Birth rates now are about half of what they were during the height of the “baby boom.” That’s because women are waiting to start their family until they are more settled in their careers, relationships and lifestyles. Unfortunately, this same study also found that about 40% of women between 44 and 50 years of age have had fewer children then they would have preferred. That’s why it is so important that women consider what their family buildings are and consider egg freezing during their mid thirties. Technology now offers women the best of both worlds; delayed reproduction and achieving their ideal family size! https://www.washingtonpost.com/news/wonk/wp/2016/08/16/why-american-women-are-having-fewer-babies-than-ever/
Coffee has remained a matter of debate and controversy for some time in the fertility world. Initially it was thought to promote miscarriages and reduce uterine blood flow. Newer data is suggesting that it can reduce the risk of diabetes and may actually promote arterial blood flow. Until more information is obtained or you have been specifically advised by your provider to abstain from coffee; practice moderation or consider tea! Here’s a great video to bolster your confidence. http://nutritionfacts.org/video/coffee-and-artery-function/
This news will come as no suprise to our patients as we have been demonstrating this for years. It is good to have yet another study that further supports this recommendation. The cautionary note here for patients is to check with their center on the method of freezing used in their lab–if it not the modern rapid-freeze technique called vitrification then you might be better served by a fresh transfer. http://www.latimes.com/science/sciencenow/la-sci-sn-ivf-frozen-embryos-20160809-snap-story.html
Writing about nutritional choices is tricky. One author recently compared our dietary choices as being like our own personalized religion. We’re all born into certain dietary patterns. Then as we grow, we either accept or modify these choices based upon our own belief as well as our own personal preference. Unfortunately today, many of the fad diets are like dietary cults—people not only want to make their own choice but they encourage others to embrace their decision as well. Unfortunately, most of these popularized diets are based upon scientific rhetoric. They often use encouraging language and small bits of science (often taken out of context) to try to create a compelling message. They want you to join them. As a scientist and a as a physician, I find this troubling because it often has a negative impact upon the care of my patients. For example, let’s consider gluten.
Gluten is a combination of proteins found in wheat, barley, rye, oats and various other grains. It has become a very prominent part of our diet because these proteins help dough to rise and retain their shape in baked goods. Although gluten has been vilified by some recent nutritional gurus; many foods that contain these proteins have major health benefits. These whole grain foods are attributed with a lower risk of developing obesity, diabetes, heart disease and various types of cancer. It is estimated that about 1-2% of us may have a true allergy or autoimmune disease (Celiac disease) as a reaction to these proteins. So let’s consider the possible health benefit for the other 98% of the population.
Gluten is also a prebiotic. Prebiotics are the nutrients necessary to help the healthy bacteria thrive within your body. A common reason that many people today are taking probiotics is because their diet is not providing these healthy bacteria the nutrients that they need to survive. However, taking a probiotic is not sustainable without feeding these healthy bacteria so they can thrive. There is also evidence that gluten can be an immune booster.
Natural Killer cells (NK cells) are part of your body’s immune system. Despite their ominous sounding name, they serve a sort of security role. They are responsible for identifying and eliminating dangerous invaders like virus infected cells and potential tumor cells—they keep you healthy. Ironically, they also serve a critical role in promoting pregnancy. When functioning properly, they enhance the ability of an embryo to implant and thrive. New studies are now demonstrating that gluten can actually facilitate healthy NK cell activity. Whatever the reason, there is convincing evidence that gluten containing whole grains are associated with higher pregnancy rates in patients that are trying to conceive.
