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Phthalates: Male Fertility and Genitourinary Deformity Risks with Anna Sangster

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Phthalates: Male Fertility and Genitourinary Deformity Risks with Anna Sangster

Are you having a discussion about phthalate exposure to your male and female fertility clients?

Male fertility is a growing issue, from penile and genitourinary deformities to low sperm counts, the evidence is becoming clear; this is an issue that needs more attention.

Today we're joined by Anna Sangster who specialises in not only helping potential fathers to optimise the health of their sperm, but she's also passionate about helping parents to make educated health decisions that will impact their children, and their future generations.

Anna takes us on a concerning journey of our toxic world and how pollutants such as phthalates can affect the development of foetal male sex organs, even in-utero.

Anna's message is clear; we need to be having these conversations with our clients, no matter their age and no matter their current health journey, regardless of if they want to be parents now or in the future.

Covered in this episode

[00:56] Welcoming back Anna Sangster
[01:56] Specialising in fertility
[03:59] The concerning decline in male fertility
[06:58] Understanding male fertility decline
[12:04] Naturopaths can fulfil an educational role
[15:05] Genitourinary tract deformity: becoming more common
[17:14] Phthalates and other endocrine disrupting culprits
[26:02] Intervening to minimise exposures
[37:41] Be mindful of infant exposure
[40:06] Being a mentor



Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Anna Sangster. In her clinical work, Anna helps both men and women overcome reproductive health issues at all stages of life, from menstrual disorders, fertility issues, through to menopause.

Anna began her career in naturopathy in Sydney working at Wholistic Health Care, a centre that specialised in family healthcare and the treatment of children. It was at Wholistic Health Care that Anna began her journey into paediatric naturopathy, whilst also training in the area of reproductive health.

It was after the birth of her first child that Anna returned to Perth, Western Australia, to set up her own clinic called Perth Health & Fertility to combine her two main interests. Anna is presently doing a Masters Degree in Reproductive Medicine through the University of New South Wales. And I'd like to welcome you back to FX Medicine Anna, how are you?

Anna: Good. Thank you, Andy. How are you?

Andrew: I'm great, thank you. Now, we're going to be talking about something often skipped over because it's one of those sort of taboo subjects, and that's male fertility. We tend to sort of always, whether it's blame or whether it's automatically assume, that it's got to do with the woman. 

I think first we need to delve a little bit into your career. Tell us about how your career began and how you chose to specialise in fertility management.

Anna: Well, I was super lucky as a student in that I got a job at Wholistic Health Care actually working the dispensary there. And the principal naturopath, at the time, took it upon herself to pretty much train me in doing a lot of fertility work. So I would sit in and observe all of her cases. And I did that for my last three years of studying. And then I went straight in to working with her and then I decided to do the natural fertility management course. It was a residential course at the time, offered by Francesca Naish, which was life-changing. It was a really interesting, really fantastic course. And then I was lucky enough to be invited to join Francesca. So, I then started work at The Jocelyn Centre. And I was mentored at the time by Francesca and also by Susan Arentz. So, it was an incredible experience for a young naturopath at the time.

Andrew: And that belies the importance of mentorship, which you and I have spoken about previously.

Anna: Yeah, absolutely.

Andrew: Is there any specific area in which you just automatically tend to see more patients than others?

Anna: Well, at my clinic now we do, I would say, probably about 50% just fertility. So, if you have a couple who are struggling to conceive and have used IVF and it hasn't worked or couples that are hoping to explore natural conception. And that would be the majority of what we see. 

We obviously also see a lot of people on either end of their reproductive spectrum, so young girls with issues or women going through menopause. But we are seeing just more and more male fertility cases. 

Andrew: Yeah. 

Anna: So hence, my interest in that area.

Andrew: Have the types of fertility cases that you commonly see changed over the last, what, 16-odd years?

Anna: Well, I think definitely. I think what you said in your intro was incredibly true, where more and more...You know, the people that sit in front of you, there is the assumption that it's the woman's fault. And I think the media really do a good job in that in building up kind of the aging egg and women who are getting older.

But I think what we see more walking through our door is younger couples, which is worrying in itself, but more and more younger couples. And the man sits in front of you and we...All of our couples have to do semen analysis when they join us. And I think, you know, it's always a surprise to the man, but more commonly predictable, that there will be a sperm problem.

So, I think you've probably read that really interesting study that came out last year from Dr. Hagai Levine, and it was looking at the...It was a comprehensive meta regression analysis…

Andrew: Right. 

