Watch the recording of the webinar with Antonio Rodrigues, MBBCh, FCOG, MBA, a Reproductive Medicine Specialist and the Founder and Director of Medfem Fertility Clinic in the Republic of South Africa, who discussed infertility and lifestyle.
Dr Rodriguez during his presentation tried to answer one of the questions on why we need to focus on lifestyle to improve our outcomes both in terms of normal infertility and in vitro fertilization. Several factors are important, and according to Dr Rodriguez, the most important one that he and his team researched over the last 21 years is stress.
The rest of the things like diet, smoking, recreational drugs, alcohol and poor nutrition often follow their whole concept, and the type of stress that the team have recognized as major comorbidity of infertility is what we call time urgency perfectionism stress.
Anything that leads to a higher level of carbohydrates in your diet and, unfortunately, all those normal things that taste good causes raised insulin levels. Normally if you wake up in the morning your insolence should be low as you have your first meal, the insulin goes up, and then you are maintained until your next meal. However, Dr Rodrigues and his team found that a lot of women have raised insulin levels, and this is not diabetes, this is high insulin levels which is a pre-diabetic state. Some patients have had overweight, but a large percentage of them have normal weight. Common symptoms are fatigue, sugar cravings, weight gain, and high cholesterol levels. A lot of patients have hypertension, some have a history of heart problems, and it’s a worldwide trend that there’s a very high incidence of a polycystic ovarian syndrome (PCOS) or a spectrum of polycystic ovarian syndrome, meaning that some women might have normal cycles, but, when monitoring the ovulation and the way the uterus responds, they behave exactly like a polycystic ovary. Some of those patients have very high insulin levels, and if they have high insulin levels, they need to pay attention to their diet. All those patients are treated with Metformin to bring that insulin down. There are also some natural products called inositol, which is used to bring insulin down as well. Metformin is a drug that will help egg quality.
What about the male? There was a general tendency to blame poor-quality embryos on the egg, but we should remember that paying more attention to the male is crucial. Some men may have normal semen analyses, but on the other spectrum, they can have very low sperm counts and very abnormal sperm. If they have high insulin levels, they could have played a big role in embryo quality. Therefore, when we’re looking at IVF, it’s very important to check the male as well. A lot of research showed that if a male has high insulins and we check things like thyroid and prolactin levels in the male, and if any of those are abnormal, we need to focus on the male. It’s not all about eggs.
If your weight is normal, your insulin is normal, you need a balanced eating plan, and you need to eat a combination of vegetables, and fruits in the right amounts and not overdose on refined carbohydrates. If you have high insulin levels, you’ve got two options, you need to look at a low glycaemic diet, which means you need to eat your sugars and carbohydrates in such a way that they don’t create these big high insulin levels and that works well in the female population. Then there is also a diet called the Banting diet or the carbohydrate-free diet, and that particular diet has a very specific benefit but seems to do better in the males in controlling insulin levels. It’s very important to focus on eating habits and to keep them simple in such a way that you’re eating healthy.
In the modern type of foods and modern diets, nutrition intake plays a role. If you’re having very good food, eat vegetables and fruits that are organic, those types of foods will be full of nutrients, and there’s no necessity to look at your nutrient intake. However, sometimes in patients, there is increased demand for nutrients through what is called mitochondrial stimulation. Mitochondria are little parts of the cell cytoplasm, and they’re very significant in creating the division in the egg at the end of its development. The mitochondria need to have the right doses of vitamins, minerals, amino acids, antioxidants, and growth hormone factors.
A stress factor called time urgency means the feeling that you’re always chasing time from the moment you go to sleep at night, even chasing time in your sleep, in your nightmares, in your dreams, waking up before the alarm clock goes off and never getting enough time. Another very important factor is perfectionism, where you would go on and on in a normal situation to get something perfect. When these two are joined, perfectionism and time and urgency, start to create certain hormonal changes in the body. This group of people, in terms of these symptoms, are angry, irritable, hostile, often cynical, and blame other people, etc. It’s all related to the stress of not having enough time to do things right. Another thing that was found in the research was personalizing personality. The person takes things personally concerning this time urgency, perfectionism, and that group of people have a much higher incidence of being depressed.
What is this time urgency? We look at a situation where we get hooked on a stressful situation. Any situation that causes a negative reaction, like running late, you’ve been criticized, you’re standing in a queue, or someone moaning at you, are all hooks that will pull you into a situation and start to create a negative reaction in your body. The whole principle of managing those negative reactions is to learn how to break that vicious circle.
