IVF with hGH: time to reconsider an under-used treatment option

One of the greatest challenges that we face in treating couples with infertility, is what options to offer beyond the typical treatment protocols. Clearly, most of our patients are well served with the basic ovarian stimulation methods but in some patients that may exacerbate or simply ignore an underlying hormone imbalance that’s compromising success rates. Therefore, one of the greatest challenges is to figure out how and when to tweak the typical combination of meds in order to shift the hormone balance back to a more favorable outcome. This is the reason that we should now reconsider the use of human growth hormone (hGH) for patients that have failed previous IVF treatment.

I trained under Dr. David Meldrum at UCLA-Harbor Medical Center in Los Angeles. Back in the early 1990’s he was advocating the consideration of adding hGH to the protocol of certain patients. His reasoning was good. First of all, we know from previous research [u1] that healthy developing eggs produce a growth hormone analogue known as IGF-2.  Better still, other studies [u2] have demonstrated that hGH could possibly increase the ability of eggs to repair damaged DNA. Finally, several studies have found that growth hormone can improve the response of the ovaries to stimulation during an IVF cycle. Given that all of this information has been available for quite some time, it may be surprising to a patient that there hasn’t been wider use of hGH during IVF treatment. Recently, Dr. Meldrum and several other experts [u3] suggested that this was because there remained too much confusion amongst specialists on which patients would benefit from the use of this somewhat expensive but also possibly game-changing hormone.

The good news is that recent studies [u4] have more carefully defined the characteristics of the patients that were receiving hGH. As a result, we have some new data to better guide us as to which women may be most likely to benefit from hGH. Here is a summary of what they found:

  • In women >40 years of age, they found a higher implantation rate and better on-going pregnancy rate in women treated with hGH during ovarian stimulation.
  • In women that are poor responders to ovarian stimulation—defined as three or fewer eggs produced per IVF cycle—there was a marked improvement in pregnancy rate with growth hormone supplementation. They also found an improved outcome in FET cycles from embryos created during these cycles.
  • In women that have poor embryo quality and low pregnancy rate in otherwise encouraging ART cycles, there is not be a clear benefit of using growth hormone. Instead, other causes of poor embryo quality should be explored. Once those have all been addressed, reconsideration of hGH is worthwhile.

Robert Greene, MD, FACOG

Protecting your child’s future: obesity prevention begins during pregnancy…or sooner

 The greatest healthcare challenge facing us as a society today is related to obesity. It is now estimated that by 2030, 42% of the population in the USA will be obese resulting in a rise in healthcare costs of nearly $149 billion per year. But beyond the financial cost is the impact that obesity has on an individual basis. It is clearly the leading risk factor in the development of heart disease, diabetes and many forms of cancer. Clearly any one of us would like to minimize the impact that this could have upon our own child. New research has confirmed that our efforts to insure a child’s healthy future should begin even before that child has been conceived. Theories were proposed nearly two decades ago that a child’s life-long health risks for problems like diabetes begin shortly after conception. But it is within the last 5 years or so that studies actually began to prove that characteristics like a person’s ability to regulate their body weight can be permanently altered by their mother being overweight or obese during pregnancy. That’s because our ability to regulate our calorie balance (i.e., hunger, satiation, metabolism, etc) has to do with the hormonal and chemical balance that our developing brain was exposed to during fetal development. Although the early studies were done on animals, it hasn’t taken long to establish similar ties in humans as well. For instance, one recent study found that for every 22 lbs that a woman was overweight prior to pregnancy, her baby’s birthweight would predictably be about a half of a pound over the average. Then for each additional 10kg that an overweight woman gains during pregnancy, her child’s birthweight increases by an additional half pound. Along with this higher birth weight is a higher risk of cesarean section and subsequent health problems in childhood. That’s because birthweight is the earliest predictor of how our physiology will respond to our high-calorie and increasingly sedentary lifestyle. Babies either above or below the averages are at highest risk of being overweight or obese before they reach puberty. It has been confirmed that when overweight or obese women become pregnant, their children are at high risk of developing problems with high blood pressure, elevated cholesterol and an increased risk of becoming diabetic before they complete their teenage years. Recently, the Center for Disease Control and Prevention revealed the shocking statistic that nearly one in four adolescents today has diabetes or pre-diabetes. That’s nearly triple the rate of just a decade earlier—an alarming increase. So while we work toward finding more treatment options for overweight children and teens, we should also put greater effort toward identifying and assisting women at risk. Intervention before they become pregnant and during pregnancy can not only improve their health (and fertility), but their child’s entire future. Here are just a few of the strategies that have been shown to work: • Whenever possible, assist patients in losing weight prior to conception • Encourage healthy nutrition during pregnancy • Promote exercise during pregnancy • Identify and treat insulin resistance as early as possible (preferably prior to conception) • Encourage breast feeding—helps mom get back to healthy weight after delivery while reducing rapid weight gain in newborn infants • Avoid hormone disrupting chemicals like bisphenonal A (BPA)—which have been linked with excessive weight gain

