research and infertility is really kind of coming of age and blossoming.
And that's really cool.
And we're really starting to understand that there's a relationship between these two things and a lot of other subtle environmental factors that you and I have kind of talked about and probably won't get too into today.
But we are really starting to understand kind of how important this microbiome is where back in medical school, it was just kind of like an aside, like, oh, and you have this microbiome and it digests your food and moving on.
Right?
I don't even know if I learned that word in medical school.
I don't know, like, relatively each other where we were, but like, I truly think I think I heard that word well after medical school, which is wild to me.
Right?
Yeah.
Yeah.
And so I know your listeners are highly educated and I'm so excited about that because we can talk about this on a level that we can't really talk about or discuss necessarily with all audiences.
But I, so I won't go super into what the microbiome is.
You know, we, we know it's the bacteria, fungi, protozoa viruses that exist.
And when we talk about microbiome, often people think of gut microbiome, so existing in your intestinal tract, but really it's present all over you.
So I, I really think of it as how we interact with the world.
So our skin has a microbiome and anything that has an outside interaction that's not completely isolated and protected in the body has a microbiome.
And so, you know, mouth to anus, we do, we're open on both ends, but also the vagina has a microbiome.
The cervix has a slightly different microbiome and the uterus has an even different microbiome or armpits have a microbiome.
You know, these are all very niche specialized areas and that's what we're starting to understand and also starting to understand how our environment, our food systems, everything is affecting these and changes, changing these things and playing a role in, in chronic diseases, but other something that, that maybe I wouldn't think of as a chronic disease like infertility.
And so that's what is really exciting and interesting.
And so I don't know how, do you want to kind of get into how the microbiome, the gut microbiome maybe is where we'll start, how that plays the role in fertility.
So the microbiome we know digests our food, extracts nutrients, energy.
The other two really important roles that we're recognizing that it plays now, one is immune system growth and regulation.
And so our immune system is spending a lot of time in our gut to go kind of to bootcamp is how I like to think of it.
So they're, they're training with the bacteria.
They're learning what should be creating inflammation and what should be tolerated.
And then the other part is we think of it as now our largest endocrine organ.
And that's because we are producing neurotransmitters in our gut, our gut bacteria are dictating what neurotransmitters are produced and also our sex hormones.
And so our bile acid salts are being activated by the microbiome, which then help recycle our sex hormones.
And so they have a direct influence on how much goes back into the system by conjugating or decongigating and saying, Oh no, we're going to degrade this estrogen.
Or no, we need to put this progesterone back into the system.
And so has a pretty direct effect on fertility and cycles and whether those are regulated or dysregulated.
And Dr. Erica, I cannot remember if it was you, if you were sitting around the table when we were having this conversation about PCOS, but I am just, I'm fascinated by PCOS because in medical school, I thought that was a hormone problem.
And now I'm starting to understand that's actually a metabolic problem and even further understanding that it's a metabolic problem that originates out of the gut and how, how the gut is managing energy.
And then, and so it's, you know, we think of it, Oh, it's an ovarian.
It has ovarian in the name polycystic ovarian syndrome.
And it's actually coming from a totally different part of the body.
Let's talk about that for a second.
Cause I don't think most people know about that.
Yeah.
So, so tell us more because when I was in medical school, it was like, this is a, is this an ovarian problem or a brain problem?
Right?
Is it, is it the fast pulses of the gene or age pulse generator, or is it primarily an ovarian issue?
And we also know that all PCOS is not created the same because it's a syndrome.
And so you can have two out of three different aspects of it, you know, clinical or bio chemical hyper androism, the ultrasound criteria, and then also the irregular mentees.
And so tell me what you know about the, the role, because this is actually knowledge that I'm not aware of.
And I think we need our listeners to know all the things there are to know, many of whom are affected with PCOS.
Yeah.
Full disclosure.
I'm an ID doctor.
I'm an expert in this.
But I was having a conversation with a colleague about the GLP1 agonist and the effect it had on the gut microbiome.
And they were saying, we love those for treatment of PCOS.
And I was like, what?
That why, why would you treat PCO?
How does that affect anything?
And they're like, well, it's actually more of a metabolic syndrome and very similar to diabetes to, to where it seems to have the same pathway in that we are kind of dysregulated in how we're managing energy, if that makes sense.
So how, how, how the gut bacteria are harvesting energy for some reason, they're feeling that they need to extract more nutrients from food than what the body actually needs.
And then the signal isn't going of what to do with that extra energy.
So the gut bacteria actually trigger production of GLP1 in, in the intestinal cells.
And then they send further neurotransmitters to the hypothalamus on, you need to release, excuse me, leptin or ghrelin or, or what, you know, these satiety hormones.