Anna: And between '73 and 2011. 

Andrew: Yep. 

Anna: And it showed about a 50% decline in sperm count. And what was really interesting was it included Australian men in that, and so Australian studies. It was so telling, that yes, in front of us, we are seeing a really marked decline in male fertility.

Andrew: Now, that was a study regarding sperm counts. Is that correct?

Anna: That's right. So, it looked at research between 1973 and 2011. And it really showed that in Western men there's been a sort of marked decline in count. 

But I think what's really interesting is it wasn't the first...it's certainly not the first time this research has come up. So, as far back as 1992, there was a study also published in The British Medical Journal by Carlson. He showed decreased sperm counts in the preceding 50 years.

But I think from the one from Dr. Levine, what was really interesting was it was looking at men that were unselected for fertility issues. So often when we're looking at, you know, pools of men, they're often men in fertility centres because they're having, you know, struggles with conception.

Andrew: It's a bias sample size.

Anna: That's right. But this research was done on men not selected for fertility. So this sort of stock standard men across the society, and we've seen this marked decline in sperm count.

Andrew: Previous research also showed this over the previous 50 years?

Anna: Yes. Yes, it's been shown quite often. But there's always controversy with these studies. So, you know, they're always saying it's not a...And that's totally fantastic because it provokes, you know, debate. But often these studies are looking at certain groups of men within society. 

Andrew: Right. 

Anna: So this most recent one because it was so broad that it really did highlight a decline in sperm count.

Andrew: So forgive me, so the previous research was a biased sample?

Anna: Well, no. Actually the Carlson one wasn't. I think you'll find that that was non-selected. But it was...I think when you start looking at an entire population with a declining sperm count, I think there's always...it always raises debate and controversy. 

Andrew: Yeah. 

Anna: So, the more recent one was fantastic in that I think it's now a bit more universally accepted that we really have an issue with male fertility.

Andrew: What are the current theories regarding the decline in male fertility? What do they think it's caused by? I remember one old one thinking about, like, population density and perhaps pheromones. There's also phthalates and things like that in our environment.

Anna: Well, that's actually what Dr. Levine brought to the public attention. And if you listen to any of his interviews right now, he's a real advocate for saying, "Look, one of the biggest issues that's linked to declining male fertility is our exposure to phthalates and pesticides." 

Andrew: Yeah. 

Anna: And I think this was...You know, when we're talking about, you know, penny-dropping moment, or you know, a changing moment. I think what's so interesting is the time frame in which these chemicals are thought to have their biggest impact.

So, although infertility is considered to be an adult problem because the chap sitting in front of you in consultation is a male adult saying, "Well, goodness, I've got no or I've got very low sperm count." What we're actually finding or what the research looks like it's pointing towards, is that the impact is possibly in-utero. 

So, all the way back, in the very beginning we're looking at when the foundations of spermatogenesis are actually being laid in that young foetus, we may be seeing the impact of phthalates there, which is very worrying.

Andrew: Where's the exposure of phthalates coming from in utero? I'm aware of like phthalates. You know, they're all banned now, the old rubber ducky. And that's obviously in kids. And you're thinking about a hot bath with a male child. But that's after they're born. When we're talking about in utero, what's happening?

Anna: So, well, there's lots of different sources of phthalates in our environment. So, yes, in certain children's products in certain countries they have been banned. But then phthalates are also wonderful at being used in personal care products for adhering smell to the skin. So, pregnant women who walk into my clinic covered in fake tan, with hairspray on, smelling of perfume, they're just sort of a bit of a cocktail of phthalates at the time.

So, we're looking at...And the research is really, really interesting, and I'd love to sgo through it with you because it looks, I think...So this is that aha moment of going, "Wow, this is a window of opportunity here where we can really make a difference, not just to the chap in front of us, but to his offspring." 

Andrew: Yeah. 

Anna: So, I think it's a potentially really exciting area for the naturopath.

So, what we're looking at is this window of...So when sperm and egg meet, for example, we either have an XX female genetic sex or an XY male genetic sex. But in-utero at that point in time, we're also to be bi-potential. So we can either develop male genitalia or female genitalia. And for an XY genetic male to be heading in a direction of making male genitalia, we need to make sure that there's enough testosterone present.

Andrew: Yep.

Anna: So, if we go back and have a look at what happens with that testes differentiation, we...What happens is we start making these cells called the Sertoli cells. And they start producing and differentiating. We then make the Leydig cells, the foetal Leydig cells. And they start making testosterone.

