The path to delivering a healthy, full-term baby is a multi-step, intricate process. If there is a breakdown in any one of the steps, the final result will not occur. The key to understanding is to look at each step and correct each issue.
SPERM MEETS EGGS
The first step is making sure that the sperm meets the egg is correct timing. If Day #1 is the first day of the menstrual cycle and Day #28 is the day before a woman begins her period again, then Day #14 is the approximate time of ovulation. Prior to this time, the LH (luteinizing hormones) will peak, and after the LH surge, an egg will be released approximately 24 to 36 hours later. The egg will then journey through the fallopian tube where it will be fertilized. An egg is viable for approximately 12 to 24 hours before it starts to disintegrate, so the sperm must be in place prior.
Sexual intercourse must be timed prior to ovulation to give the sperm time to swim up to the egg and unite. Use of ovulation predictor kits is helpful, as well as looking for fertile cervical fluid, which has a stretchy, egg white consistency. As a general rule for patients, I recommend they have sex from day #5 every other day, or daily if sperm counts are normal, until the woman has passed the signs of ovulation. Engaging in enough foreplay to increase male and female secretions is vital as well, so that the sperm can have enough fluid to swim through.
The woman should elevate her hips for 20 insulin after the male ejaculates. They must not get up to go to the bathroom prior to doing this. In addition, I recommend the male keep his penis inside as long as possible, to not pull any sperm out and away from the cervix.
To allow the sperm to meet the egg, appropriate lubrication is necessary. Sperm needs an alkaline environment in which to survive. Both the male and female partners should consume an alkaline-promoting diet, that is, avoiding coffee, soda, energy drinks, meat and white flour. Of importance, is to avoid saliva as a lubricating effect as it may harm the sperm, and avoid using soaps around the time of intercourse, as soap residue can damage sperm.
For a woman, strategies to increase cervical mucus can include increased water consumption as well as N-acetylcysteine and Mucinex.
Ovulation should occur 14 days prior to menstruation. These last two weeks in the cycle are known as the luteal phase. If however, the female is not ovulating a full 14 days prior to menstruation, she may have what is called a luteal phase defect. This is corrected by progesterone administration, which I use in my patients. Progesterone has been shown to improve miscarriages and improve sperm mobility.
SPERM FERTILIZES EGG
Male factor infertility may account for 30% of all fertility issues. Male infertility problems can be spotted in an abnormal semen analysis, a fairly inexpensive, quick, and noninvasive process. All males need to have a semen analysis. Simple lifestyle changes, and evaluating factors that effect fertility, should be ruled out such as bicycling, wearing tight clothing, solenoid hot tubs, obesity, excessive alcohol consumption, and smoking.
Obesity poses a significant threat to fertility as well as the offspring born to obese patients. In obese men, there is an increased aromatase activity, which irreversibly converts testosterone to estradiol, resulting in decreased testosterone and increased estrogen levels. It is likely that this plays a role in a lower sperm count, lower sperm concentration, and poor sperm morphology seen in men with increased Body Mass Index and central obesity. Obese men also have fewer modal sperm, and lower testosterone levels.
It is not only men who experience decreased fertility as their weight creeps up; women are also affected. Obese women have lower pregnancy rates, and obese women are more likely to experience preterm birth. Together, obese couples experience higher rates of miscarriage in both spontaneous conception and assisted reproduction. In addition to the hormonal changes noted for men, this decreased fertility may be due to increased levels of inflammation, which affect a ovarian response and the uterine and endometrial environment.
Addressing obesity for patients is essential to support a healthy conception and pregnancy, and maintenance of a healthy weight should be a first goal for couples wishing to get pregnant. In my practice, I use medical foods as well as encourage a Mediterranean diet. Of note, a Mediterranean diet pattern showed the lowest difficulty of women getting pregnant, and a Dutch Study also found they had an increased probability of pregnancy while on the Mediterranean diet.
Stress has a documented impact on fertility. The stress hormones cortisol, epinephrine and norepinephrine, and the hypothalamic-pituitary-adrenal axis directly interacts with several other hormones including the hormones that regulate the menstrual cycle and maturation. Stress can directly modify levels of FSH and LH which directly effects synthesis of estrogen and progesterone. These have an effect on follicular maturation and ovulation in women, and in the manufacture of sperm and testosterone in men. Elevated cortisol levels and ACTH in men can also inhibit the conversion of androstenedione into testosterone in the Leydig cells. Higher follicular cortisol/cortisol ratios are associated with higher rates of infertility in women. It has been noted that men with increased stress have decrease in glutathione and free sulfhydryl content of semen. These are both important compounds to combat oxidative stress in toxic exposure.
IMPROVING INFERTILITY WITH MULTIVITAMINS
In women who are on multiple micronutrient supplements, studies have shown that there were increased conception rates noted. Consumption of prenatal multivitamins has also been associated with improved birth outcomes in healthful birth weight babies and decrease of stillbirth and miscarriage.
Fish oil is another key supplement to include in preconception protocols for every couple who are contemplating pregnancy within the next six months. It has been observed that fertile men tend to have higher blood and sperm levels of Omega-3 fatty acids compared to infertile men. Fish oil supplementation has also been correlated with increased superoxide dismutase as well as other positive parameters.
YOU NEED TO DETOXIFY PRIOR TO CONCEPTION
Both partners should detoxify prior to conception. This includes an evaluation of toxicity to include heavy metal toxicity, infections, and other toxins. I perform this in all my patients and evaluate their nutritional needs with a comprehensive panel. I also suggest hormone balancing, which is evaluated through extensive testing. I believe that detoxification is the key to help alleviate the infertility crisis. Men are becoming women, the so-called feminization of men. Hormone imbalance must be checked. Diet must be corrected. Detoxification is a key element.