Patients undergoing IVF provide a unique opportunity to study interventions in a closely monitored setting. Recently, the impact of eating whole grains was investigated at Harvard University as part of the Environment and Reproductive Health (EARTH) study. In this study they were tracking whole grain content by following the diets of women going through IVF treatment. They found that women that were eating more whole grains had a higher pregnancy rate and a higher live birth rate (53% vs. 35%) than those eating little or no whole grains. In fact, at least one serving per day of a whole grain food was able to boost the odds of success by about 33%. Another recent study that was looking at comprehensive dietary patterns and success during Advanced Reproductive Treatment (ART) found that women eating whole grain cereals had about a 30% greater chance of fertilization and early embryo development and an almost a 60% greater chance of becoming pregnant. Finally when researchers measured the urine for a marker of whole grain food consumption in a healthy population of fertile women they found that those eating more gluten containing foods took fewer months to conceive naturally. Taken together, it seems that we should encourage women that are not truly allergic to gluten to eat more whole grain as part of their fertility boosting diet.
One of the most frustrating questions for women trying to conceive is “what can I do to improve my chances?” Given that women are born with every egg that they will ever have, there are a limited number of ways to optimize the health of the remaining eggs. But for those that are motivated, I have described steps like the use of Acai berry extract and CoQ10 as well as improved sleep and Vitamin D. Now for the first time, there is evidence that some women may be able to improve the responsiveness of their ovaries in as little as one month!
The typical diet of people living in the USA has changed dramatically over the last century. One glaring example has been in the type of fats that we consume on a daily basis. Essential dietary fats—those that we must get from foods because our bodies can’t make them—are typically classified as Omega-6 and as Omega-3 and serve many important physiologic functions. The ideal ratio of Omega-6 to Omega-3 is 1-to-1. However, the typical Western diet—popular amongst most Americans—has a ratio as high as 25-to-1. The result of this unhealthy shift is that many people are eating foods that promote inflammation. This unhealthy shift is associated with a higher risk of heart disease, diabetes, cancer and infertility.
Given that it’s not easy to encourage people to make lasting dietary changes, a recent study looked at the effects of starting a high potency omega-3 fatty acid supplement upon ovarian function and hormone balance. For this study, they put 27 women on a 4 gram supplement and measured their FSH levels before and 30 days after starting this program. Even within this short time frame—effectively one menstrual cycle—they found a dramatic improvement in the omega-6 to omega-3 ratio. Their inflammatory markers improved and their FSH levels dropped. Given that FSH level is considered a marker of ovarian sensitivity; this result is interpreted to mean that their ovaries were more sensitive and thus more fertile.
A cautionary note; they did not find an improved ovarian sensitivity in the women in the study that were obese. It is possible that with longer time and with weight loss, obese women might also experience improved fertility. Obesity has been linked to worsening infertility as well as resistance to some of the treatments offered to normal weight women. It is theorized that obesity itself produces inflammatory chemicals in the body which in turn trigger a state of hormone imbalance. In act, it was discovered that all of the women in the study—including the women that were obese—had improved markers of glucose metabolism. That suggests that the omega-3 fatty acids could help reduce the risk of diabetes and maybe make it easier to lose weight as well.
Another important benefit of omega-3 fatty acids is that they can reduce oxidative stress. That means that consuming these healthy dietary fats can reduce the risk of DNA damage to a woman’s eggs—another important fertility promoting benefit. So although this was a small study and needs to be confirmed in a longer time period, you don’t need to wait. Make this health promoting change in your fertility promoting plan now. Here are a few practical suggestions:
- Switch to a low-fat diet plan taking care to avoid animal fats when possible
- Use products at home that include healthy omega-3 fatty acids instead of butter
- Incorporate more olive oil, Flax seeds and tree nuts into your daily diet
- Start taking a daily supplement—preferably a plant based one (rather than fish oil) like those made by Life’s DHA
- IMPORTANT NOTE TO MEN: Emerging evidence suggests that increasing your omega-3 fatty acid consumption can improve sperm shape (teratospermia) as well!!
Most women are aware that their fertility declines more rapidly than other—often more visible—signs of aging. In fact, the ovaries have very unique properties. They begin a prolonged hibernation-like state from infancy until the start of puberty. During this ten to fourteen year period, the ovaries remain inactive; producing neither hormones nor mature eggs. However, there are still biological signs of aging taking place within the resting ovary but at a much slower pace than after the menstrual cycles begin. Then throughout the reproductive years a group of eggs is lost each month. In some women—depending on their diet and lifestyle—eggs may be lost at a faster pace. This happens for instance in women that use tobacco products. As I’ve written about previously, the blood test for the hormone AntiMullerian Hormone (AMH) is considered by most fertility specialists today to be the most reliable assessment of a woman’s ovarian reserve (the approximate number of immature eggs that she has available at any given time). Now there are also new ways to actually measure how we age physiologically as well.
