The stress related to a diagnosis of infertility parallels what is experienced with a cancer diagnosis or grief of the loss of a loved one. We all recognize that stress has a negative impact on our health and can impact fertility. However, most of what we know has been from studies based on the female partner. New research demonstrates that the stress of infertility on male partners should be considered as well.
Nearly 50% of men seeking IVF reported symptoms of depression. 50%! This study found that although major depression is more common in female partners than in male partners, it can still have a significant impact on fertility success. Couples in which the male partner had major depression were 60% less likely to conceive and have a live birth than those in which the male partner did not have depression.
Although this study shows an association between male depression and decreased likelihood of success with fertility treatments, it leaves many questions about whether one causes the other unanswered. What this study does a great job at, however, is demonstrating the need for us to focus on the health of all our families prior to conception.
Take Home Points:
- Infertility and the associated treatments are a major life stressor.
- Depression during fertility treatments can be common, in both female and male partners
- Untreated depression in men may decrease fertility
- Talk to your REI and primary care doctor if you think depression is impacting your life
I still remember feeling completely overwhelmed the first time I shopped for prenatal vitamins when I was ready to try to conceive. I’m sure I was putting too much thought into it, but like many others, I was going to take my fertility seriously and I wanted the BEST option. So why did my drugstore have over 5 different types of prenatal vitamins, all with a different concoction of what they claimed was “best?” Some of my friends reported using “prescription prenatal vitamins” and swore they were worth the cost.
I ultimately ended up buying prenatal vitamins that contained docosahexaenoic acid (DHA) since they were advertised as “supporting neurodevelopment” and who wouldn’t want a smarter baby? DHA is an omega-3- fatty acid that is important for brain development. It has been recommended to eat foods which are high in omega-3 fatty acids for women who want to become pregnant or when nursing. Although vegetarian sources are now available, fish and fish oil are often utilized for DHA supplementation. For months, I endured gross fishy tastes in my mouth and a fishy odor to my breath; all in the sake of helping my baby’s brain develop. Was it worth it?
The sale of prenatal supplements with DHA continues to increase, despite limited evidence that it actually helps brain development. A recent study suggests that DHA may not be all that it was chalked up to be. This group evaluated pregnant women who took DHA supplements and compared them to women who didn’t. There was no difference in cognitive, language, or motor development in the children from moms who took DHA compared to those that didn’t at 18 months, and 7 years- DHA doesn’t seem to result in smarter kids. This data is strong enough for me to recommend that you can skip the DHA supplement in your prenatal vitamin, especially if you are having undesirable side effects like gross fish burps.
So what does a good prenatal vitamin need, anyway?
- Folic acid- at least 400 micrograms; some patients require higher doses of folic acid
Although a prenatal vitamin will help supplement your diet with extra amounts of vitamins and minerals, your diet should be the primary source. Iron, calcium, and vitamin D are particularly important in pregnancy.
My advice to anxious patients (like myself a few years ago) is simple: eat a well-balanced diet, stay healthy, and find an inexpensive prenatal vitamin that you like so that you remember to take every day.
Much of modern psychiatry is about using medications to try to normalize brain chemistry as a tool to help resolve mood disorders. Having been involved in considerable research on how hormonal shifts can cause changes in brain chemistry–I am always interested in trying to help my patients understand what may occur and what they may be able to do to take preventive actions. Here is a study that suggests that using a dietary supplement containing tryptophan (2 grams) and tyrosine (10 grams) may prevent postpartum blues without changing breast milk contents. Better still, this might interrupt the spiral to postpartum depression! Check out this link and then talk with your doctor before starting any program.
There is a global obesity epidemic. More than one BILLION adults are projected to be obese by 2025. Obesity is a major risk factor for the development of medical conditions such as diabetes and cardiovascular disease, as well as numerous types of cancers. Obesity, in either male or female partners, is associated with a decrease in the ability to become pregnant. Obese women are not only at an increased risk of having trouble conceiving, they are also at risk of: needing medications to conceive, being less responsive to fertility treatments, losing pregnancies to miscarriage, having children with birth defects, as well as having complications during pregnancy such as high blood pressure and diabetes.
Many people use artificial sweeteners or “diet” drinks as a substitute for whole ingredients with the hope of cutting calories. A recent study suggests that this may be a bad idea. This group followed people for 10+ years and found that people that used low-calorie sweeteners had a higher body mass index (BMI), larger waist circumference, and were more likely to be obese. This paper suggests that using low-calorie sweeteners may not be effective means of weight control, and might even lead to harm.
When I review studies like this, I think it’s important to note that these studies are NOT designed to prove that artificial sweeteners CAUSE obesity; rather, they show an ASSOCIATION at a population level. For me, as a physician and mom, this association is reason enough to be cautious about the use of artificial sweeteners. For others, especially die-hard Diet Coke drinkers, they might want more proof before changing their diet habits.
