Fertility Mythbusters

FACT FROM FICTION

When it comes to matters of the womb, everybody seems to have advice.  Fertility is a field at the intersection of old wives' tales and the latest advancements in science. The information out there can be overwhelming! And the internet is a dangerous place to go looking for answers (yup, I know...bear with me).  At Xandara, we go back to the basics - with both an evolutionary lens on women's biology and a focus on published scientific research to back our claims. Here we tackle some popularized claims about fertility to separate fact from fiction. 

Myth: A woman's fertility rapidly declines after age 35.

The most commonly cited statistic is that one out of three women over the age of 35 will fail to conceive after a year of trying.  Any Google search, women's magazine article, or even ob/gyn appointment may equip a woman with this same benchmark. It's enough to leave any woman in the vibrant years of her mid 30's completely panic-stricken.

So where did this bleak statistic originate? It appears this figure was first cited in a 2004 paper published by the author Henri Leridon in the Human Reproduction journal. The source of the data? Birth records from around 18th century France, a time before the availability of things like antibiotics and birth control pills - nevermind reliable nutrition and healthcare access. Women at that time likely were not even trying to conceive in their 30's and 40's; in fact, they may have been actively trying to avoid it by not having/or having less sex. A decrease in frequency of intercourse is common as couples age, and it has even been suggested that this accounts for much of the disparity in birth rates. One should be quite skeptical about applying data from this cohort to the typical modern woman who has much more agency over her reproductive health and planning.

Instead of continuing to cite this three centuries old, confounded data, it is worthwhile to examine what more recent studies show. Birth records nowadays are useless for an entirely different reason: women who don't want to conceive have ready contraceptive options to prevent it. It would be most informative to look at women in every age bracket who are actively trying to conceive and compare their likelihood of success. A 2004 publication by David Dunson did just that. The study looked at around 780 healthy European couples actively and naturally trying to get pregnant.

  

The results: of women aged 35-39 years old, 82% of them conceived within one year of trying.  

 

Compare that with women aged 27-34 years old where the success rate was 86%. That's only a 4% change. The numbers beyond the age of 40 were more difficult to interpret. Likely fertility does decrease with age, but it is not the precipitous drop women are lead to believe it is. Time, ladies, may not be so dire.   

    

Myth: Prenatal supplements are only for women.

It's obvious to focus on a woman's nutrient status when it comes to fertility matters. After all, she provides the egg, housing accommodations, and basic utilities to the placenta as the child grows and develops. However, for conception to even take place, and to do so with the highest quality genetic material, she is only half of the equation. In fact, 1/3 to 1/2 of all infertility cases are related to male factors. Male factor infertility can be caused by structural problems like varicoceles (enlarged veins in the testes), undescended testicles, scar tissue from surgery, or genetic factors. However, such causes represent only a small percentage of male factor infertility. The majority of cases involve immune, hormonal or "unexplained" factors; and these usually translate to problems with the sperm themselves.

 

Sometimes abnormalities are seen on semen testing: like low sperm count (how many sperm there are), poor motility (how well the sperm move) or morphology (how normal the sperm appear). Sometimes, however, the performed testing looks normal. That doesn't mean the male factor is truly unexplained, though; it just means that traditional testing isn't able to give us the complete picture. The last breakthrough in understanding male factor infertility was the discovery of sperm DNA fragmentation and the ability to test for it. There is evidence that the sperm of infertile men contain more damaged DNA than the sperm of fertile men, and that this even correlates with lower success rates in both IUI and IVF. The reason for DNA damage, or poor quality sperm, largely has to do with oxidation. Oxidation is what happens, for example, when a cut apple turns brown; it's a chemical reaction in the body where oxygen gets metabolized and free radicals are released. These free radicals must be neutralized by the body's antioxidant pathways, otherwise they can cause damage to surrounding molecules and DNA. When the number of free radicals produced surpasses the body's ability to detoxify them, oxidative damage results. Oxidative damage in sperm is thought to contribute to upwards of 80% of male infertility. And it has been shown that infertile men with high levels of these free radicals in their semen have greater DNA fragmentation in their sperm and less normal sperm available.  