One study recently demonstrated that people do age at variable rates. They quantified the aging process by measuring various physiologic and genetic markers over a 12 year period in 954 individuals beginning at age 26. They correlated their findings with each test subject’s appearance and their quality of life. They found that those that appeared to be aging faster also had measureable changes in their physiology, cognition and physical complaints consistent with their appearance. The researchers also analyzed their DNA. Their analysis supported that some individuals were aging faster than others and that diet and lifestyle seemed to be a major influence on the rate of aging. In fact, some people seemed to age 3 years for each 1 year that passed on the calendar while others didn’t seem to be aging at all during the 12 years of the project. So taking steps to improve your health and wellness may in fact slow your rate of aging. However, there are still some changes taking place that can’t be delayed indefinitely.
In most species, females are able to conceive throughout their natural lifespan. Humans are unique from most other mammals in that women typically live about half of their life after their fertility has ceased. It has also been reported that women that conceive later in life tend to live longer. Efforts to look at the genetic relationship have found that there are 17 genetic markers that explain about 30% of the occurrence of premature ovarian failure. That means that most ovarian aging is related to other factors including damage to the egg’s DNA (telomere length) that naturally occurs over time. There are also changes that occur in the egg’s power house, the mitochondria. Each egg has 20,000 to 800,000 of these important power units. Each mitochondrion has its own small strand of DNA. We inherit all of our mitochondria from our mother. As women age, the DNA of mitochondria within the eggs becomes damaged. This damage cannot be repaired. As a result, the mitochondria are intimately linked to egg quality. They not only impact the chance that an egg will fertilize and grow successfully but also the health of the child that results. There are also other ways that delaying pregnancy may influence the child’s health but in a more positive way. There is considerable evidence that children born to older mothers may have more positive cognitive and behavioral outcomes.
There is a growing trend for women to delay childbearing. Doing so is associated with higher socioeconomic status, increased educational achievement, higher income level and smaller family size. It may be due to any or all of these reasons or it may be due to greater readiness for pregnancy or more that children of older mothers tend to fair better when it comes to cognitive and behavioral measures. Others feel that it may due to a more mature mother-child interaction. Whatever the reason the benefits are present without any elevated risks in psychiatric problems. So even though cause and effect cannot be established in the available studies, advanced maternal age seems to have a protective effect upon the psychological and cognitive development of children. Now there is also evidence that carrying a pregnancy may in turn have healthy implications on the aging of the mother as well.
A new series of investigations is finding that a healthy pregnancy may slow aging process. In animal studies, it has been a consistent finding that pregnancy has a rejuvenating effect upon mother through a process called parabiosis (connecting the circulation between the young and the old). In humans, studies have found measureable benefits including improved liver functioning, improved reparative abilities within the central nervous system and protective effects upon the heart following a healthy pregnancy. There is also data suggesting that unhealthy pregnancies can identify women at risk of age-related conditions like diabetes, stroke and heart disease—possibly identifying those at risk so that preventive measures can be initiated. So it seems that healthy women have a longer opportunity to conceive and that when women in their later years get pregnant that they remain healthier longer.
In summary, the links between fertility and healthy aging are far more complicated than previously believed. We can reassure women that taking steps during their younger years to live a healthy lifestyle should optimize their opportunities for pregnancy. We can not only track a woman’s fertility status through ovarian reserve testing but now we can also freeze/store eggs to extend their reproductive years. Then, by taking steps to optimize a women’s health during pregnancy, women may both have a healthier child as well as slow their own aging.