There is no easy solution for weight loss; diet drinks probably aren’t going to help. If you are overweight or obese, don’t lose hope. Even a modest weight loss (10-15% body weight) can enhance your natural fertility. It will take hard work through diet and lifestyle changes. Avoid sugary snacks and drinks in general. Consider using natural sweeteners like stevia (Dr. Greene’s favorite!) or honey (my favorite!) instead of artificial ingredients. Your selection in which sweetener you use, is likely going to depend on what is most important to you including considerations like why you are using a sweetener, why you are looking for artificial sweeteners (cutting calories), and taste. Please be an informed consumer and make sure that you know why you are making the choices that you make. Taking care of yourselves will help prepare you for a healthy pregnancy and prepare you to be healthy parents.
One of the most important aspects of boosting your chances of becoming pregnant is to optimize blood flow to your pelvis–this is true for both men and women! For women, this is even more important since pregnancy can exacerbate blood pressure problems dramatically. Rather than resort to medications, here’s a great nutritional tip. Introduce 30 grams of ground flax seed into your daily diet–that’s about a 1/4 cup. You can add this to salads, soups, cereals, smoothies or just about anything. Studies now show that this simple intervention can reduce your blood pressure more effectively than many of the popular–and much more expensive–medications. For those of us that love the science and want to see the proof, watch this brief video with links to the supporting studies: http://nutritionfacts.org/video/flax-seeds-for-hypertension/
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.
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.
Timing may be important for couples experiencing secondary infertility. “Birth spacing” refers to planning the ideal interval between pregnancies. Along with thinking about how far apart you want your kids to be in age, you need to think about hormone balance. It takes time after childbirth for your nutritional status to improve enough to support another pregnancy. It takes time for your body to reestablish hormone balance as well. But if you wait too long, your reproductive hormones may fall out of balance. A recent analysis of 67 studies looking at the outcomes of more than 11 million pregnancies demonstrated that the ideal interval between pregnancies is between 18 months and 6 years. Waiting fewer than 18 months resulted in a much higher chance of preterm birth or having a baby with low birth weight. Women that waited less than 6 months also had a higher risk of miscarriage. Couples, especially those who remarry, might want to keep the 6 year mark in mind when planning to expand their family together.
From PERFECT HORMONE BALANCE FOR FERTILITY[u1] : Book Excerpt: P. 16
Traditionally, bed rest has been recommended for women after any medical procedure. For instance, after delivery of a baby, women were prescribed 6 weeks of bed rest until it was ultimately proven that that inactivity increased their risk of DVT (blood clots in the deep veins). Even though bed rest had been encouraged with good intentions; it did not result in the best outcome. Nonetheless, it is challenging to reverse widely accepted but unhelpful advice. Now that IVF has been around for over 3 decades, it is time to review how we advise patients going through treatment and reconsider whether bed rest is still advisable.
In the early days of IVF, women were restricted to bed rest for 2 weeks after an embryo transfer. In fact, patients were not even allowed to stand up for quite some time after the procedure. Instead they were transported to a hospital gurney and relocated to a hospital bed—even using a bedpan when required instead of going to the toilet. It gradually became apparent that such severe limitation wasn’t needed. Back in 1997, the first study [r1] appeared suggesting that even a 24 hour period of bed rest was unnecessary. Specifically they demonstrated that even when patients were only limited to 20 minutes of activity restriction; pregnancy rates were comparable.
Subsequently, in 2005 a much larger [r2] and well designed study found that when patients were allowed to get up immediately after their embryos were placed; their pregnancy rates were as good as patients that were asked to lie flat for an hour. Finally, a 2011 review [r3] of all of the published research on this subject confirmed that there is no advantage to bed rest and instead that there may be a disadvantage to being totally sedentary. This isn’t surprising since inactivity combined with high levels of estrogen can promote blood clot formation as well as a rise in insulin resistance. By contrast, exercise reduces inflammation, lowers stress hormone levels and promotes healthy blood flow.
During pregnancy there has also been a reversal of the popular myth that exercise should be limited. In 2008, the US Department of Health and Human Services issued comprehensive guidelines that healthy women should begin or continue aerobic exercise of moderate intensity during pregnancy. In fact, it was confirmed in a well designed study [r4] that both mother and baby benefit from aerobic work outs. Despite the research, it is difficult to dispel advice from popular culture. It was even found in one study [r5] that when IVF patients were advised by their doctors to remain active; most still restricted their daily activity. So as we look for ways to further boost our pregnancy rates and improve the health of the pregnancies that result it is important that we constantly re-evaluate how we guide women following IVF.