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Does acupuncture increase IVF success rates? An update.

You don’t have to look far to find stories of women doing IVF reporting that acupuncture was the reason they got their take home baby. Acupuncture has many possible benefits to an IVF cycle including increasing egg quality, uterine blood flow and implantation(1) as well as reducing stress and it is certainly worth considering.

The research

Back in 2014 Nandi and colleagues summed it up perfectly when they said

basically, the evidence regarding the efficacy of acupuncture to improve clinical pregnancy rate is controversial. In spite of 40 clinical trials and nine systematic reviews, the debate still continues.’

If you are going to stop reading now, overall, that still stands.

If you are thinking about spending your hard earned cash on acupuncture, it pays to drill down a little more.

>>>If you are about to do an IVF cycle and are looking for evidence based ways to increase your success rates, make sure you check out Eat Think Grow.

Is it a sham?

In randomized control trials, when researchers are trying to ‘prove’ that a treatment, such as acupuncture, has an effect, it will often be compared to a control. The control could be receiving no treatment at all or in this case it could be the use of sham or placebo needles.

When placebo or sham needles are used the person receiving the treatment, in this case the woman doing IVF, really thinks they are having proper acupuncture. It might be that the needles just don’t penetrate the skin the same way or they are put in just slightly away from known acupoints and therefore aren’t doing what they should.

One recent systematic review looked at all the studies that examined the difference in IVF outcomes (such as clinical pregnancy or live birth) depending on whether they had placebo or actual acupuncture around the day of embryo transfer. What they found was that there was no statistical difference in clinical pregnancy rate, ongoing pregnancy rate or live birth rate between placebo or sham acupuncture and real traditional acupuncture.

When the control though was changed from being placebo to having no treatment at all there was a significant difference, in this case there was an increase in the live birth rates of those women having acupuncture when compared to those that did not. Those women that had the acupuncture were 1.15 times more likely than those that did not have the acupuncture to have a live birth (1). Interestingly it was not associated with clinical pregnancy rate or ongoing pregnancy rate.

Before rushing out to have acupuncture there are a number of things to consider.

Firstly, an odds ratio of 1.15 is still kind of small in the scheme of things. But hey, if that was a definite, I’d try it. Secondly, it’s not a definite. The research is not water tight and there remains lots of conflicting studies and also sometimes the studies they use to get to such numbers can be of low quality.

What is interesting though is that it may not be the actual acupuncture – that is the insertion of needles on the acupoints making the difference- it may be the experience. It might be the stress relieving properties of lying down for 30 minutes while the needles are in, or the placebo effect of really feeling as if you are making a difference to your next cycle or even just the chat with the practitioner.

Who knows.

Building on this theory, if you are thinking about acupuncture but aren’t so sure or can’t afford it, in the first instance I would a) find an activity that you genuinely enjoy and relaxes you and b) find an activity that you genuinely feel is going to make a difference to your cycle (you may find the mindfulness activities in Eat. Think. Grow! fits this bill ;)) It can’t hurt and just might get you some of the side benefits of acupuncture without the actual acupuncture. It would be interesting to see studies in the future that compared the IVF success rates between those that used acupuncture and those that used general relaxation strategies and determine what the difference to IVF success rates is.

It should be noted that other reviews have evaluated the impact of acupuncture in comparison to no treatment and found that it statistically increased the chances of an ongoing pregnancy but not clinical pregnancy rate or live birth rate to any statistical significance (Manheimer as cited in 3). Just to further highlight the fact that the evidence around this one really is conflicted.

Timing and dosage of acupuncture

Embryo Transfer
Many women doing acupuncture will typically go to the acupuncturist once or twice around embryo transfer and call it a day. Generally speaking this is insufficient to increase the possibility of live birth rates – though they are associated with reducing stress (3). This finding was also supported when a systematic review was completed of studies that when combined looked at the cycles of over 6300 women (4).

Egg Retrieval
This finding was similar when studies looked at women who had acupuncture around the time of egg retrieval – there was no difference in live birth rates between those that had acupuncture around the time of egg retrieval and those that didn’t (4). To be fair though, acupuncture done around the time of egg retrieval is generally more focused on pain relief being the goal of the treatment rather than increasing live birth rates, so that is reasonable.

First two weeks of cycle
The next grouping when looking at the timing of acupuncture and its impact on take home baby rates looks at women who have acupuncture during ovarian hyperstimulation – so those having acupuncture in the first half of their cycles while on gonal f, menopur or whichever follicle stimulating drug you are taking. These ladies typically had at least four sessions and it was found that overall, the pooled pregnancy rates were higher for those having acupuncture than those that were not. Specifically those that had the acupuncture throughout ovarian hyperstimulation where 2.41 times more likely to have a live birth than those that did not (4). To reach this figure there was only three studies that used the data from 435 women so it is not a large pool of women in the scheme of things and therefore, again, should be interpreted with caution. But it’s still interesting.