 

Such data makes sense. When it comes to fertility sperm have one objective; survive a trip through the female reproductive track, penetrate the awaiting ovulated egg and deliver genetic material to fertilize it.  Thus, the quality of the DNA is paramount. Subpar genetic material is either too damaged to lead to a viable fetus, so the egg does not get fertilized - or is prevented from doing so by the body's protective mechanisms, so that the pregnancy miscarries. Since fertility is a game of statistics, the more good quality sperm a man has available to fertilize an egg, the greater the likelihood that one will succeed in doing so.

As with so much at Xandara, we believe one need not leave things to chance. There is a growing body of evidence that environmental influences have a powerful effect on a man's oxidation burden and sperm quality. Sperm quality, then, is partly in a man's control through measures that decrease his oxidative stress. This can be accomplished by avoidance of certain environmental toxins to reduce his oxidative load and targeted vitamin supplementation to increase his antioxidant capabilities.  The life cycle of a sperm is around 90 days. That means a man has at least 3 months to hack his habits for superhero sperm.

 

Some environmental exposures are, unfortunately, only within one's control to a small degree. For example, there is strong and rather consistent data that certain circulating pesticides, insecticides and ambient air pollutants increase oxidative stress and have detrimental effects on various sperm characteristics. Even organic environmental toxins like PCBs, which have been banned by the US Environmental Protection Agency (EPA) and various international agencies since the 1970's, remain widely in circulation as contaminants in our food supply and existing buildings and rivers. Unless your hubby takes a leave at work to play "bubble boy" for a few months, it is inevitable that he will be exposed to some degree.

 

On the flip side, there are a host of behaviors within one's control which have been found to promote oxidative damage in the testes and even reduce sperm parameters through additional mechanisms. In numerous studies male smoking, alcohol consumption, obesitydrug use including steroids and poor diet have all been highly implicated. Behaviors that increase the temperature of the testicles can also be problematic for sperm production.  Additionally, exposure to radiation from cell phone use in men has been clearly shown to cause increased oxidation in sperm leading to reduced sperm motility, vitality and accelerated DNA damage.

 

Other exposures may he hiding in less obvious places. For example, BPA (bisphenol A) and a group of compounds called phthalates, are chemicals widely prevalent in common household products and have been shown to increase oxidation and damage sperm DNA, in addition to acting as hormone disrupters in the body. It is no surprise these two toxins have also been shown to have deleterious effects on egg quality in women. BPA can be found in plastic containers and as a coating on paper receipts, and phthalates are widespread in plastic products, air fresheners and personal care products. For good reason phthalates are banned in children's products and widely in Europe, but regulation does not go far enough here in the US so one has to be vigilant in choosing hygiene products that are phthalate-free. Additionally, we'd advise that men minimize their handling of paper receipts.

 

The importance of a healthy lifestyle with a whole-food based diet, regular exercise, and avoidance of toxins and radiation can NOT be underemphasized in men planning a pregnancy with their partner. As we've discussed, it is clear that too much oxidation in sperm is a main driver of male factor infertility. So, what other steps can a man take to combat oxidative damage? Antioxidant supplementation for men has been shown to be particularly powerful. A large scale review of 24 published studies on the topic included antioxidants like vitamin C, vitamin E, selenium, zinc, folate, N–acetyl–cysteine, and carnitine amongst the studies. The authors concluded that oral antioxidant supplements are beneficial in improving sperm function and DNA integrity. Specifically, when it comes to pregnancy outcomes in couples struggling with infertility, a large Cochrane review published in 2011 looked at over 2,800 couples undergoing assisted reproductive techniques (ART) and found that antioxidant supplementation in subfertile males improved the pregnancy rate (by up to 4 fold) and live birth rate (by up to 6 fold) with no report of side effects.

 

This is an easy recommendation to make. Fathers-to-be should take prenatal antioxidants. The science is clear that this increases the chances of a successful conception both for couples trying to conceive naturally and for those undergoing specialized fertility treatments. The optimal dose and combination of antioxidants has not yet been clearly teased apart, but we would suggest supplementing with the antioxidants that have been most studied.

 

Specifically, we recommend vitamin C, vitamin E, zinc, folate, selenium, and coQ10.

