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Becky Saer: Hello, and a warm welcome to Becky & Ben’s Fertility Spotlight. I’m Becky.
Ben Saer: I’m Ben.
Becky: We coordinate IVF treatments, and we’ve got two wonderful IVF daughters aged 11 and 9.
Ben: Our focus is on the things that really matter to fertility patients.
Becky: In this episode, we’re looking at fertility nutrition. Our guest is Milena Mastroianni, a nutritional therapist and part of the team at Habitude.
Ben: Just so you know, our podcast is general information only. For a personalized diagnosis, always speak to a healthcare professional.
Becky: Let’s explore the fascinating world of reproductive nutrition.
Ben: We have a very special guest in the studio today, and that is Milena Mastroianni. I hope I pronounced that right, who is a nutritional therapist from the Habitude team, and something a bit more niche than that, which has been of great interest to both of us over the years. That is the health of the reproductive tract, you could say, on the female side, and the health of sperm on the male side. The thing I wanted to start off by saying is this. A lot of people listening will probably know about probiotics, the stuff they buy at the supermarket for their gut health, and they know about good bacteria and bad bacteria. Am I right in saying that it’s the same concept in the reproductive area?
Milena Mastroianni: Yes, it is the same concept. Everyone by now has heard of the word microbiome, right? It’s all the rage. Microbiome is simply a term to say a community of bacteria that live inside the gut, or they can live on other parts of our body. They can live on our skin. We have oral microbiome, we have our gut microbiome, as we just said, and then we have obviously the vaginal microbiome. There’s also now even more research about the seminal microbiome. All of this microbiome research has exploded in the last 10 years.
When it comes to the reproductive microbiome, it’s been mostly in the last five years or so, so it’s very new. We’re finding microbes in all sorts of places where we thought there was nothing, like it was sterile, like we thought the seminal microbiome was sterile, but it’s not. When it comes to the vaginal microbiome, though, there needs to be a differentiation between the gut microbiome and the vaginal microbiome.
When we talk about the gut microbiome, maybe we’ve heard that we have to have a diversity of plants because those feed a diversity of strains in the gut microbiome, so the more, the better, as it were. In the vaginal microbiome, it’s almost the opposite. In the vaginal microbiome, we want to have a dominance of a particular type of bacteria, which is mostly the lactobacilli bacteria.
Ben: We call that good bacteria.
Milena: They are good bacteria, yes. The reason why they’re good is because they produce lactic acid and they produce hydrogen peroxide, which sometimes ladies can see on their underwear as well, and that’s a good thing. That makes the vaginal environment acidic enough to inhibit pathogens coming in because obviously, that is an entry point of the body.
Becky: Can I just ask, what are pathogens exactly?
Milena: Pathogens would be bad bacteria. Let’s call them bad bacteria, but they would be bacteria causing infections. They don’t necessarily have to be STIs, but they could be typically bacteria, like for BV, thrush. We’ve all heard about these. Those bacteria, when they’re taking a bit too much space in the vaginal environment, unfortunately, they cause an imbalance, which we call dysbiosis. That dysbiosis often comes with inflammation and with a little bit more of alerted immune system. Most importantly, what we don’t want is we don’t want the translocation of the vaginal microbiome, any pathogens in the vaginal microbiome to go in the uterine cavity.
Becky: That’s interesting. Can I just ask, do the bad bacteria have any connection with infertility?
Milena: Yes. That is what the research is actually looking into, especially in the IVF context. We have more data in that context. We know that even in asymptomatic people, when there is an infection, which could be BV-related or it could be other bacteria, then there is a correlation with, unfortunately, a negative outcome of fertility treatment or IVF cycle. We do know there is this correlation. Obviously, the positive thing is we want to keep it in balance, but unfortunately, there is also the correlation with too many pathogens affecting fertility as well.
Ben: Let me ask then. It’s very interesting. A relatively new science. Certainly, 10 years ago, the patients we were helping 10 years ago, the clinic that we work with, I certainly don’t remember any protocols that included something for vaginal health or uterine health or whatever, in the same way as the yogurts did it for gut health. More recently, we have noticed it, haven’t we?
Becky: Yes, certainly.
Ben: The occasional protocol will include vaginal probiotics. It’s typically for patients, I think, who’ve had quite a lot of difficulties. In some cases, they’ve taken a test called the endomeTRIO test, which includes looking at the fauna, doesn’t it, the bacteria in the vagina. It’s quite interesting that fertility clinics are now aware that it’s not just about the sperm, it’s not just about the egg; it’s about the environment.
Milena: Absolutely, yes. That endomeTRIO test that you’re discussing, that looks at three tests specifically to the endometrium. The ALICE, EMMA, and ERA test. What they do is they do a– it’s almost like a biopsy of the endometrium. They obviously look at the proportion of bacteria in there, how many are positive, how many are negative. Again, this is where we want, ideally, not too many bacteria, but we want a majority of lactobacilli bacteria, which are the positive ones.
What they do, they just simply calm the environment, they calm the immune system, and they create a situation of low inflammation, whereas the pathogens, the bad bacteria, do the opposite. We don’t want that in a situation where there could be implantation.
Ben: It’s worth mentioning, isn’t it, Becky, that the endomeTRIO test that you’re talking about there, it’s a very expensive specialist test. Not everybody who’s thinking of having fertility treatment needs to immediately go towards that expensive test. That happens quite late for a lot of people. Are fertility clinics asking for more testing of people’s vaginal [crosstalk]
Milena: That is a wonderful question, actually. In clinic, this is the kind of test we would do ourselves as nutritional therapists. As I said, the vaginal microbiome is the entry point. We know there is a correlation between the endometrium and the vaginal microbiome. If we could ideally do a test about the vaginal microbiome early on in the fertility journey, there are quite a few vaginal, not endometrial, but vaginal microbiome companies around that you can do the test primarily. Ideally, you want to do it with a practitioner so that you can do something about it if something comes up.
Becky: Can you do it on the NHS, which is the National Health Service in the UK?
Milena: Unfortunately not. The issue with the testing is that because of that explosion in research, the technology has to keep up with it as well. In the NHS, unfortunately, the testing is pretty limited. It tends to be culture-based. Culture means that they take a sample, they grow in a petri dish, and they see what happens, what grows in there. Culture is okay for certain infections, but it won’t pick up everything.