Entire cycle
When looking at how many treatments you would need to during a cycle, one study suggested that eleven acupuncture treatments during an IVF cycle was associated with significantly improved IVF birth outcomes and fewer miscarriages and another suggested 13–14 sessions was associated with significantly more live births compared with no treatment or embryo transfer day only acupuncture (3).

14 sessions in one cycle though is a lot! That is nearly once session of acupuncture every two days. I wonder if there are other forces at play in this group that weren’t measured in the study. For example, it would take a particular type of woman to go to acupuncture every second day during an IVF cycle. Presumably she wouldn’t work (or have a very flexible work situation), has the finances to attend all these sessions and clearly has some firm beliefs that acupuncture and/ or Chinese medicine is going to make an impact and therefore might also engage in other beneficial health practices also. Maybe these other hypothetical situations are also contributing to the increased success rates?

Like all things in fertility, it seems likely that the ultimate dosage will differ person to person (3), from what I have read though, highlighting the ineffectiveness of acupuncture on transfer day only towards live birth rates does seem more or less consistent across the research.

Types of acupuncture

The type of acupuncture can also make a difference to the likelihood of success. There is traditional acupuncture which is where needles are inserted into acupoints (usually around 4 to 10) along meridians in your body (this is the type you are probably most aware of). When these needles are stimulated by a small electrical current it then becomes electroacupuncture. There is also auricular acupuncture and laser acupuncture, which as the name suggests uses small laser beams to effect the acupoints instead of needles (4).

Essentially, out of all these types, electroacupuncture seemed to have the most affect. Those women that had electroacupuncutre in comparison to a control group were statistically more likely to have a clinical pregnancy and live birth. But noteworthy, they did not have higher ongoing pregnancy rates.

Possible harm

As stated earlier, acupuncture is generally believed to do no harm to an IVF cycle. I am only aware of one study where they found acupuncture to lower IVF success rates when done around transfer day. One theory for the reason for this result was that the acupuncturist was not ‘on site’ where the embryo transfer was being completed. It is thought that driving to this extra appointment timed just before and just after the transfer, added stress in an already stressful day and this extra stress helped explain this difference (5). It should also be noted that the group not receiving acupuncture had a freakishly high success rate – nearly double of what it would be expected to be. This in turn would make anything in comparison look bad.

Another point to take into consideration, and this assumes that you believe acupuncture does have the potential to have an impact, is that there are some acupoints that are believed to be associated with miscarriage or at the very least contra-indicated to pregnancy (3). This serves as another reminder to make sure that you are visiting an experienced practitioner.

Things to keep in mind

You can see the research is mixed. Although it may be simply that acupuncture does not work, one of the other reasons the research didn’t indicate any benefit (assuming there is one to reflect in the first place!) is that there was is so many differences in the methodology of administering acupuncture. There is simply too many variances in the methods acupuncture practitioners would use including acupuncture point selection, number of sessions, timing of when sessions are administered, type of needling control and location of treatment (1).

The Final word

As I started off saying the evidence is controversial. I believe that it is an all or nothing thing. If you are only going to go on transfer day because a friend of a friend did and she got a positive result on a pregnancy test, I’d probably give it a miss. If though you believe in Chinese medicine philosophy and are willing to integrate it into your life as well as attend as many as 14 sessions over the course of your cycle, then I think it might be worth a shot.

Also, just because the evidence that says acupuncture increases IVF success rates isn’t necessarily solid, that also doesn’t necessarily mean it doesn’t and with further study, well, who knows?

Reference

1. Cheong, Y.C., Dix, S., Hung Yu Ng, E., Ledger, W. & Farquhar, C. (2013). Acupuncture and assisted reproductive technology (Review). The Cochrane Library, Issue 7
2. Nandi, A., Shah, A., Gudi, A. & Homburg, R. (2014). Acupuncture in IVF: A review of current literature. Journal of Obstetrics & Gynaecology 34 (7) 555-561
3. Hullender Rubin, L., Anderson, B. & Craig, L. (2018). Acupuncture and in vitro fertilisation research: current and future directions. Acupuncture Medicine 36 (2) 119 – 122.
4. Qian, W, Xia, X-R., Ochin, H., Huang, C., Gao, C., Gao, L., Cui, Y-G., Liu, J-Y. & Meng, Y. (2017). Therapeutic effect of acupuncture on the outcomes of in vitro fertilization: a systematic review and meta-analysis. Archives of Gynecology and Obstetrics 295, 543–558.
5. Stener-Victorin, E. & Manheimer, E. 2011. Commentary on the Cochrane Review of acupuncture and assisted conception. Explore (NY). 2011 ; 7(2): 120–123. doi:10.1016/j.explore.2010.12.01

5 easily overlooked things to check before your IVF cycle

Your anti-müllerian hormone (AMH) is checked, you can tell to the hour when you are ovulating and you are pretty sure you’re the only one of your friends who uses acronyms such BFP, DPO and CD* in their every day life. You are just about ready to go for your next IVF cycle.