IMPROVING FEMALE FERTILITY
Before we discuss the interventions researched to enhance fertility in women, it is interesting to note that far more research exists on interventions for men. This is likely due to the comparative ease of a study in men, where semen can be analyzed before and after an intervention, to determine any effect on sperm parameters; where in women, analysis is far more challenging, since egg retrieval is a far more invasive procedure.
POLYCYSTIC OVARIAN SYNDROME
One of the most common causes of infertility or irregular menses, as in anovulation or irregular menses, is polycystic ovarian syndrome, or PCOS. PCOS affects 10% of women of reproductive age, and is characterized by irregular menses, cysts on the ovaries, blood sugar dysregulation, and hormonal imbalances. These hormonal imbalances are seen as increased testosterone, or increased LH/FSH ratios. Women with PCOS may experience difficulty maintaining a healthy weight, hirsutism, and frequently, infertility. I address PCOS in all my patients.
In woman with PCOS who are undergoing Clomid supported cycles, co-administration of N-acetylcysteine daily from cycle day #3 through #8 were significantly found to have improved ovulation rates from 17.9% in the control to 52.1% in the treatment group. In addition to an increased ovulation rate, women in the treatment group also produced more mature follicles and had greater endometrial thickness, and higher follicular estradiol levels. There was also increased luteal phase progesterone levels seen. These are all signs of improved hormone balance and enhanced fertility.
A thin uterine lining can prevent proper embryo implantation. Unfortunately, a thin uterine lining is a common side effect of fertility promoting drugs, such as Clomid. Clomid acts as an estrogen blocker to decrease the negative feedback signals that estrogen provides to the hypothalamus and pituitary glands. This communication block can result in enhanced production of GnRH and FSH, which provides additional stimulation to the ovaries to enhance follicular production. One downside of this medication is that with the blocking of estrogen comes the side effect of decrease in endometrial development and cervical mucous production, both of which are enhanced by estrogen. Some studies have demonstrated the promise that black cohosh may be protective against this as well as estradiol. The women receiving the black cohosh extract needed fewer days for follicular maturation and had thicker endometrium, as well as higher estrogen levels. Also, there luteal phase progesterone levels were higher, which can indicate an improved quality of corpus luteum that develops in the follicular phase of a woman’s menstrual cycle. Clinical pregnancy rates were also significantly higher in the black cohosh group than the ethinyl estradiol group, 36% versus 13%. Black cohosh appears to provide a safe and viable option for women who are experiencing negative side effects of Clomid.
IMPROVING OVARIAN RESERVE
For women over 35, ovarian reserve can be one of the most challenging areas of fertility to overcome. Ovarian reserve describes the quantity and quality of eggs in response to natural or drug-stimulated follicular development. It is unknown whether poor ovarian reserve is caused by an abnormally rapid loss of normal-sized follicular pool, or by a normal rate of degradation of the pool. Either way, conventional medical options are limited.
Just as well as free radicals and oxidative stress plays a role in males by decreasing the sperm count, it is believed to play a major role also in egg quality in women. For women with decreased egg quality, additional antioxidant support should be considered in every patient. An Italian study published in 2010 has also suggested that melatonin may also be a useful antioxidant to support egg quality. This study was done on women with antioxidants and melatonin, and there was a significant increase in the number of mature eggs seen. Other studies also showed a positive trend in clinical pregnancy rates and implantation rates.
DHEA is commonly prescribed to women with poor ovarian reserve. In fact, it is used by over one-third of all in vitro fertilization centers world wide. DHEA is thought to improve ovarian function and ovarian reserve by promoting preantral follicular growth, reducing follicular atresia. Several studies have looked at the effect of DHEA supplementation in women undergoing in vitro fertilization with decreased ovarian reserve, and these studies generally found that women supplemented had higher pregnancy rates and lower miscarriage rates, especially with women over the age of 35. Some studies show supplementation with DHEA significantly increased women’s levels of anti-mullerian hormone (AMH). This is a hormone produced by developing follicles that is currently considered the best indication of good quality eggs in quantity. The improvement of AMH was approximately 60%, and longer use, up to 120 days showed the greatest improvement. In addition to tests for egg quality, treated women also experienced a significant increase in the number of fertilized eggs, and normal-looking day #3 embryos.
FERTILITY FRIENDLY DIET AND EXERCISE
For many women, I recommend a diet that excludes alcohol, caffeine, sugar, dairy and gluten. Healthful fats, avocados, whole grains, organic fruits and vegetables are essential. Grains-fed meat, or wild, low-mercury fish should be the bulk of the patient’s diet. High-protein diets may be too acidifying in the body. I have my patients check their pH, either salivary or urine, and ask them to maintain an alkaline environment. There is also evidence which concludes that higher intensity of exercise may lower fertility, so be careful. Exercising to exhaustion was associated with 2.3-times the odds of fertility problems, versus low intensity.
Each patient of mine is evaluated with a comprehensive blood test, evaluating toxins, infections, hormonal imbalance, and vitamin levels. I believe the nutritional as well as hormonal aspect is extremely important. I use intravenous amino acids that have been documented to help infertility cases. For example, L-carnitine and amino acids has been shown to increase sperm count and motility. Q-10 has also been shown to improve sperm quality and motility, and vitamin D3 improves fertility in both men and women. Arginine is extremely important. Simple changes in nutritional status is my first-line treatment to improve fertility. I then add hormones, diet and exercise, which are extremely important.
If you are suffering from infertility and wish to pursue an integrated approach, please call my office for an appointment.
Best in health,