 

Ideally, men should begin this at least 3 months before trying to conceive. He can also get a rich supply of antioxidants by increasing consumption of brightly colored fruits and vegetables. To supercharge your man's fertility make sure he takes his vitamins, eats his vegetables, gets moving, says yes to boxers and no to smoking and excessive boozing, carries his phone around in a man-purse not pocket, lays off the cologne, and never wants a copy of the receipt. Cake.      

Myth: There is nothing a woman can do to affect the quality of her eggs.

This is a topic that doesn't get as much attention in discussions about fertility. Most advice about increasing the chances of pregnancy circles around timing - how to measure ovulation and time sex. However, your diligent tracking of cervical position and mucous are irrelevant if the egg that gets fertilized is not of good enough quality to support the development of a child. What then does "good quality" mean in terms of a woman's eggs? Not surprisingly, like its sperm counterpart, much comes down to the integrity of the cell's DNA. The most common complication in pregnancy is a miscarriage, and chromosomal abnormalities have been found to be the number one cause for this.  
By conservative estimates, between 10-15% of pregnancies will result in a spontaneous miscarriage. I say "conservative" because many pregnancies abort before the pregnancy is even realized. Taking that into account it has been estimated that 70% of all conceptions are lost prior to live birth. 70%! Chromosomal abnormalities are implicated in more than half of these. Specifically, chromosomal abnormalities refer to errors during cell division that result in an incorrect number of chromosomes within the egg (called aneuploidy). This can mean missing chromosomal material, or the presence of extra chromosomes as occurs in Down Syndrome, for example, where the egg contains 3 copies of chromosome 21 instead of only 2 copies.
 
So, most cases of aneuploidy result in a spontaneous miscarriage in utero. As with so much in fertility, this has been pinned on old women with old eggs. But let's look at the science. Is aneuploidy really the inevitable consequence of aging? Recent studies have challenged this. It appears that these chromosomal errors do not gradually accrue over time so that as we age we accumulate more and more defective eggs. Rather, science suggests that these errors cluster around the time of ovulation with several different mechanisms implicated. An egg is just like any other cell in the body. Except that unlike other cells which are constantly dividing to make new cells while old cells die off, the human egg exists in a state of suspended animation - essentially frozen in time from prenatal life. After puberty, in the months leading up to ovulation the body releases hormones which stimulate some of these eggs to come back to life and continue the process of maturity. Each month, one will eventually mature fully and ovulate. The complex machinery in the cell that coordinates this maturity and cell division is error-prone and it is during this short window when most abnormalities accumulate. Let me say that one more time.
 
The evidence shows that the chromosomal errors affecting a woman's eggs do not accumulate gradually over the course of her life. They occur over the span of only a few months; when an individual egg reactivates leading up to its ovulation.  
 
So, if a woman can optimize the conditions during this time period when the egg matures and divides can she improve the quality of her eggs? The science suggests so. Ladies, you are in the driver's seat!
The jump start required to turn a hibernating egg into an animated, maturing one requires a significant amount of energy. And the power players here are structures in the cell called mitochondria, which serve as energy generators and must multiply further to meet the increased energy demands during egg maturation. Damaged mitochondria means no fuel, and no fuel means the engine won't start. So not only can't the egg mature properly, but it also can't survive fertilization, make the road trip down to implant in the uterus, and power embryo development. In fact, dysfunctional mitochondria have been implicated in a wide array of human disease from Parkinson's disease to cancer. Mitochondria number in the thousands in each cell; they are also, however, pretty sensitive little power plants and can be profoundly impacted by the environment.   
Lesson one in how to kill your mitochondria - poison them. This includes exposures like alcohol, tobacco and prescription medications, but even over the counter ones like aspirin can do the trick. Being too stressed can also cause damage via excess release of a hormone called cortisol, as well as consumption of partially hydrogenated oils, i.e. trans fat, which has no place in the human diet. You can protect your mitochondria with a diet rich in antioxidants. As we mentioned above in relation to sperm, oxidation in the cell produces free radicals and drives injury to both mitochondria and DNA. Antioxidants help neutralize these particles. A whole-food based diet rich in antioxidants like fresh vegetables and berries, fresh herbs, turmeric, pecans and raw cacao with the addition of targeted supplementation is advisable. Select vibrantly colored produce - in general the darker the green, the deeper the blue, the brighter the red, the richer its store of antioxidants. In terms of vitamins there is not enough data yet to definitively say what dosages of which supplement combinations provides the most benefit, but perhaps the greatest amount of data exists for co-enzyme Q10 (in its ubiquinol form, which is better absorbed). In addition to being an antioxidant, CoQ10 has a direct role in the cascade of energy production within the mitochondria. Higher levels of CoQ10 are associated with increased pregnancy rates, higher quality embryos, and supplementation has also been shown to counteract ovarian aging. Doses between 100-300mg ubiquinol are typically used, depending on other fertility factors. There is also suggestion of benefit for vitamins C and E, and for women undergoing ART, the powerful antioxidant melatonin in low doses. Melatonin can adversely impact ovulation so is only advisable for the IVF population, not for women trying to conceive naturally.
 
