Reproductive Immunology: a delicate balance to a healthy pregnancy

Arguably the least understood aspect of modern reproductive medicine is the complex interaction between a woman’s immune system and a newly arrived embryo into her uterus. The immune cells are the means that your body is protected from anything that is genetically different. Typically, these cells are preventing invasion of viruses, bacteria or parasites. But in order to become pregnant and not experience a miscarriage—the immune system has to not only allow an embryo to “implant” but it has to actually help it establish a health blood supply to grow. Failure to do so, results in a negative pregnancy test, miscarriage or pregnancy complications like preeclampsia, preterm labor or fetal growth restriction.  

Most fertility treatment is focused on helping women initiate a pregnancy. As we’ve gotten better at initiating pregnancy, we need to place greater attention on fostering the changes to help that pregnancy continue to a healthy delivery. That’s the focus of reproductive immunology. Recently I listened to an evidence-based podcast that explains the emerging science that makes this complicated subject very accessible: .**

**This podcast is created by a non-profit so if you found it useful please consider making a donation

One of the most fascinating studies on the maternal-fetal immune response compared the outcomes from women that conceived with their own eggs vs women that used the eggs from an egg donor. Not surprisingly—it was found that women that became pregnant with an egg donor were at greater risk of adverse outcome due to non compatible immune reactions. They also found that using more than one embryo at a time during a Frozen Embryo Transfer was associated with an increased risk—even when women were conceiving with their own eggs. Both of these observations support the hypothesis that a successful pregnancy is dependent upon cooperation between the maternal immune cells and the placenta.

Here are some key points to assist with this reproductive challenge:

  • Transferring ONE embryo instead of two or more reduces the risk of adverse outcome
  • Suppressing the maternal immune reaction with steroids is not helpful and may actually add to risk of pregnancy failure by reducing the ability of maternal cells to support blood flow
  • The need to increase the availability of nutrients to support the growing fetus may explain some of the reason that metformin is associated with a reduction in the risk of miscarriage and of pregnancy complications
  • There are other techniques to optimize the maternal immune response to the placenta. Talk to your provider to determine if any of these treatments would be appropriate for you.

Stay informed,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

PCOS Awareness; self advocacy through knowledge

Polycystic Ovarian Syndrome (PCOS) has been described as the most common hormone imbalance of reproductive age women. Yet it is estimated that only half of the women whose lives are affected by PCOS actually know that they have this condition. Despite their lack of awareness, PCOS may be contributing to their infertility, elevated risk of miscarriage, pregnancy complications as well as impacting their overall health and wellness. 

Recently we recorded one of our Clinical Conversations to help better explain the nuance of the diagnosis and management of PCOS with goal of empowering women to help actively manage their condition:  (21min, 48 sec)

(0:30)—Reason for PCOS Awareness Month

(2:15)—Definition of PCOS

(3:30)—PCOS goes beyond the challenge of becoming a pregnancy

(5:15)—Emerging Categories/Types of PCOS

(6:00)—Rotterdam Criteria for PCOS diagnosis

(9:15)—Actively managing PCOS

(11:00)—Potential problems associated with PCOS in absence of management

(11:30)—Dynamic nature of PCOS

(14:00)—Creating short term and long term management goals

(16:30)—A few helpful tips to manage PCOS

        —Some dietary tips

        —Ironic benefits of eating soy

        —More evidence-based nutritional advice

(20:00)—Active management means directing your care

Stay aware,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

COVID19—Late Summer 2021 Update for Fertility Patients

As we continue to experience fourth spike in new infections—we felt it was time to post an update on if/how we feel that the pandemic will effect the care of fertility patients. We have previously posted on the mRNA vaccines—which are now fully recommended to all women that pregnant, breastfeeding or attempting to conceive.  Here is a link to our original post on the vaccines. This Clinical Conversation  is an update on where we’re at in late summer 2021.

COVID19 (SARS-CoV-2) Late Summer 2021: UPDATE (16 minutes):

0:30 Perspective on where we’re at

2:40 Timing of vaccinations & organizations supporting use in reproductive seeking women

3:30 Passive Immunization—how a mom can protect her baby

4:20 Safety Data supporting vaccination

7:30 Facts vs Fears

8:30 Unvaccinated at greater risk of being required to delay fertility treatment

9:45 Some tips to optimize your immunity

11:00 Forest Bathing: bringing some of the immune-boosting benefits of nature indoors

With informed optimism,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

“Unexplained infertility” explained: insights into one of the common diagnoses for couples trying to conceive

When couples are trying unsuccessfully to conceive and then present for evaluation—a variety of standardized tests are performed. If these tests all return with reassuring results, they are left with a diagnosis of “Unexplained Infertility” (ICD-10 Code 97.9). This is the treatment code used for about a third of patients diagnosed/treated in the USA. For many couples, this is very unsettling. In this episode of our Clinical Conversation series we try to provide details on what this means. Our hope is that this information is reassuring and helps more people move on from the diagnostic phase to the treatment phase with greater confidence.     