From a private point of view, from other vaginal microbiome testing options’ point of view, we then moved on from culture to PCR, which COVID made famous. PCR looks at the genetic component of the bacteria, so it can identify more than the ones that grow in a petri dish. Now, even in the last few years, which is incredible, we have even NGS, which is next-generation sequencing technology, which actually looks at the whole microbiome, and then it can identify the percentages of the type of strain. Like you could say 80% lactobacilli, 1% pathogen.
Ben: That’s a genetic test.
Becky: This is a genetic test, yes.
Ben: NGS, if I’m right in saying so, it’s the same overall technique that they use for testing of eggs and embryos, isn’t it?
Milena: Not quite. Not quite the same. It’s very similar to the tests that you mentioned before, the endometrial, the three tests, because they also look at the whole microbiome, and they take percentages. If you imagine a pie chart, that’s what you would get as a result. You get the percentages of the different strains of bacteria that are inhabiting that environment.
Becky: For example, if you have a fertility patient visits your clinic, what do you advise to them? What do you say? “Okay, we’ve got to do this, and this”? What would be your plan?
Milena: I think in general, because of what we know about the vaginal microbiome and because of what we know about the correlation with infertility, if somebody is coming to a clinic because he’s struggling, that is almost a prerequisite now. If anything, you want to rule it out. The cost of this vaginal microbiome testing is much more convenient compared to endometrial testing, so we’re talking 200 pounds. Now we can do both vaginal and seminal microbiome, which is incredible because, at this stage, then we can see the correlation between the two because, obviously, if you think of the reproductive microbiome, things are shared, right?
Becky: That’s really interesting.
Ben: Yes.
Milena: If there’s some pathogens in one of them, the vaginal environment, there would probably be also in the seminal. Sometimes there isn’t, but we also, again, want to rule it out.
Ben: Once you know that there’s an issue that needs to be dealt with medically, do people take pills for that?
Milena: Yes. It depends what comes up. Most of the time, the first thing we look at is the lactobacilli population. Is that lactobacilli population big enough in the first place or stable enough? There are different lactobacilli. There are not many, but there are different lactobacilli in the vaginal tract. Some of them are stronger than others in producing those lactic acid, hydrogen peroxide materials to keep the vaginal environment acidic.
If we see that there are unstable lactobacilli strains, then we can supplement with probiotics that have got more of the stronger strains, which tends to be a strain called lactobacilli crispatus, or if there are pathogens, we also know there are certain lactobacilli species that may not necessarily be related to the vagina, but can be deterrent to the pathogens as well. It will all depend on what’s happening. In some cases, we have to also look at antibiotics because the infection may be more prominent and we need to act. Obviously, there’s often the consideration of time, right? When are people doing their cycle? When are they doing their transfer, for example?
Becky: They need antibiotics. Can you write a prescription, or do you have to go through a GP?
Milena: That is where things become a little bit more complicated. I tend always to write to a GP. We do want a relationship with the GP and the clinic, absolutely, because ultimately, we’re working for the same goal. The clinic sometimes are very happy to prescribe if they’re working with a clinic. If not, the GP, given an explanation through a letter, would do as well.
If that doesn’t work either, because unfortunately, GPs cannot be expected to be up-to-date with the latest research either. They have to follow the nice guidelines. If that doesn’t happen with the GP, then there’s always the option of private pharmacists that I can personally refer to that are versed in this context, and they would know which antibiotics to prescribe for what.
Ben: To go back just a little bit to our imaginary, as it were, fertility patient listening to this. This patient may be trying IVF for the first time, or they might have had several goes at it. Do you think, in terms of this microbiome health, they should be looking into it at the very, very start, or is it something maybe a little bit further down the line? Which is the best approach?
Milena: For me, obviously, if you’re symptomatic, I would do it straight away. Absolutely straight away, because obviously if there are symptoms, there is some sort of imbalance there. It could be–
Becky: Say, for example, you might have thrush, or you might have a tricky or STI or whatever.
Milena: Yes. The usual symptoms that people may get, like itching or irritation, that kind of stuff. If there is a symptom that is recurrent or there’s a history of it, absolutely test from the beginning because you just don’t want to waste time, especially if things are exacerbated after intercourse as well. If there is no symptom, maybe waiting about six months or so is fine to absolutely do that.
Then, especially if there is the idea of a particular treatment or a UI or IVF coming up, I would definitely do that in that case because even though the vaginal microbiome is not going to affect potentially the embryo, but it will affect the transfer side of things and the implantation side of things if there are issues. Again, it’s ruling out a potential that could be– In the case of miscarriages, absolutely, always.
Becky: Funny enough, I was just about to ask about miscarriages because we’re looking at uterine health, aren’t we? That is so key, isn’t it?
Milena: Yes.
Ben: People know because the patients that we help, there are other uterine interventions that we know of. I hadn’t heard of microbiome in the vagina or the uterus until just a few weeks ago, when we thought of inviting you. We know there’s a thing called the endometrial scratch, but that’s not related to the four now, as it were. We know there’s steroids that people consume. The clinics know that armory. Intralipid infusions is another one. To me, this is an extremely interesting area, and I’m sure we’re going to see more clinics taking this more seriously.
I wanted to move on, though, to how it relates to sperm health, semen health. A couple beginning their fertility journey, the male partner is going to have a semen analysis, and the female partner is going to have a blood hormone test and a scan. Should the male partner, alongside the semen analysis, be going to have one of these microbiome tests at the same time?
Milena: Yes. Ideally, if the lady is doing the vaginal microbiome test, then the male partner should do the seminal, ideally at the same time. Sometimes, what may happen is that the male is often asymptomatic anyway. Sometimes, what may happen is that the lady does the vaginal microbiome, something comes up. If something doesn’t come up, great. If something comes up, then we have to think, “Okay, where is that coming from?” Because of that sharing of microbiome, we need to think, is this something that is affecting the male side? Then we can do testing on the male side.
Even before all this NGS testing, urologists would test with culture for specific bacteria, which we knew, and we still know, affect semen. Not necessarily from the point of view of the results of a semen analysis, but more from a DNA fragmentation. Any infection in the seminal fluid would, unfortunately, impact the sperm, the head mostly, the DNA. They’re very, very delicate things. Any infection would affect the quality of the sperm.
It’s unfortunately something we don’t see in the semen analysis. Sometimes we can guess something may be going on if there are seminal analyses that maybe identify white blood cells or things like that. We see it more having an impact on DNA fragmentation.