Other toxins that can adversely impact egg health are hiding in plain sight. Unfortunately, many chemicals we are exposed to on a daily basis are detrimental to fertility and egg health (among other things). Yet, despite a plethora of scientific studies validating their harm there is still no regulation in place in the US. Organic solvents, heavy metals, triclosans, phthalates and pesticides are abundant and have been shown to be harmful for various measures of fertility and pregnancy outcomes. However, when it comes to egg quality specifically, most published studies implicate the chemicals bisphenol A (BPA) and bisphenol S (BPS).
 
The bisphenols are used in manufacturing plastic containers, glues, canned foods, and coating currency and paper receipts, and in addition to their well-described disruption of female hormones, they have been shown in eggs to impair maturation and cause direct chromosomal damage and even cell death. Since the health issues around BPA became popularized in 2008, there has been a push for BPA-free plastics. However, there is mounting evidence that the chemicals that have been used to replace BPA may be just as, or perhaps even more, hazardous.    
It is probably sound advice for everybody, but particularly if you are planning a pregnancy within the next 6 months. We suggest replacing plastic water bottles with refillable glass or steel, dumping plastic food storage containers in place of sustainable glass ones, and avoiding any plastic food wrap. Additionally, you should also minimize handling of paper receipts. Personally, we tend to lose them anyway. Any invoice you need can usually be emailed if you ask. Also pay mind to wash your hands after handling paper money or receipts.     

Unfortunately, in the US, the adage is: use first, test later. Manufacturers are not required to show safety data before new industrial chemicals are added to consumer products. So, it may be a bit more time before we have enough data to identify other potentially hazardous chemicals. For any woman planning a pregnancy, we suggest adopting a "guilty until proven innocent" mentality when it comes to personal care products. Stick with toiletries and cosmetics that contain natural ingredients, avoid fragrances and perfumes - use organic essential oils instead, and opt for natural household cleaning products. The Environmental Working Group (EWG) is an independent, consumer database that provides safety ratings on thousands of cosmetics and personal care products based on the toxicity of their ingredients. You can search for products easily at EWG's Skin Deep database. After making the switch, you may never go back. 

Myth: All I have to do is stop the pill and my body will be ready to conceive.

There are a few problems with this one. I'll start with the most basic: it depends on why a woman went on birth control in the first place. Some women who go on the pill do so for strictly contraceptive purposes. They had regular menstrual cycles prior to starting and have had no changes in their general health since that time. This may be the ideal scenario. Available data from the  CDC collected from 2011-2013 show that of women 15-44 years old, across the board, about 23% use some form of hormonal contraception; that's around 14 million women at any given time. Now, that is a percentage of all women in that age bracket, including those who are not sexually active as well as those who are trying to conceive. If we just look at the proportion of women who are actively trying to prevent a pregnancy the number using hormone contraception jumps to near 50%

However, birth control is not the sole reason women start such medications. Actually, 58% of women use oral contraceptive pills for reasons other than contraception. These include indications like heavy menstrual bleeding, endometriosis, PMS (pre-menstrual syndrome), menstrual cycle regulation from things like PCOS (polycystic ovarian syndrome) or amenorrhea (no period), or acne treatment. It goes without saying that many of these indications reflect a possible underlying hormonal imbalance to begin with. This is certainly the case for women with ovulation disorders like PCOS, which is the most common endocrinologic disorder in women with a prevalence upwards of 20% in women of childbearing years. Also, in the reproductive population, around 4% of US women have secondary amenorrhea, and 85% of women experience PMS symptoms. In total, that's about 1/3 of all women who have some form of menstrual dysfunction. 

