PFC patients often inquire about the use of acupuncture as a part of their infertility treatment, and, as such, PFC brings you insight from Bethany Richardson M.S., L.Ac and Leslie Oldershaw, L. Ac., two Bay Area acupuncturists who integrate fertility treatment into their practices. As background, Bethany Richardson was originally a massage therapist who took a Chinese diagnosis course while working on her Shiatsu certification. That course sparked her interest in pursuing a degree in acupuncture and led her to discover her love for science and the integration of eastern and western medicine. Leslie Oldershaw entered the field of acupuncture after spending her college years dedicated to pre-med courses. She became aware of Chinese medicine as a system of treatment while in college, and it fit perfectly with her passion for eastern philosophy and culture. She had always been interested in women’s health and found that fertility treatment in Chinese medicine truly encompasses all aspects of a woman’s health. Recently, PFC interviewed Leslie and Bethany about their approach to infertility, integrative medicine, and the strengths and weaknesses of acupuncture as a fertility treatment.

PFC: When a patient first comes to you and cites infertility as the reason for their visit, what sort of initial work-up do you do?

Leslie Oldershaw: I do a very comprehensive intake that involves an interview that takes a full medical history. Depending on their history, they may have had labwork done, or I may be ordering tests. From a fertility standpoint I like to see the basic hormone panels, including a cycle day 3 FSH, TSH, Estradiol, and also a mid-luteal progesterone test. If they have done a Clomid Challenge test, I love to see those results. If they have had a HSG or an ultrasound, I like to see that as well. From a general wellness perspective, I need to see a CBC and lipid panel and a comprehensive metabolic panel. When it comes to age, if a patient is younger we can be less aggressive. If a patient is older, we will be more aggressive. If they are 30, I will do this basic work-up, but I will be more inclined to just look at how they do over the next 6 months. If someone who is 40 comes to me, I will recommend that they consult a reproductive endocrinologist. They may want to have more of an accelerated timeline in terms of their treatment options. One of the challenges that I have is that I get patients who don’t want to do the western tests. They don’t want a workup, or the partner doesn’t want to do a semen analysis. I spend a lot of time educating patients to make an informed decision rather than shooting in the dark. I will be more persuasive with my arguments as the patient gets older!

Bethany Richardson: Normally, by the time a patient sees me they have already been to a fertility expert. I ask them to bring in their most current blood work. If they have had an antral follicle count, I want to know what that is. The basal temperature chart gives me a wealth of information. I look at it more in terms of a Chinese diagnosis, not necessarily are they ovulating or when they are ovulating, which is important, but are they running too hot or too cold. It gives me a lot of subtle information from a Traditional Chinese Medicine (TCM) standpoint. If I am looking at a woman who is younger, maybe 31 or 32 years old, then I look at her history of antibiotic use and if they have a history of digestive problems. I look at her menstrual cycle, her PMS, and if she is able to detoxify her hormones correctly. If I am looking at an older woman, I look and see if she is too hot or too cold. Does she have an excess of hormones? I see people mainly when they are desperate. They come to me after two cycles of IVF and want to do everything they possibly can for the next cycle. And unfortunately, I would be more effective if I saw them earlier on, but I do what I can when patients come to me.

PFC: If a patient comes to you and she already knows she must do IVF or IUI to get pregnant, what type of protocols do you offer in conjunction with her fertility treatment?

Leslie Oldershaw: When I work with a patient leading up to the treatment cycle, there are a couple of different protocols we can utilize. The more comprehensive protocol requires 2-4 months and allows you to incorporate nutrition, acupuncture and herbal modalities. We can do a tremendous amount to build a patient up, particularly if they are coming out of a miscarriage. We also work with patients on a shorter timeline, where they might be coming in to work with us a few weeks before an IVF cycle, and then we are primarily relying mostly on acupuncture to promote good blood flow and circulation. We will talk to the patient about nutritional support, including a pre-natal vitamin and omega-3 essential fatty acids. There is not enough research at this point to use fertility medications in conjunction with herbs. If things don’t go as expected the doctor needs to be able to troubleshoot what went wrong. My feeling is that acupuncture is of benefit to everyone. The people for whom acupuncture does not work are the patients who are very needle phobic. And I have to say, my IVF patients are champs. They look at my very small needles and they scoff!

Bethany Richardson: The type of treatment depends where on the continuum they are. I look at whether or not they have done IVF before, and what the results were. Were they a poor responder? How old are they? Sometimes they come to me and they tell me their IVF cycle is in three weeks. I can’t do anything with herbs in three weeks, but I can do some acupuncture. If it is six weeks or eight weeks, then we will have a real protocol. From my perspective the hormones you inject are a very warm tonic, which can burn out your cooling system. Depending on how they react to the injectables, I might try to work with them to take some time off from IVF and load them up with cooling tonics. What I see then is that cervical mucus increases, sleeping patterns regulate and stress levels go down. It’s hard for me to prove that it works, but I honestly believe that it does. Stress management, diet, acupuncture and IVF combined can add up to a much greater level of success.

PFC: What are the strengths and weaknesses of using acupuncture to treat infertility?

Bethany Richardson: It regulates the hormones, helps detoxify the body so you don’t have systemic inflammation, reduces PMS and pain. I think its only downfall is that it takes time. And a lot of the time—women aren’t willing to wait. And that’s where I come in again and say, it’s not a sprint, it’s a marathon. Acupuncture isn’t a golden pill. If you continue to eat poorly and not give your body good nutrients and antioxidants, then I can’t do as much.

PFC: Is there anything you want to add about treating infertility with acupuncture?

Leslie Oldershaw: I have always been keen on integrative approaches. There is a tremendous amount that western medicine can do to help people achieve a pregnancy. But what makes a critical difference for me is the integrative approach. What I am doing with my patients is different than what a Reproductive Endocrinologist does, but together we can work synergistically to create the best outcome.

Bethany Richardson: I am very excited about the future. I am hoping that eventually there will be research money that is earmarked for this arena. Often times acupuncture is seen as competitive with western medicine, and I don’t think it has to be. If we join forces we can be more effective together.

In last month’s issue we introduced our readers to Peggy Orlin, MFT, Pacific Fertility Center’s in-house therapist. This month we interviewed her about the key psychological issues affecting individuals and couples experiencing infertility.

What is the most common reason why someone comes to see you at PFC? At Pacific Fertility Center everyone who uses a known or unknown egg or sperm donor or a gestational carrier is required to meet with me. This is mainly an educational session designed to help people think through and discuss the issues involved with using a third party to assist them in building a family. Each meeting is custom tailored to meet the patient’(s) particular needs.

	Use of a third party for reproduction and its impact on a relationship.
	Attachment to a non-genetically related child.
	Disclosure of third party reproduction to family, friends and the child.
	Choice of meeting or not meeting with the donor.
	Use of a family member or friend as the donor.
	Multiple pregnancy (twins or triplets) and its impact on your lives.
	Support services during and after treatment.

What are some of the other reasons people seek your help?
Some patients have had a failed cycle and are having trouble coping with the losses. Other patients have experienced a miscarriage. Both of these scenarios can leave patients feeling bereft and not sure how to move forward. During a session, I can help them understand the grieving process and we can discuss ways that they might ritualize their loss in order to move forward.

The stress of infertility diagnosis and treatment often brings them to me either at the center or in my private practice. It is important to understand that no two people will have exactly the same experience and that infertility can strongly impact those within a committed relationship. A recent diagnosis of infertility, as well as the stress and/or disappointments of treatment, can lead to feelings of isolation and depression. Additionally, people may experience grief over the loss of fertility choices. It is not uncommon that I am the first person, other than their partner, with whom they discuss their feelings about their infertility challenges.

There are those who are at a critical decision point and are seeking help thinking through their reproductive alternatives. This may include deciding whether or not to do one last IVF, move on to egg donation, select an egg donor or complete their family through adoption or childfree living. In the therapy sessions, we discuss and explore the pros and cons of a decision from the unique perspective of their life beliefs and situation.

Others may need help with developing positive coping mechanisms and stress reduction techniques such as setting aside time each day to discuss infertility with their partner, rather than allowing it to be a constant topic of conversation. We may also discuss how they can reduce their isolation possibly by talking with others who are having similar experiences. We may even explore how to include moderate exercise in their schedule to reduce symptoms of depression.

What is your advice to those who are uncertain whether or not they should see a therapist?
For patients at the clinic, one exploratory visit can be helpful. Their doctor can refer them to me for one free session during which we can discuss any concerns they may have and talk together about whether or not seeing a private therapist might be useful for them. They are not signing on for long-term therapy by talking with me. As with stress reduction techniques-it can’t hurt and it might help.

Could you discuss the Mind/Body@PFC Workshop and who might benefit from attending?
The jury is still out on the connection between stress and infertility. Recent studies indicate that there may be a stronger connection between depression and infertility than between anxiety and infertility. The Mind/Body classes not only teach people simple ways to relax, but the small group class gives them the experience of being in a safe environment with others who are all experiencing infertility and know just what it’s like to be going through infertility treatment. This group experience helps to reduce stress and may be helpful to ease mild depression. (Call 888-834-3095 to register or Click here for more information)

How does your private practice differ from your practice at Pacific Fertility Center?
Clients in my private practice tend to be those who are interested in more than one session. Some stay for a few sessions and some want longer-term therapy. Many are couples who are struggling with how differently they are approaching and/or moving toward resolution of their infertility journey. Sometimes clients are self-referred for infertility issues and then as we meet, they chose to move on to other issues in their relationship or their lives. Although I have a specialty with infertility patients, my private practice is with adults experiencing all types of distress.

Depression frequently accompanies infertility. When should someone seek a therapist?
The experience of symptoms of depression which last more than a couple of weeks is an important reason to set up an appointment with me or a therapist of your choosing. Remember, everyone will feel some of these symptoms, some of the time. They become a problem when the number and intensity of symptoms increase and/or don’t abate.

Symptoms of depression:
Feelings of emptiness or extreme sadness
Loss of interest and motivation to do regular activities
Increased level of anxiety
Decreased level of energy
Difficulty sleeping or sleeping more than usual
Difficulty concentrating
Abnormal weight loss or gain
Obsessive thinking about your infertility
Feelings of isolation from friends and family
Extreme and persistent feelings of anger
Persistent thoughts of death or suicidal thoughts or attempts
Persistent feelings of inadequacy, or worthlessness

What is the best way to make an appointment with you?
PFC patients phone the front desk at (415) 834-3000 and ask to set up an appointment. Those who prefer to see me outside PFC can make an appointment for a visit at either my San Francisco or Berkeley office by calling (510) 528-2750.

– Peggy Orlin, M.S., M.F.T.

Exercise and diet improvements are excellent enhancements to fertility therapy. There is evidence of a reduced risk of diabetes, high blood pressure, and pre-eclampsia in women who exercise in pregnancy. Some reports have identified a greater sense of well-being, shorter labor and fewer obstetric interventions in physically well-conditioned women. The standard recommendation by the Centers for Disease Control and Prevention, as well as the American College of Sports Medicine suggests that a minimum 30 minutes or more of moderate exercise per day, every day of the week, is ideal for pregnant women. The American Academy of Family Physicians and the American College of Obstetricians and Gynecologists (ACOG) endorse this 30 minutes per day recommendation.

In addition to physical benefits, gentle to moderate exercise is a healthy way to control the stress related to dealing with infertility diagnosis and treatment, but not all exercise is beneficial.

Level of Exercise
Everyone has a different level of exercise at which point it interferes with fertility. There is risk that the biological stress associated with exercise may induce ovulation problems and can, at times, increase the risks associated with fertility treatment. Maintaining or initiating a well balanced diet is important. This includes diverse nutrients (complex carbohydrates, balanced protein, low fat), a vitamin supplement and adequate hydration, especially during periods of exercise. Weight should be monitored: if weight loss occurs, intake should be increased; if weight gain occurs, intake should be evaluated and revised accordingly. Rapid weight gain or loss is not recommended.

Extreme exercise may affect fertility in both men and women. Serious athletes may have to add more calories to ward off fertility problems. Individual evaluation by a physician is recommended for those who are in a rigorous exercise program and concerned about their fertility.

If a woman has an established exercise program prior to treatment, that level of activity may be maintained and continued with some minor modifications and reasonable precautions.

If a woman has not begun an exercise program prior to treatment, a gentle start is advised such as walking or swimming 15 to 30 minutes, three days a week. A slow and steady increase in duration and frequency can be accomplished over a period of several weeks. A good guideline to follow is if it is difficult to carry on a conversation, slow down. For those starting a new program and can afford the luxury of a professional trainer, working with one who has expertise in exercise during pregnancy is a great way to begin.

Heavy exercise spurts followed by long periods of no activity is not recommended. Gentle to moderate, regular exercise is best.

Modifications to Exercise During Infertility Care
Generally, it is safe to assume that if an activity is uncomfortable, don’t do it, especially when considering discomfort in the region of the ovaries. Near the end of an IVF cycle and for a month after, avoid jostling tender ovaries and activities where even slight injury to the abdomen may occur. Ovaries are enlarged and may be uncomfortable when being jostled. Aside from causing discomfort, there is an increased risk of ovarian torsion, particularly after 5-7 days of gonadotropins. Bouncing exercises to avoid include vigorous step aerobics and running. Less traumatic, low impact exercises, such as walking, yoga, Pilates, swimming, are preferred.

A general rule of thumb is to aim for a target heart rate of 120-130 from stimulation day 8 to one week post transfer.

Contact sports or other activities that may increase the chance of bumping or hitting the abdomen or increase the risk of a fall such as horseback riding, vigorous racquet sports and downhill skiing should be avoided.

Avoid overheating especially during exercise; this includes hot tubs, hot yoga and exercising during very hot days.

Avoid conditions that limit oxygen availability especially during aerobic exercise; hiking up to a 6000 feet altitude is an acceptable limit.

Scuba diving is absolutely not recommended.

These are general guidelines, however, everyone’s level of comfort and physical condition is unique. It is always recommended patients discuss their exercise regimen with their physician.

– Philip Chenette, MD

It has been known for quite some time that many lubricants used to facilitate intercourse or as an aid in masturbation for sperm collection may actually be toxic to sperm. A new study presented at the American Society for Reproductive Medicine 2005 conference confirmed this through a more rigorous study analyzing sperm motility and DNA damage after exposure to four brands: FemGlide, Replens, Astroglide and Pre-Seed.

Although no single product left the sperm completely free of damage, the research identified the Pre-Seed product as causing considerably less motility and DNA damage than the others.

The company that distributes this product claims that Pre-Seed is of the same osmolarity (salt density) and pH as seminal fluid. They further claim that it contains a plant sugar that acts as an anti-oxidant.

The study was jointly conducted without funding from any of the lubricant companies by researchers at Cleveland Clinic Foundation in Cleveland, Ohio; South Dakota State University in Brookings, South Dakota; and Washington State University in Spokane, Washington.

In the first experiment, sperm from 13 different donors was analyzed for progressive motility after 30 minutes of exposure to each lubricant while compared to a control batch from the same sperm donors with no lubricant exposure.

The results showed that sperm activity ranged from a high of 66 percent in untreated sperm, followed by 64 percent with sperm treated with Pre-Seed, followed by 51 percent with FemGlide and 25 percent with Replens. The lowest reported sperm motility was 2 percent in a solution containing Astroglide.

In a second experiment, spermatozoa was exposed for 4 hours and then evaluated for sperm chromatin integrity and then analyzed for percentage of DNA fragmentation, and then compared to non-exposed sperm. Again, the results indicated that Pre-Seed was associated with the smallest amount of sperm DNA damage at 7 percent more than untreated sperm, followed by KY at 10 percent and FemGlide at 15 percent.

Besides the brands tested, it is also thought that KY Jelly, Vaseline, and even saliva can have a negative impact on sperm. (One of the least toxic substances is pure mineral oil but it is generally not advised that women use lipid-based products in the vagina. Mineral oil remains an excellent choice for lubrication for masturbation.)

We welcome the news that a product that is backed by independent laboratory analysis is now available that can make vaginal intercourse more comfortable as well as acting as a promoter of fertility.

– Carolyn Givens, MD

One of the most common questions from patients about to embark on any fertility treatment plan is “What are the side effects of the medications I will be taking?” This is a most appropriate question to which I’d like to provide an in-depth answer.

When discussing any medication, it is important to keep in mind some concepts when discussing “side effects.” Side effects are really those symptoms, usually minor, most commonly suffered by a significant proportion of patients taking the medication. Typically, this would include nausea or headaches.

There are also “adverse effects.” These are more serious events, usually rare and often unpredictable. Examples would be a stroke or a heart attack. An example of a less severe adverse effect would be ovarian hyperstimulation syndrome. If a drug has been found to have a significant incidence of severe adverse effects, it is not likely to pass FDA approval. If the adverse effect is extremely rare, it may not be discovered until very large numbers of patients have taken the drug and the medication may be pulled from the market after approval (e.g. Bextra).

Separate from side effects and adverse effects, are “long term effects.” These are generally serious adverse effects not discovered until well after the drug therapy is undertaken. An example of this is the effect on the uteri of daughters of mothers who took the drug DES during pregnancy. When patients ask us about the safety of fertility drugs, they are usually referring to adverse or long-term effects as much as concerns about side effects.

When reading the FDA-approved package labeling for almost all medications, fertility drugs included, it’s important to be aware that any possible adverse effect anyone has ever experienced on the drug will be reported. Unfortunately, this almost renders this information useless because there are virtually no drugs that someone somewhere has taken without something happening at the same time. It is often impossible to prove whether or not that medical event was related to taking the drug or not.

None of the medications that are in use for fertility treatment are known to have such serious adverse effects that the FDA has even considered withdrawing its approval.

Overall, we believe fertility medications to be very safe, usually associated with only very mild side effects, relatively rare and treatable adverse effects (mostly commonly ovarian hyperstimulation) and no known significant long term effects.

Below is a list of some of the most common side effects our patients mention, as well as some of the more common adverse effects. It is by no means an authoritative or exhaustive list.

THE MOST COMMON SYMPTOMS AND SIDE EFFECTS:

Clomiphene (Clomid, Serophene®)
• FDA: FDA-approved for ovulation induction in anovulatory women, but widely used for unexplained infertility in women who do ovulate regularly on their own.
• Most common side effects: Hot flashes, night sweats, dizziness, mood swings
• Adverse reactions: ovarian hyperstimulation, abdominal pain or bloating, temporary visual disturbances.
• Long term effects: Possible increased incidence of noninvasive (“borderline”) ovarian tumors – not proven to be causative. Most recent studies find no link with invasive ovarian cancer.

GnRH agonists (Lupron, Synarel)
• FDA: Although Lupron and Synarel are not FDA-approved for IVF use, they are widely used in the U.S. to prevent premature ovulation in IVF cycles.
• Most common side effects: Mild headache
• Adverse reactions: Patients with unrecognized pituitary tumors can experience a type of pituitary “stroke” when on Lupron. This is very rare but potentially serious.
• Long term effects: bone loss in long-term users, not significant for the short courses used for IVF.

Gonadotropins (Follistim, Gonal-f, Repronex, Menopur)
• FDA: FDA-approved for super-ovulation and in IVF to recruit multiple eggs.
• Most common side effects: Tiredness, local injection site skin reactions such as pain and redness (especially Repronex), abdominal fullness, bloating. Contrary to popular belief, we rarely hear our patients complaining of mood swings on gonadotropins.
• Adverse reactions: Ovarian hyperstimulation, multiple pregnancies (twins or more).
• Long term effects: Some concern was raised in the early 1990′s about whether these drugs could increase a woman’s risk of ovarian cancer. Most recent studies are reassuring that there is not an increased risk. These studies are ongoing because this class of drugs has only been in wide use for about 25 years.

GnRH Antagonists (Ganirelix, Cetrotide)
• FDA: FDA-approved for use in IVF to prevent premature ovulation.
• Most common side effects: None that we have seen.
• Adverse reactions: Earlier (pre-FDA approval) versions of these medications were sometimes associated with severe allergic reactions but we have not seen any yet in our practice.
• Long term effects: bone loss in long-term users, not significant for the short courses used for IVF.

hCG (Novarel, Pregnyl)
• FDA: FDA-approved for ovulation induction. Commonly used in clomiphene, gonadotropin and IVF cycles to time insemination or egg retrieval.
• Most common side effects: Some increased discomfort, rarely outright pain, at the time of ovulation.
• Adverse reactions: If a patient has multiple follicles on gonadotropins, hCG can be the final kick to the ovaries to tip someone over into hyperstimulation syndrome. This is not seen in natural cycles or in most patients on clomiphene.
• Long term effects: None known.

Progesterone (Prometrium, Progesterone suppositories, Progesterone in oil)
• FDA: Only Prometrium is FDA approved and it is approved for use in menopause in conjunction with estrogen hormone replacement. It is pure oral micronized progesterone. Progesterone suppositories and Progesterone in oil are usually compounded by individual specialty pharmacies (pharmacies that specialize in distributing fertility drugs). Most progesterone packaging advises not to use in pregnancy but these drugs are the exact same progesterone produced by the human ovary in the luteal phase and in early pregnancy so are widely used in fertility treatment.
• Most common side effects: Mostly very minor things like breast tenderness or mild bloating. For patients on progesterone in oil, local pain and redness at injection sites is common.
• Adverse effects: Local vaginal reactions such as irritation or itching from suppositories. Severe local skin reactions to progesterone in oil are fairly rare.
• Long term effects: Questions have been raised as to whether high doses of progesterone in early pregnancy may be associated with urinary tract abnormalities in the fetuses of the mothers taking progesterone. There has never been any such association proven.

– Carolyn Givens, MD

In the last ten years or so in the U.S., we have seen an explosion in the number of over-the-counter dietary supplements for all manner of ailments as well as for the promotion of general health. Some are vitamins with well-known beneficial properties. Some are herbal supplements with a history of traditional Chinese medicine yet with little in the way of Western scientific studies to substantiate their use. Many other supplements contain elements and substances with very little known benefit.

Now there are several preparations being marketed to promote fertility. In this article, I chose to review three of the major products being actively marketed for the purposes of improving sperm.

The oldest supplement is ProXeed™. ProXeed™ is a citrus-flavored powder and can be dissolved in juice or other cold beverages. It is recommended by the manufacturer to be taken twice a day. The active ingredients in Proxeed™ are L-carnitine, L-acetyl carnitine and fructose. The cost is approximately $335.00 per 3-month supply.

Fertile One® is a pill that contains L-carnitine, anti-oxidant vitamins (ferulic acid, vitamins C and E, garlic, co-enzyme Q10 and selenium), ginseng root, zinc and B-complex vitamins (B-6, B-12, B-9 and folic acid). Cost is approximately $273.00 per 3-month supply.

FertilityBlend® for Men is a supplement containing L-carnitine, ferulic acid, vitamins E, B6, B12, and the elements selenium and zinc. The cost is only about $80.00 per 3-month supply.

Several studies have shown that the amino acid L-carnitine may promote sperm development. In a recent clinical trial¹, 102 men with low sperm motility were treated with L-carnitine and acetyl L-carnitine. There was a significant correlation between higher levels of carnitine in the seminal (sperm) fluid and better sperm concentration, total sperm count, sperm total motility, rapid forward progression, live sperm count, membrane function, nuclear DNA integrity, capacity for cervical mucus penetration, linearity of spermatic movement, and amplitude of lateral sperm head movement after 3 and 6 months of L-carnitine/acetyl L-carnitine treatment. Another high quality study, a randomized, placebo-controlled trial of L-carnitine and acetyl L-carnitine showed that after 6 months of treatment increases were seen in all sperm parameters and the most significant improvement in sperm motility was present in patients who had lower initial absolute values of motile sperm (<4 million forward or <5 million total motile spermatozoa per ejaculate)². There are no published randomized controlled trials looking at pregnancy rates on L-carnitine.

Several studies on the B Vitamins have been published showing anti-oxidant effects and virtually all find some benefit to the addition of this group to a daily vitamin regimen.

Ferulic acid is found in various medicinal herbs, has recently been shown to scavenge oxygen free radicals and increase the intracellular cAMP and cGMP (energy molecules). The only published article on ferulic acid involved adding this substance to previously ejaculated sperm specimens where it was shown to improve sperm motility³. A medline search did not reveal any studies on sperm after ingestion of ferulic acid.

It is interesting that Fertile One® contains garlic; at least one study has reported an inhibitory effect on garlic on sperm motility and survival in human and mouse sperm⁴ and crude extracts of garlic bulbs have been shown to immobilize ram sperm and are being investigated as a potential male contraceptive⁵.

Selenium is a trace mineral that is incorporated into several anti-oxidant proteins. It has been shown to improve human sperm parameters⁶ and fertility improved slightly when selenium-deficient mice were treated with it ⁷. What is not clear is whether most men with a normal diet would be selenium-deficient.

Folic acid supplementation may also be beneficial, especially for men who smoke Cigarettes⁸. Treatment of men with folic acid and 5 mg zinc improved sperm counts by 60% and also improved morphology (shape)⁹. Vitamin E has also been shown to improve sperm parameters and sperm-egg binding¹⁰. Co-enzyme Q10 has been shown in one small uncontrolled study to improve sperm motility in males¹¹ but studies of men with a varicocele (dilated scrotal veins) suggest that high levels of seminal fluid Co-enzyme Q10 are found with men with the lowest sperm motility, suggesting that Co-enzyme Q10 would not be beneficial for men with a varicocele¹².

Considering all these studies, there does seem to be a beneficial role for dietary supplementation for men with low sperm counts and low motility. The supplement marketed as FertilityBlend® for Men has almost all of the most well studied ingredients and is considerably less expensive than the others. Avoidance of garlic extracts and further supplementation with folic acid may also be beneficial.

– Carolyn Givens, MD

References:
1. Correlation between seminal carnitine and functional spermatozoal characteristics in men with semen dysfunction of various origins. De Rosa M, Boggia B, Amalfi B, Zarrilli S, Vita A, Colao A, Lombardi G. Drugs R D. 2005;6(1):1-9.

2. A placebo-controlled double-blind randomized trial of the use of combined l-carnitine and l-acetyl-carnitine treatment in men with asthenozoospermia. Lenzi A, Sgro P, Salacone P, Paoli D, Gilio B, Lombardo F, Santulli M, Agarwal A, Gandini L. Fertil Steril. 2004 Jun;81(6):1578-84.

3. Effects of ferulic acid on fertile and asthenozoospermic infertile human sperm motility, viability, lipid peroxidation, and cyclic nucleotides. Zheng RL, Zhang H. Free Radic Biol Med. 1997;22(4):581-6.

4. Spermicidal effect in vitro by the active principle of garlic. Qian YX, Shen PJ, Xu RY, Liu GM, Yang HQ, Lu YS, Sun P, Zhang RW, Qi LM, Lu QH. Contraception. 1986 Sep;34(3):295-302.

5. Sperm immobilization activity of Allium sativum L. and other plant extracts. Chakrabarti K, Pal S, Bhattacharyya AK. Asian J Androl. 2003 Sep;5(3):230.

6. Male fertility is linked to the selenoprotein phospholipid hydroperoxide glutathione peroxidase. Foresta C, Flohe L, Garolla A, Roveri A, Ursini F, Maiorino M. Biol Reprod. 2002 Sep;67(3):967-71.

7. Sperm oxidative stress and the effect of an oral vitamin E and selenium supplement on semen quality in infertile men. Keskes-Ammar L, Feki-Chakroun N, Rebai T, Sahnoun Z, Ghozzi H, Hammami S, Zghal K, Fki H, Damak J, Bahloul A. Arch Androl. 2003 Mar-Apr;49(2):83-94.

8. Low seminal plasma folate concentrations are associated with low sperm density and count in male smokers and nonsmokers. Wallock LM, Tamura T, Mayr CA, Johnston KE, Ames BN, Jacob RA. Fertil Steril. 2001 Feb;75(2):252-9.

9. Effects of folic acid and zinc sulfate on male factor subfertility: a double-blind, randomized, placebo-controlled trial. Wong WY, Merkus HM, Thomas CM, Menkveld R, Zielhuis GA, Steegers-Theunissen RP. Fertil Steril. 2002 Mar;77(3):491-8.

10. A double-blind randomized placebo cross-over controlled trial using the antioxidant vitamin E to treat reactive oxygen species associated male infertility. Kessopoulou E, Powers HJ, Sharma KK, Pearson MJ, Russell JM, Cooke ID, Barratt CL. Fertil Steril. 1995 Oct;64(4):825-31.

11. Coenzyme Q(10) supplementation in infertile men with idiopathic asthenozoospermia: an open, uncontrolled pilot study. Balercia G, Mosca F, Mantero F, Boscaro M, Mancini A, Ricciardo-Lamonica G, Littarru G. Fertil Steril. 2004 Jan;81(1):93-8.

12. Coenzyme Q10: another biochemical alteration linked to infertility in varicocele patients? Mancini A, Milardi D, Conte G, Bianchi A, Balercia G, De Marinis L, Littarru GP. Metabolism. 2003 Apr;52(4):402-

Prolactin is a protein hormone produced in the pituitary gland that controls lactation. This hormone in women is normally produced at low levels except after birth, when suckling at the breast stimulates secretion of breast milk. Prolactin inhibits reproductive hormones and during breast-feeding is responsible for decreasing the chances of conception during the postpartum period.

A relatively common benign tumor of the pituitary can result in the over-secretion of prolactin. If this happens, a woman may develop galactorrhea, or inappropriate secretion of breast milk when not in the postpartum (after birth) period. If the levels of prolactin are high, she may develop a short luteal phase (second half of the menstrual cycle) or even stop ovulating altogether.

