Bed rest following Embryo Transfer–time to revise an out-dated recommendation

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.

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

High Fat Diet BEFORE Pregnancy INCREASES Risk of Gestational Diabetes

A recent study [u1] from the National Institute of Health found lowering dietary fat intake can reduce a woman’s risk of developing gestational diabetes. They were tracking the diet and lifestyle habits of 13,000 women that were between 22 and 45 years of age and enrolled in the US Nurses’ Health Study II. They found about 6% of women developed gestational diabetes. However upon analysis they found that women eating more foods that were high in animal fats had double the risk of developing this problem compared to women on a low fat diet. When they performed a more detailed nutritional analysis, they found that dietary cholesterol and animal fats were the only foods consistently associated with an increased risk of gestational diabetes. So carbohydrates (sugars) did not create any measurable impact. Exercise was found to reduce the risk of diabetes but not enough to offset the effects of a high fat diet. They concluded that reducing the consumption of animal fat by as little as 5% while trying to become pregnant –even if replacing it with plant derived fats—measurably reduces a woman’s risk of diabetes during pregnancy.

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

  Reprint from post for Conceive Magazine Online >
 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

Thyroid Hormone, conception and miscarriage: here’s what the studies show regarding borderline low thyroid levels

There are many hormones that are involved in establishing and maintaining your health so that you can conceive and carry a pregnancy. One of the most important is the hormone called thyroxine which is produced by your thyroid gland. The role of this hormone is to regulate your metabolism much like the computer that regulates the idle speed in your car. If your thyroid hormone production is too low; you may feel sluggish like a car that is trying to stall whereas if your levels are too high you may feel overheated and agitated like a car whose engine is revving inappropriately. Although these examples of the extreme shifts of thyroid hormones are fairly easy to diagnose and treat; there are many subtle imbalances that may still hamper your fertility. An example is the condition called “subclinical hypothyroidism.”

Subclinical hypothyroidism is defined as the state of having an elevated level of TSH (thyroidstimulating hormone) but a normal thyroxine level. In other words, the brain is sending a signal to the thyroid gland to boost production of thyroxine but the thyroid gland isn’t responding fully. This imbalance occurs in about 8% of the general population but it is much more common in women with infertility. If left untreated, several studies suggest that overt hypothyroidism can result; having an adverse effect upon both the mother and her developing baby.  New studies are now providing much needed information to settle this debate on when and if this subtle hormone imbalance should be treated.

Earlier this year, a study reviewed the impact that treating subclinical hypothyroidism had upon the outcome of IVF treatment. Since the IVF process allows us to assess egg quality, fertilization, embryo quality and the implantation rate following embryo transfer, it offers us the most precise means to assess the impact of this therapeutic intervention. In this study patients with subclinical hypothyroidism were randomly assigned to treatment with thyroid supplementation or placebo. Those that received the hormone boost had better embryo quality, higher implantation rate and a reduced chance at having a miscarriage–all positive findings for couples trying to have a child.

Another larger study was published last year which was designed to evaluate the pregnancy loss rate as well as the preterm delivery risk in pregnant women with subclinical hypothyroidism. This was a “non intervention study” which means that they were just observing the outcome of the pregnancies without deciding when or who to treat. They found that women with untreated subclinical hypothyroidism had twice the risk of first trimester loss providing strong evidence to support the therapeutic intervention with thyroid supplementation.

Finally, there have been studies suggesting that women with subclinical hypothyroidism may develop low thyroid hormone levels if they consume a diet that is high in products made from soybeans (defined as more than 30g of soy protein per day which includes 16 mg or more of phytoestrogens). That’s because these estrogen-like chemicals produced by soy can reduce the ability of your body to convert thyroid hormone into its active form. In one study that actually looked at the effect of this dietary change, they found that 6 out of 60 patients developed low thyroid hormone levels due to a shift to a high soy diet. So although this healthy change in food choices can increase the risk of hypothyroidism it is not an inevitable change.

My recommendation is that if you have subclinical hypothyroidism that you monitor your condition closely and consult with your doctor as to whether or not you may benefit from supplementation with thyroxine (thyroid hormone) during your fertility treatment and pregnancy.