An important aspect of “lifestyle medicine” is helping our patients take control of the factors of their daily routine that may tip them towards a higher pregnancy rate. Toward that end, one of important determining factors of egg quality has to do with whether not the egg has been damaged prior to fertilization. So let’s consider what causes egg damage and what we can do to prevent it.
Each egg that you have has been waiting since you were an infant for the opportunity to grow and develop. During the years that the eggs remain dormant, they are very susceptible to adverse conditions. For instance, small charged particles called free radicals can damage the proteins, membranes and the DNA within the eggs. These free radicals are formed normally as a result of physiologic processes like digestion and ovulation. However, there are lifestyle situations like tobacco use or over-eating that can promote free radical formation. Additionally, conditions like endometriosis are believed to impair fertility at least partially due to the increase in the production of free radicals. A recent review detailed how eggs that have been damaged by free radicals have a lower capacity to produce a successful pregnancy.
Your body makes chemicals called antioxidants whose purpose is to be there to capture and neutralize free radicals when they are formed. Since free radicals only exist for an instant, it is important that these antioxidants are always around. Unfortunately, most of us don’t make enough of these little protectors. That’s why foods that contain antioxidants are believed to be so healthful. Not only can they provide us with these chemicals that we need but they can do so when they would be most useful—during digestion. There is evidence that berries of the Acai—a palm tree grown primarily in northern Brazil—may be able to tip the delicate balance in your favor and therefore protect your ovaries from damage.
Studies suggest that Acai berries may contain more antioxidants than blueberries, raspberries or any other potent natural antioxidants. Additionally, the juice contains healthy omega-3 fatty acids suggesting that this may be another means by which it may provide health benefits. To date, one on-going study suggested that women that had failed IVF due to poor egg quality; had an improved outcome after taking an Acai supplement prior to their next attempt. The two to three months prior to an egg’s release represent the time when it is most susceptible to harm. Therefore if you have a low ovarian reserve and/or a history of poor egg quality; you should consider taking an Acai Supplement. A convenient dosing schedule is 1000 mg taken twice each day. There are various supplements available or you can try consuming Acai products two to three times each day as part of a healthy diet. I find the Sambazon products (http://www.sambazon.com/products ) to be diverse and very appealing because they are organic and sustainably harvested.
Unlike men, it is very difficult to assess a woman’s fertility at any given time. A man simply needs a quick trip to the video closet to collect a sperm specimen for viewing under the microscope; whereas it is only through the process of IVF that it is possible to truly assess the quality of a woman’s eggs. This entails several weeks of medication to prepare for an egg retrieval at which time her eggs are collected, fertilized and then monitored for normal embryo development prior to placing them back in her body to implant and become a pregnancy. There is no comparable test. As a result, recommendations of treatment to improve egg quality have been based upon unproven and often misguided observations.
One of the more popular myths has been to encourage women to consume wheat grass. Although the suggestion is harmless enough, the only basis for its link to “improved fertility” can be traced back to a Kansas farmer from the 1930’s named Charles Schnabel. He claimed that when he fed wheat grass to his ailing chickens that they not only recovered but increased their egg laying potential. Not the best model to making assumptions about human egg quality.
Another folk remedy is the use of royal jelly. This is a special secretion made by honey bees and fed to future generations in order to cultivate the conversion of a drone to a fertile queen bee. Unfortunately, it doesn’t work as well in humans and has been linked to severe allergic reactions, asthma and even in rare situations death. Analysis of this chemical product reveals that it is little more than vitamins and other healthy nutrients. I think the lesson here is that good nutrition is important which is why it is a good idea to start a prenatal vitamin at least 3 months prior to trying to conceive.
A more recent recommendation has been for women with low ovarian reserve to take the pre-hormone supplement DHEA. While there is limited data that it may cause a slight increase in the number of eggs produced— in this clinical trial the average participant went from producing three eggs to four—there was not any demonstration of an improved pregnancy rate. From a practical standpoint, since it required 90 days of the supplement prior to undergoing IVF these patients may have produced even more eggs by going through 2 or 3 cycles of IVF instead. Most importantly, without a measureable improvement in pregnancy rate, it is premature to suggest that this may improve egg quality. There are ongoing studies which may provide insight as to whether there are some women that can benefit from this treatment but at this point the question remains unresolved. In fact, the available research is given a “C” grade indicating “there is unclear scientific evidence for its use.”