And the most important thing that happens right there is that testosterone stimulates the proliferation of those Sertoli cells. And what they’ve found, or what we think from animal studies and from...and different studies on humans, is that the number of Sertoli cells we make in this foetal window will be a really great determinant of how much sperm we can make as an adult. 

So, it's really important that that process of Sertoli cell differentiation is not interrupted. So we need adequate testosterone stimulation to not allow that process to be interrupted. So, if we go back...There's actually that...a theory that there's three pockets or three windows in a young...in a man's life, where we start with a...where we start making more Sertoli cells. 

So we've got a really big issue in foetal life. That's where we start making them. Immediately after we're born this other area...time of Sertoli cell proliferation. And once again just prior to puberty, and then that's it. It's a done deal. It's a locked in thing. Done deal. You've got how many cells that can make sperm in your body.

And so it's really important in that process isn't interrupted. And I think that that's where we've seen the impact of phthalates, is that because they have that anti-androgen effect, they can really affect Sertoli cell differentiation, and the ability of the Leydig cells to function properly.

Andrew: So we're talking counts here? What about morphology?

Anna: So, at this point in the development of the foetus, they're actually talking about count. So, Sertoli cells...So the number of Sertoli cells, if you talk about...It's an indicator of your ability to make sperm. It's also linked to testicle size. 

So, the number of Sertoli cells you make is one of the reasons...That's one of the reasons you all just have those wonderful little beads, I don't know if you've ever seen them, which they compare to male testicles because when you have very small testicles, the assumption is you have a very low number of Sertoli cells. And when you have lovely big testicles, the assumption is that you often have a greater sperm-making capacity because you have more Sertoli cells.

Andrew: Okay, so you mentioned about this window of opportunity that naturopaths have. What can naturopaths do to intervene in this sort of important area in-utero?

Anna: Well, I think if we understand that what happens in-utero has such profound effect on the fertility of the next generation of a child being born, I think then we can start helping and educate our patients to start seeing that they have this phenomenal ability to influence the health and reproductive capacity of their own offspring. 

So, we do a lot of education in our clinic where we're looking at and teaching our patients about endocrine-disrupting chemicals. And particularly in this context, about the impact that phthalates have in utero. And I think that that's the key.

So, it's interesting because some of the studies that we talk about are done by people linked to IVF clinics. But we never have patients coming in saying, "Oh yes, of course my IVF doctor told me to minimise my exposure to perfumes, aftershaves, deodorants, so you know, certain chemicals in my house." And I think that that's the role that naturopaths can play is that sort of wonderful educator role where we can help women identify, and help men, as well, identify their exposure to phthalates and start working at how to reduce it.

Andrew: Can I also ask, Anna, that we're speaking about foetal formation here and malformation, you mentioned previously that there's three windows of opportunity, if you like. Can we help a newborn child, if there is issues? I guess that might be an issue. What about puberty? Can we intervene then?

Anna: Well, that's an interesting question. Because I do talk about an irreversible and reversible impact of phthalates. So, the irreversible impact is generally prior to the child being born. So, you either make those Sertoli cells, and after that, you know, differentiation and proliferation of the Sertoli cells. Or if that process is interrupted, then they result, you know, in a lower number of Sertoli cells.

But the reversible area comes in when...once a child is born, and in those windows of opportunity. So we've got just after birth and pre-puberty, we can do everything we can then to reduce exposure. And obviously when, you know, a man's looking at, you know, trying to have a child, then we can again teach him how to reduce his exposure to factors that can reduce androgens in our body. Or have an anti-androgen effect.

Andrew: And would you have, like, a cumulative deleterious effect to, you know, if the child that's already been exposed to phthalates had future exposure to phthalates, and then his offspring might be even worse affected?

Anna: I don't know. They do talk about a transgenerational effect. But I think the great thing that we can help the patients learn is that they don't...Phthalates are ubiquitous and that's their problem. But they are...They don't have a very long half-life in our body. So if we do minimise our exposure, we do minimise their impact. So, it's just that unfortunately most people don't know how to minimize their exposure.

Andrew: We've mentioned sperm counts. What about things like morphology? What about things like the effect on birth with things like hypospadias or penile size?

Anna: That's a fantastic example. Because there is...It looks globally like there is an increasing incidence of hypospadia. So, just so everyone knows, that's when the urethral opening is...So the penis is not at the end of the penis. And it can be anywhere along the shaft of the penis or even in the scrotum.

