Dads- pay attention too!

In my fertility clinic, much of the discussion about pre-conception counseling, or what should be done to prepare for a healthy pregnancy, focuses on the female. We discuss a woman’s diet, vitamins, immunization status, supplements, exercise habits and more. New research is suggesting that dad needs to be involved in this health optimization before starting a family.

Epigenetics is a new hot term in science. We all have DNA, which is a roadmap of genes that encode the proteins that are expressed that make our bodies work. To describe it simply, epigenetics is the field that ensures that these genes are expressed at the right time, the right place, and the right amount. My research over the past three years has focused on epigenetics.

I am passionate about learning how our environment impacts our fertility. Epigenetics is an emerging link  to learning about your environment and how it may impact your genetic health: most toxins in our environment are not strong enough to cause DNA damage and mutations, but are able to impact gene expression, and ultimately the health of an individual, by altering epigenetic profiles. Exposure to endocrine disrupting chemicals in our environment, like those commonly found in plastics, induce epigenetic changes in sperm. Worse yet, these changes can be transmitted to future generations.

Recent studies suggest that epigenetic changes may be the key mechanism by which paternal factors such as age and weight contribute to health outcomes in their kids. For example, dads who smoke have children that are more likely to be overweight. Similarly, dads that are obese are more likely to have obese children as a result of epigenetic changes.

Dads- don’t lose hope. There are early indications that some paternal lifestyle-associated effects on sperm can be reverse through exercise, diet, and/or surgical weight loss. In my practice, I like to focus on the couple becoming the healthiest they can be before conceiving. Because ultimately, our goal is similar: we don’t just want to help you get pregnant, we want to help you be a healthy and happy family for generations to come.

If you’d like to take some steps to reduce the impact of your environment on your fertility, consider the following:

 

More Reason to Eliminate Phthalates from your home: impaired sperm function

We’ve already provided pretty compelling reasons why it is worthwhile to avoid these chemicals with a funny name but now there is even more evidence. A new study has now found that these chemicals can reduce the chance that a man’s sperm will make a healthy embryo. Bottom line is that paying careful attention to your potential exposure risk with both your chances of having a healthy pregnancy and a healthy home to raise your child.

Here are some easy steps that you can take to begin reducing your phthalate level today:

  • Only use nail polishes that are phthalate free—most add a phthalate called DBP to reduce chipping
  • Don’t microwave or cook your food in plastic containers or use plastic utensils to eat hot foods—heat leaches this chemical out of the plastics and into food—the easiest pathway into your body
  • Avoid plastic bottles—seek out glass or metal instead. When you must use plastic seek out bottles with the #2, #4 and #5 in the recycle triangle
  • Avoid perfumes and scented products—phthalates (DEP) are used to prolong fragrances
  • Don’t use air fresheners—most contain phthalates
  • Avoid vinyl containing products—many products like lawn furniture, rain coats or shower curtains can not only release phthalates that can be inhaled but they can also be absorbed through the skin as well.

Is YOUR Makeup Speeding Our Journey Toward Menopause? The Scary Association That You Need to Know About

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One of the first research projects I did on the impact that lifestyle can have on fertility showed that women exposed to a handful of common chemicals classified as EDCs (endocrine disrupting chemicals) go through menopause earlier than women who have less exposure. It gained a lot of media attention because several of the toxic chemicals I found in my study are common in makeup products. A more recent study highlighted the continued importance of addressing this issue in women’s health and prompted this post.

This group evaluated the top beauty brands for each type of makeup and found 1322 ingredients. They then went on to summarize the evidence suggesting the association between each of these chemicals and menopause. Most of the chemicals they found are absorbed through the skin, meaning that all these chemicals are entering our bodies each day. Although the group admits there aren’t enough studies to show a direct link between cosmetics use and menopause, I think it’s enough to have me question what I’m being exposed to on a daily basis and how it’s going to impact my health.

Even though you may be far from menopause, I think it is still important for you to consider how chemicals that you’re exposed to can be impacting your ovaries. Women who go through menopause early are likely to have a shorter fertility window, meaning that they may use up their eggs at a faster rate than someone else their age. In the fertility world, this can translate to women who respond less to medications or are less successful with their use of assisted reproductive technology compared to others their age.

As a woman, as a mother, and as a fertility specialist, my first response to learning how many chemicals we are exposed to daily was disbelief: Why aren’t we protected as consumers from these potentially toxic chemicals? Why are they still exposing people to these toxic chemicals? Although the Food and Drug Administration monitors the chemicals that go into food and drugs, cosmetics are not subjected to the same regulation. Here are a few things that we can do to protect ourselves by limiting the numbers of chemicals we are exposed to daily.

 

Take home points:

  • Women are exposed to 1000s of toxic environmental chemicals each day.
  • Some of the chemicals found in makeup have been linked to health problems, including earlier menopause
  • Physicians and patients need to do a better job learning about the risks to their health so that they can make more informed choices in selecting their personal care products
  • What you can do:
    • Limit the number of personal care products you use. For example, try to limit to one type of shampoo to minimize the exposure to multiple chemicals.
    • Avoid any personal care items that have fragrances or scents.
    • Read labels and support companies that disclose what their ingredients are and support their efforts to remove those that are not necessary or are suspected to be unsafe.
    • Be an informed consumer: know what you are being exposed to. Here is a list of great resources.

Zika Virus for Fertility Patients: here’s what you need to know

We’re all frightened by what we don’t understand. Many infectious diseases feed in to that fear. Consider for example the recent media frenzy over Ebola Virus; then again over Bird Flu and then more recently over Chikungunya—all of which have died down without the nightmare scenarios coming to fruition. Now we’re focusing on Zika virus.  This is admittedly scary due to its possible link to birth defects in babies born in Brazil. So let’s review what we know, what we don’t know AND what we can do in the meantime.

Recently the Society of Maternal-Fetal-Medicine held a special session to review this important topic and provide updated advice and guidance for women’s healthcare specialists in the USA. Zika is a virus transmitted by mosquitos. Those developing a symptomatic infection during pregnancy may be at high risk of having a child with a birth defect known as microcephaly. Although this link has not yet been definitively established it is recommended that we provide very close surveillance of any suspected cases while additional information is gathered. Although this sounds scary here are some of the key facts to keep in mind:

  • Only 1 in 5 people bitten by an infected mosquito is likely to develop an infection
  • Those infected have pretty specific symptoms including sore joints, a rash and conjunctivitis (red, swollen areas around the eyes)
  • The infection will appear within one or two weeks of the mosquito bite
  • The current test available is nonspecific and can create concerns due to false-positive results (a positive test due to a related virus that has not been linked with birth defects)
  • The Center for Disease Control and Prevention is monitoring places in the world known to have active Zika transmission for travelers and advising those that are pregnant or planning pregnancy to avoid traveling to those locations
  • Meanwhile, alternate causes of the fetal malformations are being investigated including a possible link to an insecticide widely used to control mosquitos in the area of Brazil most heavily effected by fetal microcephaly

Clearly we need to learn more about the Zika virus. In the meantime, here is some practical advice for patients that want to become pregnant:

  • If possible avoid traveling to areas effected by Zika for at least one month prior to starting fertility treatment
  • During mosquito season (as well as while traveling to effected areas) consider the following protective steps
    • Wear long sleeves when possible and stay in air conditioned facilities (rather than using open windows for cooling
    • Use insect repellants to reduce the risk of mosquito bites. Here are two that are among the safest (and least toxic) for women trying to conceive:
    • If you live in an area with a high rate of Zika virus exposure, consider undergoing fertility treatment and freezing the embryos for delayed embryo transfer–a process known as embryo banking.
    • If you develop the symptoms of rash, joint pain and red eyes, contact your healthcare provider to discussed current recommendations on testing.
    • Stay informed. If you subscribe to this blog, I will do my best to remain current on this topic.