 

In such cases, birth control pills are a band-aid. Let's briefly cover what birth control pills actually do. Pills provide varying doses of synthetic estrogen and/or progesterone to suppress the body's natural rhythm of hormone secretion, prevent ovulation, and induce menstrual bleeding on a regular basis when inactive pills are taken. Essentially, they mimic the hormonal state of pregnancy. The withdrawal bleeding that takes place is not truly a period. The pills do not correct the underlying hormonal dysregulation that lead to the menstrual problem in the first place. So, it is no surprise that once they are stopped, other factors unchanged, the body's underlying hormonal issue again becomes apparent.

 

Additionally, birth control pills can be problematic because of the fact that they are so good at their job- creating the appearance of a regular menstrual cycle. Given the convenience and effectiveness they afford women, many remain on birth control pills for years at a time. And so, if in the interim, a woman develops a problem with her cycle (from changes like weight gain or weight loss, new life stressors, medication, or an endocrine or autoimmune disorder), the problem may go undetected for years. When a woman finally stops the pill to begin trying for pregnancy and seemingly inexplicably her regular cycle does not resume,  it may take a lot of time and backtracking to identify and correct her hormonal issue that lay hidden for so long.

Aside from the issue that oral contraceptive pills may mask an underlying problem with a woman's natural hormone cycling,  the pills themselves can also disrupt nutrient balance in the  body.

 

The World Health Organization (WHO) as far back as 1975 acknowledged this concern citing that "oral contraceptives, which are now so widely used, have far-reaching metabolic effects on many tissues and organs, and these include effects on the levels and possibly the activities of various vitamins."

Specifically, decades of well-designed scientific studies have demonstrated that key nutrient depletions occur in folate, vitamins B2, B6, B12, vitamin C, vitamin E and the minerals magnesium, selenium and zinc in women using birth control pills. Furthermore, most investigators recommend that supplemental vitamins like B2 and B6 be routinely given to women on birth control pills as well as B12 and vitamin C if they are deficient. Practically, thought, one would  be hard pressed to find a doctor who routinely tests these vitamin levels when prescribing birth control pills or counsels a patient about the need for supplementation.

 

Exploring  the particular attributes of each of these essential nutrients is beyond the scope of this article. However, suffice it to say that they each plays a crucial role in a woman's fertility. Folate in particular (also known as vitamin B9) is an essential supplement recommended for all women planning to conceive given the important role it plays in fetal growth. It is essential for cell division and the production of DNA, and is particularly impactful in the development of the baby's central nervous system. Studies demonstrate that supplementation prevents 50% of cases of neural tube defects, which include serious birth deformities like spina bifida where the spinal cord fails to fully fuse and anencephaly where the baby is born without part of the brain and skull.

 

Given this dramatic benefit, in 1998 the FDA began supplementing grain products in the United States like enriched flour and breakfast cereal with folic acid (the synthetic form of folate); this practice continues even though folate can naturally be found in foods like green leafy vegetables, lentils, eggs, and beef liver. The CDC recommends that all women thinking of having a baby supplement with, at a minimum, 400 micrograms of folic acid every day and the amount jumps to 4,000 micrograms per day for women who had a previous pregnancy with neural tube defects. Most prenatal vitamins provide this minimum amount, 400 micrograms of folic acid. But clearly, women coming off of birth control pills will need doses much higher than that in order to replete their stores and be effective at preventing birth complications in the fetus.

Folate, additionally, has been found to have a host of other benefits related to fertility. Studies have shown that it reduces the risk of ovulation disorders and increases progesterone levels, and may also improve egg quality and the success rate of IVF along with vitamin B12. The data is irrefutable that birth control pills have consequences beyond just their transient effect on a woman's hormonal cascade. They also disrupt the body's delicate milieu of vitamins and minerals that are essential for her future fertility. The good news is that once it's recognized, it's fixable. And once balance is restored to the body, it can return to its vibrant, fruitful self.

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When it comes to your fertility and your child's health, do better than chance.

In health,

Dr. R