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Unexplained Infertility (17:20):

0:55 Unexplained Infertility—brief definition and use in coding

2:00 How if “infertility” defined

3:50 Creating a new definition: “Infertility, unspecified”

6:46 Sometimes greater clarification of diagnosis is revealed during treatment

                —(9:00) Example: Implantation Problems

9:45 When to stop testing—balancing risk vs benefit vs cost

11:30 Moving from Testing to Treatment

                –(12:15) Example: Male Factor—mild vs moderate

14:00 Each patient / couple has unique circumstanced making diagnosis more challenging

With kindness and optimism,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

ENDOMETRIOSIS UPDATE; latest information on how it impacts fertility

We have been talking about endometriosis since I began my career as a fertility specialist in 1995. Yet it is really over the last several years that I feel we are finally beginning to understand the various ways it can impact fertility. Like most disorders, it is a condition on a spectrum that can manifest in various ways with varying implications.  Here is a link to an episode of our Clinical Conversation series where I am sharing some of the latest science.  This episode includes some questions submitted by some of our regular listeners. I hope you find it to be helpful.

Endometriosis: clinical conversations with Dr. Greene and fertility coach Lisa White

(~27 minutes):

0:35 Definition: what is endometriosis?  

2:50 How common is endometriosis?

4:30 How can you rule out endometriosis as a contributing factor?

4:50 Submitted question: Do you approach IVF differently in women with endometriosis?


–Implications on egg quality

9:15 Submitted question: Is it safe to have endometriosis during a pregnancy?

                —some rare forms of endometriosis described

11:00 Submitted question: Are we seeing an increase in women with endometriosis?   

12:30 Some Diet/lifestyle tips to reduce the risk od developing endometriosis?

—BONUS: link to recent article from EndometriosisNews

14:30 What supplements do you recommend for endometriosis

                —Pycnogenol: link to previous blog post

                —BONUS: new research suggests curcumin may also be of benefit

19:40 Submitted question: Is it a good idea to treat endometriosis prior to IVF?

21:30 Endometriosis and Egg Quality

—BONUS:  One topic that I overlooked in this review is emerging data on how

                Endometriosis can cause hardening of the surface of the egg which can be overcome

                by using ICSI to fertilize the eggs. Here is a link to supporting research.

24:00 What about adenomyosis (endometriosis in the muscle of the uterus)?

—BONUS: There is a test for inflammation due to endometriosis as a factor in implantation failure. It is called a Receptiva-BCL6 test. Here is a link to additional information. 

As you can note, this is such a large topic with so much information we are still learning. Use this information to assist in guiding your treatment decisions.

With informed optimism,


Robert Greene, MD, FACOG Conceptions Reproductive Associates of Colorado

DIET, LIFESTYLE AND FERTILITY: emerging science on steps to improve outcome

There is a growing body of research that explains how we can actively improve our own health, wellness and fertility. It involves paying attention to our food choices, our activities and the chemicals that we allow ourselves to be exposed to through our choices as consumers. Here is a link to Clinical Conversation episode where I am sharing some of the latest science. 

Fertile 2021: nutrition and lifestyle (29:53):

1:00 Moving beyond theories and popular recommendations

2:00 Creating evidence-based diet-lifestyle tips to boost health, wellness and fertility

2:50 Food—let’s define what we need it to do

5.25 Moving from surviving to thriving

6:10 Eating Mindfully

                —Seeking foods in their most natural state

                —9:00 Food preparation methods (i.e., microwave oven, air fryers, etc)

                —11:30 Organic—why it matters

                —12:15 Plant-based eating

                —13:00 Timing healthy changes to fertility treatment

                —15:50 SIRT foods

                —16:40 Intermittent Fasting; what it is and why it may help

                —19:30 Concerns of ketogenic diets during fertility treatment/pregnancy

                —20:15 Alcohol—total abstinence may not be needed

22:15 Emotional Stress and is management

                —Meditation and slow deep breathing

                —Studies on fertility and egg quality

24:50 Some Additional Tips to consider

—Sleep and the potential role of melatonin

—Exposure to cold temperatures may have health promoting benefits

—Forest-bathing; emerging science how trees can influence immune resonse

27:45 Follow the evidence and make your decisions consciously

With informed optimism,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

COVID Vaccination Guideline for Fertility Patients and Pregnant Women: Phase 1

As we proceed with the first efforts to vaccinate against SARS-CoV-2; many patients are scrambling to decide how they feel about receiving a vaccination. The current efforts are complicated by opinions that are often driven by politics. The goal of this clinical conversation is provide you with the science—so that you can make your own evidence based decision.  It is also worth nothing that organizations that guide healthcare professions are supporting the use of the vaccine for women that are pregnant or breastfeeding. These organizations include The American College of OB/GYN (ACOG), The American Society for Reproductive Medicine (ASRM), The American Society for Maternal-Fetal Medicine (SMFM) as well as the US Center for Disease Prevention and Control (CDC). In case you don’t want to listen to the entire conversation, here’s the listening guide.