Ben: I was going to mention that.
Milena: An oxidative stress.
Becky: I was going to mention that the DNA fragmentation test is the better-known genetic-based test, isn’t it, for sperm?
Milena: Yes.
Ben: Certainly, some of our patients have had that alongside the seminal analysis.
Becky: Can I ask about how the couples are when they come in? Do you find that they are quite nervous? Do they feel a bit shy about having these tests? What’s the general feeling when a fertility couple comes into your clinic? Can you generalize?
Milena: In general, if they’ve come to me, somehow they’ve heard about it as well. They’ve heard about it in the news. They’ve seen sponsored ads. There are a lot of companies, sperm tech companies, obviously, that work in this field. I think, in general, the lady has already prepared the gentleman, the male partner, about this conversation. I do tend to have mostly a conversation with the lady, with the female partner, and then somehow that gets translated in their own time. There’s nothing to be ashamed of because it is part of evolution.
Ben: In terms of that revolution, I sensed it a little bit because I went to a fertility fair recently. In the past, this fair had many, many stalls for clinics. This year, there were many, many more nutritional product companies and wellness companies. We’re seeing this age of wellness.
Becky: It’s kind of a revolution, actually.
Ben: It is. It’s the idea that people are taking more control of their overall fertility health, going beyond the traditional tests and procedures that were done 5, 10 years ago when we did it. Nutrition and owning of one’s nutritional health is so clearly augmenting itself as an option for patients. I think in five years’ time, we’re going to see even more of this.
Milena: There is definitely a movement towards empowerment, understanding your body better. Also, people want to find the answers of why they’re not getting pregnant. If this is something that can provide an answer, the most annoying diagnosis is unexplained infertility.
Becky: That was what we had.
Milena: If this can provide an answer and a reason, it’s so liberating and so empowering because there is a solution.
Becky: It’s really interesting. What comes across in this episode, interviewing yourself, is that you are such a good communicator. Now, I’m really interested in your background. Can you tell us a bit about how you became a nutritionist and where you came from in your professional life?
Milena: Yes. I started studying nutrition out of interest, as we all do sometimes, because of personal reasons. Health was not great at the time. It was okay, but definitely could have been improved. Then, when we started trying to conceive, it was quite later on in life. It was past the age of 35. Obviously, we were starting to hear clock ticking, messages all around. What we decided to do at the time was to apply what I was learning in my nutrition studies to our own lives. There wasn’t a lot around vaginal and seminal microbiome at the time, but there was definitely a lot about the gut microbiome and its impact on all the body, right?
Becky: This was how long ago?
Milena: That was more than 10 years ago. Through my nutrition studies, I had access to some of this testing that wasn’t normally available in the NHS. We were able to test a few things around, and basically, we were able to optimize our health as much as possible from what we were learning. That paid off because we were able then to, for pregnant later in life, 37 and 41, with healthy pregnancies. I knew as soon as I graduated, I wanted to work in the fertility space because I knew there could be so much that could be done to help couples.
Ben: Your personal experience, your personal journey, motivated you to look more closely at this, and the result is that you’re part of this movement that is seeing the importance of this particular kind of reproductive health.
Milena: Yes. Involving the couple. For me, it’s so important that both partners are aware that the implications come from both. It’s 50/50.
Ben: We also know, don’t we, that with infertility, half the time it is a male issue, half the time it’s a female issue, half the time it’s this dreadful term that you say unexplained, where you want to say, “Well, you’re the doctor, you explain it.” Any sort of thing that chips away at that unexplained bit, your field, has got to be a good thing. I’m sure there’ll be other things that come into the fertility space in the next few years or probably even now that are chipping away at that unexplained infertility infuriating tag.
Becky: I love the way that you mentioned empowerment and that couples are feeling more empowered to explore this kind of alternative, or I’m not sure if you like to be under the bracket of alternative, or holistic area. Couples are more confident, in a sense, to explore these avenues and not to go down, as Ben said earlier, the traditional medical scientific route. I’m not saying that nutrition isn’t scientific, but I’m saying that it’s definitely holistic, isn’t it, the idea that couples, or women especially, are looking at the whole body.
Milena: Yes, indeed. We’re not looking just at hormones.
Becky: Yes, exactly.
Milena: We are looking at everything because, ultimately, the body is connected.
Ben: Just as relevant to me as acupuncture, or reflectology, or yoga. In a sense, they’re holistic, aren’t they? They’re looking at the body in a slightly different way as well. People perhaps know a bit more at this stage about, “Oh, yes, let’s have acupuncture before and after our embryo transfer. Reflectology, we had it. It was good.”
Milena: If we’re talking about the microbiome side of things, let’s stay in that area. Let’s stay in the area of maybe the gut microbiome, how that can impact both seminal and vaginal microbiome. Mostly the vaginal, for sure. In that particular case, instead, what we look at is, as I said, we want to have a diversity of bacteria in our gut. Normally, the more diverse our gut microbiome is, the more commensal are in there. It’s because, normally, they’re fed by good food. The more diverse food we have and plant food, especially different colors, will feed the different strains.
Obviously, the gut microbiome will have an impact on immunity. Again, calming down that immunity, making sure that the body feels safe for fertility, especially. This is so important. It’s also very important for absorption. We know that it’s important for digestion, but we never think about absorption of nutrients. Our gut microbiome is where we absorb and sometimes manufacture some of our nutrients that are needed for fertility, like folate, B12. They’re also produced in the gut by our bacteria.
Ben: Just the gut. You talk about you’re getting closer to more of a general good diet through the gut. I know, having read up a little bit about this, that you can take oral pills, can’t you, of the good bacteria that can also reach the vaginal area. Is that right? This is almost like you should be asking this question, but should you just be taking vaginal probiotics, or can you take oral probiotics that get to your reproductive area?
Milena: In general, the way we should work in terms of probiotics is we should really be using a strain based on what we need it for. If we do need rebalancing in the vaginal microbiome or seminal microbiome, mostly in the vaginal, then there are particular strains that you can take orally. They don’t have to be necessarily used locally. There are also now brands that are producing vaginal probiotic in the form of pessaries, which you can use, but orally can work perfectly fine because, indeed, there is this translocation from the gut to the vaginal area. They’re quite close. We know that certain strains do reach the vaginal environment, the urinary tract, for example, if we’re talking about UTIs as well, that kind of stuff.