For the latest updated information from the CDC on this emerging problem, check out the following link: http://www.cdc.gov/zika/

Latest Update 02/29/2016: “It’s entirely possible there’s something else going on in Brazil — something unique to the population or environment in which transmission takes place.”  – Dr. Anthony Fauci, Direct of National Institute for Allergy and Infectious disease 

http://www.latimes.com/science/sciencenow/la-sci-sn-zika-microcephaly-link-20160226-story.html 

 

Early Pregnancy Loss; simple changes to reduce your risk

 

One of the most challenging problems to diagnose and treat for couples trying to conceive is the problem of recurrent early pregnancy loss (REPL). As fertility specialists, we spend a tremendous amount of time and energy making sure that we control all of the variables that might improve the chances that a pregnancy gets a healthy start. New evidence shows that women can—and should—make some simple changes in their lifestyle to also improve their chances for a successful outcome.

 

A study presented at the 2015 meeting of the American Society for Reproductive Medicine recently highlighted the potential impact of a chemical called phthalates on the pregnancies of women going through IVF. This was part of a study called the EARTH study; an investigation on how environmental and lifestyle can impact reproductive health. They measured phthalate levels in the urine of about 250 women going through fertility treatment and then followed these levels in nearly 300 pregnancies. What they found was that women going through fertility treatment that had higher levels of this chemical in their body had a much higher chance of miscarrying then the fertility patients with lower levels. In fact, their risk could be as much as three to four times higher—depending upon their level of exposure.

 

An important aspect of modern research is to pose the question of “why?” In this case, the question would be “why would phthalates increase the risk of miscarriage.” The answer to that question is by interfering with the ability of ovary to support the development of the early pregnancy. Specifically, after an egg is released from the ovary; the cells that remain at the site of the egg’s origin form a hormone producing unit called a corpus luteum (CL). The function of this CL is to help get the pregnancy off to a strong start until the placenta is large enough to take over hormone production. In 2014 a well designed study found that phthalates directly interfere with the ability of the CL to perform this critical role.

 

A recent multi-centered clinical study found that women pursuing Advanced Reproductive Treatments (ART) like IVF had lower levels of phthalate in their body than infertility patients pursuing other forms of treatment. The believed explanation for this finding was that patients undergoing IVF may pursue healthier lifestyle choices. For instance, it is estimated that at least 90% of the phthalates in our bodies are due to dietary intake. By reducing processed foods and decreasing consumption of animal fats, phthalate levels fall rapidly. In fact, our bodies are able to eliminate phthalates after only 6 to 12 hours. So it is only through the continued exposure that these chemicals persist in the bloodstream. So by making better choices, patients may be able to reduce their risk of miscarriage by 75%.

 

Here are some easy steps that you can take to begin reducing your phthalate level today:

  • Only use nail polishes that are phthalate free—most add a phthalate called DBP to reduce chipping
  • Don’t microwave or cook your food in plastic containers or use plastic utensils to eat hot foods—heat leaches this chemical out of the plastics and into food—the easiest pathway into your body
  • Avoid plastic bottles—seek out glass or metal instead. When you must use plastic seek out bottles with the #2, #4 and #5 in the recycle triangle
  • Avoid perfumes and scented products—phthalates (DEP) are used to prolong fragrances
  • Don’t use air fresheners—most contain phthalates
  • Avoid vinyl containing products—many products like lawn furniture, rain coats or shower curtains can not only release phthalates that can be inhaled but they can also be absorbed through the skin as well.

