Vitamin Recommendations for Conception and Pre-pregnancy

I believe it is beneficial for all women, pre-pregnancy, as a general rule to take the following:

1. Prenatal vitamin with 800-100 micrograms of folic acid or a general multi-vitamin that has this is in. These can be obtained over the counter and reading labels will provide the appropriate information.
2. Omega 3 capsule 1000 mg, two per day. These can be obtained over the counter also.
3. A B-complex vitamin (also over the counter) that has folic acid, B-6, B-12 at minimum. One such simple B-complex vitamin with the combined prenatal vitamin/multi-vitamin noted above is a good recommendation.
4. Calcium/Vitamin D 1000-1200 mg per day (any over the counter supplement is sufficient).
   
   These are simple, general recommendations that, for most patients, are sufficient and beneficial. If you are taking specific medications, it is always wise to speak with your physician regarding such medications and vitamin supplementation. Other supplements (like soy, etc) we do not feel to be detrimental, but their benefit is not known either. The supplements above and otherwise that you may be taking are not thought to be the ‘make or break’ for fertility treatments, but are a general health recommendation.
   
   Please feel free to contact me via e-mail at pahlering@sherinstitute.com or via phone at (314) 983-9000 if you have questions regarding any of this information. Visit the SIRM website at www.haveababy.com for additional information on fertility and conception.

Important Fertility Considerations For Patients Getting Chemotherapy

• Chemotherapy/ radiotherapy always adversely affects reproductive function
• At least 3% of patients with breast cancer are peak reproductive age (25-35 years)
• We can preserve fertility for future; this is for females (egg freezing and other techniques) and males (sperm freezing)
• Although chemotherapy may not always result in premature menopause, it always has some affect on fertility, namely loss of ovarian follicles to some degree. It often causes ‘pre-menopause’ which can be reproductively devastating as well. FSH level alone is not a good indicator of ovarian problems or premenopause.
• Chemotherapy adds at least 10 years to ‘real age’ or ‘ovarian age’ in terms of reproductive function. A 30 year old now behaves reproductively like someone that is 40 years old.
• With women that have breast cancer and carry the BRCA gene, we can detect this gene in embryos using preimplantation genetic diagnosis (PGD) techniques through IVF, reducing if not eliminating the risk of transmission of the gene to offspring.
• Ovarian dysfunction post-chemotherapy is related to patient age at the time, type of chemotherapy/radiotherapy, and ovarian function at start of therapy (this can be assessed rapidly - generally in one day - with simple tests prior to therapy)

Please contact us at SIRM-St. Louis at 314-983-9000 if you are preparing to undergo cancer chemotherapy or radiotherapy. We will expedite a consultation and provide you with information and options for fertility preservation. You can email me directly at: pahlering@sherinstitute.com

ENHANCING EGG QUALITY

We all understand the concept of the biologic clock and how it affects fertility and reproductive potential. Unquestionably the so-called biologic clock is the single most important influence on fertility potential for any given couple. Problems with quantity and quality of eggs are the most important issues to be assessed and discussed with any couple considering fertility future or reproductive abilities. This is regardless of any male factor infertility that may or may not be present.

Ultimately, egg quantity and quality are the major determinants of success in natural conception or any other treatment for a couple (Clomid, IUI, injectable medications, and even IVF).

Patients often ask me, “How do we improve egg quality?” People often ask about diet, exercise, etc., and how this may improve egg quality/competence. Certainly, as with male factors, environmental and lifestyle issues may influence ovarian function and subsequent egg quality. However, assessing this scientifically and making the determination of how these influences affect eggs is quite difficult. All doctors would advocate a so-called “healthy lifestyle” with diet, exercise, etc. This is not only potentially beneficial for egg quality, but certainly beneficial on several other levels and therefore, is recommended.