Ben: Am I right in saying that in this country, and again, I’m only saying this because some of our patients have been prescribed vaginal probiotics, and they find it quite hard to find those in the UK, and they were told to just take the best oral one you can find. Why is there a shortage of these things?
Milena: I think it’s changing. There’s definitely more. Even for me in the last year, I was struggling as well to find topical probiotics for women. There is definitely a change because there is more research. More supplement companies are coming up with products that can be applied topically as well.
Ben: There you are, those supplement companies that I saw at the fertility fair. You’re seeing the industry respond to that.
Milena: Yes, absolutely.
Becky: Can I just ask, how do you keep the gut healthy and the vaginal area or the seminal area healthy at the same time?
Milena: If you keep the gut healthy, that means that we tend to crowd out the pathogens in the gut as well. Some of those pathogens, things like E. coli, E. faecalis, which come from the gut, they are also often inoculating the vaginal and even the seminal microbiome. The more we keep the gut, we don’t have to necessarily destroy those strains, those pathogens. They just have to be kept at bay because they do have some function as well.
As long as we keep them at bay and we focus on really supporting our commensal with really rainbow foods, plant foods, also probiotics from fermented foods, they’re wonderful. As long as we keep those commensal happy, then we know we can influence the other microbiomes as well.
Ben: Well, Milena, honestly, it’s an absolutely fascinating subject. It’s something we would never have dreamed of discovering for ourselves when we did our treatment. We are seeing, as I mentioned, more patients talking about this and more clinics talking about this. Thank you so much for filling us in on all of this.
Milena: Thank you for inviting me.
Becky: It’s been really, really interesting. As I say, it’s very exciting. I think for fertility couples out there listening to you, I feel that it’s pioneering and a whole new frontier.
Ben: It feels like the tide is turning in this particular topic. I would be fascinated to know in five years’ time how embedded in the fertility landscape this becomes.
Becky: Thank you so much.
Milena: Pleasure. Thank you so much as well.
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Becky: That was Becky & Ben’s Fertility Spotlight. Read more about us on the podcast website, fertility-spotlight.com, or our social media, facebook.com/fertilityspotlight and instagram.com/fertilityspotlight.
Ben: All feedback is welcome, and do share this episode. If you’d like to make a donation, details are on the website.
Becky: Tune in next time for more fertility insights that could just boost your chances.
Ben: Do remember, always speak to a healthcare professional for medical advice specific to you.
Becky: Join us next time. Remember, don’t despair.
Ben: We’ll get there.
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The Vaginal Microbiome and Fertility – What We Know Now
Our guest blogger this week is nutritional therapist and fertility specialist Milena Mastroianni. She highlights the increased interest in the microbiome of the gut and reproductive tract – and how this impacts fertility and pregnancy.
In the last decade, the term microbiome has moved from research papers into everyday conversations about health. Most people are now familiar with the idea that the gut is home to trillions of bacteria that influence digestion, immunity, and metabolism.
What is still less widely understood is that the reproductive tract (male and female) has its own microbiome, and that this can play a meaningful role in fertility, implantation, and pregnancy outcomes.
The vaginal microbiome has become an area of growing interest within fertility care. While it was largely overlooked until relatively recently, it is now increasingly recognised as one of the factors that can influence reproductive outcomes, especially in cases where standard investigations have not provided clear answers.
What do we mean by the vaginal microbiome?
The vaginal microbiome refers to the community of bacteria that live in the vaginal tract. Unlike the gut microbiome, where diversity is generally associated with resilience and health, the vaginal environment functions best when a relatively narrow group of bacteria dominate.
In many cases, this balance is characterised by the predominance of Lactobacillus species. These bacteria help maintain an acidic environment through the production of lactic acid and other antimicrobial substances. This acidity creates conditions that discourage the growth of potentially harmful bacteria and helps regulate local immune responses.
When this balance is disrupted, a state known as vaginal dysbiosis can develop. Importantly, this does not always present with obvious symptoms such as thrush or bacterial vaginosis. Many individuals with an altered vaginal microbiome feel entirely well, yet subtle inflammatory changes may still be present.
Why does vaginal microbiome balance matter for fertility?
The vaginal tract is the entry point to the reproductive system. Sperm must pass through it, embryo transfer catheters pass through it during IVF, and more importantly, its microbial environment can influence what happens further upstream, in the uterine cavity.
Research has consistently shown that a vaginal microbiome dominated by Lactobacillus species is associated with higher implantation rates, improved pregnancy outcomes, and a lower risk of early pregnancy loss. Conversely, even in asymptomatic individuals, studies in both IVF and miscarriage research have linked reduced lactobacilli dominance to poorer reproductive outcomes, including lower implantation rates and an increased risk of miscarriage.
This does not mean that an altered vaginal microbiome is the sole cause of fertility challenges, but it can be one contributing factor among several. One key concept here is immune tone. A vaginal environment dominated by protective bacteria tends to be associated with lower inflammatory signalling.
In contrast, higher levels of pathogenic or opportunistic bacteria may stimulate immune responses that are less compatible with implantation or early pregnancy.
The expanding availability of vaginal microbiome testing
Alongside growing research interest, access to vaginal microbiome testing has expanded significantly in recent years, largely driven by the rise of femtech companies focused on reproductive or female health.
What was once limited to basic culture-based testing, which identifies only bacteria that grow easily in laboratory conditions, has now evolved into a range of more sophisticated options that can be accessed privately and at a relative low cost.
More recent approaches include PCR-based testing, which detects bacterial DNA and allows for more accurate identification of specific organisms. However, the most advanced options now use sequencing technologies, including next-generation sequencing (NGS) and shotgun sequencing, which analyse the entire microbial environment rather than isolated species.
These technologies make it possible to assess the vaginal microbiome as a whole and to report on the relative proportions of different bacterial groups, showing more clearly the balance between lactobacilli and other bacteria.
This shift from identifying single organisms to understanding overall microbial patterns has made testing more informative and clinically useful, particularly when considering fertility outcomes.
Finally, these new technologies are now being employed for testing and learning more about the seminal microbiome.
The emerging role of the seminal microbiome
One of the most significant developments in recent years has been the growing understanding of the seminal microbiome. Semen, like the uterine cavity, was long assumed to be sterile, yet we now know that it contains its own microbial community.
