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Sperm meets egg. Sperm fertilizes egg. And a baby is born 9 months later. It sounds like an easy process, but for a woman struggling with infertility, it can be an elusive process – one with no easily explained reason why she can't get pregnant.
The path to delivering a healthy full-term baby is a multistep, intricate process. If there is a breakdown in any one of the steps, the final result will not occur. If we can understand each step, and potentially correct the issue, the likelihood of conception and delivery increases. My goal in this article is to arrange a comprehensive checklist of initial recommendations from which to work. In other words, my intent is not to focus on only one detailed piece of the fertility puzzle, but instead outline as many of the steps in an initial comprehensive list.
Sperm Meets Egg
It's easier said than done, and so we must focus on making sure that the path of sperm to the woman's egg is clear and that timing is correct.
The first step in making sure that sperm meets egg is correct timing. If day 1 is the first day of a menstrual bleed, and day 28 is the day before a woman begins her period again, day 14 is approximately the time of ovulation. Prior to this time, LH (luteinizing hormone) will peak and after the LH surge, an egg will be released approximately 24 to 36 hours later. The egg will then journey through a 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. In essence, sex must be timed prior to ovulation to give the sperm time to swim up to the egg. 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 that 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 sperm can have enough fluid to swim through. Even though it is not documented in scientific literature, I have seen many women conceive after elevating their hips for 20 minutes after ejaculation. They must not get up to go to the bathroom prior to this time. Also, I recommend that the man keep his penis inside for as long as possible to not pull any sperm out and away from the cervix.
To allow for sperm to meet egg appropriate lubrication is necessary. Sperm need an alkaline environment in which to survive. The male and female partners should look to consume an alkaline-promoting diet (avoiding coffee, soda, energy drinks, meat, and white flour), avoid using saliva as a lubricant during sex as it may harm sperm, and avoid using soaps around the time of intercourse, as soap residue can damage sperm. No purchased lubricant should be used with the exception of Pre-Seed. For a woman these strategies can help increase cervical mucus:
- increase water and electrolyte consumption to a minimum of 64 oz of water daily
- N-acetylcysteine 900 mg twice daily
- guaifenesin 1200 mg twice daily (Mucinex)
Ovulation should occur 14 days prior to menstruation. These last two weeks in a cycle is known as the luteal phase. If, however, the female is not ovulating a full 14 days prior to menstruation, she may have what is termed luteal phase defect. This typically is due to a progesterone deficiency in the last half of the cycle. For many patients, I recommend that they take between 50 and 200 mg of progesterone daily after ovulation. Progesterone has been shown to prevent miscarriages and improve sperm motility.1 I recommend working with a physician on progesterone timing, dose, and administration.
If it is not psychologically stressful, I often ask women (and men) to start testing for fertility roadblocks early in their process of family planning. As a physician, I would rather know if there is a structural or diagnosable problem immediately. For women, I recommend the following tests:
- TSH, free T3, free T4
- cycle day 2 FSH and LH
- anti-Müllerian hormone
- vitamin D3 25(OH)
- cycle day 3 estradiol
- cycle day 19 progesterone
- free and total testosterone
- pelvic ultrasound
o which can rule out anatomical abnormalities, uterine fibroids or other uterine abnormalities, ovarian cysts or other ovarian growths or abnormalities
- HSG (hysterosalpingogram)
o which can rule out blocked tubes from endometriosis, previous pelvic or abdominal infections or surgeries/procedures resulting in scar tissue
For men, I would recommend the following tests:
- vitamin D3 25(OH)
- free and total testosterone
- semen analysis, to be done immediately
- possible testicular ultrasound to rule out varicocele
One of the most common issues affecting female fertility is PCOS, or polycystic ovarian syndrome. Symptoms include hirsutism (or increase in body hair), acne, abdominal obesity, high androgen (male hormone) levels, and possible menstrual cycle irregularities. The crux, however, is the lack of ovulation in these patients, and the key cause is insulin resistance.
What are the causes of insulin resistance? First, insulin is released in response to eating carbohydrates, so oftentimes the patient is consuming too many sugars in the diet even if those sugars are complex or fruit based. Insulin resistance is also present in those patients who have excess central abdominal obesity (fat in the trunk area), as this adipose tissue produces hormones that make one insulin resistant.