So, it's actually a very common genitourinary tract deformity. It's very common. But it does seem to be having increase in incidence, which is an issue. 

Andrew: Right. 

Anna: And it's often also associated with that condition called chordee, which is when the penis has a bend in it. And it's also often associated with cryptorchidism. So that's when the testicles don't descend.

Andrew: Yep. 

Anna: And both of those are definitely linked...Well, both of those are thought to be linked to phthalate exposure. 

Andrew: Got you. 

Anna: And there's more and more research coming out that the severity of the forms of hypospadias...So, imagine a young boy being born and the opening to his penis or the urethral opening where urine is meant to come out and where sperm is meant to come out is actually found in the testicle. So, I know. And so it can be corrected. It can be corrected with surgery, but...

Andrew: Well, you you have long-term effects, haven't you?

Anna: Well, it does. And also they talk about there's less psychological effects, if it's corrected earlier. So, a boy can...You know, doesn't have to sit to urinate and he can...You know, he doesn't have psychological problems due to, you know, the shape and size and look of his penis. But it can also have longer-term fertility effects if...But mainly only the very severe forms have longer-term fertility effects.

But those two conditions or those three conditions are actually...are thought to be linked to phthalate exposure in utero. So when that penis...when it's developing, it really needs good androgen stimulation for correct development. And if we have chemicals like phthalates, it may interfere with that process. We do end up potentially with increased incidence of genitourinary tract deformity.

Andrew: Can I ask here, so are we only talking about phthalates or are there other culprits that we need to be aware of?

Anna: Well, that's a good question. The reason that I was particularly interested in phthalates is only because it has things like...Certain endocrine-disrupting chemicals have an oestrogenic effect. Whereas phthalates it's specifically thought to...One of the ways they act is kind of anti-androgen effect. And it's just in this window of opportunity or this window of development that it's so important to have testosterone and/or androgen secretion. And when we have that anti-androgen effect, that's when we start seeing the really deleterious effect of the phthalates.

Andrew: Right. 

Anna: But they also...And I was reading a really interesting or I was listening to an interesting podcast. And they were looking at the impact...And this is throwing a big theory right out there. But they were looking at the impact that possibly paracetamol is having on these sorts of problems, as well, in-utero. And they were saying does it potentially have a phthalate-like action? 

Andrew: Oh?

Anna: So what you were saying before is there are actually lots of different chemicals in the environment and different chemicals, man-made as well, that can have a really big impact on genitourinary tract formation at that really sort of vulnerable window.

You know, we've seen an increased incidence of those conditions like you mentioned, hypospadias. So, that we're looking at an incidence now of anywhere between 1 in 150 to 1 in 250 boys being born with these sorts of conditions. So, you know, it is fairly prevalent. And I think it is something that, you know, probably deserves more attention. And if we're looking at phthalates as playing a role, then the great thing is with education, phthalates can be avoided.

Andrew: Is there one set effect, if you like, from being exposed to phthalates all throughout or at different times during pregnancy. Or do you get different effects during different developmental periods?

Anna: Well, there is considered certain times in a woman's pregnancy when we are or when male foetuses are more vulnerable to the negative impact of phthalates. 

And this is obviously from animal studies. So, from rodent studies, they found what's called a foetal masculinisation programming window. And in humans, that's thought to be somewhere between about 9 and 14 weeks gestation. So, if we... And this is where some of the confusion from some of the studies on phthalates actually comes into play. Because if you do longitudinal studies and you do, you know, urinary metabolites and you measure them at let's say 20 weeks gestation and 30 weeks gestation, then you can't correlate that with, you know, genitourinary tract deformities that might be occurring in the first trimester.

So that's where, you know, it's really important when we read these studies that we understand what's happening as to what may cause certain problems. So, there is...In the eight to nine-week, that area/time of gestation, that's where they think there's going to be the really big impact of phthalates in terms of the potential for hypospadias. Whereas penile width, they look at it more being a bit later on, and so in the second trimester.

Andrew: And can researchers measure these levels of androgens in a first trimester foetus?

Anna: Well, what they actually do is there are certain markers that they take as to show us that androgen exposure. So, one of the big ones is the anogenital distance. So, male foetuses have a far greater anogenital distance than female foetuses because it's linked to androgens. So, the more androgens we have, the longer that anogenital distance.

And so that's used commonly in research in human studies and in animal studies to be a marker for androgen exposure in the first trimester. So, if we have lower levels of androgen exposure or higher exposure to phthalates, then the male foetus or the baby being born has a much shorter anogenital distance, which tells the researcher that they’ve been...something's interrupted that androgen exposure.