When people ask about improving egg quality, what they usually mean is improving the chance that any given egg that is fertilized will develop into an embryo that will subsequently make a baby. Again, this is very difficult to determine and obviously very complex. In the end, there is some evidence in the context of IVF that may be beneficial to some patients, depending upon the details of their situation:

1. Human growth hormone. HGH has been shown in the context of IVF to have a positive influence on egg factors, thereby increasing the probability of success in certain cases with IVF.
2. Antioxidant supplements. The evidence supporting the use of antioxidants in female factor is early but there may be some suggestion that it is beneficial. Obviously, there may other health benefits from taking these supplements; and therefore we often use them a lot.
3. Lifestyle Factors. Not doing things that can have a negative influence such as smoking, exposure to toxic chemicals, etc. Discontinuing such lifestyle factors may remove negative influences and in the end have a net positive effect on oocyte quality and fertility potential. In males we often recommend the same; if there is any level of male factor, the principles are similar.

Hopefully, this is of assistance with information. Please feel free to contact me or visit the the Sher Institute website at www.haveababy.com and my male infertility blog at www.maleinfertility.info. There are lots of other informational tools on many subjects at these sites as well.

Natural Cycle Frozen Embryo Transfer--Lower Cost and Works!

One of Many issues that couple face with seeking reproductive medicine treatments is cost. We are always seeking to lower costs here for our patients with various pricing options and plans. Of course the key is not to compromise outcome and individualize management. Unfortunately for many, they sacrifice quality/optimal services and outcome seduced by lower costs....one must look around for sure. However this concept we should delve into later in more detail as i see it alot.

One way for couples to often lower costs significantly and to take ALOT fewer medications is with the concept of natural cycles. THis is not for everyone let me say that right now (there is no one formula for all couples...I wish it were that easy) but only for situations where in the female:
1) has normal fairly predictable menses cycles.
2) there is orderly growth and development of a pre-ovulatory dominant follicle as determined by US--not just an ovualtion kit/LH surge kit (though this is helpful often in indicating the patietn is a good candidate for this)

when these conditions are present, then one can often try and exploit these thingst in the context of IVF either fresh or frozen embryo transfer. The Frozen embryo trnsfer situation is better with antural cycle as fresh natural cycle has other issues that can make it complex (but do-able. The couple really needs to disucss the pros and cons with M.D.) so this is antoher topic that can be addressed later...

However with NC FET (natural cycle FET) it is great for the patients in several ways---lower cost, less medications and we have found with our protocol pregnancy rates even better than medicated cycles. So i can say when it meets the right criteria, this is the way to go and does not compromise outcome.

I am available via blog/email/website to provide info or discuss.

Happy Holdiays to all.

Peter Ahlering MD
http://www.maleinfertility.info/
http://www.peterahleringmd.com/
pahlering@sherinstitute.com email
http://haveababy.com/?St._Louis_IVF_Clinic website

New Tests for Male Factor, Looking at Quality

We have always had a keen interest in optimizing male factors during treatment with IVF and ICSI.
The key points to this are:
1) assessing quality and quantity first off. It is not jsut count and motility, these are the elast important things to look at, albeit necessary during the evaluation. Looking at quality ahead of time is key. We see often where the count and motility are fine, but the DNA fragmetnation is abnormal or the high resolution morphology (not just your verage morphology--see MSA elsewhere in Blog) is abnormal---these are quality indicators.
2) When there is a male factor (quantity issue, quality issue, or BOTH) then treatment PRIOR to an IVF cycle can be done (email me directly if one wants articles on this pahlering@sherinstitute.com) and there is no doubt that this can improve outcome potential.
3) using the newest techniques in an IVF cycle to select the best ones. There are different ways to do ICSI for example (seee HRSS articels in this blog) AND now we have special techniques that we can use to remove bad sperm ahead of time so we have a pool of better ones to then select from. This is really exciting new stuff. This is not just 'washing the sperm'--that is no longer adequate in todays world of IVF and ICSI.

so the using new ideas to diagnose and manage male factors is criticla to optmizing an IVF cycle. There are new things to be done! Diagnosing problem with proper testing, managing pre-IVF cycle with treatments, and then selecting optimal sperm on 'game day'...these are the pinciple concepts.
Also remember most importantly---just because the basic analysis done shows he is a 'star' with high count...this does not mean the quality is not a factor. Thus one needs to look.