The Ugly Side of Beauty Products: many are loaded with toxic chemicals

Everyone likes to look and smell their best. But what is the real cost of that silky smooth skin and shiny hair? Cosmetics and personal care products contain various combinations of nearly 11,000 chemicals; only 11% of which have been evaluated for their safety. Maybe more concerning is that the Food and Drug Administration (FDA) [r1] has not set any premarketing standards for testing these products or disclosing the results when problems are detected. With the exception of California—which passed the California Safe Cosmetics Act of 2005 (Senate Bill 484)—the production of cosmetics is a self-regulated industry that generates over $50 billion annually. One easy (but inaccurate) way of trying to put consumer’s minds at ease by these companies is by promoting the notion that beauty products are applied externally and therefore have minimal opportunity to impact internal physiology.

Even though personal care products are applied topically; they are absorbed. How much they are absorbed depends upon several factors like, are they are applied near an opening (lipstick and eyeliner for instance gain entry easily); are they applied to a part of the body that is shaved (making for easier absorption); is it a moist or covered area (boosting the amount that penetrates the skin) and how often does is it applied or how long does it linger after application (dose). Another important aspect of a cosmetic’s ability to penetrate has to do with fragrance; the simple rule is if you can smell it, it is getting into your body and often into the bloodstream.

Let’s consider the example phthalates. These chemicals are plasticizing agents that add flexibility and a moisturizing sheen to products like nail polishes/nail hardeners, fragrances, mascara, lotions, shampoos/conditioners and sunscreens. If they appear on labels—not all cosmetics reveal ingredients—they are named for their specific chemical like DEP—most commonly used; DBP—used widely in nail polish; DMP—becoming more popular amongst manufacturers. They are well known for their ability to cause hormonal imbalance in both people and animals. They have been linked to early onset of puberty in girls[r2] , genital malformations in boys[r3]  born to women exposed during pregnancy and now there have been several studies linking them to an elevated risk of obesity[u4] . Most troubling of all, they aren’t even a necessary ingredient.

Nail products tend to be one of the greatest sources of exposure for women. Although one would not think a product could be absorbed through the nail, DBP is water soluble so slight amounts leach out each time the nail is wet. As a result, it can be absorbed by the skin or taken in orally if the leaching takes place during food preparation. In fact, the reason that nail polish becomes brittle and chips over time are due to the loss of DBP which is used to keep polishes flexible. Rest assured, there are phthalate-free products available now, and consumers have the right to be educated on why avoiding such hormone disruptors is important to their reproductive health.

The simplest way to reduce exposure to phthalates is to buy products that don’t contain them. By doing so, you’re also supporting manufacturers that are making more responsible decisions. If you’d like to check out your favorite brands as well as get some leads on healthy alternatives, go the Environmental Working Group’s Skin Deep Cosmetics Database[u5] . They have the lowdown on over 69,000 products.

The Newly Discovered Fat Hormones*

*The following is an excerpt from my book PERFECT HORMONE BALANCE FOR FERTILITY[u1] . If you’re working to lose weight or wondering if/how this may improve your chance for conception then read on…

Fat cells are not passive calorie warehouses, but rather mini endocrine factories that produce at least 20 different hormones, collectively called adipokines. These hormones direct your metabolism and help your brain keep track of your energy stores to control appetite and budget how your body uses this energy. Adipokines also help your brain determine if you have enough fat stores to sustain pregnancy. Your brain also takes into account how effectively you can share your energy with your baby—if you’re insulin-resistant, your body doesn’t channel energy to the fetus as effectively. As you modify your diet, fat cells adjust their adipokine secretions to bring them more into balance, improving your fertility profile. Here are some of the key adipokines and how they affect your weight.

  • Leptin tracks how many calories you have stored as fat—the more fat you have, the more leptin in your blood. When leptin levels are high, your brain suppresses your appetite and revs your metabolism to help you burn calories. But when leptin is chronically elevated, at it is in obesity, your brain tunes out the appetite-suppressing effect. Low leptin, on the other hand, signals low fat stores—a red flag that your brain should halt ovulation.
  • Adiponectin helps your body use fat as fuel. As you gain weight, though, you produce less adiponectin, and low levels are associated with fertility problems. As you lose weight, fat cells release more adiponectin, increasing your chance of conception.
  • Resistin is released by fat cells, resisting insulin’s ability to help store glucose. If you’re overweight, resistin rises, leading to insulin resistance and reduced fertility.

Are you seeing double? Recent CDC study reports on rising rate of twins.

  Reprint from post for Conceive Magazine Online > http://www.conceiveonline.com/articles/are-you-seeing-double
 If you haven’t had twins, chances are someone you know has. According to a recent report from the Centers for Disease Control and Prevention (CDC), one of every 30 babies born in 2009 was a twin. That’s nearly twice the rate of twins that was reported in 1980. The   biggest reason for this growth in twin rates is that more women are  having children later in life. Whether through fertility treatment or  naturally, the incidence of twins rose by 100 percent for women 35 to 39   years of age and by more than 200 percent when women over 40 conceived.Even when conception occurs naturally, women are more likely to have twins in their later reproductive years. That’s because as a woman ages the hormones produced by her brain to  signal her ovaries to produce eggs begin to shift into a higher gear. As   a result, a woman of 40 is at least twice as likely to conceive  twins—if she is still fertile—as she would have been at age 20. The  recent CDC report suggests that at least one-third of the rise in twin  rates may be related to the rise in the average age at which women are  having children.

But there are other factors at work as well. The increase rate of twins may be one of the best examples of how food choices can affect you hormonally. In 2006, a study demonstrated that women who ate two or more servings of non-organic  dairy per day were five times more likely to have twins as women who ate   no dairy at all. Other studies have shown that the growth hormones  given to dairy cows can stimulate a woman’s ovaries to release more eggs   at the time of ovulation. In fact, Britain banned the use of these  growth hormones in their dairy farms. British women are about half as  likely to have twins as women in the U.S.

These dietary influences aside, fertility treatment is the most easily documented factor in the rising rate of twins. More than half of the twins conceived today are through fertility treatment. A common strategy used to help women become pregnant is to increase the   number of eggs that they release; with this treatment comes the risk of  a multiple pregnancy. The use of medications to promote ovulation is   not easily monitored and is often prescribed by non-specialists, such as  gynecologists rather than reproductive endocrinologists (REs), which   specialize in the treatment of infertility. Nonetheless, these basic  fertility therapies are responsible for nearly half of the twin  pregnancies attributed to medical intervention; the remainder of the  twins produced through fertility treatment is the result of IVF (in  vitro fertilization) pregnancies.

In the process of IVF, eggs are  fertilized and allowed to go through their initial stages of  development in the laboratory. That allows REs to select the embryos  that are most likely to implant and become a healthy baby. Since the  process can be expensive, there is a tendency to put back more than one  embryo at a time. In fact, a recent experiment even suggested that when two embryos are transferred together they may interact in a way that improves the chance that they will both thrive. That can not only improve pregnancy rates, but it also increases the  risk of having twins.

As a fertility specialist, I know that many of my patients actually want twins. They are eager to complete their family and they view twins as a way of achieving their goal instead of having one child at a time. In other words, patient preference has also  contributed to the increase in twins. That said, the recent CDC report  did find that the rise in twin pregnancies due to fertility treatment  has leveled off considerably since 2005.

If you wish to minimize your risk of having twins, here’s what you can do:

  • Go organic. By  avoiding growth hormones, especially in dairy products, you may  minimize any      dietary boost to your chance of having twins.
  • See a specialist. A board-certified reproductive      endocrinologist is a fertility specialist      trained to safely improve your odds of  pregnancy while minimizing your risk of      a multiple pregnancy.
  • Consider IVF with ESET. Many patients going through treatment are considering elective single embryo transfer (ESET),      in which just one embryo is transferred during IVF, to reduce their risk      of twins.

Have you had twins? Were you counseled on steps you could take to reduce your risk or was this your goal?

