Women with Polycystic Ovarian Syndrome (PCOS) can have a variety of symptoms including irregular/infrequent menstrual cycles, skin problems and weight gain. This creates a diagnostic challenge as many healthcare providers rely heavily upon these symptoms to make their diagnosis. New discoveries over the last two decades have demonstrated that PCOS is not a simple cluster of findings. Instead it is a spectrum of conditions with a variety of presentations. New information has provided greater understanding why some PCOS patients may present primarily with infertility alone and none of the other commonly associated symptoms.
PCOS is essentially a hormone imbalance. One of the most important hormones that is typically involved is one called Anti-Müllerian Hormone (AMH). What’s disappointing is that some physicians either don’t measure this hormone or don’t understand its implications. Many women with PCOS have very high levels of AMH. Having too much of this hormone may be their greatest obstacle to becoming pregnant.
A new study shows that AMH (referred to as Müllerian Inhibiting Substance or MIS in this article) can inhibit the maturation of eggs. In fact, it can be so potent that it may someday be used as a contraceptive. But most importantly, having a high AMH level can make a woman’s ovaries behave like a woman that has PCOS; even if she does not have any of the other common symptoms. Regardless of what we call this hormone imbalance; women with a high AMH often benefit from similar treatment recommendations as women with PCOS.
Robert Greene, MD, FACOG
Conceptions Reproductive Associates of Colorado
The problem of iodine insufficiency during pregnancy has troubled me for years. So much so that I spoke at length about this in pregnancy book that I wrote as well as the fertility book. Now there is a very brief video made by Dr. Michael Greger that explains this problem more articulately than I ever did with simple recommendations—check your prenatal vitamin! Only about half contain this nutrient that is so important for your baby to build a healthy brain. http://nutritionfacts.org/video/iodine-supplements-before-during-and-after-pregnancy/?utm_source=NutritionFacts.org&utm_campaign=94b0f568b9-RSS_VIDEO_WEEKLY&utm_medium=email&utm_term=0_40f9e497d1-94b0f568b9-23307533
Birth rates now are about half of what they were during the height of the “baby boom.” That’s because women are waiting to start their family until they are more settled in their careers, relationships and lifestyles. Unfortunately, this same study also found that about 40% of women between 44 and 50 years of age have had fewer children then they would have preferred. That’s why it is so important that women consider what their family buildings are and consider egg freezing during their mid thirties. Technology now offers women the best of both worlds; delayed reproduction and achieving their ideal family size! https://www.washingtonpost.com/news/wonk/wp/2016/08/16/why-american-women-are-having-fewer-babies-than-ever/
Too often people take for granted how special each conception and birth is when it occurs naturally. There are so many events that need to occur and so many factors at play that the opportunities for failure and misadventures are vast. As a specialist whose main job it is to help people overcome infertility or prevent yet another pregnancy loss, we need to create a unique plan for each patient/couple. In order to do so, we must take a few steps to better understand and organize their journey. I begin by categorizing the key factors into one of the four “P’s”: the patient, the partner, the passenger and the placenta.
- The Patient–this special designation refers to each woman that decides to become pregnant. Her role is paramount in the success of the process. She not only contributes the egg but also 280 days of around-the-clock care. During pregnancy, a woman provides her developing baby with each calorie, every breath of oxygen, and countless nutrients while maintaining a protective, safe environment. Think about THAT that next time that you celebrate Mother’s Day. During a fertility evaluation or an assessment for Recurrent Pregnancy Loss (RPL) we focus on the patient’s overall health/wellness. We assess her ability to produce an egg. And we evaluate her anatomy–uterus and tubes–for their ability to provide a safe haven
- The Partner–refers to male’s ability to fertilize an egg. This is why the male fertility evaluation is so simplified in comparison. Although we hope and expect for the partner’s full participation in raising the child; until birth their physiologic role is quite limited. This is the reason that male fertility evaluation centers on the semen analysis. More recent studies are now validating that simply observing sperm under a microscope does not rule out male contributing factors to infertility or miscarriage. But this simple test does identify most male factor problems.
- The Passenger–is a unique designation for each individual embryo that successfully implants and grows to become a fetus. Given that each egg and sperm represents a distinctive shuffling of the DNA of the person that they came from–their union represents another opportunity for individuality. Unfortunately, many of these unions are flawed from the beginning. Depending upon the severity of that flaw, they may fail to grow beyond a specific point in development. As a general rule, the earlier that failure occurs; the most severe the genetic anomaly. Studies have shown that typically, failed pregnancies come from flaws in the egg but sometimes it can either be from the sperm or an event that occurs shortly after conception. With today’s technology we cannot correct any of these genetic abnormalities but we can often identify them when they occur. One proven strategy has been to select embryos that are free of major additions or deletions of DNA prior to placing them into a woman’s uterus.
- The Placenta–is the connection that a developing fetus has with the woman carrying the pregnancy. It is through this vascular organ that a fetus receives all of its calories, oxygen and nutrients. It is also through this structure that all waste products are removed as well. But the placenta is not a just filter; it is a vital organ that also regulates a woman’s physiology throughout her pregnancy. It performs this function by producing most of the hormones that control a pregnant woman’s physiology. The placenta also regulates her immune system. Aiding a placenta to meet the needs of an ongoing pregnancy is something that steer the course of pregnancy; but only if the Passenger and Patient are healthy.