HORMONE HAPPENINGS—Greene Guide’s News Recap

It’s time to review the latest findings in Reproductive Medicine. This month there are new insights into why more boys are born in the US than girls as well as a new strategy for women undergoing fertility treatment to reduce the risk of having a child with autism. As always, I have included links to the studies for you check them out for yourself:

  • More Boys are Born than Girls; here’s why—about 51% of all of the babies born are male. This observation has been consistent for several hundred years.  A new study  has provided the most comprehensive data to explain why we don’t see an equal number of boys and girls in the delivery room. It turns out that the explanation is based upon what happens during pregnancy; not prior to fertilization as previously assumed. The researchers found that although a higher number of male are lost during the first trimester; female fetuses are more likely to miscarry later in pregnancy. The end result is that a slightly higher number of males survive until birth than females.
  • Supplementing Estrogen Does Not Improve Pregnancy Outcome—there has long been debate amongst fertility centers as to whether or not additional estrogen is beneficial to pregnancy rates. New data  shows that levels higher than the normal physiologic ones are not helpful. Other studies have suggested the extra estrogen may even boost the risk of blood pressure problems later in pregnancy. Combined these findings support the ongoing trend to create a hormonally balanced environment rather than simply adding more.
  • Genetic Testing improves Live Birth Rate in Women over 40—using pre-implantation genetic screening (PGS) to identify the healthiest embryos for transfer is an effective tool according to new information . They demonstrated a live birth rate that was three times higher using this technique then using standard IVF alone for women over 40. This means that identifying healthy embryos prior to transfer is a highly effective strategy to achieve a successful birth.
  • Single Embryo Transfer associated with Lower Risk of Autism—previous data has suggested that there may be a higher risk of Autism Spectrum Disorder (ASD) associated with advanced reproductive techniques (ART). Other studies have shown that this is more likely age related or that it might be due to the population of patients seeking fertility treatment. This new study  found that when only singleton pregnancies result following IVF; the observed risk disappears. This is another good reason to consider elective single embryo transfer (ESET).
  • Vitamin D Deficiency associated with Lower Pregnancy Rate in IVF—a comprehensive review  of 34 published trials has found that women with lower than normal vitamin D levels have less success when undergoing IVF treatment. There is not yet proof that supplementing with vitamin D reverses this trend. However, given the other health benefits and the low cost of this “sunshine hormone” it sure makes sense to consider vitamin D supplementation for women whose level is lower than normal.
  • Smoking during Pregnancy can have Lasting Effects Upon your Child—it has long been recognized that women that were smokers had lower fertility rates, higher miscarriage rates and earlier onset of menopause than nonsmokers. New information  now suggests that at least some of these negative reproductive effects can be passed on their children as well. Specifically, they found girls born to women that smoked had an earlier onset of puberty than those born to nonsmokers. Noted by the investigators was that early onset of puberty is also linked to a higher risk of certain types of cancer including breast cancer.

[r1]Link to http://www.pnas.org/content/early/2015/03/27/1416546112

[r2]Link to http://link.springer.com/article/10.1007/s10815-014-0402-1?wt_mc=alerts.TOCjournals

[r3]Link to http://link.springer.com/article/10.1007/s10815-014-0417-7?wt_mc=alerts.TOCjournals

[r4]Link to http://consumer.healthday.com/cognitive-health-information-26/autism-news-51/ivf-kids-have-higher-odds-of-autism-study-finds-697622.html

[r5]Link to http://link.springer.com/article/10.1007/s10815-014-0407-9?wt_mc=alerts.TOCjournals

[r6]Link to http://www.reuters.com/article/2015/03/19/us-womens-health-smoking-pregnancy-idUSKBN0MF29W20150319

Successful Fertility Treatment; it’s about much more than what happens in the office

Whenever someone asks me “what else can we do to boost our chances?” it represents one of the most exciting and challenging moments of our interaction. It’s exciting because it shows a willingness to make changes in their current diet and/or lifestyle. It’s challenging because there are no simple answers and most of the data is rather loosely supportive of the recommendations. Fortunately better studies are coming out all the time.

The January 2015 Issue of the journal Fertility & Sterility put this topic front and center. The journal opened with a commentary  that pointed out the fact that each egg–even those from fertile egg donors–has no more than a 40% chance of becoming a successful pregnancy. Therefore, we need to look beyond what we do with the sperm and eggs and also direct our attention toward what else can impact their quality. A “global medicine approach” proposes  that we look at the nutritional status, environment and lifestyle for additional answers and better outcomes. The journal went on to present three papers to bring us closer to that goal.

