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.
One of the greatest challenges that we face in treating couples with infertility, is what options to offer beyond the typical treatment protocols. Clearly, most of our patients are well served with the basic ovarian stimulation methods but in some patients that may exacerbate or simply ignore an underlying hormone imbalance that’s compromising success rates. Therefore, one of the greatest challenges is to figure out how and when to tweak the typical combination of meds in order to shift the hormone balance back to a more favorable outcome. This is the reason that we should now reconsider the use of human growth hormone (hGH) for patients that have failed previous IVF treatment.
I trained under Dr. David Meldrum at UCLA-Harbor Medical Center in Los Angeles. Back in the early 1990’s he was advocating the consideration of adding hGH to the protocol of certain patients. His reasoning was good. First of all, we know from previous research [u1] that healthy developing eggs produce a growth hormone analogue known as IGF-2. Better still, other studies [u2] have demonstrated that hGH could possibly increase the ability of eggs to repair damaged DNA. Finally, several studies have found that growth hormone can improve the response of the ovaries to stimulation during an IVF cycle. Given that all of this information has been available for quite some time, it may be surprising to a patient that there hasn’t been wider use of hGH during IVF treatment. Recently, Dr. Meldrum and several other experts [u3] suggested that this was because there remained too much confusion amongst specialists on which patients would benefit from the use of this somewhat expensive but also possibly game-changing hormone.
The good news is that recent studies [u4] have more carefully defined the characteristics of the patients that were receiving hGH. As a result, we have some new data to better guide us as to which women may be most likely to benefit from hGH. Here is a summary of what they found:
- In women >40 years of age, they found a higher implantation rate and better on-going pregnancy rate in women treated with hGH during ovarian stimulation.
- In women that are poor responders to ovarian stimulation—defined as three or fewer eggs produced per IVF cycle—there was a marked improvement in pregnancy rate with growth hormone supplementation. They also found an improved outcome in FET cycles from embryos created during these cycles.
- In women that have poor embryo quality and low pregnancy rate in otherwise encouraging ART cycles, there is not be a clear benefit of using growth hormone. Instead, other causes of poor embryo quality should be explored. Once those have all been addressed, reconsideration of hGH is worthwhile.
Robert Greene, MD, FACOG
Although regulatory agencies continue to debate the impact that chemical compounds have upon our health; endocrinologists and healthcare providers express growing concern about their impact. Currently there are about 80,000 commercially produced chemicals in the USA with about a 1000 new ones added each year. Many of these substances are classified as “hormone disrupting agents because of their ability to trigger hormone imbalance. Yet only about 5% of these have been tested for their impact upon our reproductive function. One of the chemicals that is produced in the largest quantities is the plasticizing agent called Bisphenol A (BPA).
BPA is so pervasive that we’re exposed to it through the foods we eat, the water drink, and the products that we apply to our skin. The US Center for Disease Control and Prevention estimates that 95% of us have measureable levels of this hormone-disrupting chemical in our body. In fact most of us are regularly receiving doses of BPA that are 20 times higher than the Environmental Protection Agencies target of acceptable daily
intake (50 mcg/Kg). This level of BPA exposure has been linked to hormone changes that can promote obesity as well as increase the risk of heart disease and diabetes. Finally, we’re beginning to understand how BPA can impact fertility in people.
Although it has long been known that this common hormone disrupting agent can impair fertility in animals; there was an absence of studies confirming this in people; until now. A recent study has now confirmed that a majority of women undergoing IVF treatment have measureable levels of BPA in their urine. Worse still, women with higher BPA levels were able to produce fewer eggs that were also of poorer quality. As a fertility specialist that sees a growing number of women with unexplained decline in their ovarian reserve, I recommend that you don’t wait for additional proof. Here are some steps you can begin taking today to reduce any further impact of BPA upon your health and your fertility:
- 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.
Over 5 million women in the USA have polycystic ovarian syndrome (PCOS) and yet many, don’t even know it. Estimates are that the cost of this manageable condition exceeds $4.4 Billion per year. Less than a quarter of the money is spent providing fertility related treatment. Ironically, earlier diagnosis and management could result in a tremendous potential for reducing cost and improving outcome as well as boosting pregnancy rates for women with this condition. So why is it so difficult to identify and diagnose this problem? It all comes down the diversity of the women that have PCOS.
The term “syndrome” refers to a group of signs or symptoms that occur together and are typically triggered by the same underlying condition. There is no single diagnostic finding that defines a syndrome but instead a necessary combination of concomitant features. PCOS, like any syndrome, represents a spectrum of clinical problems that can be very different depending upon each woman’s unique combination of findings. The result of this diversity has created a diagnostic dilemma.
To date, there are at least three different sets of guidelines that are used to define PCOS; National Institutes of Health (1990), Rotterdam Consensus Group (2003) and the Androgen Excess Society (2006). Each is well recognized and has its merits. The problem is that a patient may be defined as having PCOS by one doctor but not another depending upon which criteria they embrace. Personally, I feel that the Rotterdam Consensus Group represents the most organized attempt to define the vast number of presentations of PCOS. Using the Rotterdam Consensus Criteria, over 90% of the women whose infertility is impacted by this hormonal imbalance can be properly diagnosed and treated.
Better still, for women that want to get a quick estimate of their risk of having PCOS, I encourage you to review your symptoms by taking the PCOS quiz. Then check out the recent ACOG Practice Bulletin on PCOS. This publication will empower you with a summary of the latest information on the diagnosis and management of this common condition. In fact, it should even serve as the basis for a thoughtful discussion with your doctor on the treatment options available to improve your health, your quality of life and your fertility. Here are just a few key topics addressed in this bulletin:
- Suggested evaluation including ultrasound criteria to confirm PCOS (p 938)
- Who should be screened for Congenital Adrenal Hyperplasia (p 940)
- There is no need for specific tests to justify the use of insulin sensitizing medications like metformin (pp 940-2) and the dose most commonly used is 1500 to 2000 mg/day.
- Shaving does not increase hair follicle density or size of the hair shaft for women with hirsutism (p 944)