Fertility Treatment+COVID+Vaccine (26:09):

1:10  Become informed so you can make your own choice

1:45  Perspective on status (mid December 2020)

4:20 What makes these first vaccines unique ?

6:15 Why are these new vaccines considered so safe?

                ***Listener’s note; this recorded live and I correct myself a couple of times for

                                Mistakenly using the word “virus” instead of  “vaccine”

10:30 [UPDATE] This vaccine has now been approved and is in use

11:45 Why does these vaccines use two injections?  

14:00 Recommendations for women currently going through fertility treatment

17:00 What about women that are currently pregnant or breastfeeding?

20:00 What about vaccines for other preventable diseases like measles?

21:45 Importance of being informed so that you can make an educated decision

23:00 Experience of other democratic countries and how they’re dealing with this pandemic

25:00 Note of gratitude

Stay informed,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado


ACOG Statement on the Johnson & Johnson COVID-19 Vaccine

On April 13, 2021, ACOG released a statement following the CDC and FDA decision to put the Johnson & Johnson COVID-19 vaccination program on hold.

“At this time, there is no clear phenotype of women who are more or less likely to experience this rare complication. However, until there is a better understanding of the frequency and impact of this finding, it will be important to encourage pregnant and postpartum women who wish to be vaccinated to receive the mRNA vaccines: Pfizer or Moderna.

“Individuals who have been vaccinated with the Johnson & Johnson vaccine within the last 21 days who experience severe headache, abdominal pain, leg pain, or shortness of breath should seek immediate evaluation. They should be certain to communicate that they have received the Johnson & Johnson vaccine to prompt appropriate evaluation. Given the elevated risk for thrombosis experienced by women during pregnancy or the postpartum period and while using birth control pills, evaluation of acute thrombosis is commonly performed in our specialty. Rapid treatment with anticoagulation is the standard; however, this is not the same event and anticoagulation for treatment of CVST is dangerous.” Read the full statement.

Introduction to Egg Quality: optimizing pregnancy rates and minimizing miscarriage risk

Too many people rely upon their fertility center to create results. In reality, one of the most important aspects of fertility treatment in determining success is egg quality. I’ve been doing a deep dive on the latest research to try to determine what can be done to optimize egg quality. Attached is a link to a Clinical Conversation created to begin analyzing this topic. The goal is to provide women with data-driven practical tips. I hope that you find this helpful as well as motivating to help you begin making some healthy choices to insure your success:

Egg Quality Part 1 (23:10):

  • 1:20 natural pregnancy rate
  • 3:00 Comparison of Sperm Quality vs Egg Quality and how they impact natural rates
  • 5:00 Components for estimating Egg Quality
  • 7:00 Aspects of egg quality
  •                 —DNA
  •                 —Mitochondria
  •                 —Other physical components of the egg
  •                 —Metabolism of the egg
  • 9:00 A new perspective on fertility treatment
  • 10:45 Age and egg quality / egg number
  • 13:00 Emerging view of egg development
  •                 —wave theory vs. continuous recruitment
  •                 —DNA markers vs age (~15:00)
  •                 —Hottest topics—>new data on genetics of eggs
  •                 —Individual variation offers hope for intervention
  • 19:30 Egg quality if often a key component of “Unexplained Infertility”

With kindness and optimism,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

TWINdemic: fall 2020 update on COVID+Flu season for fertility patients

Unfortunately, the number of cases of SARS-CoV-2 is increasing—not just here in Colorado but in most of the country and other parts of the world as well. Additionally, we’re heading into flu season which further complicates our ability to keep our patients, our staff and our families healthy. Ironically-from the perspective of a fertility center-this combination is often being referred to as a Twin-demic.

Below is a link to our latest videoblog updating you on the current public health status. In the meantime, please take precautions:

Here’s a link:  (about 20 minutes)

Stay informed,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Embryo Grading Explained—this is what those numbers and letters mean

Previously, we discussed what the current means of embryo testing is and what insights it provides about the DNA. In this clinical conversation, we review the way embryos are described based upon their development and their description.

If you’ve completed an IVF cycle and are now getting ready to prepare for an embryo transfer, your embryologist will tell which embryo(s) they recommend for transfer. Although there is a lot that goes into this recommend, there is a shorthand description that they use to summarize each embryo. That is the “embryo grade.”

  • 0:45        How important is embryo grading?
  • 4:15        Summary of the current (most popular) grading system
  • 8:35        Correlation between embryo grade and implantation rate
  • 12:30     Lisa’s experience—a real life example shared
  • 14:00     Genetic testing vs grading
  • 15:30     Transferring more than one embryo of different grades

This video is about 20 minutes long. Here are a few key points if you don’t want to listen to the entire post:

Here’s a link:  (about 20 minutes)

Stay informed,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado