In a new fertility education article, Dr. Meldrum presents exciting new findings that indicate possible ways to influence the health of eggs and sperm in younger and older couples alike. From diet and exercise to smoking and stress, the modification of many lifestyle choices can increase a couple's chances of being successful.
Read the full Lifestyle and Fertility article here.
One of the most frequent questions I am asked by both men and women is whether stress may be affecting their fertility. There is a lot of evidence that stress can adversly affect a woman's fertility.There are studies showing that interventions with acupuncture and Mind-Body programs can have a positive influence on the chance of IVF success.
Now a multi-center study in the March 2010 issue of the journal Fertility & Sterility shows that more than two recent stressful life events decreased sperm parameters. In order to decrease the affect of variables that they may have found in infertile men, they examined the sperm of 744 fertile males. They found that men reporting more than two recent stressful life events had an increased risk of being classified below standard thresholds for “normal” defined by concentration, motility and morphology criteria, compared with men reporting less than two stressful life events.
The authors conclude that stressful life events may be associated with decreased semen quality in fertile men. Based on these findings the experience of psychosocial stress may be a modifiable factor in the development of male infertility.
And its appearance is not a reflection of the DNA. That's what I've been telling couples when the male has severe abnormalities in his semen parameters. This especially applies to the appearance of the sperm (teratozoospermia), the strict morphology. Now a study in the March 2010 issue of Fertility & Sterility confirms the accuracy of my statement.
They looked at couples going through cycles of IVF with ICSI and correlated their outcomes with the degree of abnormality in the measurement of sperm appearance, the strict morphology. Fertilization rates were high (74%–77%), and clinical pregnancy rates ranged from 60% (subgroup with 0% normal sperm) to 56% (subgroup with ≥7% normal forms). The highest pregnancy and live birth rates were actually observed in eggs fertilized with sperm from specimens with the most severe teratozoospermia. The percentage of high-quality blastocysts was significantly greater in the severely teratozoospermic patients compared with patients with ≥5% normal sperm (37% vs. 28%). This is likely because in the lower morphology subgroups, female factors are less prevalent and the primary infertility problem is male factor.
So, according to this study, those couples needing IVF with ICSI for severe teratozoospermia can rest assured that they do not have to worry that this abnormaility will adversly affect the outcome of their IVF cycles.
One of the discussions we may have with patients prior to a blastocyst transfer is the supposed increased chance of an embryo at the blastocyst stage splitting and becoming an identical twin pregnancy.
In this study in the February 2010 issue of Fertility and Sterility, the authors monitored almost 2000 IVF cycles and found in this group of single-embryo transfers there was no statisically significant difference observed in the probability of monozygotic twinning between the cleavage-stage (Day 3) and the blastocyst group (Day 5). The odds of an identical twin pregnancy was 2.6% in the cleavage-stage group (8/308) and 1.8% (5/271) in the blastocyst group The odds ratio for the incidence of monozygotic twinning after Day-5 embryo transfer was calculated to be 0.71 compared to the Day 3.
Despite the stage of the embryos at the time of transfer, one must be mindful of the almost 2% chance of monozygotic twins when selecting the number of embryos to transfer.
One of the issues I discuss with new patients when it's pertinent is weight loss in order to improve the chance of IVF success.
The latest evidence supporting this is in an article in the February 2010 edition of Fertility & Sterility looking at the outcomes in different groups based on BMI (body mass index as kilograms per square meter). They compared lean (<20 kg/m2); normal (20–24.9 kg/m2); overweight (25–29.9 kg/m2); and obese (≥30 kg/m2) women in 6500 IVF cycles. Although there was no difference in insemination procedure, fertilization rate, day of transfer, mean number of embryos transferred and cryopreserved embryos, percentage of blastocyst transfers, or embryo quality on day 2 and 3 among groups, pregnancy and live birth rates were reduced progressively with each category of increase in BMI. In addition, the cumulative pregnancy rate after four IVF cycles was reduced as BMI increased.
This confirms other studies that being obese or even just overweight overweight has a negative effect on IVF success.
Some fertility centers promote preimplantation genetic screening as a way of improving IVF success rates in women over 35 (defining advanced maternal age).
Now a study in the January 2010 edition of Fertility & Sterility shows that PGS does not significantly improve implantation, pregnancy or live birth rates. In this randomized control study from Belgium, the clinical implantation rate per embryo transferred was compared between the PGS group (analysis of chromosomes 13, 16, 18, 21, 22, X, and Y by FISH) and the control group without PGS.
No differences were observed between the PGS group and the control group for the clinical implantation rate, the ongoing pregnancy rate at 12 weeks and the live born rate per embryo transferred. A normal chromosome component was observed in only 30.3% of the embryos screened by PGS.
In this randomized controlled trial, the results did not confirm the hypothesis that PGS by FISH in 3-Day embryos results in improved reproductive outcome in patients with "advanced maternal age.".
In the future newer techniques of chromosome analysis such as comparative genomic hybridization (CGH) which can analyze all chromosome pairs and the ability to analyze blastocyst cells, freeze the embryos and transfer only chromosomally normal embryos may result in better outcomes and the need to transfer fewer embryos and reduce high-order multiple pregnancies as well.
In a variation on the theme of transferring fewer embryos to reduce high-order multiple pregnancies, an article in the January 2010 issue of Fertility & Sterility shows that transferring two instead of three embryos leads to equal success and a lower triplet rate.
In reviewing 145 frozen embryo transfers, doctors at the University of Connecticut found that transfer of two instead of three frozen embryos in patients less than 35 years old resulted in a significant decrease in multiple pregnancy rate without compromising pregnancy or live birth rate. Transferring additional embryos when a patient had an unsuccessful fresh cycle was not warranted. In the age group 35–39 years, transferring two instead of three embryos did not decrease pregnancy or live birth rate and had no effect on the risk of high-order multiples.
So even in frozen embryo cycles the trend is to transfer fewer embryos.
It seems like there is a story almost every day about threats to our health from products we use almost every day. Today's threat is to reproduction. The Los Angeles Times reported, "In a study published today, a decreased likelihood of pregnancy is linked to flame-retardant chemicals in foam furniture, electronics, fabrics and more. Californians may have higher exposures compared with residents of other states. Their study joins several other papers published in the last two years suggesting that the chemicals, polybrominated diphenyl ethers, or PBDEs, affect human health.
PBDEs have been used as flame retardants for four decades and are found in foam furniture, electronics, fabrics, carpets and plastics. The chemicals are being phased out nationwide, and certain PBDEs have been banned for use in California. But they are still found in products made before 2004. Californians may have higher exposures compared with residents of other states because of the state's strict flammability laws, according to the study authors, from UC Berkeley."
I have been impressed with the increasing numbers of men I am seeing with motility and morphology issues with no apparent reason and have thought that environmental factors may be partially to blame. This is just another of those potential threats.
There is now more evidence that women who have two copies (are homozygous) of mutations for genes that can cause inappropriate blood clotting (thrombophilia) are not as likely as previously thought to suffer from some pregnancy complications. The Jamuary 2010 issue of the medical journal "Obstetrics & Gynecology" contains two articles and an editorial, "The Truth About Inherited Thrombophilias and Pregnancy" discouraging random testing for thrombophilias, and when found, treatment with anticoagulants.
One study shows that although the prothrombin gene mutation results in an increased risk for the development of certain pregnancy complications in asymptomatic women, another thrombophilia, MTHFR, may actually protect against those complications. Their overall conclusion was that the majority of asymptomatic women who carry an inherited thrombophilia mutation have a successful pregnancy outcome. The other study showed no association between the prothrombin G20210A mutation and pre-eclampsia, premature separation of the placenta or small-for-gestational age babies in a low-risk group of women. These findings raised the question of the need for screening asymptomatic women for this mutation.
Based on these studies and others, Dr. D. Ware Branch wrote an editorial expressing concern that doctors are prescribing heparin and other anticoagulants too frequenlly after testing women who had almost any adverse pregnancy experience. The enthusiasm for using heparin and its derivatives comes from success in heparin treatment of antiphospholipid syndrome in pregnancy. He believes that a primary cause of an adverse pregnancy outcome may be inflammation, not thrombosis which would not be helped by anticoagulants. Using heparin and related drugs can lead to serious complications.
Regarding this question, infertility specialists deal mostly with patients who have experienced recurrent early pregnancy and Dr. Branch points out that two prospective trials show no improvement in live birth rates using low molecular weight heparin in women with antiphoispholipid antibodies and recurrent miscarriage. Years ago there was a great deal of enthusiasm for testing women with recurrent miscarriage and other pregnancy complications for thrombophilias and antiphospholipids and, when found, treating with heparin or one of its derivatives. Now the tide seems to be turning against even testing. Definitive multi-center studies are needed to determine "The Truth."
A question that I occasionally hear is whether inherited tendencies to clot abnormally (thrombophilias) are a cause of infertility or early pregnancy loss. Most people asking this question have gotten this notion from surfing the internet. Our group’s opinion on the subject has been that these conditions are not major factors in either early pregnancy loss or infertility.
A study in the December 2009 online edition of the medical journal “Fertility & Sterility” found no significant difference in the prevalence of three genetic mutations associated with the increased risk of thrombophilia (Factor V Leiden G1691A, prothrombin G20210A, and methylenetetrahydrofolate reductase [MTHFR] C677 T) in 100 infertile women with unexplained infertility when compared with 200 control fertile women without an infertility history.
There can be issues in late pregnancy in women who are homozygous (have two copies of the mutant gene) for some of these conditions and these women may require significant anticoagulation. But prevailing current thinking is that women with infertility or early pregnancy loss do not need significant anticoagulation even if homozygous for these genetic mutations.
This is important because anticoagulation beyond one baby aspirin a day may result in health and potentially even life-threatening complications
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