A well researched suggestion has been to optimize the energy storage/ utilization of the egg through supplementation with CoEnzyme Q10. This has not been considered a necessary supplement since your body can manufacture this on its own. However, the human egg has the greatest energy demand of any cell in the body; and its needs go up considerably during the process of follicle growth. It was therefore theorized that supplementing with CoQ10 could improve egg quality. Early studies have confirmed this theory.
Finally, it’s worth mentioning that avoiding harmful chemicals is also likely to improve egg quality as well. There is a growing list of toxins referred to as endocrine disrupting chemicals (EDC’s) that have been linked to diminished fertility and reduced egg quality in animals. Many of these same products have been tied to a reduction in male fertility which is easier to track through diminished sperm counts and decreased motility. Until it’s confirmed that EDC’s don’t compromise egg quality as well, I recommend that you take steps to reduce your exposure to chemicals like Bisphenol A (BPA) and phthalates.
In summary, here are some steps you can take and have confidence that you’re doing all that you can to optimize your chance becoming pregnant:
- Avoid well intended but not well researched recommendations
- Begin a prenatal vitamin several months before you want to become pregnant
- Take CoEnzyme Q10 to optimize the quality of your eggs—typical dose is 100 mg taken two or three times each day
Consider modifying your food choices, cooking preparation, personal care products and lifestyle to reduce your exposure to endocrine disrupting chemicals. If you need some specific advice, check out my book PERFECT HORMONE BALANCE FOR FERTILITY which is loaded with useful charts, tables and tips.
A reader of this blog recently requested that I explain why I utilize certain medications for my IVF/fertility patients and caution against the use of others. It all comes down to their effect upon egg quality. Although there is still much to be learned, most fertility specialists agree that what is going on hormonally in a woman’s body will impact the success of her cycle. That’s why I feel that it’s so important to optimize their hormone balance and individualize the protocol to suit each woman’s unique situation. Here’s what we know.
Prior to the month that an egg is going to have its opportunity to ovulate, the DNA within it remains inactive. It has been in this state of rest since birth. Whether or not egg develops in an environment that is balanced more toward estrogen or testosterone is the key factor which will determine whether it will mature normally. Eggs that are “estrogenized” are more likely to mature earlier, fertilize normally and develop into healthy embryos. “Androgenized” eggs are more likely to become atrophic, fertilize abnormally or become a first trimester miscarriage.
Typically, a woman’s fertility begins to drop dramatically about 13 years before she’s going to enter menopause; typically their mid to late thirties. This drop is associated with a shift toward a higher level of testosterone within the ovary and not surprisingly a drop in egg quality. What triggers this hormone shift within the ovary is that as women age they produce a more potent form of the hormone LH as well as develop a tendency to have greater sensitivity to this hormone. Therefore, when designing a protocol for a fertility treatment cycle, I feel it is important that we shift the balance toward a higher level of FSH relative to LH in order create a more favorable setting for egg maturation. Creating such protocols has been among the great accomplishments of my friends and colleagues Drs. Geoffrey Sher and Jeff Fisch when they demonstrated in their landmark paper that pregnancy rates can be substantially improved in women with a history of previous fertility treatment failure. The trick is to stimulate the ovaries with an FSH dominant signal early in their development and then add in a low level of LH late in maturation to optimize the quality of as many eggs as possible. From a practical standpoint, that means being able to control FSH and LH levels independently.