But here are 5 tests that may significantly impact on your fertility and IVF success.

As always though, don’t just start supplementing and self treating these things without medical advice as if your levels are already spot and you start self-prescribing, supplementation could do more harm than good. But they are definitely worth chatting to your fertility specialist about if you are concerned or have had recurrent failures.

Vitamin D

Like everything in fertility the research is mixed, but low levels of Vitamin D has been associated with endometriosis, the development of insulin resistance in women with PCOS and uterine fibroids¹. When the vitamin D in follicular fluid (the fluid surrounding each of your eggs) was measured in a group of women doing IVF, it was found that when women were deficient in vitamin D, for every one unit increase in vitamin D there was a 6% increase in the chances of an ongoing pregnancy rate². I’d take that.

Speak to your fertility specialist to see what your levels are (when you are pregnant they will test you for it anyway) and in the meantime focus on absorbing vitamin D from the sun – in a completely sunsmart way of course.

Thyroid function

That pesky thyroid has a big role to play and if it isn’t working properly can impact pretty much everything you can think of to do with reproducing life. This includes impaired ovulation, fertilization, implantation, miscarriage, and late pregnancy complications³. The acceptable levels of thyroid hormones can vary and there is some debate whether or not things like thyroid autoimmunity even matters enough to need to be tested³; though a recent meta-analysis suggests that although it does not impact number of eggs retrieved, fertilisation, implantation or clinical pregnancy rate thyroid autoimmunity may be implicated in miscarriage rates (this is still overwhelmingly unlikely to happen though and certainly not something to add to your worries – I have high thyroid antibodies and still got a take home baby. Two, infact.)⁴. What it does highlight though is that completing thyroid testing is a worthwhile activity, especially because depending on your medical history thyroid problems can often be treated.

Immunology issues

The role of autoimmunity in fertility is becoming more accepted and many doctors may test for immunology issues as standard when you start treatment. Some autoimmune tests include anti-nuclear antibodies, anti-DNA/ histone antibodies, antiphospholipid antibodies, antisperm antibodies, natural killer assay and cardiolipin antibodies. That is a lot of antibodies and only the tip of the iceberg.

Not all these markers are always a direct reason for infertility and some women can have them and oops! just happen to fall pregnant accidentally. They all are implicated in infertility though and it is certainly worth another blood test or two to ensure that they aren’t a hiding passenger on your fertility journey. Again, if something is found, depending on your circumstances, your fertility specialist may have a suitable treatment.

Melatonin

Melatonin is a powerful antioxidant and may benefit fertility by helping to keep oxidative stress in ovaries and eggs to a minimum which in turn improves egg quality. Several studies have been conducted investigating melatonin as a supplement for women undergoing IVF and found that when the optimal level of melatonin was reached that it was associated with a higher number and quality of mature eggs at harvest⁵. It has also been found to support the production of progesterone in women with luteal phase defect (though don’t even think about stopping those progesterone suppositories if you doctor has prescribed them; although a significant difference was found the impact on actual progesterone levels was still relatively small)⁵.

As always, do not go self-medicating, as although melatonin has not been found to be poisonous, supplementation is not always recommended in women undergoing IVF for a number of reasons. Supplements can sometimes interact with the prescribed medications taken and in women with autoimmune conditions melatonin supplements can have immune-stimulatory capabilities. Speak to your doctor before starting any supplements and in the meantime try to balance your melatonin levels by ensuring you get adequate sleep and natural daylight.

Sperm fragmentation

This isn’t a blood test but rather a sperm test for the men. Ideally it should be done as part of your initial work up at your clinic but it can easily get overlooked – particularly if you and your partner already have an obvious reason for your difficulty with fertility. In fact one study suggests that for couples with unexplained infertility, 80% of these couples later had their reason ‘explained’ as being due to sperm defragmentation when the appropriate tests were done⁶. That does seem a little amazing…

After a sperm sample is provided, in a sperm fragmentation test, the sperm is looked at to see if the DNA is healthy and intact. If DNA fragmentation is high this means that a high percentage of sperm is damaged. The treatment options are limited, though Menevit supplements may be of assistance (your doctor may have recommended this anyway), and it may mean that ICSI will have a greater chance of success for you than standard IVF.

Please note that this list is not exhaustive. They are just a few points designed to open up the conversation with your fertility specialist. Iron, zinc and magnesium levels are just a few others you might want to discuss.

*If you’re not quite there with the acronym thing BFP means big fat positive, DPO is days post ovulation and CD is cycle day.

Vanni, V., Vigano, P., Somigliana, E. , Papaleo, E., Paffoni, A., Pagliardini, L. & Candiani, M. 2014 Vitamin D and assisted reproduction technologies: current concepts. Reproductive Biological Endocrinology. 2014; 12: 47. Published online 2014 May 31. doi: 1186/1477-7827-12-47
Ozkan, S., Jindal, S., Greenseid, K., Shu, J., Zeitlian, G., Hickmon, C. & Pal, L. (2010) Replete vitamin D stores predict reproductive success following in vitro fertilization. Fertility and Sterility. Vol 94 (4) 1314–1319.
Unuane, D., Velkeniers, B., Deridder, S., Branvenboer, B., Tournaye, H. and De Brucker, M. (2016) Impact of thyroid autoimmunity on cumulative delivery rates in in vitro fertilization/intracytoplasmic sperm injection patients. Fertility and Sterility. 106 (1) 144 – 150.
Busnelli, A., Paffoni, A., Fedele, L. &, Somigliana, E.(2016). The impact of thyroid autoimmunity on IVF/ICSI outcome: a systematic review and meta-analysis. Human Reproduction Update. 22(6) 775-790.
Fernando, S. & Rombauts, L. (2014) Melatonin: shedding light on infertility? – a review of the recent literature. Journal of Ovarian Research 7 98
Lewis, S. (2013) The place of sperm DNA fragmentation testing in current day fertility management. Middle East Fertility Society Journal. 18 (2) 78 -82

How environmental toxins can impact your IVF cycle

It seems we can’t avoid environmental toxins. Being aware of this and where possible reducing your exposure is one step you can take to improve the chances of creating your little family.

You’ve modified your diet, significantly cut down on alcohol and well, smoking was never your thing anyway. The next thing you might be wondering is about toxins and the potential impact that has on egg and sperm quality and the little embryo about to implant. If you believe the news environmental toxins are EVERYWHERE but do they really matter or is it yet another, hippie fad?

Call them toxins, environmental contaminants, chemical contaminants or environmental toxicants, the synthetic chemicals that we come across in our daily living seem to be linked more and more to declining fertility in ‘normal’ populations and poorer outcomes in the IVF world. These chemicals have been linked to all sorts of conditions including cancers, neurological conditions and even mental health conditions. For the purposes of your upcoming IVF cycle we are most concerned with link to a decline in fertility and poorer IVF outcomes.

Endocrine Disruptors Explained

Environmental contaminants are often referred to as being ‘endocrine disruptors’ as they can interfere with the bodies endocrine, or hormone, system and more specifically in this instance with estrogen. The chemicals do this by either mimicking how estrogen works, blocking its use or simply just interfering with the way it is made or controlled (National Institute of Environmental Health Sciences). Regardless of the exact mechanism, they are preventing the normal functioning of our endocrine system from happening and this has the potential to adversely impact on our fertility and IVF success.

Endocrine disrupting contaminants are in many different substances (both natural and man-made) with some of the main ones being certain pharmaceuticals, dioxin and dioxin-like compounds, DDT and other pesticides, and plasticizers such as bisphenol A and phthalates.

Endocrine disruptors have been given a bit of attention recently and are thought to be so important as they can travel vast distances both through air and up the food chain (1) meaning that their impact can be wide reaching. The two ‘plasticizers’ have particularly been topical recently and are further discussed here (though pesticides and other contaminants are also of importance and should be reduced where possible).

Ive heard of it… but what is BPA?

Bisphenol A, or BPA, is a substance that was primarily used in the manufacturing of plastics (which is why it is called a ‘plasticizer’. It is still often used in the lining of tin cans and in some plastic drink bottles and is even used on the coating of til receipts that is then absorbed through our skin when handling the receipt (2).

There have been small studies that have been conducted analyzing the levels of BPA in the blood of women undergoing IVF and it has been found that the higher the levels of BPA the lower the fertilization rates (3). Other studies have also shown that for women doing IVF, those with higher levels of BPA in their blood had lower numbers of eggs, less mature eggs and lower rates of fertilization (2).

Now there are two things to be mindful of when getting your morning coffee – too much caffeine AND BPA from the cash register receipt!

BPA is found in many plastic containers and coatings and although the studies are small, at times contradictory and inconclusive, where possible it does seem like it is beneficial to limit the amount of BPA that you come into contact with (despite studies from the United States Food and Drug Administration saying that the level of BPA that is absorbed in day to day activities is within safe limits). This would include looking out for BPA free plastic containers (preferably glass containers because who knows what they are replacing the BPA with in other plastics), being mindful of which brands of tinned food that you eat (as BPA is often in the coating) and avoiding drinking water from plastic bottles. Oh and if you work in retail try and reduce the amount of receipt handling you do – just to be safe.

…and phthalates?

Phthalates are a group of chemicals that are used to make plastics more flexible and harder to break (Center for Disease Control; CDC). They are also used to in anything that is fragranced which is why they are found in many personal care products including perfumes, soaps, deodorants, hair sprays and even nail polishes! This is together with the hundreds of products including flooring, adhesives, detergents, lubricating oils, automotive plastics, plastic clothes such as raincoats and sometimes children’s toys, plastic packaging and medical tubing. It seems, phthalates are everywhere!

Similarly to BPA we can ingest phthalates by, for example, eating food that has been in contact with the plastic containers it has been heated in or particularly in the case of cosmetics and personal items, absorbing them through our skin. You can even breathe in phthalates. Once the phthalates are in our body, they are metabolised into metabolites are are then excreted in urine.

Reduce your exposure to phthalates by only using phthalate free makeup and toiletries.

It is by analyzing the metabolites in our urine that researchers are able to quantify how much phthalates a person has been exposed to and make comparisons to various outcomes, such as, the success of an IVF cycle. Before we look at IVF specifically, there is a significant body of research that has been done in animals implicating phthalates with poorer reproductive outcomes and also linking phthalates to an increase in oxidative stress in our body (particularly researched in men and pregnant women).

From what I have seen though, whilst it seems increasingly undeniable that the influence of phthalates negatively impacts our IVF cycles the hard human evidence demonstrating its impact in women is still coming. However, a study in 2016 (4) reported that when analyzing the metabolites found in the urine of women undergoing IVF the higher the amounts of metabolite DEHP and DiDP found, the lower the number of eggs produced and number of mature eggs produced. Additionally, an increased presence of the metabolites DiNP and DiDP were associated with lower fertilization rates. This ultimately led the researchers to conclude that higher levels of DEHP ultimately led to lower clinical pregnancy and live birth rates.

Whilst having high amounts of phthalates in your blood (and urine) isn’t going to be the only factor to make or break your cycle, or even be the major factor, it may be at the very least a significant risk factor and is certainly worth reducing your exposure where possible.

It should be noted though that not all studies support this. For example in 2017 a paper was published (5) that indicated that male, but not female, urinary concentrations of phthalates influenced blastocyst quality and another study reported that even though metabolite MEHP and MBP where found in follicular fluid and urine of females doing IVF these were not associated with the usual IVF outcomes (which may include things like egg quality, number, fertilization rates etc).

As we have already stated though, regardless of the evidence being somewhat inconclusive, there does seem to be enough evidence to suggest that it is worthwhile reducing your exposure to endocrine disruptors as much as possible.

So, how do we do this?

Throw out the plastic storage containers in your house and investing in either glass or stainless steel. Watch out for plastic recycling codes 3, 6 and 7 as these may contain endocrine disruptors. Particularly avoid reheating your food in plastics as when the plastic is heated the integrity of the plastic is changed making it easier for the transfer of phthalates to your food.
Try not to use cling film and other products to wrap your food in. Paper bags for sandwiches may seem like a throwback to the fifties but its at least worth a try. So is aluminum foil.
Use ‘natural’ cosmetics products available such as those from Nourished Life (this is an Australian website but there are others in the US). Or if this proves to be cost prohibitive looking for products that are ‘phthalate free’ (and their derivatives). This can be tricky and they can hide so it pays to do your research as sometimes the name can be somewhat ‘hidden’. Remember products that have added fragrances nearly always contain phthalates so looking for ‘fragrance free’ is worth a try also.
Beware of the scented candle! They may also be a source of phthalates.
Reducing chemical cleaners in your home. I have recently started using ‘Enjo’ and although expensive and at times does take a little more work the benefits of not having harsh chemical cleaners make it worthwhile.
Try eating organic. Non organic vegetables can often contain residue pesticides which although not directly discussed here can also be endocrine disruptors. Additionally, non organic meat can contain remnants of hormones and antibiotics given to the animals which then passes up the food chain to us.
Limit handling til receipts!
Stick as much as possible to unprocessed foods and avoid canned foods (unless you know that the lining of tins are BPA free).
Being aware of the environment you are in. For example, trying to avoid places where you know lots of air freshener or scented candles are used or if you have laid new carpet, for example, ensure it has been aired out as much as possible before you move back in.

For more practical ways to reduce your exposure to chemicals to increase your chances of IVF success, have a look at Eat Think Grow.

The bottom line

Although the evidence to say that phthalates negatively influences IVF outcomes is not yet conclusive, there does seem to be a growing body of evidence to say that they are very likely to have at least some impact. Although it will be near impossible to ever completely eliminate your exposure to phthalates, BPA and other environmental toxins, given that your IVF cycle is potentially the most important thing to ever happen to you and you want to do all you can to support its success it wouldn’t hurt to eliminate reduce your exposure as much as possible whilst still living life. This includes eating organic, reducing use of nail polish hair spray and especially fragranced cosmetics and minimising food that has been inside plastic (especially plastic that has been heated such as in a microwave) containers. You know, while living in the 21^st century, juggling work and ultrasound appointments.

References

Younglai, E, Holloway, A, Foster, W. (2005). Environmental and occupational factors affecting fertility and IVF success. Human Reproduction Update, 11 (1) 43–57, doi:10.1093/humupd/dmh055
Ehrlich, S., Williams, P., Missmer, S., Flaws, J., Ye, X., Calafat, A., Petrozza, J., Wright, D. and Hauser, R. (2012). Urinary bisphenol A concentrations and early reproductive health outcomes among women undergoing IVF. Human Reproduction 27 (12) 3583–3592.
Fujimoto, V., Kim, D., vom Saal, F., Lamb, J., Taylor, J. & Bloom, M. (2011) Serum unconjugated bisphenol A concentrations in women may adversely influence oocyte quality during in vitro fertilization. Fertility and Sterility 95 (5) 1816 – 1819
Hauser, R., Gaskins, A,, Souter, I., Smith, K., Dodge, L., Ehrlich, S., Meeker, J., Calafat, A. and Williams, P. for the EARTH Study Team (2016). Urinary Phthalate Metabolite Concentrations and Reproductive Outcomes among Women Undergoing in Vitro Fertilization: Results from the EARTH Study. Environmental Health Perspectives 124 (6) 831- 839.
Wu, H., Ashcraft, L., Whitcomb B., Rahil, T., Tougias, E., Sites, C. and Pilsner, J. (2017). Parental contributions to early embryo development: influences of urinary phthalate and phthalate alternatives among couples undergoing IVF treatment. Human Reproduction 32 (1) 65- 73.

Protein – Carbs = Increased IVF success rates

Eating an ‘IVF Diet’ is a minefield. Eat organic, don’t eat sugar, eat brasil nuts, don’t eat soy – no wait, DO eat soy, eat pineapple – but don’t eat it before transfer, drink raspberry tea, avoid peppermint tea.

It does NOT STOP!

And here is one more. But this one is really promising and has some good elementary science to back it up.

Looking at the amount of carbohydrates and protein in the diets of women doing IVF, researchers where able to provide some suggested guidelines on the ratios of how much of these foods you should be eating to best increase your chances of IVF success. As always though, make sure you check with your fertility specialist before making any major changes to your diet to ensure it is right for you and your unique situation.

>>If you are looking for easy, simple ways to increase your chances of IVF success, make sure you check out Eat Think Grow. It’s got over 340 pages of reliable, easy to read scientific information as well as thorough meal plans, daily mindset tips and loads of other essential evidence based information to help your IVF cycle<<

Peas. Obviously. And a decent source of plant based protein too.

THE IVF CONNECTION

In 2013 in a fertility clinic in the U.S, fertility doctors were noticing that young women (aged 36 and 37) of normal weight and no obvious reason for it where getting eggs of poor quality.

Although these women were eating what some would consider a healthy diet – oatmeal for breakfast, bagel for lunch and pasta for dinner it was observed that there was no protein in their diet. It was believed that the lack of protein was contributing to the poor results.

A low protein, high carbohydrate diet potentially has negatives on two fronts. One, carbohydrates essentially convert to sugars which can fuel the insulin resistance cycle and hormonal disturbances (not only in women with PCOS, 1) but proteins are the building blocks of the body – and hence our eggs. If we are missing out on them, it makes it harder for the supercharged process our ovaries are going through to make high quality eggs.

120 of these women were split into two groups, one group who ate over 25% of their diet as protein and the other that ate under 25%. They had three outcome measures: 1. Blastocyst formation (that is the embryo could make it to day 5) 2. Clinical pregnancy rates and 3. Take home baby rates

Here are the results

Protein vs Carbohydrate success rates — Blastocyst formation, clinical pregnancy rate and live birth rate for women who ate under and over 25% protein in their diet respectively

My excel spreadsheet skills aside, you can see that those women that had over 25% protein had higher rates of blastocyst formation, higher rates of clinical pregnancy and higher rates of a take home baby. Much higher rates. And with the statistical p values ranging from .002 to .0005 there is only quite a small chance that these results were due to coincidence.

BEFORE YOU START THE ATKINS DIET

Have you heard of the Atkins diet? It’s that one that says to eat ONLY meat effectively letting your body go into ketosis to burn lots of fat.

We don’t want that. Eating before going into IVF shouldn’t be about a going on a particular fad diet and if you are just about to start a cycle the goal isn’t to lose weight. You don’t want to shock your body or do anything like that. Eating sensibly is the goal. Additionally, it takes 3 months for an egg to form so any dietary changes that you are doing to increase egg quality should be done this far out from your planned IVF cycle.

THE ISSUE OF PLANT PROTEIN

If you have read The Fertility Diet you would know that not all proteins are considered equal and they recommend eating plant protein over animal protein.

They go as far as to say if you add animal protein instead of carbohydrates this causes even more disruption to normal ovulation.

Salmon. It's a protein so the picture is kind of relevant. Did you know farmed salmon has higher content than wild? I'd still stick with wild though. — Salmon. Not only is it a good source of protein but also of omega 3, win, win.

But combining these two pieces of research and eating 25% of your diet in plant proteins is HARD. I’ve been trying to do it for awhile now and it seems to be impossible. Unless it seems you eat a ton of eggs (one serving a day of fish and eggs didn’t influence ovulatory functioning apparently) and effectively cut out grains and potatoes, but then that seems like too much of a fad diet to me. There must be a happy medium.

And for me, that is sticking as close as possible to the 25% protein intake and eating as much plant proteins as possibly but inevitably there is a bit of animal protein in there as well. Also, we have to remember that The Fertility Diet is for women who wish to conceive naturally . For women doing IVF that dream has long sailed. So in my opinion, The Fertility Diet is not always going to be relevant to women doing IVF and I think it is more important to make sure you get proteins in, while following those rules of not eating too much red meat and avoiding the transfats that meat contains as much as possible.

Dairy products also contains a healthy amount of proteins. Some women would have heard that dairy is one of those inflammatory foods that should be avoided during IVF. Personally, I have not seen enough research to validate this claim and believe that dairy foods should be one of those things consumed in moderation. Or maybe its just that I love cheese too much. If you have ovulatory dysfunction as your reason for all this mess, when I say ‘mess’, I mean infertility and everything that comes after, The Fertility Diet recommends full fat varieties citing that the process of producing the skim milk and making it look creamier adds substances that disrupts hormonal and ovulatory functioning.

High Protein. Low carbohydrate. Plant based. Tick, tick, tick!

Oh, and just lastly, if you have access to Lupin Flakes, these bad boys are a whopping 40% protein. That’s pretty high for a plant based protein that is also gluten and soy free. You can use them as a breakfast cereal, make it up to be like a cous cous, a substitute for breadcrumbs, the list goes on. Check out their facebook page for details.

THE MAIN POINTS

Try and eat 25% of your diet as protein – there are free apps around that you can download onto your phone to help you monitor this. They are way easier and quicker to use than what you think. At the moment I’m using ‘My Fitness Pal’.

When increasing protein, try and make it a plant based protein (or at least not traditional meat type protein all the time). This includes fish (but remember to eat the right type of fish to avoid mercury), eggs, lentils, beans and peas.

Cheese and dairy is also high in protein (make sure the added sugar, such as in yoghurts is kept low).

Don’t make it a faddy diet and don’t lose too much weight with it (unless of course your doctor has advised you to).

Most importantly, if you are looking to make major changes to your diet make sure you consult a qualified dietitian before doing so. We all have different medical needs and histories and what is going to benefit one woman may not benefit another.

Well, I hope that is all just a little bit clearer than mud. Good Luck!

P.S If you have liked this article don’t forget to download your free guide to find 19 different ways that are easy to action that will hopefully improve your egg quality, implantation and ultimately IVF success.

References:

Chavarro, J. & Willett, W. 2009. The Fertility Diet. McGraw Hill
Johnson, Kate (2013). Low Carb Diet Improves In Vitro Fertilisation. www.medscape.com

9 Things You Should Know About the EmbryoScope

The EmbryoScope seems to be the latest ‘big thing’ in the fertility clinics and is being offered by more and more clinics to more and more women. Although it seems there are definitely benefits to using the EmbryoScope it may not be useful to everyone. Here are 9 things you need to know before deciding with your doctors whether or not to use the EmbryoScope:

It is a new type of incubator

Essentially, EmbryoScope is the trade name for a type of incubator that uses time-lapse photography to continuously monitor the embryo as it grows in the laboratory.

