- FOLATE aka FOLIC ACID (most important)
- +/- Iron (this can also be supplemented separately as needed, such as for anemia)
- Folate reduces risk of neural tube defects (birth defects), such as spina bifida
- Iodine optimizes thyroid health and fetal brain development
- Optimal to start about 3 months prior to conception
- Take 1 serving (number varies by vitamin) daily
- At least 400 mcg folate per day, but individual needs may be higher
- 150 mcg per day of iodine
- Any pharmacy or grocery store, or available online
- Limited evidence for other ingredients, but they are usually not harmful.
- It is important to avoid excessive quantities, such as for Vitamin A or B vitamins.
Which are legitimate products?
- Prenatal vitamins can be given as a prescription from your doctor
- Prescription brands are FDA-regulated
- Direct-to-consumer (aka over-the-counter, or OTC) brands are not as strictly regulated
- If you buy it OTC, check for the following certification standards:
- Look for NSF (National Sanitation Foundation) certified
- Or look for USP (United States Pharmacopeia) verified
Bisphenol A (BPA) is commonly found in plastics and the majority of us are exposed to this hormone disruptor multiple times daily. We previously introduced BPA and the negative health impacts here. We know that BPA exposure when trying to conceive can negatively impact multiple aspects of your health, including your fertility and the likelihood of your children having health problems.
New basic science research is adding to our previous concerns about this endocrine disrupting chemical:
- BPA negatively impacts how an egg matures and egg quality by increasing DNA damage and oxidative stress. This study also shows the potential for the damage that BPA causes for mom to impact her future children.
- BPA can decrease sperm count in males and lead to neurodevelopment problems in their children. This study also was associated with increased obesity in female offspring.
What you can do:
- 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.
At a recent trip to Target, I realized just how many things are labeled as “antibacterial.” But what is antibacterial, anyways? And why do we need it?
“Somehow, through marketing or misinformation, we’ve been led to believe that if we get rid of bacteria, we’ll improve our lives and our health. In fact, the opposite is probably true” –Dr. Martin Blaser In fact, to date, there is no evidence that washing your body and home with antibacterial products does any good compared to old fashioned soap, water, and scrubbing!
Triclosan is an anti-bacterial compound added to personal care products like soaps but it is also added to plastics found in toys and medical devices. Triclosan is so common that the majority of people in the US population are exposed to this chemical; triclosan exposure is real and widespread.
Breaking news this week reveals that triclosan may target the ovary and make it harder for a woman to conceive. This group investigated whether ovarian reserve, a marker of how many eggs a woman has and how she might respond to fertility treatment, was different in women with high levels of exposure compared to those with lower levels of exposure. They found that antral follicle count, a marker of ovarian reserve, decreased as the triclosan levels increased. Perhaps even more concerning was that this relationship became even stronger in lean and young women, suggesting that this may contribute to reduced natural fertility and could lead to a need for fertility treatment at a younger age.
Other studies have found similar concerning results: women with higher levels of triclosan exposure take longer to conceive when compared to women with lower levels of this chemical. Triclosan is also associated with lower oocyte yield in couples undergoing IVF. Similarly, triclosan has been found to disrupt implantation of a pregnancy and alter placental function, leading to pregnancy complications in animal models.
The good news is that the FDA is banning the use of triclosan in antibacterial soaps, effective next month (September 2017). Way to go FDA! Thank you! Unfortunately, manufacturers can still add this chemical to dish soaps and toothpaste.
What you can do:
- Reduce your exposure. Avoid purchasing anything labeled “antibacterial”.
- Use bar soap and water, instead of hand-sanitizers.
- Avoid toothpastes that include triclosan, such as Colgate Toothpaste
- Read here if you want to learn more about triclosan and how to reduce your exposure
My neighborhood pools opened this week for summer and my family couldn’t be more excited. Unfortunately, mosquitos are popping up again and reminding me of the importance of discussing insect repellants with my friends, families, and patients.
Many women who never wear insect repellants have recently become interested in these products because of the news coverage of the Zika virus. The Zika virus was introduced to the world during the most recent Olympic games in Brazil. Mosquito bites were linked to severe birth defects and the Zika virus was identified.
The number of pregnant women with laboratory evidence of possible recent Zika virus infection and the number of fetuses/infants with Zika virus–associated birth defects continues to increase in the United States. About 1000 pregnant women in the US were diagnosed with Zika virus infection last year. Of these pregnancies, birth defects were reported in 15%. Congenital microcephaly, or severely small head in the affected child, has been a hallmark of intrauterine infection with Zika virus. However, the full clinical spectrum and severity of Zika remains unknown. Others have recently reported much lower rates of confirmed Zika virus in other parts of the US and no confirmed fetal or neonatal infections, which puts some doubt on the true prevalence of this widely publicized virus. The field of perinatal Zika virus infection is evolving and we continue to learn more about the virus as well as the risk of disease.
Insect repellants can be a good option for reducing your exposure to mosquitos and tics. The EWG has published excellent resources for consumers to learn about what is in their bug repellent.