Andrew: So, we've spoken about other culprits. What about phthalate exposure causing other things than hypospadias and things?

Anna: It is. It's linked to obviously what we were talking about before is, you know, lots of genitourinary tract issues. It's also linked to...And these are studies that, you know, I think have a long way to go. But they're really interesting. 

And there have been studies linked to in utero phthalate exposure to poorer infant executive functioning, to attention issues, to motor reflex issues, and also to conditions such as allergies and asthma. So, on the whole, really a good thing to be trying to avoid.

Andrew: Wow. Absolutely. Well, so what about further research in this area? Like, this is a hot topic. You could go anywhere with this.

Anna: I know. So, there's been some really fascinating studies. So there was a TIDES study, which is a multi-centre study. And I think it's really an interesting read. And it basically looks at...It examines common chemicals in household products, in food, in cosmetics, and then it looks at...So, it's really interested in mother's exposure for the child in-utero. And then they're looking at markers of children's health and development.

So, I think they had about 753 mother-baby pairs in the analysis. And it doesn't just measure genitourinary tract issues. It measures everything. And it's really worth a read. But it definitely came back yet again showing exposure to phthalates reduces anogenital and anoscrotal distance, was linked to reduced penile width, reduced testicular volume. Is often also looked at as being an issue for placental damage. So, you know, the studies are fascinating and ongoing into this area.

Andrew: There was also a Western Australian study. It was Raine’s Study, is that right?

Anna: That's it.

Andrew: Yeah?

Anna: Yeah.

Andrew: What's the main sort of focus or thrust of that?

Anna: Well, the Raine Study was really interesting because the Raine Study was...One of the key authors was Professor Hart. Which is, so, local to... He's from one of the fertility labs in Western Australia, which is always interesting when you read anything to do with Western Australia in your research. And they were looking...And this just shows you how long this has been a problem because their study I think started over 20 years ago, and...

Andrew: Wow.

Anna: I know. So it's not...This isn't new stuff. This has been going on for ages. But unfortunately I just don't think it's being disseminated enough.

Andrew: No.

Anna: And quickly enough into the population saying, "You know what? You can do something here." 

So, that study started about 20 years ago and they actually...they were measuring...And unfortunately, with that study... And one of the things they do say in that study is one of the limitations is at that time, they were measuring phthalates as...in the serum whereas now, they're more commonly measured in...as urinary metabolites. 

Andrew: Right. 

Anna: But even then, the research is still saying, "These phthalates are causing a problem."

And now the young boys that have been born, I think they're in...they're about 22. And they're looking at the impact of maternal phthalate exposure. Bear in mind this is 20-odd years ago. To looking at their associations now with sperm counts and anogenital distance and testicular volume and what-not.

Andrew: Urinary metabolites obviously are those things that are being metabolised out of the body and being extracted. So, if you're catching what's coming out, do they correlate with serum levels, with what's in the body?

Anna: So, that's what they did. Generally they do to an extent. But I think that it's generally considered better now to look at the urinary metabolites, rather than the markers in the serum.

Andrew: Because it's non-invasive or...

Anna: No, actually I'd have to go back and have a look at the study. But actually we're talking about some of the different reasons why it's harder to capture it in the serum than it is in the urine.

Andrew: Okay. That's interesting.

Anna: So, I think what was interesting is, so Professor Hart from Fertility Specialists of Western Australia...and I think it's so exciting when you have people from...you know, sort of doctors from fertility centres looking at this impact of phthalates and saying, "Well, do you know what? This might be one of the big causes or this might be a cause, potential cause, or a contributing cause of fertility issues in men today." And I think that it might be the beginning of fertility labs starting to educate their patients saying, "Do you know what? We can do more than this. We can actually not just help you overcome your fertility issues, but hopefully help you have children that don't have fertility issues, that are making...you know, are having adequate Sertoli cell proliferation." 

And so therefore, the next generation has a better chance, rather than declining male fertility.

Andrew: By waiting until these couples visit a fertility clinic though, is that early enough to be able to change the future or do we really need to be, as naturopaths, doing our thing that we've been doing for decades about toxicity? Like, is this really the key where naturopaths can fit in?

Anna: Well, do you know, I think...One thing that Francesca Naish used to say is, "What we need to do is prevent a downward evolutionary spiral." And hopefully, we think with conception care what we're doing is creating an upward evolutionary spiral.