We also need to recognize that there’s good stress, unlearned stress that happens out of nowhere. Stress releases adrenaline, you feel good, for example, you put a project in a work, and you get rewarded for that. Learned stress happens all day, every day, from the time you wake up to the time you sleep, and secretes hormones such as cortisol and noradrenaline. Cortisol is an immune suppressant type of hormone, so that leads to a lot of things like infection, chronic immune diseases, and autoimmune diseases, it plays an important role in the entire process. Noradrenalin has a lot of symptoms that it can bring up.
Another research done on a group of women with infertility problems revealed that a lot of them had endometriosis. There was a large group of symptoms that they had. Once they managed that stress, those symptoms went away, such as hot burn, chest pains, headaches, muscle pain, joint pain, diarrhoea, and irritable bowel syndrome, those things disappeared, and there was a lower rate of depression after managing it.
There’s a value for the patient not in terms of just falling pregnant but in terms of their pregnancy because there’s a lot of work that shows that if you fall into this type of stress, it has a negative impact on the baby as you go through pregnancy. Lifestyle management can improve not only the pregnancy rate, but also shortens the time of pregnancy.
IVF cannot just be repeated over and over again, every single failure needs to be looked at carefully, so we bring this type of optimization or fertility into our programs very early, and we do it by what we discussed stress management trying to get balanced eating managing insulin problems in males and females and dieting males. We mustn’t neglect the male, they need to understand that they need to be fit and healthy to create a good embryo. Smoking has been extensively studied both in males and females, and if you do smoke there’s going to be a reduction in your IVF pregnancy rate, recreational drugs have an effect, and if you’re not drinking too much alcohol, it sometimes tends to play a role in diet especially if it’s wine and things like that. That’s very high in carbohydrates, but alcohol in excess is a problem. In summary, it’s very important as an added benefit to all fertility patients to focus on these things to optimize their fertility.
It depends on whether in your fertility clinic they’re looking for things like insulin, thyroid, prolactin, and they usually are, they are important and play a role. Also, we mustn’t always blame the egg. We need to focus on the male as well. If you haven’t had those sort of tests, insulin, thyroid, prolactin in a male, they should have those done. I’ve seen patients who had multiple IVF treatments, they had poor egg quality, and they were suggested that they go for a donor egg, but when you manage them well, and you treat them and get those parameters right, you can actually improve the egg. Lastly, if you’ve had IVF and you’ve had poor eggs, it is important to review the type of stimulation you’ve been having. What is important is that if you’re having poor eggs, in terms of IVF whether they’re using normal doses, it’s often a very good idea to drop those doses down, and start to use smaller doses, those stimulation protocols are very important. At the end of the day, if you’re having IVF for a reason such as a blocked tube, and they keep having poor egg quality, there’s always the option of natural IVF because sometimes, some patients just don’t do well with injectables, and if you go for a natural cycle, they create a natural embryo, and you will end up with a baby from.
If you look at it from a point of view of IVF and weight. If you’re overweight and your insulin levels are high, that will definitely influence your egg quality. That group of people need to lose weight, it’snot even a weight thing, they need to actually get their diet right so that their insulin levels are controlled, and once you control the insulin level, even if they are overweight, they can have a baby. That’s what people look at in research projects, they say women who are overweight have a lower chance of pregnancy, it’s actually the control of insulin, so if you control the insulin by a diet or by a diet plus medication in the form of metformin, then you don’t have to be a skinny person to have a baby. I agree with you, there’s a lot of overweight people, but they often have a different spread of weight, and often when we test that group of woman, they have a normal insulin level.
Natural IVF is when a woman has a normal cycle, so she creates a normal follicle, and I’m sure you all know the follicles are a collection of fluid with an egg in it. If she has a normal follicle and endometrial lining in the uterus looks good, we would then take that natural egg out, so it’s exactly the same as IVF, and we’re taking out naturally without drugs. There is a group of woman who needs to have that form of treatment. If we keep trying to get eggs from someone, and we’re not getting numbers, we will often go for a natural IVF. Especially, if there’s a male factor involved, and the other group is where you keep having poor quality eggs, in normal stimulated cycles, it is a way, in some women, you will get a normal egg without drugs.
The normal level is less than 9, I’m depending on the units, but most places in the world use those units, so it needs to be fasting insulin, and it needs to be less than 9.
In our particular practice, if we find someone who has poor mucus, we will take them through an operative procedure first to clear up the endometriosis. Then we will try and get a natural pregnancy. I need to emphasize, in our particular practice, 90% of women don’t have symptoms of endometriosis. They don’t have pain, they don’t have discomfort with a period, of ovulation and they don’t have painful intercourse, so we wouldn’t know unless we did that mucus test. We tend to do a laparoscopy, and the other thing is that around 15% of patients who have recurrent failed IVF, if they’ve never had a laparoscopy, they might have underlying endometriosis, and it might be affecting the quality of the eggs. To your question, if you can manage stress to prevent it occurring, the answer is yes. If one managed stress and keeps to that, there’s no question. A lot of those patients fall pregnant naturally before you do any form of intervention, and we’ve changed people’s lifestyles for years that we’ve known for 20 years now that managed to change their lifestyle and maintain their lack of symptoms.