There are many causes of high prolactin levels, such as diet, stress, breast stimulation, and exercise. Occasionally, a small growth, or tumor, of the pituitary can be responsible. If the levels of prolactin are high, a woman will be advised to undergo an MRI of the pituitary gland to determine whether a tumor is present, and, if so, its size. If it is less than one centimeter in diameter, it is called a microadenoma. If it is greater than one centimeter, it is called a macroadenoma. Macroadenomas can cause pressure on the optic nerve, leading to headaches and partial visual loss in some cases.

Most of the time, high prolactin levels can be treated with either bromocriptine (Parlodel) or cabergoline (Dostinex). These medications will usually shrink the tumor size and restore the prolactin levels to the normal range. If the medications do not shrink the tumor and symptoms persist, a surgical procedure to remove the tumor known as a “trans-sphenoidal resection” will be advised. Surgery today is rarely performed.

Many women will be found to have mildly elevated levels of prolactin with no apparent symptoms. At these levels, there are rarely symptoms of galactorrhea, anovulation or headaches and visual changes and an MRI is not necessary. However, if the woman is trying to conceive, it is recommended that she start medication to restore the prolactin levels to the normal range. Even mild elevations of prolactin can be associated with infertility. Usually, the medications are discontinued once pregnancy occurs. The only women that are advised to continue Parlodel or Dostinex during pregnancy are those with confirmed macroadenomas (large pituitary tumors), as they can grow in pregnancy and cause optic nerve compression.

There are some things that can result in mild and transient elevations of prolactin. These include nipple stimulation, a high protein meal, birth control pills (sometimes) and some psychiatric medications such as phenothiazines for psychosis. These should be avoided just prior to having prolactin levels drawn.

Considering prenatal diagnosis once pregnancy is achieved is an important and complex decision. Although there are a wide variety of screening options available, prenatal diagnosis is the most accurate method for detecting chromosome abnormalities, such as Down syndrome. Diseases like cystic fibrosis, Tay-Sachs, sickle cell anemia, and thalassemias can be tested for if the parents are known to be carriers for these genetic diseases. Because prenatal diagnostic testing allows genetic experts to test placental cells directly, the results are diagnostic and specific for the fetus.

There are two different prenatal diagnostic tests, chorionic villus sampling (CVS) and amniocentesis. CVS is a procedure in which a small amount of tissue (chorionic villi) is obtained from the developing placenta at approximately 10-13 weeks of pregnancy. The tissue is then evaluated for chromosome abnormalities, and if indicated, specific genetic diseases. The primary advantage to CVS is that this test can be performed much earlier in pregnancy than amniocentesis. However, CVS does not detect neural tube defects (spina bifida, meningomyelocele or anencephaly). Therefore, patients who opt to pursue CVS undergo an AFP blood test and a high-resolution ultrasound later in pregnancy to screen for these defects. Also, approximately one percent of all CVS results will show a mixture of normal and abnormal chromosomes, which is called mosaicism. The majority of the fetuses in these pregnancies are normal, however additional testing, including amniocentesis, may be indicated.

CVS can be performed one of two ways depending on the location of the placenta within the uterus. The transcervical method is performed by inserting a thin catheter, guided by ultrasound, through the vagina and cervix to reach the chorionic villi. The transabdominal method is similar to amniocentesis. Using ultrasound, a thin needle is inserted through the mother’s abdominal wall to obtain a small amount of tissue. In either case, this placental tissue is then sent for analysis.

Amniocentesis is typically performed between 16-20 weeks of pregnancy. Under ultrasound guidance, a thin needle is inserted through the mother’s abdominal wall into the amniotic fluid surrounding the fetus. A small amount of fluid is then taken and analyzed for chromosome abnormalities, neural tube defects, and if indicated, specified genetic diseases. The main benefit to amniocentesis is that although it is performed later in pregnancy, it is possible to test for genetic disorders, including chromosome abnormalities and specific genetic diseases, AND neural tube defects, such as spina bifida, all at once.

Whether patients choose CVS or amniocentesis, it is possible to obtain the same information with either procedure. However for patients who choose CVS, it is necessary to do a follow up blood test and detailed ultrasound in the second trimester to rule out neural tube defects. It should be noted that the results from this blood test and ultrasound are not as conclusive on neural tube defects as the results from an amniocentesis. Because both procedures are considered invasive, meaning that it is necessary to enter the womb with either a needle or a catheter in order to obtain cells, there is a small risk of miscarriage due to the procedures. The risk for either CVS or amniocentesis is approximately 1/200. Diagnostic results from either procedure take about ten days to be completed.

Regardless of whether you are considering CVS or amniocentesis, genetic counseling is an important step in your overall decision-making process and in assessing your risk factors for genetic disorders. Genetic counselors are available to discuss in further detail the benefits, limitations, and risks for prenatal diagnostic testing in order for you to make the best decision for you and your family.

– Kendall Glynn, MS, CGC, Certified Genetic Counselor, California Pacific Medical Center

The trend towards using more laptop computers in public places and airports will continue to grow as wireless internet access “hot spots” proliferate. This year laptop use in the U.S. is projected to grow to 60 million users. Additionally, laptops are also increasing their heat output with ever-faster processing power. Which begs the question: are we staring at a potential cause of male infertility without even knowing it?