Emerging research suggests that the seminal microbiome can influence sperm health, particularly in relation to DNA integrity. An imbalance or the presence of potentially harmful bacteria within the semen may increase the risk of sperm DNA fragmentation. This is clinically relevant because a standard semen analysis does not assess DNA damage directly, and higher levels of DNA fragmentation have been associated with an increased risk of miscarriage, as well as reduced embryo development and implantation potential.
Another important consideration is that the reproductive microbiome is shared between partners. This means that microbial imbalances may move between vaginal and seminal environments, even when one partner has no symptoms. In some cases, looking at both environments together can help explain persistent findings or repeated imbalances that do not fully resolve when only one partner is treated.
Looking beyond the vagina: uterine microbiome insights
Advances have also been made in understanding the uterine environment. Again, this environment is far from sterile and, similarly to the vaginal microbiome, a dominance in lactobacilli appears to offer greater protection and is associated with more favourable reproductive outcomes.
Endometrial microbiome testing, often performed via biopsy, has been used for quite some time in more complex cases such as recurrent implantation failure or repeated miscarriage. These tests can be invasive and costly, and they are not always appropriate for the early stages of their conception journey.
More recently, alternative approaches have emerged, including the analysis of menstrual blood as a proxy for the uterine microbiome. While this remains an evolving area of research, it may offer a more accessible way to gather information in selected cases where repeated treatment attempts have not been successful.
Probiotics: a rapidly changing landscape
Another notable change over the last year has been the increased availability of vaginal probiotic products in the UK. Until recently, options were limited, and oral probiotics were often the only practical recommendation.
There is now a broader range of vaginal probiotic pessaries designed to support specific Lactobacillus strains associated with vaginal health. These can be useful in certain situations, particularly following antibiotic treatment or when targeted support is required.
Oral probiotics still have an important role, especially when selected based on strain and purpose. Certain strains are known to influence the vaginal environment indirectly translocate from the gut to the vaginal environment, highlighting once again the interconnected nature of the body’s microbiomes.
Greater recognition within fertility clinics
Clinical practice is also beginning to shift. More fertility clinics, particularly those outside the UK, are recognising reproductive microbiome testing and, in some cases, incorporating results into treatment planning. Vaginal and seminal microbiome assessments are being discussed more openly, especially in complex or recurrent cases.
While uptake and protocols vary between clinics, this growing recognition reflects a broader move towards viewing fertility as a whole-body process rather than focusing solely on eggs, sperm, and treatment protocols.
Conclusions: why this conversation is important
We now have access to broader testing options, greater insight into the seminal and uterine microbiomes, and increasing recognition of reproductive microbiome findings within fertility clinics.
This means that microbiome testing represents a meaningful step forward, particularly for those who have been told that everything looks normal, or who have experienced repeated setbacks without clear explanations. It offers an additional layer of information that can help move the conversation forward when standard investigations have reached their limits.
By placing the vaginal microbiome within the wider context of gut health, immune balance, and shared reproductive environments, it becomes possible to ask better questions and make more informed decisions. Rather than viewing fertility through isolated markers or single test results, this approach supports a more integrated understanding of reproductive health.
In my clinical practice, assessment of the reproductive microbiome sits within a broader picture of in-depth nutritional, metabolic, and hormonal assessment for both partners. This includes evaluating and supporting the gut microbiome, given its potential to influence immune balance and the health of other microbiomes throughout the body, including the couple’s reproductive microbiome.
Milena Mastroianni is a Registered Nutritional Therapist specialising in fertility and reproductive health. Her work is informed by both clinical practice and personal experience of starting her family later in life. She supports individuals and couples to explore fertility through a whole-body lens, offering guidance on personalised nutrition and lifestyle changes alongside advanced testing, to help identify what may be influencing outcomes and support more informed decision-making throughout the fertility journey.
www.rootandleafnutrition.com
To hear our podcast interview with Milena Mastroianni, you can listen to the episode below.
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Becky Saer: Hello, and a warm welcome to Becky & Ben’s Fertility Spotlight. I’m Becky.
Ben Saer: I’m Ben.
Becky: We coordinate IVF treatments, and we’ve got two wonderful IVF daughters aged 11 and 9.
Ben: Our focus is on the things that really matter to fertility patients.
Becky: In this episode, we’re looking at fertility nutrition. Our guest is Milena Mastroianni, a nutritional therapist and part of the team at Habitude.
Ben: Just so you know, our podcast is general information only. For a personalized diagnosis, always speak to a healthcare professional.
Becky: Let’s explore the fascinating world of reproductive nutrition.
Ben: We have a very special guest in the studio today, and that is Milena Mastroianni. I hope I pronounced that right, who is a nutritional therapist from the Habitude team, and something a bit more niche than that, which has been of great interest to both of us over the years. That is the health of the reproductive tract, you could say, on the female side, and the health of sperm on the male side. The thing I wanted to start off by saying is this. A lot of people listening will probably know about probiotics, the stuff they buy at the supermarket for their gut health, and they know about good bacteria and bad bacteria. Am I right in saying that it’s the same concept in the reproductive area?
Milena Mastroianni: Yes, it is the same concept. Everyone by now has heard of the word microbiome, right? It’s all the rage. Microbiome is simply a term to say a community of bacteria that live inside the gut, or they can live on other parts of our body. They can live on our skin. We have oral microbiome, we have our gut microbiome, as we just said, and then we have obviously the vaginal microbiome. There’s also now even more research about the seminal microbiome. All of this microbiome research has exploded in the last 10 years.
When it comes to the reproductive microbiome, it’s been mostly in the last five years or so, so it’s very new. We’re finding microbes in all sorts of places where we thought there was nothing, like it was sterile, like we thought the seminal microbiome was sterile, but it’s not. When it comes to the vaginal microbiome, though, there needs to be a differentiation between the gut microbiome and the vaginal microbiome.
When we talk about the gut microbiome, maybe we’ve heard that we have to have a diversity of plants because those feed a diversity of strains in the gut microbiome, so the more, the better, as it were. In the vaginal microbiome, it’s almost the opposite. In the vaginal microbiome, we want to have a dominance of a particular type of bacteria, which is mostly the lactobacilli bacteria.
Ben: We call that good bacteria.
Milena: They are good bacteria, yes. The reason why they’re good is because they produce lactic acid and they produce hydrogen peroxide, which sometimes ladies can see on their underwear as well, and that’s a good thing. That makes the vaginal environment acidic enough to inhibit pathogens coming in because obviously, that is an entry point of the body.