If we look at it from a symptom point of view, that can indicate that there might be the endometriosis, but it could also be normal. Just to explain what happens during ovulation. The first thing is that you get, the follicle getting quite distended and intense, so it has a very strong nerve supply delivery. In a certain group of the woman, when they release that fluid into the abdomen, it has a high level of what we call prostaglandins, and these prostaglandins are quite vicious in terms of the abdomen, and if there’s any blood in that fluid is also very painful. You can’t do much about it, and again the problem is that the treatment for that is anti-inflammatory, but it’s generally recommended that you don’t use anti-inflammatories around ovulation because it might affect the way that the egg ovulates. It can indicate that you have underlying endometriosis.
I’m not too sure about the salty food, but the other 2 in a balanced way could be part of a balanced eating plan. You know the problem with all of this is if we look at it and if we read on the Internet and everything is good for infertility, and I think the reason for that is because, at that moment in time for a patient, he’s gone through a struggle period of trying to get pregnant. They will read about something, and in that particular month they’ll take Brazil nuts and pineapple, and they fall pregnant, and that’ll become the story. So, my personal feeling is the right nutrients, balanced eating plan, and you can’t do too much of that and try and manage your stress, as a general principle.
DHEA is a male type hormone, that’s normally secreted by the adrenal gland, and it is used to increase the number of eggs in IVF programs. There’s some work to suggest that it has a benefit in people who have low egg reserve. The problem with DHEA in people who have normal egg reserve is because it’s a male hormone, it can actually bring on a polycystic like ovary and can have the opposite effect. So this is for the right patients, if it’s recommended by your doctor, it’s fine. But to say it is improving egg quality, my personal feeling is that it is not my favourite drug because it affects some woman on male hormone and its effect on producing a polycystic like picture. If you falling into that group of patients with a low reserve, there’s no harm in taking it, and in some people, it plays a role in improving the outcome.
Inositol is a natural insulin reducing drug, it got folic acid, normally the combination of it in, which is an antioxidant. So again, it is going to be for patients with the polycystic ovarian syndrome (PCOS). But just to put that towards polycystic picture into perspective. It is quite a spectrum, so if you look at the patient, they have a scan that looks like they are ovulating normally, and the endometrium is okay, but they’ve got what we call a multicystic ovary, so the dominant egg hasn’t actually switched off all the other eggs. That is that sort of one end of a multicystic polycystic picture, and then you go right up to your patient who has polycystic ovaries without any periods and without any menstruation, and the abdomen ovulation. All those patients do well over time as well, and it is a good medication to use in that group of people. And it has been scientifically proved it is beneficial.
I’m going to assume by good viable blastocysts, these blastocysts have been tested. So if they haven’t been tested and you’ve got no implantation, we tend to look at quite a lot of the poor implementation factors before we put patients on programs. We do screening antibody tests, Anti-thyroid. Antibodies play a big role in poor attachment of embryos, there’s an antiphospholipid syndrome, anticardiolipin, anti-nuclear factor. Those immunological factors are about 15% of our patient profile in South Africa, so we do test people upfront. If we’re talking about good viable blastocysts, we will often recommend that patient undergoes pre-genetic testing if we do it, and we’ve looked at uterine factors, done by X-ray or hysteroscopy, it is very important to make sure that there’s no block tube anywhere if there’s a blocked tube at the end of the tube, we call that hydrosalpinx or water on the tube, that can also be the reason for the lack of implantation. So if we make an assumption, that we’ve done all of those things and we’ve tested the embryos, it’s unusual not to get implantation, so I think if the embryos haven’t been tested, they should be, and I think you need to have some immunological tests to make sure that everything’s all right and you must also be sure that you don’t have any blocked tubes and that you don’t have anything in the uterus that can be inhibiting it. It’s a very small group of a woman where an embryo can’t implant in, and those patients often need to go to surrogacy, but that’s a very small group of people.
Absolutely, so that’s the whole thing, so there’s the spectrum of high insulin, not being diabetic, so your blood sugar levels are normal or low with high insulin. So what effectively happens when you wake up in the morning if your insulin says 15 and you have your breakfast, then insulin will go up to 40 or 50, and because it’s started off at 15, it actually drops your blood sugar. So what will happen, in 1 or 2 afterwards, you’re going to feel a little bit of a sugar low, you’re going to feel hungry, you might feel shaky, tired and if you eat something, you feel better. So it’s exactly what you’re talking about, blood sugar is actually low with high insulin. It only becomes high when you become diabetic, and the reason that does that is you’ve overused your pancreas over the years, and the pancreas carries on secreting insulin, but the insulin stops working, so initially, the insulin, when it’s high, overworks, and therefore drops your blood sugar, and with time stops working and can’t get into the cells, and you’ll end up becoming diabetic.