I remember that from 20 years ago, and I think that, you know, it was...it's what we need to be working on. So, I think, you know, there's a much greater community understanding now that alcohol and pregnancy is a problem. I think more and more people are recognising that obesity and pregnancy has potential, you know, really negative effects for offspring. And I think now is the time where we need that sort of greater awareness in the community that, wow, phthalate exposure may have a really negative long-lasting effect on, you know, male fertility.

And I think that if, as naturopaths, I think there's a phenomenal role that we can play in helping couples to recognise their exposure and how to reduce it. And hilariously, I think in clinical practice, the minute you start talking to a couple about, you know, trying to avoid their baby being born with hypospadias, or a short or small penis, or a bent penis, very quickly the male, you know, the man in the relationship, he's on board. He's ready to do anything to not allow that to be the problem.

Andrew: Yeah, which is interesting, isn't it?

Anna: It is. It shows what motivates us. And the same with the woman. I think if you start talking about, you know, "You want to be a grandparent. Let's look after your child in-utero," then I think it's really easy to inspire and encourage these couples to start making life changes. 

Because as soon as they can start seeing that, you know, these chemicals are potentially having these massive negative impacts on their hormones and on their potential for genitourinary tract deformities, you know, reducing.. if they can reduce their exposure, I think these couples jump on board really quickly.

Andrew: Poignantly showing the longer foresight of females versus males.

Anna: That's it. And, you know when we talk about that other window, when we're talking about how Sertoli cell proliferation, we see it in foetal life, we see it just after birth, and we see it in pre...in that sort of pre-puberty area, I think that one thing that really motivates me is I've got two boys. And when they come home talking about, you know, the Rexona wars in the gym change rooms...

Andrew: The what?

Anna: Rexona wars. So, spraying deodorant at each other. Thankfully, my boys hopefully don't do that, but...

Andrew: Oh, god.

Anna: I know. And this is that time when boys are starting to cross… They're starting to wear these products. And I think we have this issue of going...of educating them and saying, "Now is not the time to be using chemicals that may have an anti-androgen effect." 

So, that education I think...As naturopaths I think we have a phenomenally important role. And we really go to town in our clinic discussing, you know, the research into personal care products, about storing food in plastics. There's a really interesting study about phthalate levels and eating out. And people that eat out more or people that eat out in takeaway fast food restaurants have a much, much higher phthalate exposure.

Andrew: Eating out or eating from takeaway?

Anna: So, takeaway is the biggest disaster. 

Andrew: Yeah, yeah. 

Anna: But couples that eat out versus couples that eat home-cooked meals also had a higher level of exposure. So, just teaching...You know, it's not...This isn't like teaching...you know, asking patients to jump through hoops. It's asking patients to have a gentle look at their personal care products and providing alternatives. And, you know, looking at the sorts to food storage containers that they're using and, you know, with that person, you know, what's happening around the house with exposure to, you know, vinyl floorings and shower curtains and, you know, the raincoat that they bought their child, you know, those sorts of things.

They're looking at plastics in their home environment and starting to change them. And I think the really wonderful thing is then you've got these people who give birth to children. And they're already more conscious of what they're exposing their next...you know, their children to when they are born.

The couple that would come in and sit in front of us who've been trying for five years, they might both be smelling of either aftershave or perfume. They might be sitting there with their takeaway coffee cup or their plastic water bottle. They, you know, just washed and shampooed their hair. They've got their deodorant on, their makeup. You know, they've driven there in their brand new car that's off-gassing.

Andrew: Yes. 

Anna: They're sitting there with their muffin wrapped up in plastic in their, you know, their handbag for morning tea. And they have no understanding that this sort of continual thing that they do every single day may be having a really negative impact on their potential for reproduction. 

So, I think that, you know, these are simple things that make a really big difference. 

Andrew: Yeah. 

Anna: And I think that that's where naturopaths can come into their own.

Andrew: And all of the simple activities. You know, if you get a new car, it's not like you're going to not get a new car because of that concern. What about opening the windows when you get into the car? You know, like these really simple activities that we just don't understand. That's where I think our...the sort of naturopaths can really play a great part in reducing overall exposure.

Anna: Do you know, one other area of phthalate exposure which I think is really quite alarming and quite worrying is when we're looking at phthalates added to the PVC plastics in medical equipment. 

So, it's a really big issue because a young baby born premature is possibly going to be, you know, on a number of medical devices. 

Andrew: Yes. 