In closing, the process of becoming pregnant and delivering a baby is extremely complicated. There is rarely a single explanation for why any individual/couple is not achieving success. The best path for a successful outcome is to fully evaluate the situation in an organized fashion. Creating an organized plan helps assure that details were not overlooked. Through greater understanding, it is possible to create greater success as well as realistic expectations.
Writing about nutritional choices is tricky. One author recently compared our dietary choices as being like our own personalized religion. We’re all born into certain dietary patterns. Then as we grow, we either accept or modify these choices based upon our own belief as well as our own personal preference. Unfortunately today, many of the fad diets are like dietary cults—people not only want to make their own choice but they encourage others to embrace their decision as well. Unfortunately, most of these popularized diets are based upon scientific rhetoric. They often use encouraging language and small bits of science (often taken out of context) to try to create a compelling message. They want you to join them. As a scientist and a as a physician, I find this troubling because it often has a negative impact upon the care of my patients. For example, let’s consider gluten.
Gluten is a combination of proteins found in wheat, barley, rye, oats and various other grains. It has become a very prominent part of our diet because these proteins help dough to rise and retain their shape in baked goods. Although gluten has been vilified by some recent nutritional gurus; many foods that contain these proteins have major health benefits. These whole grain foods are attributed with a lower risk of developing obesity, diabetes, heart disease and various types of cancer. It is estimated that about 1-2% of us may have a true allergy or autoimmune disease (Celiac disease) as a reaction to these proteins. So let’s consider the possible health benefit for the other 98% of the population.
Gluten is also a prebiotic. Prebiotics are the nutrients necessary to help the healthy bacteria thrive within your body. A common reason that many people today are taking probiotics is because their diet is not providing these healthy bacteria the nutrients that they need to survive. However, taking a probiotic is not sustainable without feeding these healthy bacteria so they can thrive. There is also evidence that gluten can be an immune booster.
Natural Killer cells (NK cells) are part of your body’s immune system. Despite their ominous sounding name, they serve a sort of security role. They are responsible for identifying and eliminating dangerous invaders like virus infected cells and potential tumor cells—they keep you healthy. Ironically, they also serve a critical role in promoting pregnancy. When functioning properly, they enhance the ability of an embryo to implant and thrive. New studies are now demonstrating that gluten can actually facilitate healthy NK cell activity. Whatever the reason, there is convincing evidence that gluten containing whole grains are associated with higher pregnancy rates in patients that are trying to conceive.
Patients undergoing IVF provide a unique opportunity to study interventions in a closely monitored setting. Recently, the impact of eating whole grains was investigated at Harvard University as part of the Environment and Reproductive Health (EARTH) study. In this study they were tracking whole grain content by following the diets of women going through IVF treatment. They found that women that were eating more whole grains had a higher pregnancy rate and a higher live birth rate (53% vs. 35%) than those eating little or no whole grains. In fact, at least one serving per day of a whole grain food was able to boost the odds of success by about 33%. Another recent study that was looking at comprehensive dietary patterns and success during Advanced Reproductive Treatment (ART) found that women eating whole grain cereals had about a 30% greater chance of fertilization and early embryo development and an almost a 60% greater chance of becoming pregnant. Finally when researchers measured the urine for a marker of whole grain food consumption in a healthy population of fertile women they found that those eating more gluten containing foods took fewer months to conceive naturally. Taken together, it seems that we should encourage women that are not truly allergic to gluten to eat more whole grain as part of their fertility boosting diet.
You were born with every egg that you’ll ever have. Although studies suggest that there may be a process where we can create eggs; such technology is far into the future. More importantly, you’re losing eggs at a rate that far exceeds what you would guess. Current research suggests that most women will lose about 500 to 1000 eggs per month through a process of attrition called apoptosis—yet only one or two eggs each month will be capable of fertilization. A recent summary of all of the available research has shown that most women will only have about 3% of their eggs remaining by age 40.
Estimated number of remaining follicles (from birth)
Although the slope of that curve appears intimidating, the goal of this blog post is to increase your awareness and to empower you to take action. Some women are born with more eggs than others. Some women will lose their eggs at a faster rate. Most importantly, the eggs that remain in your ovaries at any given moment represent your ovarian reserve. Therefore, it is very relevant for you to consider how many eggs you have now and then plan how many (more) children you think you might someday wish to have.
This diagram shows the various stages of egg development summarized in a single ovary.
It takes an egg several months to develop from its status as a primordial follicle to that of a mature fertilizable oocyte. It is only when they reach that stage that the ovary releases the egg through a process called ovulation. Fewer than 300 of your eggs are likely to ever complete this journey. In other posts on this blog, we focus on various steps you can take to optimize the health of your developing eggs; but for now let’s focus on the future of your fertility in the months and years to come.
At least 99% of your remaining eggs are dormant—alive but not metabolically active. They have been in this resting state since you were a newborn. The eggs that are in these intermediate stages of development—which represents your fertility—can be estimated by a simple well timed blood test. Consider having your ovarian reserve tested today. Then think about how many children you envision yourself having. Consider when you will be ready to start or expand your family. By doing so, you can better estimate whether or not egg freezing or embryo banking (creating and storing embryos for future use) are steps you should be considering to assist you in creating your future family.
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