Robert Greene, M.D., FACOG, is a physician at the CNY Fertility Center in central New York and the author of Perfect Hormone Balance for Fertility, Perfect Hormone Balance for Pregnancy, and Happy Baby, Healthy Mom Pregnancy Journal

Bisphenol A; a common hormone disruptor that may be impacting your fertility

Although regulatory agencies continue to debate the impact that chemical compounds have upon our health; endocrinologists and healthcare providers express growing concern about their impact. Currently there are about 80,000 commercially produced chemicals in the USA with about a 1000 new ones added each year. Many of these substances are classified as “hormone disrupting agents because of their ability to trigger hormone imbalance. Yet only about 5% of these have been tested for their impact upon our reproductive function. One of the chemicals that is produced in the largest quantities is the plasticizing agent called Bisphenol A (BPA).

BPA is so pervasive that we’re exposed to it through the foods we eat, the water drink, and the products that we apply to our skin. The US Center for Disease Control and Prevention estimates that 95% of us have measureable levels of this hormone-disrupting chemical in our body. In fact most of us are regularly receiving doses of BPA that are 20 times higher than the Environmental Protection Agencies target of acceptable daily 

intake (50 mcg/Kg). This level of BPA exposure has been linked to hormone changes that can promote obesity as well as increase the risk of heart disease and diabetes.  Finally, we’re beginning to understand how BPA can impact fertility in people.

Although it has long been known that this common hormone disrupting agent can impair fertility in animals; there was an absence of studies confirming this in people; until now.  A recent study has now confirmed that a majority of women undergoing IVF treatment have measureable levels of BPA in their urine. Worse still, women with higher BPA levels were able to produce fewer eggs that were also of poorer quality. As a fertility specialist that sees a growing number of women with unexplained decline in their ovarian reserve, I recommend that you don’t wait for additional proof. Here are some steps you can begin taking today to reduce any further impact of BPA upon your health and your fertility:

  • Switch to BPA free drinking bottles like those with a #5 stamped on them or use either glass or metal instead;
  • Purchase soups and foods packaged in cardboard cartons or glass instead of the plastic lined cans;
  • Hand wash plastic dishware with mild soap in warm water instead of using dishwashers for these products;
  • Don’t place plastic ware in microwave ovens to warm;
  • Express your support to companies that are voluntarily phasing out the use of BPA in their products.

Do your hormones feel out of balance?

Hormones represent an integral communication system. They are chemical messages that are made in one part of your body and sent through your blood stream to coordinate everything from digestion to ovulation. They even make it possible for you to sleep. They are essential to your health and wellness. Yet most people don’t realize that they also impact how you feel. Your energy level, your hunger even your physical attractions are profoundly impacted by what is happening in your body hormonally. Although we may not think of this delicate balance when we’re at our peak of fitness; people often have a strong sense of “imbalance” they’re not doing well. Yet these symptoms are often overlooked when they can actually provide tremendous insights into what’s going wrong as well as provide strategies to improved health and quality-of-life. By paying attention to your symptoms, you can feel better while boosting your chances of conceiving as well as improve the health of your baby. Here’s how it works.

There are over 200 hormones that can be circulating through your blood stream at any given time and new ones are being discovered every month. I like to think of these hormones in groups according to their function. Most people have heard of the fight-or-flight hormones associated with the stress response. The other groups to consider are tend-and-befriend, rest-and-digest, mate-and-relate. Think of them as if they are different elements on a mobile in a dynamic state of equilibrium; an imbalance in one group can cause an imbalance in another.  If you have too much stress hormone for instance, it can cause digestive problems, difficulty with sleep and infertility problems.

Some of the most exciting research in this field is shedding light on the dual role some hormones can play. For instance, one study recently demonstrated that the same hormone—called oxytocin—which is responsible for promoting feelings of love and affection can also contribute to jealousy and envy. Some imbalances can be ominous. For instance, another recent study demonstrated that women with even slightly reduced levels of thyroid hormone during pregnancy are associated with blood pressure problems during pregnancy.  That’s why I feel it is so important to consider how hormones interact with one another.

I’ve spent a decade and a half now studying symptoms and how they relate to hormone balance. In my books, I’ve tried to use questionnaires in order to help people gain insight into their own hormone milieu as well as provide practical tips on how they can restore harmony when problems occur. I encourage you to check out PERFECT HORMONE BALANCE FOR FERTILITY and PERFECT HORMONE BALANCE FOR PREGNANCY in order to learn more about how you can optimize how you feel as well as maximize your chance of success. And please check back here as I update this blog with the latest research in this exciting field.