My family uses DEET. It protects you against tics and mosquitos. DEET is the only insect repellant that has been tested on pregnancy women. The children of mothers who used DEET in their second and third trimesters showed no birth defects, changes in body size or developmental problems. No studies have examined the children of women who applied DEET during their first trimester. However, at toxic doses, DEET has been associated with seizures and neurological damage. Although this risk is scary, The EPA reports that this risk is very low- 1 per every 100 million persons. As with medications, I tend to recommend limiting the use of multiple products in order to limit exposure to multiple chemicals. Choose one insect repellant and stick with it.
A more natural alternative is also available as oil of lemon eucalyptus. The tree extract is refined to intensify the concentration of the naturally occurring substance para-menthane-3,8-diol (PMD) from 1 to 65 percent. The resulting oil is very different from unprocessed tree oil. Some testing shows that concentrations of 20 to 26 percent PMD may perform as well as 15 to 20 percent DEET against both mosquitoes and ticks (Barnard 2004, Consumer Reports 2010). I think it is important for us to recognize the limited safety data available on essential oils in pregnancy and in children. Refined oil of lemon is classified as a possible biochemical pesticide. Oil of lemon eucalyptus and essential oils have disadvantages but is a good choice for people who want a botanically based bug repellant. EWG recommends that consumers who are in high-risk areas for bug-borne disease or need long-lasting, effective bug protection avoid botanically-based bug repellents, aside from Oil of Lemon Eucalyptus. In other cases, you may find it worth your while to try botanical repellents to identify one that works well for you.
What you can do:
- Avoid exposure to mosquitos: use insect repellants with <50% DEET when trying to conceive and during pregnancy. More is not better. My family uses 30%.
- Wash your hands well after applying insect repellant. Wash repellant-coated skin at the end of each day.
- You and your partner should avoid travel to areas with Zika virus when trying to conceive and during pregnancy. Discuss your travel plans with a physician if there is any question about the safety of travel. Talk to your physician if you or your partner are concerned that you have been exposed to the Zika virus.
For more information:
The terrifying association between consumer products and health problems is described in this recent article found in Time Magazine. Wow. What a headline. This article was written as a result of a large lawsuit for baby powder being associated with ovarian cancer. Yep, you read that right.
I’ll leave the rest of the reading up to you if you are interested but just had to share one more quote from the article:
“But it’s actually not surprising. The fact is, many personal care products on store shelves—products we lather in our hair, rub on our skin, and put in our babies’ bathtubs—contain chemicals with known links to health problems, with no warnings at all to consumers.
Many of us assume the companies are using the latest science as a guide to choose the safest ingredients, especially for products used on babies.
We should be able to expect that.
Unfortunately, nobody is watching the store. Companies in the U.S. are allowed to put ingredients into personal care products with no required safety testing, and without disclosing all the ingredients.”
What you can do:
- Keep reading our blog to stay current .
- Be an informed consumer
- Check out the Environmental Working Group to check the safety of the products you already use.
- I use this website every time I need to buy a new product so that eventually I will only have the safest products in my house and in my life. For example, I needed to re-stock on hand soap this week and used the EWG app to ensure I purchased the best rated kind.
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.
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
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.
There have long been rumors that lipstick contains lead and but since cosmetic producers are not mandated to release the ingredients of their products, this fact remained hidden for many years. Back in 2007 the Campaign for Safe Cosmetics [r1] sent 33 brands of lipstick to an independent lab for testing and found that 61% tested positive for up to 0.65 parts per million of lead. What’s more they found top selling brands—including one that sold for $24 each—had the highest lead content! They reported their results to FDA and were promised an investigation.
It took the FDA two years and a letter from 3 US Senators to perform a follow up study. They found lead in every brand that they tested[r2] . Some of the brands had four times more lead in them then the Campaign study results. Despite these findings, the FDA did not take any action to protect consumers. More recently, an expanded analysis found lead levels as high as 7.19ppm. Even more surprising 5 of the top 10 most heavily contaminated brands were made by a one manufacturer[r3] , Loreal USA. Why aren’t consumers being made aware that something as toxic as lead is being sold to apply to their lips? That’s a hard question to answer.
The US Center for Disease Control and Prevention states that there is “No safe blood level for lead.” Lead is a neurotoxin. It accumulates in the body and it can even cross the placenta to harm a developing fetus. That’s why the only effective strategy against heavy metal poisoning is to minimize your risk of lead exposure. The effects of lead are well known and include lower IQ scores, behavioral problems, aggression and learning (especially language) disabilities.
More recently, a study demonstrated that high levels of lead can also contribute to infertility. In this study[r4] —conducted by the National Institute of Health—they found that women and men with higher levels of the heavy metals lead and cadmium experienced a nearly 30% reduction in their chance of conceiving. Although their study considered cigarettes to be the primary source of exposure to these toxic metals; their study was completed before the high lead levels in lipstick were revealed. Be a smart consumer and check out your personal care products and cosmetics before you apply: http://www.ewg.org/skindeep/browse/lipstick .
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.