And so that's kind of the, the pathway in which diabetes occurs is that we're not getting the, we're getting a dysregulated release of these hormones, even though we've extracted enough energy, the body's still saying, I'm hungry, I'm hungry, I'm hungry.
And it seems that a similar process is happening in PCOS or it's manifesting as PCOS.
Yeah.
That's fascinating.
And I feel like there's a lot of female physicians who have lean PCO, which I've always found very interesting because there's this population of people that kind of do a pendulum between functional hypoglycemic amenorrhea and PCO.
So it can get kind of tricky, but I will also say there's a lot of things that people do with their lifestyle to really restrictively manage.
And so you do wonder, I mean, it's this combination of like what we are consuming, how our body is interacting with that.
But then, you know, you might hear, Oh yeah, I ran three marathons this year.
So I, you know, manage my diet this way.
And so, you know, that's not necessarily typical.
And so I think the more we can understand what's happening at the interface of the thing that we need to do several times a day, which is to eat, to restore and what foods, you know, give us that power and what foods just kind of like, you know, those simple carbs, they just kind of get, like the body just absorbs them, right?
In a different way than maybe somebody without PCOS.
I think it's really interesting to think about how we can improve our microbiomes to maybe have, you know, better interactions and maybe GLP one is one of those strategies.
I'm also curious in the PCO population, if there's anything that you have found or even in general, really, but more about, I'd love to talk about what can we do to improve our gut microbiome so that we can have better health outcomes.
Yeah.
And this isn't going to be specific for PCOS, but in preparing for this, I was like, okay, let's, I'm going to do some research on what is the fertility diet?
Like what foods are healthy for fertility and all the things that come, came up, green leafy vegetables, legumes, fruits and berries and nuts and things that are high in omega three, like salmon, lean meats are also all the things that, that we want to be putting into our, our mouths to maintain a healthy microbiome, even if you're not on a fertility journey.
And so I thought that was really interesting.
I'm like, it's the same thing that I've been saying for everything about how to improve this gut microbiome.
So what I, I see happening is that since the seventies, we've really seen a shift in our food systems.
It really started back in more the fifties with industrialized agriculture, but then in the seventies, we started making these ultra processed foods.
So where we started putting additives and emulsifiers and extra sugar and shelf stabilizers into our food so that we could make these packaged foods that could sit on the shelf in your bomb shelter or whatever, you know, they could, they could last forever.
And then those have slowly taken over our food supply.
So the American diet, most adults get about 65 to 70% of their foods from ultra processed foods.
And so they've got a lot of salt added.
They've got a lot of sugar added.
They've got all these other dyes added and they're, they're manipulated in such a way that, you know, they're soft to eat and you don't really have to chew them and they go down easily and you don't feel full.
And that's where we're seeing these disruptions in these neurotransmitters going to our brain saying, ah, we've harvested enough energy.
Now you can stop eating your sated.
These foods have been manipulated in a way to not tell our brains that we're sated because we need to eat the whole bag of chips, you know, and then we can supersize it and then you're going to not feel full.
So you'll eat that whole larger bag of chips or, or the bigger soda, you know, instead of having the, remember we went from a 12 ounce can now to a 16 ounce bottle.
And so adding more and more of these sugars and things into the food system at the expense of our health, at the expense of our fertility.
Now seeing these rises in chronic diseases like diabetes, autoimmune disorders, you know, Alzheimer's disease.
Which is really interesting.
And again, likely this same metabolic process.
And so what is now missing from our diet is fiber.
And so we're replacing fiber with these easily accessible package, ready to go foods.
And I'm not saying they're all bad.
I'm a physician, you're a physician.
We're busy.
I know your audience is mostly physicians.
And so we don't always have time to prepare a nice, big, healthy meal or, you know, sit down for breakfast before you rush out the door.
You know, it's a granola bar in the purse and maybe eat it on the way or hopefully you find a break.
And so it's really being kind of mindful about what, what, which foods these are and trying to minimize them.
And I'm not, you know, expecting anyone to be perfect, but just trying to recognize, okay, maybe I could grab an apple and a banana instead of the granola bar and eat that first and feel how I feel.
And then decide, do I want that granola bar or do I want to, you know, try to wait till lunch when I can make it to the cafeteria and hit the salad bar or whatever healthy option they may have.
So then, so when we do this, and I think it's, it's, it's helpful to think about, okay, well, maybe I could do this instead of this.
And I know that there's some granola bars.
Like when I go to my grocery store, like there's like the, the ones in the aisle, but then there's the ones at the checkout that are freshly made and they expire soon, but they're more delicious and have more fight, like all the things.
And so if, if I make those shifts in my diet, what then do I see in my gut microbiome?