Becky: Can I just ask, what are pathogens exactly?
Milena: Pathogens would be bad bacteria. Let’s call them bad bacteria, but they would be bacteria causing infections. They don’t necessarily have to be STIs, but they could be typically bacteria, like for BV, thrush. We’ve all heard about these. Those bacteria, when they’re taking a bit too much space in the vaginal environment, unfortunately, they cause an imbalance, which we call dysbiosis. That dysbiosis often comes with inflammation and with a little bit more of alerted immune system. Most importantly, what we don’t want is we don’t want the translocation of the vaginal microbiome, any pathogens in the vaginal microbiome to go in the uterine cavity.
Becky: That’s interesting. Can I just ask, do the bad bacteria have any connection with infertility?
Milena: Yes. That is what the research is actually looking into, especially in the IVF context. We have more data in that context. We know that even in asymptomatic people, when there is an infection, which could be BV-related or it could be other bacteria, then there is a correlation with, unfortunately, a negative outcome of fertility treatment or IVF cycle. We do know there is this correlation. Obviously, the positive thing is we want to keep it in balance, but unfortunately, there is also the correlation with too many pathogens affecting fertility as well.
Ben: Let me ask then. It’s very interesting. A relatively new science. Certainly, 10 years ago, the patients we were helping 10 years ago, the clinic that we work with, I certainly don’t remember any protocols that included something for vaginal health or uterine health or whatever, in the same way as the yogurts did it for gut health. More recently, we have noticed it, haven’t we?
Becky: Yes, certainly.
Ben: The occasional protocol will include vaginal probiotics. It’s typically for patients, I think, who’ve had quite a lot of difficulties. In some cases, they’ve taken a test called the endomeTRIO test, which includes looking at the fauna, doesn’t it, the bacteria in the vagina. It’s quite interesting that fertility clinics are now aware that it’s not just about the sperm, it’s not just about the egg; it’s about the environment.
Milena: Absolutely, yes. That endomeTRIO test that you’re discussing, that looks at three tests specifically to the endometrium. The ALICE, EMMA, and ERA test. What they do is they do a– it’s almost like a biopsy of the endometrium. They obviously look at the proportion of bacteria in there, how many are positive, how many are negative. Again, this is where we want, ideally, not too many bacteria, but we want a majority of lactobacilli bacteria, which are the positive ones.
What they do, they just simply calm the environment, they calm the immune system, and they create a situation of low inflammation, whereas the pathogens, the bad bacteria, do the opposite. We don’t want that in a situation where there could be implantation.
Ben: It’s worth mentioning, isn’t it, Becky, that the endomeTRIO test that you’re talking about there, it’s a very expensive specialist test. Not everybody who’s thinking of having fertility treatment needs to immediately go towards that expensive test. That happens quite late for a lot of people. Are fertility clinics asking for more testing of people’s vaginal [crosstalk]
Milena: That is a wonderful question, actually. In clinic, this is the kind of test we would do ourselves as nutritional therapists. As I said, the vaginal microbiome is the entry point. We know there is a correlation between the endometrium and the vaginal microbiome. If we could ideally do a test about the vaginal microbiome early on in the fertility journey, there are quite a few vaginal, not endometrial, but vaginal microbiome companies around that you can do the test primarily. Ideally, you want to do it with a practitioner so that you can do something about it if something comes up.
Becky: Can you do it on the NHS, which is the National Health Service in the UK?
Milena: Unfortunately not. The issue with the testing is that because of that explosion in research, the technology has to keep up with it as well. In the NHS, unfortunately, the testing is pretty limited. It tends to be culture-based. Culture means that they take a sample, they grow in a petri dish, and they see what happens, what grows in there. Culture is okay for certain infections, but it won’t pick up everything.
From a private point of view, from other vaginal microbiome testing options’ point of view, we then moved on from culture to PCR, which COVID made famous. PCR looks at the genetic component of the bacteria, so it can identify more than the ones that grow in a petri dish. Now, even in the last few years, which is incredible, we have even NGS, which is next-generation sequencing technology, which actually looks at the whole microbiome, and then it can identify the percentages of the type of strain. Like you could say 80% lactobacilli, 1% pathogen.
Ben: That’s a genetic test.
Becky: This is a genetic test, yes.
Ben: NGS, if I’m right in saying so, it’s the same overall technique that they use for testing of eggs and embryos, isn’t it?
Milena: Not quite. Not quite the same. It’s very similar to the tests that you mentioned before, the endometrial, the three tests, because they also look at the whole microbiome, and they take percentages. If you imagine a pie chart, that’s what you would get as a result. You get the percentages of the different strains of bacteria that are inhabiting that environment.
Becky: For example, if you have a fertility patient visits your clinic, what do you advise to them? What do you say? “Okay, we’ve got to do this, and this”? What would be your plan?
Milena: I think in general, because of what we know about the vaginal microbiome and because of what we know about the correlation with infertility, if somebody is coming to a clinic because he’s struggling, that is almost a prerequisite now. If anything, you want to rule it out. The cost of this vaginal microbiome testing is much more convenient compared to endometrial testing, so we’re talking 200 pounds. Now we can do both vaginal and seminal microbiome, which is incredible because, at this stage, then we can see the correlation between the two because, obviously, if you think of the reproductive microbiome, things are shared, right?
Becky: That’s really interesting.
Ben: Yes.
Milena: If there’s some pathogens in one of them, the vaginal environment, there would probably be also in the seminal. Sometimes there isn’t, but we also, again, want to rule it out.
Ben: Once you know that there’s an issue that needs to be dealt with medically, do people take pills for that?
Milena: Yes. It depends what comes up. Most of the time, the first thing we look at is the lactobacilli population. Is that lactobacilli population big enough in the first place or stable enough? There are different lactobacilli. There are not many, but there are different lactobacilli in the vaginal tract. Some of them are stronger than others in producing those lactic acid, hydrogen peroxide materials to keep the vaginal environment acidic.
If we see that there are unstable lactobacilli strains, then we can supplement with probiotics that have got more of the stronger strains, which tends to be a strain called lactobacilli crispatus, or if there are pathogens, we also know there are certain lactobacilli species that may not necessarily be related to the vagina, but can be deterrent to the pathogens as well. It will all depend on what’s happening. In some cases, we have to also look at antibiotics because the infection may be more prominent and we need to act. Obviously, there’s often the consideration of time, right? When are people doing their cycle? When are they doing their transfer, for example?