Neither “low-fat” nor “high-fat” but the “right fat” for better implantation and pregnancy: omega-3

Food is not only fuel to burn but also sometimes the source of basic chemicals to make hormones and various other necessary chemicals for healthy living. When these building materials are oils, they are called essential fatty acids. What makes them essential is that you’re not able to make them so you have to consume them as food. Of the 20 edible fats, only omega-3 and omega-6 fats are essential building blocks for our physiology.

Of the essential fatty acids, one teaspoon of corn oil can satisfy your daily needs for omega-6 needs yet most people get 10 to 20 times that amount. Unfortunately, most of us don’t get enough of the omega-3. In fact, the ratio of omega-6 to omega-3 for the typical USA resident is about 25:1. By contrast, the ratio consumed by our ancient ancestors was about 1:1. The health risks associated with today’s imbalance in the dietary intake of essential fats sets us up for problems including heart disease, exacerbation of inflammation and even pregnancy implantation failure. During pregnancy, these vital omega-3 fats are needed by the developing child for healthy brain and eye development. There is even evidence that they can reduce the risk of preterm birth.

The most natural way to boost your intake of these healthy omega-3 fatty acids is to boost your consumption of the fish that naturally produce them. For vegetarian’s like myself you can increase your intake of healthy plant sources in order to get your daily recommendation 1.4 grams of omega-3 per day; for instance, flax seed oil (1/2 tsp), canola oil (1 tbsp) or soybean oil (1 tbsp + 1 tsp). At the same time, you should also consider reducing your use of oils with high levels of the omega-6 like sunflower oil, corn oil and cottonseed oil.

During pregnancy, your dietary goal for omega-3 fatty acids should be 650 mg, about half should be the specific fat called docosahexaenoic acid (DHA). In order to reach this goal, you should consider taking a supplement. I feel that in order to get your pregnancy off to the healthiest start, this should be started before you actually conceive. Here are some compelling reasons to consider in making this decision:

  • Most, but not all commercially available fish oil supplements contain less than 2 ppb of mercury. Cod liver oil has additional risk since it is a rich source of vitamin A which can be dangerous in high levels during pregnancy. So if you’re going to use fish oil supplements to boost your omega-3; choose your manufacturer and your source carefully.
  • By contrast, there are commercially available vegetarian sources of DHA made from mercury free algae. Additionally, there are no environmental contaminants since they are grown and harvested in vats.
  • The use of intralipid—an IV source of healthy omega-3 fatty acids—has been shown to reduce the risk of recurrent early pregnancy loss by normalizing the immune cells that can otherwise initiate a miscarriage. In fact, we have found it to be as effective as immuno-modulatory drugs that are 10x more expensive.

Special Thanksgiving Day Note

Long weekends are a great opportunity for reflection and Thanksgiving weekend is the perfect time for such reflection. Personally, I have much to be grateful for. I’ve got a wonderful wife who is also my life partner in everything. Together we underwent a journey of fertility treatment that after 2 years resulted in the birth or our daughter. We’ve worked together for over a decade now to help other couples achieve their dream as well but now we do so with the insight of what it actually feels like to experience the emotional roller coaster of fertility treatment. Toward that end, I am even more thankful now to have the knowledge, the technology and ability to perform the work that we do. So let’s consider how this can sort of reflection can benefit you.

Studies have shown that journaling—the act of reflecting upon and then documenting your thoughts—can markedly improve your health while relieving the effects of stress. Research has shown that it can reduce the number of asthma attacks, lower blood pressure and improve your ability to heal. Although there haven’t been as many studies in patients with infertility, journaling has been shown to reduce the complications that women experience during pregnancy. That’s what prompted my wife and I to create a journal to assist women in applying this during their pregnancy.

There are many different journaling techniques but writing is more powerful than talking because it requires more deep introspection and careful thought to express one’s emotions. During this long weekend, consider starting a “gratitude journal.” You may find that it not only improves your ability to sleep and stay healthy but it may even improve your chances of conceiving. At the same time, it creates a nice record that you can later share with your child.