Some studies suggest that it might play a role, but you know the problem with the studies is that the small studies often show one or the other, but when they put all the studies in the world together, they often don’t show anything. I think it’s very important just to mention that when you are going to a fertility clinic, you’re there for a reason, and it’s usually because you feel comfortable with the medical people that are looking after you, and different doctors have a different experience with these sort of things. If your doctor believes that it has a benefit, then go with your doctor. I don’t have that big experience with ubiquinol.
In terms of the uterus preparation and trying to get the uterus better, we’ve had a few patients who benefited from it. In terms of the ovaries and enhancing the ovaries by injecting the ovary. In South Africa, there’s one unit doing it. The research is not that impressive, and we kind of refer to the one person, and if patients make a call to do it, they do it. So not the best experience from my point of view but there is literature to suggest that it has a benefit, but we haven’t had that same experience.
Assuming that the scannings have been done, and it’s been confirmed that ovulation has taken place on day 14 and that you’ve got a shorter cycle. If that hasn’t happened, it’s very important to know when you’re ovulating because your luteal phase by definition is 14 days, so if you look at a 21day cycle, you could be ovulating on day 7. You can still fall pregnant if you’re ovulating on day 7, true luteal phase deficiency is quite rare. If you are ovulating on day 14 and you’re having a short cycle, the first step is to have ovulation induction. A better route is usually injectable FSH, LH combinations with progesterone support, so that would be a way of trying to improve the way the egg creates the follicle.
It’s always been said that too much caffeine can play a role in pregnancy. There have been some very big studies done that if you’re having more than 3 to 4 cups of coffee a day, you will have a problem with fertility. Usually, if someone’s having a large enough amount of caffeine, they’re not eating properly, in other words, the caffeine is replacing the diet. So I think you should limit it to 1 to 2 cups a day, but there are studies which show that up to 4 cups a day, won’t do anything to pregnancy. You must understand that caffeine is a drug, so if you’re having a very strong coffee and get pregnant, and the baby’s going to get that caffeine in it, and that might affect your baby, that’s in terms of pregnancy.
A lot of work suggests that it does play a role. What is happening in the world for a while now, they were checking vitamin D levels and they were finding that suddenly everyone in the world was vitamin D deficient. It could be the case because we’ve been taught that we’re supposed not to sit in the sun and enjoy the sun, but they’ve actually changed the values worldwide, the normal values in terms of what is actually the vitamin D deficiency have changed. If you are found to be vitamin D deficient, you should have the replacement because it has been shown to play a role.
Effectively, if anyone tells me that they probably have an underactive thyroid, I would like to mention this very strongly, the cold hands and feet, and if you take your body temperature and if it’s below normal, if it’s under 37 and you’ve had that for a long time, it often is an underactive thyroid. Depending on who you see from a fertility point of view, the level of thyroid-stimulating hormone, which is the hormone that’s made by the pituitary gland to make the thyroid work should be more than 2.5. Some doctors say, from a clinical point of view 4.5 and above is abnormal. From a fertility point of view, 2.5 is abnormal, if you’d have an ultrasound and the lining of your uterus is thinner than 8 millimetres at the time that the follicle is normal, then we need to start thinking of thyroid disease. You should have your thyroid checked, you should also have thyroid antibodies checked, and if the lining of your uterus is thin and someone’s struggling to get it right, the thyroid plays a big role in this whole process.
There is a trend to worry about uterine infection in people with recurrent failed IVF. People are looking if the timing of putting an embryo back is a problem or not, and there is some work happening at the moment in terms of either failed IVF or early miscarriages, but that is a very specific test. If you have an infection in the uterus like chlamydia or those sorts of infections, you will have bad symptoms. There is a group of patients that have what we call microbiome, so they have some changes in the microbiology of the uterus and that it requires a very sophisticated test. It’s quite expensive to do that test, so it’s for the right patient, it might be necessary. In terms of menstrual blood, the one thing that can be picked up is TB (Tuberculosis), but in Europe, TB is quite rare as you know. In certain parts of South Africa, it has a high incidence, but it’s not common in the group of patients that we see.
PCOS if it’s severe, it can bring acne-like problems. Skin tags themselves have never been related directly to PCOS, but if you have a lot of acne in the area, it can create problems with the skin, I have no doubt. Unfortunately, the only way is to either cauterize them or take them off by some form of surgery.