Recurrent Pregnancy Loss and using IVF in the Treatment

IVF IN THE MANAGEMENT OF RECURRENT PREGNANCY LOSS
Recurrent pregnancy loss is often a complex issue as patients generally have
no difficulty initiating pregnancy but maintaining that pregnancy is a problem.
Often times patients will not have an evaluation of the pregnancy loss until
there have been several of them. This unfortunately leads to difficulty in
management when there have been several as the previous losses have
unknown cause.
The number one cause of pregnancy loss and recurrent pregnancy loss is
related to chromosomal or genetic abnormalities of the embryo. We know that
a lot of human embryos are abnormal with a condition called aneuploidy
which means an abnormal number of chromosomes. This is often readily
diagnosed at the time of miscarriage through examination of the products of
conception with D&C. Thus unless one has a D&C specifically with
assessment of the chromosomal status of the loss, one cannot prove that the
loss was indeed due to aneuploidy. Later, often in the face of further
pregnancy losses and repeated non diagnosis, one is faced with the dilemma.
Not knowing the nature of the previous losses, it is difficult to reduce the
probability of future loss in another pregnancy.
Chromosomal and genetic abnormalities cannot be “prevented” per se.
However, with in vitro fertilization one can usually obtain several eggs and
embryos from which to select multiple embryos for transfer. Thus, the
probability that one embryo is normal improves. Thus, the probability of
ongoing pregnancy is improved.
In addition to the process of IVF itself during the in vitro process one can test
the embryos for aneuploidy (again, the most common cause of future
pregnancy loss) with the process of preimplantation genetic diagnosis (PGD)
for comparative genomic hybridization (CGH). Obviously, knowing the
chromosomal status of the embryo prior to transfer in IVF one avoids putting
in abnormal embryos thus improving the probability that the “normal ones”
that were transferred will indeed implant and make a successful ongoing
pregnancy.
Thus in the face of undiagnosed recurrent pregnancy loss cases, we go about
looking at other non chromosomal/genetic causes of this condition such as:
immunologic factors, uterine factors, and clotting conditions such as
thrombophilias. This process of ruling out other conditions is simple and can
be performed rapidly and efficiently. If there are no abnormalities found,
chromosomal/genetic problems become the mostly likely cause of the
recurrent pregnancy loss by default; and one is able to consider IVF as
management with or without PGD/CGH. Unfortunately, “proving” the cause
of the prior miscarriages is difficult in retrospect. Thus, the best management
for pregnancy loss in my opinion is to diagnose every pregnancy loss with
assessment of chromosomal abnormalities at the time of D&C.
Please feel free to contact me if there are any questions or issues in regards to
this topic.

Low Ovarian Reserve Patients-Diminsihed Ovarian Reserve

Assessing ovarian reserve as best as possible is the single most importnat thing one can do in the managment of fertility/reproduction. not to say of course other things like male testing are cruical as well, just second in importance to reserve of ovaries. This is because egg issues cannot be corrected to the degree that male factors can. We cannot make mroe eggs and follicles so if thre are low numbers this has profound implications on how one manages things as well as profound impact on treatment outcome, even with IVF.

Assessing reserve with simple blood work an US is key and takes very little time. However the results can change everything.

In IVF with low responders, there are some protocols that are better than others. There are various medications and additional things, especailly in patients with prior failures, that can optimize the results and offer the best chances. Pre-treatment for females BEFORE the IVF cycle can also be of help...antioxidants for example are one thing that may give couples a leg up but have to be taken BEFORE the cycle of IVF. Again, there are other things that also can be used in these cases with the protocol that can be of beneift as well as things t;like HRSS (see elsewhere on this blog) that can optimize fertilization in cases where there are low numbers of eggs.
So keep these things in mind when embarking on fertility evaluation and make sure these are looked at, if diagnosed with low reserve investigate treatment options/regimens.

Peter Ahlering MD
SIRM St Louis
pahlering@sherinstitute.com