Cause I feel like this sets the stage for the whole rest of the conversation.
Yeah.
So what you're going to start doing is shifting for the favorable bacteria that are going to make these short chain fatty acids.
So that's kind of the key buzzword these days is short chain fatty acids.
These are the bacteria that are digesting the indigestible fiber fiber needing being necessary.
So if you want these in abundance in your GI tract, you've got to feed them what they want.
Interesting.
They're not going to live there.
If you don't provide that food.
If you're on a sugar heavy diet, you are going to feed the bacteria that like sugar.
And then they're going to tell your brain, I need more sugar.
And so you're caught in that feedback loop.
And really we're all about feedback loops in our body.
And so you're to establish a positive feedback loop where you're nurturing these colonies of, of the bacteria you want that produce these short chain fatty acids.
So there's three main ones, butyrate acetate, propionate, and these are the ones that maintain our intestinal cell lining that help produce the neurotransmitters that we want the serotonin, the dopamine, and help regulate the whole system and really keep us in that nice homeostasis that's going to promote good health, well-being, minimize depression, improve your sleep, and improve your likelihood of having a successful pregnancy.
It's amazing.
I've never heard anybody say it quite like that.
And I am learning as we go.
So thank you for sharing your wisdom with, with me.
And I know this is going to benefit so many people.
You know, it's this intuitive eating too.
Like I really help my patients and my clients say, well, what foods give you energy, what foods steal your energy and make you feel very low key.
And it is, I mean, I know everyone has individual differences, which is probably why they're, you know, people have said, you know, what is the fertility diet?
You know, there's, there's principles and then there's individual variation.
But I think when I actually listened to my patients and my own body, to be clear, you know, it does seem that it's those fruits, veggies, eating from the outside of the grocery store aisle, that the fiber, that those are the things that are energizing.
And it's a lot of the processed food, the simple carbohydrates, the stuff where you just never feel full that that seems to, to, you know, if we're intuitive about it, but there's science behind it, which I think is just, that's so fascinating to me.
Um, No, I just want to say like we have so many inputs coming in at us as female physicians.
I mean, we are, are juggling a lot.
We're in high stress careers.
There's, you know, you, you might be focused on one thing and then you're getting texted or page or, or you're getting pinged.
And so it's easy to say, Oh, I'm tired because I had a busy day at work.
And sometimes you do really have to step back and say, wait a minute.
I, you know, I kind of ate a crummy lunch and maybe that's why I'm having a rough afternoon.
And I, once I started really paying more attention, then I was able to pinpoint about like, Oh, why am I like such an a funk this afternoon?
And it's because I ate fast food.
Cause we bought, we bought the office lunch and you know, we, we didn't eat so well and really kind of, once you start becoming aware and, and I recommend food journaling, people may think it's silly or that's just one more task you're adding to my plate.
But even just for three days, if you write down everything that you're putting in your mouth, you might be surprised. Um, because I often would, you know, I, I'd grab like three or four M&Ms here or have a little candy bar here.
And I didn't, you forget about that. And then when you have to write it down, you're like, Oh yeah. Oh yeah. That, that does kind of add up. There is, there is sugar and there is, you know, this processed food that's kind of trickling in all day long because I'm, I'm tired, I'm stressed, I'm busy. I don't feel like I have time to stop and actually get something healthy. And so once you start becoming aware of that, you become so much more aware that intuitive eating is really, it's really, um, um, kind of expounds or, or becomes much, much, um, more dialed in.
That's amazing. So, um, just keep this kind of light. I'm curious. So do you have like a favorite or a couple of favorite foods that really give, make you feel like Wonder Woman?
Um, so I, I notice I like, I don't love the salad bar at work. Like sometimes I look at it and I'm just like, Oh, salad again. But I always do have more energy in the afternoon if I eat a lighter lunch and specifically if I eat a salad. And so I'll play little games with myself where I'm trying to get like 30 different types of fiber in, in a week. Um, and so then I'll go to the salad bar and you can add like, you know, you can put like 10 different things. So I'm like, Oh, I'm winning the game. And that really does. I mean, it's all just like the silly little things we do to try to get, Yeah, but that's a useful trick that I think a lot of us can borrow.
Or I'll have little challenges, you know, with my husband, I'll be like, Hey, you know, like let's see who can, who can do this. And so, or I'll do like, um, trying to get six servings of fruits and vegetables a day. I'll do like try to do one in the morning to by noon and then three in the afternoon. And I really noticed that I don't know if it's, it's just because I'm energized because I'm playing a game with myself or if I'm energized because I'm actually eating the foods that make me feel well.
It's interesting, the connection with mindfulness too, because I think like, well, my, like my top food that I've discovered that makes me feel like Wonder Woman is almonds. And I noticed this when I was a resident, I didn't have easy access to food. I kind of like, you know, went to labor and delivery. Like I was like surviving the wild.
I lost a lot of weight, my engineer, I just like, because, and I wasn't trying, it was just because I did not have regular access to food. Even though I actually brought my own food, our shifts were so long. This is back before all those duty hours and everything unhealthy and oh yeah, so unhealthy. I remember even going on like a 24 hour fast from anything in a package because I just like, I was just like, I'm so sick of, you know, unwrapping every single thing to get my nourishment, but it was really hard to do. So I used to keep like a, you know, a Ziploc bag of almonds in the back pocket of my scrubs. So if somebody called a C section, I would just like pop a handful of almonds and go back. But as, I mean, that was like what my twenties, like now that I'm like 20 plus years older, like now I'm thinking about it. I'm like to this day that remains one of my power foods. And you know, my sisters and I all actually have PCOS. And you know, I think about that when I talked to my own patients with PCOS because I'm like, I know it's not one size all, but but really dial in on those foods that make you feel fantastic on the flip side. If I have a slice of pizza, I feel like I've swallowed a brick for about three days. You know, if I start to, if I have that nightly habit of a sweet, guess what? 24 hours later, my body's going to be like, where's the sweet? You know? And, but if I don't, so I'm not saying we have to live like monks, you know, we don't, we don't have to have this like aesthetic life, but I think it's not about willpower. It's about when we realize those foods that really are energizing to us. Like that's when our, that's when we crave those foods. And that's when our health really does start to improve.
And I love that you intuitively knew that even all the way back then. And I know almonds, usually chocolate covered almonds. And then you, you cover both the sweet. Um, I, it did make me think there is a recipe. I call them power balls. Um, you can find it on the internet, but it's like oats and chia seed and peanut butter and coconut flakes and, um, chocolate chips, honey sometimes. Yeah. And yes, honey. That's right. And a little, um, vanilla extract and there, so there are not many ingredients and flax seed. And so you get your fiber, you get your sweet and those will like, I won't be hungry. I'll eat a couple of those and then I'm, I'm good. And I don't have that sweet craving. And yeah, I'm glad you mentioned though, the evening sweet craving, because I very much have that. Um, my husband's from the South. I trained in the South. I think that's I've, I've always thought that was maybe a Southern thing of like having the dessert, but maybe it's not, maybe it's not a Southern thing. I think it's a human thing of like, I've worked really, really hard today and I deserve something sweet. So I tried to stock my house with sweet fruits, like berries, smart to kind of hit that sweet craving in the evening. And five, five do Barry Barry's have a little fiber, right? They have fiber and somehow protein and they're so great for your brain and they're all in season. So again, all the games, um, which is wonderful. That was a fun detour. And maybe we should start loving science threat on like what foods are your super foods, what foods make you feel terrible? Cause I think the more we can have conversations, it's like, Oh, you know, Oh my gosh, you too, you know, and let's, we could start a whole movement. Um, but let's, let's shift a little bit. I really am so fascinated on the data about the, you know, GYN microbiome. And so, you know, let's talk about the research on that and sort of what, how we can optimize that aspect of our health.
Yeah. So, um, unlike the gut microbiome, which you want to be very diverse, the vaginal microbiome is very specialized. And, um, we have found that it should be predominantly lactobacilli like greater than 90%. And the lactobacilli, like the vet, the vagina hearts, lactobacilli is kind of how I think about it. It lowers the pH of the vagina and it makes it very, um, hostile for other bacteria that are going to be more pro-inflammatory. And so just remember, um, the vagina is next door neighbors with the anus. And so coming out of the anus and colonizing the perineum are things like E. coli, club C. L. A. Bacteroides, some of these bacteria that are not helpful in the vagina. And in my world, I treat chronic UTIs with those bugs I just named. And so what the, the lactobacilli are doing are like, no, Hey, like you stay on your side of the road over there. Um, it's, there's a very low pH here.
You know, this is, this is our environment. It enhances the tight junctions, um, to, to really kind of seal up that area. And then as you move up into the cervix, um, you have less, even less diversity and less bacteria. And then as you get into the uterine cavity, there is even less. So while there's a high number of bacteria in the vagina up in the uterus, there is, there is bacteria, but it's a low number and it should be mostly lactobacilli.