Many centers use simplified preparations of FSH and LH for their ease or lower cost. But I describe this as being similar to mixing your salt and pepper together in the same shaker. It may work in some situations but most patients need varying degrees of adjustment get “more salt” or “less pepper.” What makes this approach even more problematic is that these mixed preparations—called urinary derived gonadotropins—are made from the urine of the least fertile population, women in menopause. In effect, that “makes the pepper even spicier” as these women produce a far more potent form of LH. All too often, this results in a disappointing outcome. It is true that the lower cost, pre-combined products work well enough when given to the most fertile patients. I believe that’s what keeps the market for them alive. In addition to their impact upon egg quality however, I am also concerned about the impurities that they contain.
A recent analysis of both the standard and more highly purified urinary preparations found them to be 95 to 99% free of contamination. These contaminating proteins can not only impact the how a woman’s ovaries respond to them, they can also initiate an allergic reaction. Even more problematic, they carry a very low but real risk of transmitting infection which recently resulted in their use being banned in England and the rest of the United Kingdom.
In summary, the use of the latest technology has made it possible for companies to manufacture untainted FSH and LH in separate preparations so that their dosing can be uniquely adjusted to each patient’s individual needs. Better still, these are BioIdentical products that are exact replicas of the hormones produced by fertile women. Additionally, they are 100% pure and therefore free from the risk of allergic reaction or infection. For all of these reasons, I believe that these products are most suited toward meeting the needs of the patients that I see in my practice.
Most of us have learned to rely upon numbers. Their dependability, their consistency, their ability to communicate an unemotional truth is something that most of us have come to value. However, as a fertility specialist that counsels patients on a daily basis, I’ve come to realize how subjective numbers can be misinterpreted by people wanting to have a child. The same numbers that may discourage some; serve as a source of hope for others.
The most glaring example from recent history is the case of the “octomom.” None of us was present when she was counseled so we can only guess what was or was not discussed between her and her doctor. However, based upon the low success rate of the center that she was treated at, the odds of her accepting 6 frozen-thawed embryos and them resulting in 8 babies was calculated at 1 in 3.4 trillion. Yet we all know how that worked out.
Let’s consider a less dramatic example. The estimated chance of achieving a pregnancy for a very fertile couple on a given month is roughly about 15%. A common strategy to improve upon this for couples that experience infertility is to promote ovulation induction. Despite its popularity, studies show that this treatment either doesn’t result in pregnancy for most couples or it results in an adverse outcome. What makes ovulation induction an appealing option to couples is the perception that it is less costly. In reality, studies are consistently demonstrating that it delays the initiation of pregnancy and results in higher treatment costs due to repetitive cycles. Furthermore, the Centers for Disease Control and Prevention along with the March of Dimes just published a report that about one out of every four multiple pregnancies are due to the use of approach. Advanced treatment options such as In virtro fertilization provide us with the ability to dramatically improve pregnancy success rates and outcomes.
The process of IVF allows for more effective management and also makes it easier to prevent twins and higher order pregnancy by performing single embryo transfers and freezing extra embryos for future pregnancy attempts. Better still, the information that is gained from a single IVF attempt can be diagnostic. Therefore even when a cycle fails it can provide closure or offer new information that can be used to redirect treatment. So what seems like the most costly treatment can actually save you both time AND money.
Here are some steps that you can take to protect yourself from making decisions that don’t add up right:
- Create a “family building plan” rather than focusing on just getting pregnant—In my book, Perfect Hormone Balance for Fertility I provide a series of questions that you and your partner should consider. Some treatments are more effective than others in reducing the risks of multiple pregnancies while others are more likely to be effective quicker—a key to success for couples wanting to have more than one child or those in their later reproductive years.
- Ask your doctor what your prognosis is in words like “excellent, good, fair or poor” rather than as enticing numbers—Since statistics are calculated based upon groups of people, they don’t apply to an individual cycle. Instead, they can often be misleading. By using words to express your chance of success, you’ll get a much more accurate estimate of your chance for becoming pregnant.
- Encourage your employer, insurance coverage and legislators to make fertility treatment part of their covered benefits package—As insurance options are being evaluated, consider switching coverage to meet your needs. A recent study demonstrated that plans that paid for IVF coverage can cost less than an extra $1 per month. If you’re not currently offered a plan with fertility coverage, request it of your employer.