Becky: They need antibiotics. Can you write a prescription, or do you have to go through a GP?
Milena: That is where things become a little bit more complicated. I tend always to write to a GP. We do want a relationship with the GP and the clinic, absolutely, because ultimately, we’re working for the same goal. The clinic sometimes are very happy to prescribe if they’re working with a clinic. If not, the GP, given an explanation through a letter, would do as well.
If that doesn’t work either, because unfortunately, GPs cannot be expected to be up-to-date with the latest research either. They have to follow the nice guidelines. If that doesn’t happen with the GP, then there’s always the option of private pharmacists that I can personally refer to that are versed in this context, and they would know which antibiotics to prescribe for what.
Ben: To go back just a little bit to our imaginary, as it were, fertility patient listening to this. This patient may be trying IVF for the first time, or they might have had several goes at it. Do you think, in terms of this microbiome health, they should be looking into it at the very, very start, or is it something maybe a little bit further down the line? Which is the best approach?
Milena: For me, obviously, if you’re symptomatic, I would do it straight away. Absolutely straight away, because obviously if there are symptoms, there is some sort of imbalance there. It could be–
Becky: Say, for example, you might have thrush, or you might have a tricky or STI or whatever.
Milena: Yes. The usual symptoms that people may get, like itching or irritation, that kind of stuff. If there is a symptom that is recurrent or there’s a history of it, absolutely test from the beginning because you just don’t want to waste time, especially if things are exacerbated after intercourse as well. If there is no symptom, maybe waiting about six months or so is fine to absolutely do that.
Then, especially if there is the idea of a particular treatment or a UI or IVF coming up, I would definitely do that in that case because even though the vaginal microbiome is not going to affect potentially the embryo, but it will affect the transfer side of things and the implantation side of things if there are issues. Again, it’s ruling out a potential that could be– In the case of miscarriages, absolutely, always.
Becky: Funny enough, I was just about to ask about miscarriages because we’re looking at uterine health, aren’t we? That is so key, isn’t it?
Milena: Yes.
Ben: People know because the patients that we help, there are other uterine interventions that we know of. I hadn’t heard of microbiome in the vagina or the uterus until just a few weeks ago, when we thought of inviting you. We know there’s a thing called the endometrial scratch, but that’s not related to the four now, as it were. We know there’s steroids that people consume. The clinics know that armory. Intralipid infusions is another one. To me, this is an extremely interesting area, and I’m sure we’re going to see more clinics taking this more seriously.
I wanted to move on, though, to how it relates to sperm health, semen health. A couple beginning their fertility journey, the male partner is going to have a semen analysis, and the female partner is going to have a blood hormone test and a scan. Should the male partner, alongside the semen analysis, be going to have one of these microbiome tests at the same time?
Milena: Yes. Ideally, if the lady is doing the vaginal microbiome test, then the male partner should do the seminal, ideally at the same time. Sometimes, what may happen is that the male is often asymptomatic anyway. Sometimes, what may happen is that the lady does the vaginal microbiome, something comes up. If something doesn’t come up, great. If something comes up, then we have to think, “Okay, where is that coming from?” Because of that sharing of microbiome, we need to think, is this something that is affecting the male side? Then we can do testing on the male side.
Even before all this NGS testing, urologists would test with culture for specific bacteria, which we knew, and we still know, affect semen. Not necessarily from the point of view of the results of a semen analysis, but more from a DNA fragmentation. Any infection in the seminal fluid would, unfortunately, impact the sperm, the head mostly, the DNA. They’re very, very delicate things. Any infection would affect the quality of the sperm.
It’s unfortunately something we don’t see in the semen analysis. Sometimes we can guess something may be going on if there are seminal analyses that maybe identify white blood cells or things like that. We see it more having an impact on DNA fragmentation.
Ben: I was going to mention that.
Milena: An oxidative stress.
Becky: I was going to mention that the DNA fragmentation test is the better-known genetic-based test, isn’t it, for sperm?
Milena: Yes.
Ben: Certainly, some of our patients have had that alongside the seminal analysis.
Becky: Can I ask about how the couples are when they come in? Do you find that they are quite nervous? Do they feel a bit shy about having these tests? What’s the general feeling when a fertility couple comes into your clinic? Can you generalize?
Milena: In general, if they’ve come to me, somehow they’ve heard about it as well. They’ve heard about it in the news. They’ve seen sponsored ads. There are a lot of companies, sperm tech companies, obviously, that work in this field. I think, in general, the lady has already prepared the gentleman, the male partner, about this conversation. I do tend to have mostly a conversation with the lady, with the female partner, and then somehow that gets translated in their own time. There’s nothing to be ashamed of because it is part of evolution.
Ben: In terms of that revolution, I sensed it a little bit because I went to a fertility fair recently. In the past, this fair had many, many stalls for clinics. This year, there were many, many more nutritional product companies and wellness companies. We’re seeing this age of wellness.
Becky: It’s kind of a revolution, actually.
Ben: It is. It’s the idea that people are taking more control of their overall fertility health, going beyond the traditional tests and procedures that were done 5, 10 years ago when we did it. Nutrition and owning of one’s nutritional health is so clearly augmenting itself as an option for patients. I think in five years’ time, we’re going to see even more of this.
Milena: There is definitely a movement towards empowerment, understanding your body better. Also, people want to find the answers of why they’re not getting pregnant. If this is something that can provide an answer, the most annoying diagnosis is unexplained infertility.
Becky: That was what we had.
Milena: If this can provide an answer and a reason, it’s so liberating and so empowering because there is a solution.
Becky: It’s really interesting. What comes across in this episode, interviewing yourself, is that you are such a good communicator. Now, I’m really interested in your background. Can you tell us a bit about how you became a nutritionist and where you came from in your professional life?
Milena: Yes. I started studying nutrition out of interest, as we all do sometimes, because of personal reasons. Health was not great at the time. It was okay, but definitely could have been improved. Then, when we started trying to conceive, it was quite later on in life. It was past the age of 35. Obviously, we were starting to hear clock ticking, messages all around. What we decided to do at the time was to apply what I was learning in my nutrition studies to our own lives. There wasn’t a lot around vaginal and seminal microbiome at the time, but there was definitely a lot about the gut microbiome and its impact on all the body, right?
Becky: This was how long ago?
Milena: That was more than 10 years ago. Through my nutrition studies, I had access to some of this testing that wasn’t normally available in the NHS. We were able to test a few things around, and basically, we were able to optimize our health as much as possible from what we were learning. That paid off because we were able then to, for pregnant later in life, 37 and 41, with healthy pregnancies. I knew as soon as I graduated, I wanted to work in the fertility space because I knew there could be so much that could be done to help couples.
Ben: Your personal experience, your personal journey, motivated you to look more closely at this, and the result is that you’re part of this movement that is seeing the importance of this particular kind of reproductive health.
Milena: Yes. Involving the couple. For me, it’s so important that both partners are aware that the implications come from both. It’s 50/50.
Ben: We also know, don’t we, that with infertility, half the time it is a male issue, half the time it’s a female issue, half the time it’s this dreadful term that you say unexplained, where you want to say, “Well, you’re the doctor, you explain it.” Any sort of thing that chips away at that unexplained bit, your field, has got to be a good thing. I’m sure there’ll be other things that come into the fertility space in the next few years or probably even now that are chipping away at that unexplained infertility infuriating tag.
Becky: I love the way that you mentioned empowerment and that couples are feeling more empowered to explore this kind of alternative, or I’m not sure if you like to be under the bracket of alternative, or holistic area. Couples are more confident, in a sense, to explore these avenues and not to go down, as Ben said earlier, the traditional medical scientific route. I’m not saying that nutrition isn’t scientific, but I’m saying that it’s definitely holistic, isn’t it, the idea that couples, or women especially, are looking at the whole body.
Milena: Yes, indeed. We’re not looking just at hormones.
Becky: Yes, exactly.
Milena: We are looking at everything because, ultimately, the body is connected.
Ben: Just as relevant to me as acupuncture, or reflectology, or yoga. In a sense, they’re holistic, aren’t they? They’re looking at the body in a slightly different way as well. People perhaps know a bit more at this stage about, “Oh, yes, let’s have acupuncture before and after our embryo transfer. Reflectology, we had it. It was good.”
Milena: If we’re talking about the microbiome side of things, let’s stay in that area. Let’s stay in the area of maybe the gut microbiome, how that can impact both seminal and vaginal microbiome. Mostly the vaginal, for sure. In that particular case, instead, what we look at is, as I said, we want to have a diversity of bacteria in our gut. Normally, the more diverse our gut microbiome is, the more commensal are in there. It’s because, normally, they’re fed by good food. The more diverse food we have and plant food, especially different colors, will feed the different strains.
Obviously, the gut microbiome will have an impact on immunity. Again, calming down that immunity, making sure that the body feels safe for fertility, especially. This is so important. It’s also very important for absorption. We know that it’s important for digestion, but we never think about absorption of nutrients. Our gut microbiome is where we absorb and sometimes manufacture some of our nutrients that are needed for fertility, like folate, B12. They’re also produced in the gut by our bacteria.
Ben: Just the gut. You talk about you’re getting closer to more of a general good diet through the gut. I know, having read up a little bit about this, that you can take oral pills, can’t you, of the good bacteria that can also reach the vaginal area. Is that right? This is almost like you should be asking this question, but should you just be taking vaginal probiotics, or can you take oral probiotics that get to your reproductive area?
Milena: In general, the way we should work in terms of probiotics is we should really be using a strain based on what we need it for. If we do need rebalancing in the vaginal microbiome or seminal microbiome, mostly in the vaginal, then there are particular strains that you can take orally. They don’t have to be necessarily used locally. There are also now brands that are producing vaginal probiotic in the form of pessaries, which you can use, but orally can work perfectly fine because, indeed, there is this translocation from the gut to the vaginal area. They’re quite close. We know that certain strains do reach the vaginal environment, the urinary tract, for example, if we’re talking about UTIs as well, that kind of stuff.
Ben: Am I right in saying that in this country, and again, I’m only saying this because some of our patients have been prescribed vaginal probiotics, and they find it quite hard to find those in the UK, and they were told to just take the best oral one you can find. Why is there a shortage of these things?
Milena: I think it’s changing. There’s definitely more. Even for me in the last year, I was struggling as well to find topical probiotics for women. There is definitely a change because there is more research. More supplement companies are coming up with products that can be applied topically as well.
Ben: There you are, those supplement companies that I saw at the fertility fair. You’re seeing the industry respond to that.
Milena: Yes, absolutely.
Becky: Can I just ask, how do you keep the gut healthy and the vaginal area or the seminal area healthy at the same time?
Milena: If you keep the gut healthy, that means that we tend to crowd out the pathogens in the gut as well. Some of those pathogens, things like E. coli, E. faecalis, which come from the gut, they are also often inoculating the vaginal and even the seminal microbiome. The more we keep the gut, we don’t have to necessarily destroy those strains, those pathogens. They just have to be kept at bay because they do have some function as well.
As long as we keep them at bay and we focus on really supporting our commensal with really rainbow foods, plant foods, also probiotics from fermented foods, they’re wonderful. As long as we keep those commensal happy, then we know we can influence the other microbiomes as well.
Ben: Well, Milena, honestly, it’s an absolutely fascinating subject. It’s something we would never have dreamed of discovering for ourselves when we did our treatment. We are seeing, as I mentioned, more patients talking about this and more clinics talking about this. Thank you so much for filling us in on all of this.
Milena: Thank you for inviting me.
Becky: It’s been really, really interesting. As I say, it’s very exciting. I think for fertility couples out there listening to you, I feel that it’s pioneering and a whole new frontier.
Ben: It feels like the tide is turning in this particular topic. I would be fascinated to know in five years’ time how embedded in the fertility landscape this becomes.
Becky: Thank you so much.
Milena: Pleasure. Thank you so much as well.
[music]
Becky: That was Becky & Ben’s Fertility Spotlight. Read more about us on the podcast website, fertility-spotlight.com, or our social media, facebook.com/fertilityspotlight and instagram.com/fertilityspotlight.
Ben: All feedback is welcome, and do share this episode. If you’d like to make a donation, details are on the website.
Becky: Tune in next time for more fertility insights that could just boost your chances.
Ben: Do remember, always speak to a healthcare professional for medical advice specific to you.
Becky: Join us next time. Remember, don’t despair.
Ben: We’ll get there.
[00:28:32] [END OF AUDIO]
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