The first study  looked at infant birthweight and the risk–several decades later–of male factor infertility. Specifically, they were looking at the theory that some male infertility begins in the womb prior to birth. Other studies have found results suggesting this happens for women; that low birthweight may increase the risk of longer time to conception and a higher risk of diminished ovarian reserve. That prompted this research to determine if the same might be true in men. It was. They found that men that were born with a birthweight less than 2,500 gm (normal is 2,500 to 3,500 gm at term) were at a higher risk of having a low sperm count and their sperm was more likely to have damaged DNA. They also tended to be overweight or obese which is also associated with male factor infertility. So nutrition during pregnancy can have lasting implications for the children that are born.

A second article  summarized the concept of “ecofertlility;” environmental toxins that may alter fertility. The examples that they focused on were those that were most common and most easily controlled, tobacco and marijuana since there is typically a choice to use or not use these substances. The authors reviewed a variety of studies that consistently demonstrate that women that are cigarette smokers tend to take about a year longer to conceive, have a higher rate of infertility and are more likely to have a diminished ovarian reserve than nonsmokers. Men were impacted similarly. Male smokers had a higher risk of abnormal semen analysis as well as a higher rate of erectile dysfunction. The authors also presented evidence that various substances produced by tobacco smoke appear in the fluid that surrounds the eggs and then have a very toxic impact. These substances may actually result in a higher rate of failed fertilization. This may explain why smokers have about a 40% lower pregnancy rate when undergoing IVF than nonsmokers. Even with sperm injection (ICSI) directly into the egg; the rate of “fertilization failure” is about three times higher in smokers. The impact of marijuana was more difficult to quantify. In men it has been linked to a higher risk of sperm abnormalities, as well as various hormonal dysfunctions including gynecomastia (increase in breast size), low libido and problems with erectile dysfunction. There is less data on women as exposure is difficult to accurately assess and monitor and correlate with egg function since exposure now may impact an egg many months (or even years) later.

Finally, in a third paper  they reviewed the potential impact of one of the most widely studied chemicals that we’re all exposed to called bisphenol-A (BPA). This chemical was first produced in 1891. It was identified to have estrogen-like activity as far back as 1936. Unfortunately, that did not stop its production and distribution. Today it is recognized as one of the most ubiquitous hormone disrupting chemicals. About 20% of the BPA produced—nearly 3.4 million tons per year—is used to line various food containers. From there, it has clearly been shown to leech into the food that we eat and then contribute to various health problems like diabetes, obesity, heart disease, lung problems, kidney disorders as well as various reproductive problems. The data on its toxicity has been alarming enough to prompt Canada from banning its use in baby bottles (2008). More recently the European Union went a step further and banned its use entirely in 2011. Here in the US, there is just now legislation  proposed to require clear labeling on food containers that contain BPA.  The study authors went on to provide a further note of caution by providing evidence that two chemicals that have been proposed to replace it—BPS and BPF—may have similar negative effects based upon animal data. Human studies are pending. The bottom line is that we need to pay more attention to the chemicals that we use to package our food in as they may actually taint our food supply as well as reduce our health and fertility.

As a reproductive health specialist, I don’t want to alarm my patients but I also don’t want to marginalize the potential impact of our choices upon our ability to initiate a healthy pregnancy. Although walking the line between concern and unnecessarily upsetting people may be a delicate one; I do feel compelled to empower those that are willing to listen. Success is not just about what happens in the clinic—it begins at home.

[r1]Link to http://www.fertstert.org/article/S0015-0282(14)02274-2/abstract

[r2]Link to http://www.fertstert.org/article/S0015-0282(14)02383-8/abstract

[r3]Link to http://www.fertstert.org/article/S0015-0282(14)02354-1/abstract

[r4]http://www.fertstert.org/article/S0015-0282(14)02351-6/abstract

[r5]Link to http://www.endocrine.org/membership/email-newsletters/endocrine-insider/2015/march-19-2015/endocrine-society-endorses-bpa-in-food-packaging-right-to-know-act