However, if the vaginal microbiome is disrupted, um, either due to BV, which I think we should rename to vaginal dysbiosis, but this is my opinion. Um, so if you have some disruptions where you have more of these other bacteria in the vagina, then you're going to see that on the cervix and in the uterus. And so why it's so important in the uterus to really maintain the right kind of bacteria is because they promote fertility and implantation of an embryo. And so I kind of think of, um, an embryo implanting as like a moon landing, like it's this beautiful coordinated dance, but it's, it's very technical. There's lots of things that have to go just right. And the lactobacilli are essentially like your landing crew. They're like the on the ground crew, making sure everything happens right. And then kind of ushering in that, that embryo and saying, this is, this is a healthy environment and we need to maintain it. And so the, the uterine bacteria very much influence the immune system and the immune system plays a huge role in that moon landing or that implantation.
So when the embryo is coming in, there needs to be a little bit of a pro-inflammatory state.
So we need to be in that Th one, um, ratio higher than Th two cells. So a little bit more pro-inflammatory and we have more of our pro-inflammatory cytokines. So I think it is like, you need to create a little friction there to get, to get the embryo to attach as soon as it attaches and implants that, that inflammatory state now needs to shift to a less inflammatory state because as the embryo develops, the body can recognize it as foreign and attack it.
And so you actually need the immune system to dial down. And so now you have the Th two predominant cells, different cytokines like IL six, IL 10, and that is all mediated by the lactobacilli and that uterine bacteria. And so if you have more of these pro-inflammatory bacteria like the E. coli in the club Ciela or mycoplasma or urea plasma, and the, the uterus is recognizing that it's going to stay pro-inflammatory and the embryo may implant, but then, um, you may miscarry because the, the body is like, no, this is foreign. This isn't right. This environment is not how it's supposed to be.
Hmm. That's so fascinating. And, you know, I, I think that we are in an area, a time in, in our reproductive science right now where we're really trying to understand this uterine environment. You know, we have gotten to the point, you know, since the 1980s where our embryos are so much higher quality than they used to be. And, you know, even to the point where we can genetically test an embryo and, but why do only 65% of those embryos take at best, right? And why do people have recurrent implantation failure or why does somebody have a child and then they have secondary infertility? You know, maybe they had choreo amnioiditis or something, or maybe they had an IUD and hopefully we'll get to the stuff on IUDs as well. Not that IUDs are evil, but I'm just saying that they're foreign bodies and they can change things. And so I think that we are at this point in science, we're really honing in on the uterine environment to try to understand why does some people have a harder time getting pregnant? Why does some people have a harder time staying pregnant?
And you know, these, these extreme diets to come, come back to the dietary component, people say, I have to make it all anti-inflammatory. I have to cut out dairy and I have to cut out gluten, even if I don't have celiac disease. And I'm so glad that you brought up that we actually need some level of inflammation to make the process happen because that then says, you know, these extreme, extreme, extreme diets, like there's probably something lacking in those too. So, you know, I think it's really complex. And so I hear what you're saying that lactobacillus is, you know, what we need. What if we just can't seem to clear, you know, we do a lot of endometrial biopsies for chronic endometritis. And, you know, if we treat with a course of doxycycline, right, then a lot of this is inflammatory, not necessarily infectious, 75% of the time or so it'll clear. But what we have these subset of patients for whom they persistently have chronic endometritis or they persistently can't seem to kick that ureoplasma. What do you think in the context? I'm not just saying that we just test everybody and all the things, but like in the context of a clinical history that is more concerning for somebody who is just not yet able to get pregnant or stay pregnant.
Yeah. So in, in learning about this, I, my question was that came up and it's, it's kind of along the same lines as what, what if your lactobacillus won't stay, you know, it's, it's the same, the same other side of the coin, right? It's like, why are those other bacteria there? Why aren't they being pushed out by the lactobacillus? Why is it not working? And the lactobacillus are fed by the glycogen in the uterine lining. And so progesterone is what generates that glycogen and, and kind of manages that secretory phase and manages the pregnancy, like kind of decides as to whether we're going to shed this lining. Yeah.
Yeah. Or, or we're going to maintain this pregnancy. And so I don't know all the answers, but that makes me, the approach I would take is like, go back to, okay, are the progesterone levels is something happening here in this cycle where the progesterone isn't generating the right lining to begin with to attract the lactobacillus. So they're not staying around just like in the gut. If you're not eating the fiber, those bacteria aren't going to hang out there is the same thing. It's something similar happening in the uterus where there is a dysregulation of the systemic progesterone and, and maybe it all circles back around to the gut. So is there a gut dysbiosis where it's dysregulated on that level and then you're seeing it in the uterus?
Because there's that connection there that you can have trends. Right. Isn't it true?
I learned this in my fellowship that you can have transparent's neomigration of these organisms, actually. So you can actually have something that it originates in the gut. And because it's all connected via the abdominal cavity, that you can actually have trans migration of some of these things.
I'm not, I don't know a whole lot about that, but certainly we see, we see, yeah, those GI bacteria in places they don't belong. And same with the skin. We, we see, you know, gut bacteria dictating what happens on the skin and there, there's a communication there.
There's a communication. It's so yeah, there is definitely a communication happening. And is it happening all through the vagus nerve? Like, is it going all the way up to the brain?
That's fascinating.
I don't know the answer to that. I think.
But we're one system is the point. It's not like, you know, we, we talk about the GI tract and the, you know, GYN tract and all these things. Like it's actually in the context of a whole organism. And I think sometimes when we subspecialize, we can forget about these things.
Yeah. And I will say it's a dynamic system, just like we cycle each month in the uterus, it can change. And so I say that because I'm a very hopeful person, I think that you can't, you can change your gut microbiome. It's not going to happen by you just decide, Oh, I'm going to eat salads this week. It's going to take six to nine weeks to even start to see shifts. But the same with the uterus. I truly believe once you can identify what is the issue going on here, you know, was it, is it the IUD or is it chorio amnio, nytas or, or chronic endometriosis or, or something like that. Then you can start to, to take the steps to make the shift, whether that be a treatment course of antibiotics or something else. But along those lines, you know, I do get these patients where they, and I'm sure you've seen them where there it is refractory. You've treated with the course of appropriate and antibiotic, and it doesn't go away. It keeps coming back. And it's like, do we keep giving this person antibiotics? And I'm of the opinion, if you're going down a road and not getting where you want to go, I don't keep going down the same road.
Yeah, that makes total sense. Yeah. So do you think, I wonder, you know, sort of culminating in my mind, like for, for these people, perhaps it's not sort of continuing to hit people with, you know, doxy, ciproflagell, you know, uh, augmented, like it just, like, it just all these antibiotics that then have other effects. Like maybe we think about doing more with the vaginal probiotics and seeing what we can do on that end of things, something with a lot of lactobacillus in it. Our, our, um, one of my partners just gave a talk and it seems like even among the lactobacillus species, Alcrespata seems to, seems to be the most data behind that particular one. So make sure that you are listening to this and you have a vaginal probiotic, please make sure that that one in particular is in your probiotic. But I do wonder if maybe that would be like an underused tool that we have to think more about vaginal probiotics in terms of shifting the landscape for the GYN microbiome.
What do you think about that?
I don't know much about vaginal probiotics. I would imagine it's much like oral probiotics or, or the skincare products that you're seeing that have probiotics where it's still very much in its infancy. There's potential there, um, but maybe not enough data yet to say across the board, this is, this is what we should do, but it's kind of an exciting area. I mean, another exciting area or maybe not exciting for some people, but fecal transplants is something that we've used in infectious disease to treat C. diff colitis. But we've also found that people that have recurrent UTIs with, um, multi-drug resistant organisms have been eradicated in experimental studies with fecal transplants. And, and I mean, vaginal microbiome transplants is something that, that is being looked at. So lots of different options there, as well as kind of looking at the whole, stepping back, looking at the whole system and saying, what else is just, just regulated here? You know, why, why is that happening? Or, um, you know, you talked about the lactobacillus. There are many different species, different, um, people of different ethnic backgrounds have different predominances of lactobacilli.
And so considering that and, and what role does that play considering partners, microbiome is the partner introducing or reintroducing something that is disrupting, um, your, your clients microbiome that is, that is happening on a recurrent basis and just not being recognized.
So that's fascinating. So then how would we check for that? Would it be to look at the semen sample and, and look at the semen or a urethral swab of the Mendu? If we're talking about a male partner, they do carry, seem to carry lower, lower burdens of mycoplasma, genitalium and urea plasm, plasma, plasm on the, um, on the penis. So there's different, different utilities, but making sure, you know, if we're treating the patient or partner as well, over and over and over again, that's a really interesting thought. Um, so, so it sounds like, you mean it's, it's, it's frustrating from a clinician, like it's exciting and frustrating at the same time. So even a few years ago with this whole endometriode has came out and you, you know, great endometriobiopsy, I think that's pretty much standard of care, looking for plasma cells. And then, but then we'd get this report of like, and this is the smattering of bacteria.
And none of us knew what to do with it. It was like, okay, you know, do we treat with antibiotics? Do it like it, you know, it's, it's one of those areas where the science I think is advancing beyond what we need to, what we know what to do with it. And that's where we use our brains, use our biological possibility, try to find any day that we can and really support research in this area, because there are so many unanswered questions that I think really do have clinical impacts on people when we don't have a lot of clarity.
Yeah. Yeah. And they get these, these PCR probes. I get, um, referrals all the time of like a urine culture that's been probed and all these bacteria show up and they're all multi-drug resistant and the patient has zero symptoms. And what do I do with this?