Anna: So they probably have a breathing tube. They have a feeding tube. They're going to be, you know, have an IV line. So there's all sorts of things where they are getting continual exposure to phthalates.

And I think there's certain slightly more proactive countries. So, even as far back as 1992, Vienna started phasing out phthalates in medical supplies, in medical equipment. Other countries have followed suit. So I think countries like Norway, the Czech Republic, France, they've all started, you know, saying, "Look, this is a problem, because in our hospitals, we are hot-lining phthalates into these...you know, into these babies." And it's not just in neonate wards. But some hospitals are doing it throughout. But it's not done yet here. 

And I think that you've got these critical windows of development. And, you know, a beautiful baby that is premature and struggling, at the best of times, doesn't need to be, you know, sort of supplied exogenous phthalates like that.

Andrew: Yeah, that's right. Okay, so, not blaming, but I'm just asking. Are any of these Australian researchers championing this issue?

Anna: I haven't read anything like that. I've read more studies...You know, my favourite, I think if I had to choose where I would live, so many of the wonderful studies do come from the Scandinavian countries. But interesting, like I said, it was Vienna that started that awareness.

Andrew: Wow.

Anna: But no, as yet I haven't read anything about Australian hospitals and what their future plans are. But I think that, you know, again, with public education and, again, with that public pressure, then hopefully we can see more and more hospitals choosing to use supplies that are phthalate-free.

Andrew: Yeah. When you're talking about these non-branded spray deodorant, antiperspirant sprays, do roll-ons make a difference, or are they...is it in the chemicals that's in the...

Anna: I think that you find that the difference between roll-on and spray is the aluminium. So, I think the...I'm not entirely sure. But I'm pretty sure that you inhale a lot more aluminium when you spray than rather when you roll-on. But in terms of phthalates, you're still going to be exposed to them. And again, as, you know, that sort of artificial fragrance with something making sure it adheres to your skin, that's where we get that exposure to phthalates.

Our exposure comes through three main areas. So either ingestion, inhalation, or dermal contact. So, we talk a lot about ingestion in terms of really trying to encourage people to store food in glass or in ceramic. About really trying to encourage patients to not heat things up in plastic ever, and not use Glad Wrap and not use all those sorts of products. Not use plastic water bottles, for example.

And then in terms of inhalation, I think a lot of that is understanding that we need to keep really good fresh air coming through. We need to not be using things that, you know, that have that incredibly strong smell. So, our shower curtains, our cheap plastic raincoats, you know, that sort of vinyl flooring. And I think that's...it's a really big issue for kids because they're low to the ground. And they're exposed to that at a much higher level.

And then dermal contact. I think that's the biggest one that we've seen, and which is, people are just covered top to toe in beauty products that contain phthalates. So, I feel personally so sad when I see a pregnant woman covered head to toe in a fake tan and you can smell that they've got, you know, some very strong perfume attached to it to try and cover the smell of fake tan. 

Andrew: Oh, okay. 

Anna: And I think that poor baby is just enveloped in...you know, inside of the woman covered in phthalates.

So, we do a lot of that, just educating them in simple ways that they can start making differences. And we try and do it in a non-alarmist way, but particularly if a woman is already pregnant. But I think just the education at that time frame goes on to help them learn about how is the best way to protect their children as well.

Andrew: Now, this is really important, you made an important point there, non-alarmist. And that is key. Because there's nothing worse than inducing stress and over-worry in somebody that it may have an issue. But to make them paranoid about it? Is probably the worst thing that we can do, and certainly instill guilt. So, what conversations do you have to introduce this sort of issue?

Anna: Well, so it would depend on who's in front of us. So if it's a couple that aren't pregnant, then I feel I can give them more information to try and help them, you know, direct them into, you know, safer products and safer alternatives. 

But often we also inherit into our clinic patients that come in who are already pregnant and want help and nutritional support through their pregnancy. And if the lady is already 6 weeks pregnant, 10 weeks pregnant, you know, 20 weeks pregnant, and you can tell just as they walk in that they're, you know, covered in perfume and they're drinking from their water bottle, then you're right. You don't want to alarm them. You don't want to cause concern. So just very gently you start talking about how would be beneficial for their child and also...So when the child's inside in utero now, but also when the child is born, that we start lowering exposure to these chemicals. But we certainly don't talk about conditions like hypospadias or the potential for hypospadias there and then because often by then it's too late.

Andrew: Yeah. So, what sort of lead time is best? I mean, obviously, you know, decades. But what sort of lead time is workable?

Anna: Well, I like, I do like...The ideal would be I'd, like, say three or four months with every patient to get them, you know, ready and healthy as they can possibly get to try and conceive and therefore have the healthiest offspring. 

But often, couples come to see us after they've been trying for four or five years. And so, you know...And often some of these women are older by this stage. They may have not been older when they started trying, but, you know, all of a sudden they’re 39 or 40, and they are not at all interested in not trying for three or four months. So we just very quickly say, "Right, that's it. Let's minimise exposure from today on." 

Andrew: Yeah. 

Anna: And I have to say that those are the couples that are so responsive. And it's not a big deal for them, they really came to make the changes. And they do it very quickly.

Andrew: Because they're concerned because of their age. Is that what you're saying?

Anna: Because they're concerned for the health of their offspring and because I think they would do anything to get pregnant. So they are a very highly motivated group, which is fantastic.

Andrew: What other routes can infants be exposed to phthalates?

Anna: So, again, that's an interesting one. So, I think it's quite funny when someone passes you their baby and they smell of perfume. So that's just from mum, you know, from cuddling mum and then completely being overwhelmed by mum's perfume and it's all over their skin.

I think one area that people forget is also what we wash our children's clothes in. So, you know, when you have...you know, one of my son's friends jumps into the car and the entire care now smells of a non-branded pool of washing detergent. So, I think we've got to be really conscious of what we wrap our kids up in, what we're exposing them in in terms of, you know, their bedding, their sheeting, their clothing.

And then I think also we've got to have the understanding that kids play close to the ground. And, you know, we really want to make sure that the toys that they play with are safe, that the floor that they're being on is safe, and that there's really good ventilation in the housing. So that we get that, you know, the fresh air blowing everything through as much as possible.

Andrew: Yeah.

Anna: And they do talk about...And this is the other thing that Dr. Levine brought up in the more recent analysis of looking at declining male sperm counts. And he was saying, you know, "We've really got a big issue with pesticide exposure as well." 

So, I mean, I'm a big advocate, if we can, of trying to make sure that, you know, we eat as much organic food as possible, and that young kids are fed as much organic food where it's, you know, affordable.

Andrew: Now that we have genetically-modified plants, my issue is, the point of genetically modifying them is so that they can handle pesticides. And the point of handling pesticides is not for the benefit of that plant, per se. It's to increase yield on the farmer's land by decreasing pests. And so what they do is they can load these plants up. And they don't get affected. But the humans though who ingest them, well, there you've got a cumulative dose, haven't you?

Anna: You do. And when you have researchers like, you know, somebody who's very prominent like Dr. Levine actually calling that out, then I think that hopefully, you know, it will have people sit up and start paying attention, and sort of going, "Wow. You know, we don't think of pesticides on plants as being potentially detrimental to foetuses in-utero," but if that is a potential, then I think, you know, it deserves a lot more research. And I think it deserves a lot more attention.

Andrew: Anna, there's one last question I have to ask you. And this is something I know about you. You actually mentor naturopaths in your local area, correct?

Anna: I do have...We have a group that I mentor. And at the moment we're very busy and very full. But obviously, if anyone is interested they can give our clinic a call because we're always trying to do the best we can to, you know, help as many people on board with understanding this area of reproductive health.

Andrew: Anna, I can't thank you enough. It's not just a burgeoning issue. This is a dangerous issue. And we have to act now to make sure that we have, as you say, an upward evolutionary spiral. Thank you so much for joining us on FX Medicine today.

Anna: My pleasure. Thanks, Andrew.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

Additional Resources

Anna Sangster
The Infant Development and Environmental Study (TIDES) 
Perth Health and Fertility Clinic
Francesca Naish
Dr Susan Arentz
Dr Hagai Levine
Prof Roger Hart

Research explored in this episode

Levine H, Jorgensen N, Martino-Andrade A, et al. Temporal trends in sperm count: a systematic review and meta-regression analysis. Human Reproduction Update, 2017 Nov 1;23(6):646–659

Carlsen E, Giwercman A, Keiding N, et al. Evidence for decreasing quality of semen during past 50 years. BMJ. 1992 Sep 12;305(6854):609-13.

Hart R, Frederiksen H, Doherty D, et al. The Possible Impact of Antenatal Exposure to Ubiquitous Phthalates Upon Male Reproductive Function at 20 Years of Age. Front Endocrinol (Lausanne). 2018;9:288.

Other podcasts with Anna include:


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