PCOS is suspected through symptoms, blood work, and pelvic ultrasound results. For these patients, I would recommend greatly reducing dietary carbohydrates, increasing healthful dietary fat intake, increasing exercise, and possibly taking supplements to reverse insulin resistance. Working with a naturopathic physician or following the Insulite program online are both excellent treatment strategies for this issue.
A word on metformin: metformin is a medication that is often included in fertility protocols. It makes cells more insulin sensitive, and can thus stimulate ovulation. I recommend taking between 1000 and 1500 mg daily. I often use this medication in fertility protocols, as it does not have any major side effects.
To have healthy pelvic organs, circulation must be adequate. Nutrient and hormone delivery to these organs requires good pelvic blood flow. To improve pelvic circulation, there are several practices that may greatly improve fertility:
- Acupuncture: It has been shown to lower anxiety, balance hormones, and improve IVF (in vitro fertilization) outcomes.
- Yoga: I recommend the DVD Restoring Fertility, by Drs. Brandon Horn and Wendy Yu, which can be found on www.amazon.com.
- Arvigo Maya Massage: This great massage technique can help with other pelvic disorders such as endometriosis and PMS. Find a practitioner on www.arvigotherapy.com.
Sperm Fertilizes Egg
Male factor infertility may account for 30% of all fertility issues. Most male infertility problems can be spotted in an abnormal semen analysis – a fairly inexpensive, quick, and noninvasive process. My first recommendation is to always have a semen analysis performed by a reputable lab associated with a reproductive endocrinologist's office. A conventional lab may not perform enough of them to give the most detailed or accurate analysis. Lifestyle factors that affect fertility to rule out in men would include bicycling, wearing tight clothing, sauna/hot tub use, obesity, excessive alcohol consumption, and smoking.
Simple changes in nutritional status would be a first-line treatment strategy to improve fertility. These are some of the first nutrients that I would consider:
- Vitamin A: a necessary antioxidant that, in low amounts in the blood, has been shown to correlate with low sperm counts and anovulation (lack of ovulation).2
o Recommended dose of up to 10,000 IU natural beta-carotene (the plant form of vitamin A).
o Avoid high doses of retinols, which have been shown to cause birth defects in excess amounts.
- Zinc: Low levels of this mineral have been associated with low sperm count and abnormal sperm morphology (shape).3
o Recommended dose of 40 to 60 mg daily, should be balanced with copper as zinc supplementation can cause a copper deficiency.
- L-arginine: an amino acid that helps improve blood flow, has been shown to improve ovarian response, endometrial receptivity, and pregnancy rate in those undergoing ovarian stimulation protocols.4
o Recommended dose 1500 to 3000 mg in divided doses, on an empty stomach.
o In men, has been shown to improve sperm count and quality.
- L-carnitine: an amino acid shown to increase sperm count and motility.5,6
o Recommended dose of 2000 mg, in divided doses.
- CoQ10: an energy cofactor in the electron transport chain, which has been shown to improve both sperm quality and motility.7
o Recommended dose of 200 mg daily.
- Vitamin D3: a hormone that improves overall hormone function and fertility in the body in both men and women.8,9
o Recommended dose of 1000 to 5000 IU daily, depending on blood levels.
- Prenatal vitamin for women and multivitamin for men: reduced the incidence of low birth weight babies in women and improves sperm quality in men.10,11
o I recommend Thorne's prenatal vitamin.
- N-acetylcysteine: has been shown to improve pregnancy outcomes and ovulation in women with PCOS.12
o Recommended dose of 1200 mg per day.
- EFA (essential fatty acids) status: low essential fatty acid exposure to the fetus has been correlated with lower neurological development after birth.13
o Recommended dose of at least 1000 mg EPA/DHA supplementation.
For men and women, I recommend a diet that excludes alcohol, caffeine, sugar, dairy, and gluten. Healthful fats, avocados, whole grains, organic fruits, organic vegetables, and a small amount of grass-fed meat or wild low-mercury fish should be the bulk of a patient's diet. There has been some talk about high protein diet negatively affecting fertility – especially from animal sources.14 I would recommend moderate protein intake for women (approximately 50–60 grams per day) from fish, high-fat organic dairy, occasionally red meats, and plant sources such as pea or rice proteins. Ultimately, high-protein diets may be too acidifying in the body.
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