They're, they're anxious and stressed out because the provider that's obtained this has said, Oh, you've got this, you know, terrible thing. There's no antibiotic that's going to treat it. You've got to go see this infectious disease doctor. And then in talking to them, they're totally asymptomatic. So we do have to really individualize our care. And, um, I love that, you know, we get the histology too, and we match the histology up, right?
If the probe might say this, this, and this, but then the histology might not support that at all. And then you can individualize the care plan and say, okay, what's, what's the risk? What's the benefit? If we hit you with this antibiotic, are we going to disrupt all this other bacteria?
So fascinating. Yes. Individualized care, I feel like is always the right answer. Um, I wanted to also ask you about the I this IUD use a question. And I think there's, you know, some preliminary data about long-term IUD use, both with, you know, quote unquote inert IUDs, like, you know, copper IDs, and also progestering containing IUDs that, you know, even after a year of discontinuation, that there can be sub fertility and infertility and, uh, you know, uterine microbiome alterations persistently, and maybe some of its hormonal related to the glands, but maybe some of it is related to a foreign body. What do you think about long-term IUD use? And I mean, obviously the hard thing is we want to not get pregnant when we don't want to get pregnant, you know, and that sort of like message, I think keeps people, even people with infertility, you don't know yet that they have infertility kind of very militant about the contraception and we all, you know, sort of have different, uh, perspectives on our training, but there, there may be for many people a time when they really can't get pregnant, but then it's like, once we decide it's time, and if we have issues, like, what do we do with that? So what do you think about IUDs and the microbiome?
Yeah, I don't have a strong opinion that they shouldn't be used. I did see some, I feel like it's very preliminary data that there might be an association with a shift in the microbiome, especially it seems like more with the copper, um, shifting and changing.
And it might be something to do with like a pH change. Um, my, my thought on that kind of the big picture thought is that this is a dynamic environment. And so, um, if you are creating a change, the, the hope would be that you can shift it back. But as soon as you decide that you want to head off on this fertility journey to get rid of that IUD, because you know, the longer on something, the longer it's going to take to reverse the changes that it made. And so I wouldn't definitely wouldn't say don't use IUDs, but it is a priority and they do get colonized with bacteria. And you know, there are some very specific infectious disease conditions we see associated with IUD use, but so infrequent that I, I would not say, you know, don't use an IUD I use an IUD, you know, and I've had one too. I mean, I think that as I look at one of our, you know, sort of thinking about the unit environment, one of our biggest problems right now too, in helping people, even people who can make good embryos is this persistent thin lining. How can we get to a thicker, better lining?
And some of us do feel, you know, sort of PCO, there's like a subset of people with PCO who it's really hard to get the lining and maybe that's due to progesterone resistance.
It's hard to say probably. But then it also seems like there's a subset of people who have had long-term IUD use and for them sometimes it's harder to get a lining as well. And so I think as we progress on and, you know, have more data, I think it'll be, you know, even better to help these people. But I think we just have to think about it. And like you said, just know that this an asterisk may be a risk factor. And so just being mindful about all the goals and how to balance all those things.
Yes. Yeah. Everything, you've got to take into all the perspectives into the consideration.
That's right. So as I think about our conversation, we talked about optimizing the gut microbiome, which then helps all of our health, including our fertility. We talked about, you know, looking at the GYN microbiome and just understanding the importance. And from my perspective, especially people who have had unsuccessful embryo transfers, really doing a deep dive to say like, is there any optimization we can do on that front? Right. And then if people have had longer term IUDs, just like thinking a little bit more about that just in terms of their, their care. Yeah.
So one thing I would like to talk about is antibiotic use because this absolutely affects the gut microbiome, but also the GYN microbiome. And I treat a lot of patients that are on a lot of antibiotics and I try to counsel on lifestyle modifications that could really help them minimize their antibiotic use. And about 50% are so receptive and make the lifestyle modifications and the other half don't, they want to continue doing the same things they're doing and just get the pill to fix the problem. So one example of this is chronic UTIs. So I talk a lot about water drinking because there are studies, scientific studies that show that if you increase your water intake, 50%, you decrease your UTI incidence by 50%.
And I have patients that just say, I can't do that. I have meetings all day. They're back to back. There's no time for, for a water break. You know, I, I'm on the golf course.
There's no bathrooms. You know, there, there's various reasons I say I'll pee all day. And I remind people that is the point is that is crawling up the urethra all day long and we're flushing down. And so I just want to make a plug for lifestyle modifications that could minimize antibiotic use that then could potentially preserve your vaginal microbiome.
