We spend a lot of time and energy adjusting our patient’s thyroid hormone levels. This data helps explain why that is so important. Oftentimes a woman’s thyroid hormone is sufficient for her if she weren’t pregnant. That’s not always sufficient to foster healthy implantation. Check on the link below to learn more about why this is important.
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
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
Few disorders can be more difficult to diagnose or more frustrating to treat then recurrent early pregnancy loss (REPL). Traditional diagnostic criteria call for at least three pregnancy losses prior to evaluation and treatment of this vexing problem. With more women choosing to delay pregnancy until their thirties or even their forties, REPL can create an additional burden on their already limited opportunities to achieve a successful pregnancy. Ironically, as women age they are more likely to experience a miscarriage when/if they do become pregnant. A new technique called comparative genomic hybridization (CGH) offers couples some reassurance.
Studies show that most pregnancy losses (50-70%) are due to genetic abnormalities. In fact, the earlier that miscarriage occurs the more likely it is to be due to abnormal changes in the DNA. These are not typically abnormalities that are detected by testing the parents but rather spontaneous mutations that occur during early development. Moreover, they often go undetected by the most commonly used technique for genetic assessment, called G-banded karyotype analysis. That’s because karyotype analysis has limited resolution. It is only able to detect the addition or deletion of relatively large portions of the genetic code. By contrast however, CGH is able to detect genetic changes that are far smaller. In fact, this technique has been reported to identify genetic causes for unexplained mental retardation in about 10% of patients that had previously had a “normal” conventional genetic karyotype. Moreover, a study in the current issue of the journal Obstetrics & Gynecology found that CGH was able to identify genetic abnormalities in 13% of miscarriages that were missed using conventional genetic testing. More exciting still is the potential of CGH to detect certain abnormalities before birth.
Maybe the best use of this technique however is when testing is performed on embryos prior to becoming pregnant. Combining CGH with in vitro fertilization (IVF) allows us to perform a biopsy upon an embryo for genetic analysis prior to transfer into a woman’s uterus. Early data using IVF with CGH has been very reassuring. We’re finding that by identifying and transferring only the embryos that are determined to be genetically competent—meaning without identifiable deletions or additions to the genetic code—we may be able to double or even triple the chance of a healthy live birth. Since this technique is still relatively new, more studies are needed before it is widely accepted but it is already revolutionizing the diagnosis and treatment of couples seeking fertility treatment.
Although we still recommend prenatal screening once pregnancy is established, CGH can dramatically reduce the anxiety of couples during those critical weeks of the first trimester; especially those with a history of recurrent early pregnancy loss. Remembering when my wife and I conceived—both of us are in our forties—I know that we would have had fewer sleepless nights early in our pregnancy had we been able to have CGH as part of our fertility treatment. There is certainly an additional therapeutic benefit of that stress reduction as well!