It is well known that healthy sperm are produced ideally at a testicular temperature of 2 – 4 ºC below body temperature. Established studies have revealed a considerable decline in healthy sperm production – up to 40 % – resulting from scrotal or testicular temperature increases as small as 1 ºC. A long-term decline in sperm quality over several decades has also been identified by at least seven research studies, although definitive causes have yet to be determined. Given this, it was only a matter of time before the connection between laptops and infertility would be examined.

As reported in Human Reproduction, Vol.2, 2005, a group of scientists at State University of New York, Stony Brook embarked upon a research study monitoring the scrotal temperature change in 29 healthy male volunteers, median age 24, from laptop computer use. The researchers used two different types of laptop computers and randomly measured their thermal effect on the scrotum by using right and left scrotal temperature gauges in two separate 60 minute sessions.

They recorded scrotal temperature increases averaging 2.6 – 2.8º C.

The heat emitted by the laptops appears to be a factor, but curiously not the solo factor. The researchers also directed the study participants to sit upright without the laptop, but with their knees tightly pressed together. After sitting this way for an hour, researchers recorded their scrotal temperature, which increased on average 2.1 ºC.

This initial study may prompt further research seeking a more definitive link between laptop use and infertility, or it simply may be added to the myriad considerations of exogenous scrotal heat exposure related to lifestyle. In this same category are prolonged driving and sedentary sitting. Naturally this study calls for prudent use of laptops by men trying to become fathers while weighing in on how modern life in all of its ramifications might be boosting scrotal temperature and causing an overall decline in sperm count.

Almost 20 years ago, a paper in a British medical journal Lancet announced the arrival of a new technology: Oocyte Cryopreservation (Chen, C., 1986, Vol 1, Page 884). What was initially thought to be a landmark paper turned out to be the poster child for the procedure, as Chen himself and many others were unable to repeat the process with consistency. Although it is difficult to open any magazine today without reading about this wonderful new technology, less than 1% of eggs that have been frozen and thawed have resulted in live born infants.

We have learned much about the freezing of human oocytes over the years, yet despite a massive and consistent effort by the scientific community, a reliable method to freeze eggs with the same success as embryos and sperm remains elusive.

Our ability to freeze any cell depends on many factors, but most significantly on how much water the cell contains. Because water expands in volume as it turns to ice, cells must be dehydrated prior to freezing to prevent the cell from rupturing. The addition of a cryoprotectant, which does not expand upon freezing, can greatly reduce the risk of cell rupture.

Scientists have been freezing and thawing sperm with good success for over 100 years. In many ways, sperm are ideal for freezing as they exist as individual cells, they are the smallest human cells and they contain very little water. It is thought that sperm can be stored perhaps indefinitely after being added to a solution of cryoprotectant, and then frozen to minus 1960C.

In contrast to the sperm, the oocyte is the largest human cell and it contains much more water. The oocyte is also much more sensitive and is very intolerant of the chemical and physical stresses that are created during freezing and thawing. Further, the availability of oocytes is much more limited. When an oocyte is ovulated, or retrieved from the ovary during an IVF cycle, ideally it is ready to be fertilized by a single sperm. In anticipation of fertilization, the oocyte prepares to discard half of its DNA – a process called meiosis. Any changes in the physical or chemical environment around the oocyte can disrupt meiosis, leading to an oocyte with too much or too little DNA. Even after we overcome the hurdles of sensitivity and cell water content, there are other obstacles to freezing and thawing oocytes successfully.

In scientific literature, most papers that report success with egg freezing involve very few patients and therefore even fewer pregnancies and deliveries. Porcu et al., 1997, Tucker et al., 1998 and Young et al., 1998 are typical examples of papers that report successful deliveries from just one patient’s frozen oocytes. Between them, these authors froze 34 eggs, of which 15 survived thawing. In larger studies, Porcu et al., 2000 and Fabbri et al., 2001 were able to obtain large numbers of oocytes for freezing (1502 and 1769 respectively), resulting in overall survival after freezing at just over 50% for both studies. Just over half of the oocytes that survived freezing fertilized, and about half of these made good quality embryos. Yet the number of babies delivered reported by Porcu was low (9 births plus 7 ongoing pregnancies). Fabbri reported only fertilization and embryo development rates as a measure of success in his study and has not yet reported on pregnancies and births.

Wider application and success with oocyte freezing depends on continued improvements with the technology and on careful selection of oocytes to freeze. While many researchers are continuing to improve the freezing process, much of the success so far has been with the use of good quality or young oocytes. In the Porcu study, most of the oocytes were collected from young women who would presumably have good quality oocytes. We would expect results to be worse if the eggs were from older women, although no such studies have been undertaken. • Despite all the hype, oocyte freezing will fall short of mainstream therapy in the near future until new technologies improve the process. Oocyte cryopreservation may be an especially disappointing prospect for older women. With this in mind, this year PFC will take part in a large scale study involving Japanese IVF centers and other US centers on an alternative technology called vitrification. This involves an ultra-rapid freezing process that we hope will allow more oocytes to be frozen before they are compromised by the effects of the physical and chemical stresses indicative of typical slow freezing methods. Vitrification has shown good success with human oocytes and embryos in recent Japanese studies.