Another one is chronic sinusitis. I have patients that say, Oh, I, every time, every time I get a cold, I need antibiotics. And I'm like, no, not every time. Most of the time it's viral and this will not do anything for you. Commonly prescribed antibiotic for sinusitis is going to be augmented and guess what kills lactobacilli really, really well. So if you can, if you can really be mindful about how can I minimize my antibiotic use or not jump, not reach right for an antibiotic or as a proven bacterial infection.
I'm so glad you said that because a lot of the debate is, well, if there's a small chance I might have chronic endometritis and I have to go through the rigmarole of a biopsy and then maybe a test of care, like all the things people just say, well, why don't you just give me empiric antibiotics up front? And I will tell you, like when I was a fellow, part of our protocol was everybody got doxycycline during their embryo transfer cycle. I mean, it was just like, there are still some programs that blanketly give people antibiotics. And so I feel like our patients and clients, they get more antibiotics than other people because we're always chasing our tail or even in every protocol putting in these antibiotics. So it's, I'm so glad you said that because I think we really need to challenge that mentality and that when you try to fix one problem sometimes you create another problem and this antibiotic stewardship is something we really need to take seriously.
Yeah. Yeah. And since the 70s, 80s, we've really seen a heavy increase in antibiotic use. And so, oh, I think this is one of the tolls of that seeing increased infertility and we just maybe are not quite putting all the pieces together yet. Many people get yeast infections when they get an antibiotic and exactly what is happening there is we are killing the bacteria in the vagina and the yeast that are also supposed to be there now have no competition for real estate. And so they're overgrowing. And so we have a very direct, experienceable, visible effect with a lot of antibiotic use. And so that does take its toll and that does affect how the body will interpret whether or not it's ready to support a 40 week pregnancy.
Yeah. That makes so much sense. And I think just thinking outside the box about it, thinking about all the different factors, thinking about antibiotic use is sometimes has pretty significant consequences and this sort of blanket use of antibiotics and just to try to like skip a step is actually probably hurting us more in the long run. But yeah, to think about the yeast infection, I think that's a really good analogy. And even to think about the, I didn't realize that the microbiome included like protozoa and fungi and all those things that make total sense, but it's not just bacteria and viruses. There's just so much more. So it's, it's fascinating.
It's a complex biological system in there.
It is so complex. So is there anything else you'd like to leave us with before you tell us where people can bind you?
Yes. I listened to the podcast that you did with Dr. Chayamakesha and it totally changed how I thought about stress. And so I want to encourage your listeners, if you haven't heard that one to listen to that, but stress does affect the microbiome. And so the chronic stress state is going to create a chronic inflammatory state in the microbiome. And so really managing your stress, whatever that means to you is also going to affect your fertility journey.
And whether that means setting boundaries or having scheduled downtime or however that is, I really think we don't think about stress necessarily affecting our gut. We think more about food, but stress is a big player. There's this whole gut brain connection and it's, it's a really important piece of So fascinating. And what we, the question comes up all the time, which is why we have a whole podcast episode on it, but I also, the fact that the gut microbiome is associated with neurotransmitters and I'm always saying nothing else is right unless the brain chemistry is right. So another helpful way to get at our brain chemistry is actually to help with the gut microbiome and get that sorted out too. So I think it's all connected, which is so interesting.
Yeah. Reinforce those positive feedback loops.
Yes, that's right. This is, this is going to change my life and how I approach my diet and my microbiome. So thank you so much, Dr. Coulter. Where can people find you?
I have a YouTube channel. It, I think will be linked, but it's Katrina Coulter MD. And then I also have a website Katrina Coulter MD. And if you're interested in a coaching opportunity, that's where you'll go to find out about that and make contact. And thank you so much for having me. This was a lot of fun.
Thank you so much. Yeah. We will definitely put everything in the show notes. This is such a science-based evidence-based conversation. And I think, you know, for me, I live and breathe this stuff every day. I heard new concepts that are going to change how I think about this. And for our listeners too, who are really trying to get answers, who are really trying to ultimately finally have success in their, these long journeys. I think this is going to shed some light on those too. So thank you so much for your wisdom. Thank you for being so prepared. Gold star, gold star for all your, I know I did, I did a lit search too, just because we want our people to know the most up-to-date information. And, and you know, people can, can now come and find you. My clients, my patients can call you for your coaching services too, if they want your perspective. So another plug for Dr. Coulter, who is just amazing, who I think we're finding with coaching, we're able to reach more people as long as the understanding is it's not medical care per se. It's, it's really taking our wisdom of all these long journeys and, and sharing our perspectives.
So thank you, my friends. This was a wonderful episode and I can't wait to have some more conversations about it. Thanks again, Dr. Coulter. It was so nice to have you.