In traditional IVF, the sperm and egg are mixed together in a dish, hopefully the magic happens and the sperm fertilises the egg, or, if you are doing ICSI, the embryologist will inject the egg with the sperm, again, hopefully the magic happens and the eggs fertilise. The fertilised eggs, now embryos, are in their ‘dish’, surrounded by a ‘culture’ which is a substance that supports the growth of the embryos. The embryos are then placed in an incubator. The incubator enables the embryos to be locked away in an environment controlled for temperature, humidity, pH and gases (such as carbon dioxide, oxygen and nitrogen). About once a day the incubator is opened to monitor fertilisation rates, embryo morphology – that is what they look like, monitoring how many cells are there, if the cells dividing appropriately, if there is fragmentation and if the nuclei are behaving appropriately, just to name a few of the markers that are monitored. Each time the incubator is opened the highly controlled environment the embryo is in is disturbed. Therefore, it makes sense that the least amount of times the incubator can be opened the better.

By monitoring embryos in this way, the only information that technicians have on what has happened over the past 24 hours is what you can see at that very point in time. It provides a ‘snapshot’ so to speak. Cells can divide at different rates, can reverse the number of cells they have and nuclei can come and go over a 24 hour period. These events can be easily missed if only checking on the embryos once a day. All these events are also known to have significant impact on implantation rates and ongoing success of an embryo, therefore if extra information can be provided on early cell development it will be easier to choose the best embryos capable of ‘going the distance’.

What the EmbryoScope does is allows many photos (amount of photos per hour can be chosen by your laboratory) to be continuously taken of the embryos without them needing to be taken out of the incubator and disturbed. This ensures that the environment they are contained in is kept constant at its optimal settings. It also enables much more information to be collected on how your embyros have behaved over the last 24 hours and in theory the embryo that has shown the most favourable development and seems to be the best can be chosen.

2. Your embryos are kept at the ideal conditions for more time

The people that make the EmbryoScope, Virtolife report that the EmbryoScope incubator can hold up to 72 embryos – that is six clients can store up to twelve embryos at a time. This makes the EmbryoScope much smaller than a standard incubator. Because of this the environment inside the incubator is able to return to the ideal pH, temperature and gas levels at a much quicker rate when it has been disturbed. This is important because although the embryos do not need to be taken out to monitor them, the doors of the incubator do still need to be opened from time to time to place new dishes in or change culture media and the quicker the embryos can be returned to that ideal environment the less they are disturbed leaving them to grow into happy and healthy day 3 or 5 embryos!

3. Early evidence says that it can increase your chances of an ongoing pregnancy.

OK, so this is perhaps the thing that we want to know the most. One recent study (1) compared the ongoing pregnancy rates for women with embryos that were grown in a standard incubator against the pregnancy rates for women who had embryos grown in the EmbryoScope. What they found was that for women with embryos incubated in the EmbryoScope, there was a higher rate of ongoing pregnancy (54% for women with embryos grown in the Embryoscope versus 45% for women who used a traditional incubator) for each transfer. They were also shown to have lower early pregnancy losses and higher implantation rates, though interestingly the pregnancy rate was not statistically different. What this possibly indicates is that although there may be no statistical difference in getting that initial BFP by using the EmbryoScope and the information that is collected on your embryos early development, it allows for healthier embryos to be selected that are capable of going the distance and that are less likely to be abnormal which typically results in early miscarriage.

4. The culture that the embryos are in in the EmbryoScope is different (and some say better).

The culture system your embryos are grown in are different when using the EmbryoScope then what is used in the traditional incubators. One study (2) looked at if more fertilised eggs would grow to blastocyst when using the EmbyroScope as opposed to just a normal incubator. What they found was more embryos grew to blastocyst stage in the EmbryoScope then in the normal incubator. Remember the EmbryoScope is mostly being used as a monitoring system to pick out good embryos – and it can’t magically turn a bad embryo good – it just hopefully helps laboratory staff pick the best one to transfer. Therefore the fact that the study found more blastocysts were produced is kind of interesting, because up until now the EmbryoScope wasn’t expected to change the development of the embryos. The scientists who conducted this experiment thought of a couple of reasons for this result. One was that, as we have already discussed, the environment in the EmbryoScope was able to return to those ideal conditions much faster than a traditional incubator and the other reason was that culture system and EmbryoScope slides were different and possibly better at supporting growth to blastocyst then traditional incubator culture and equipment.

5. Its still only experimental.

Although there does seem to be some promising data coming out supporting the EmbryoScope it is still a new technology. A recent metaanalysis published in the ‘The Journal of Assisted Reproduction and Genetics’ (3) warns that despite the initial optimism, the data is insufficient to warrant the extra cost to prospective parents. In fact they were only able to find four studies that investigated using time lapse monitoring of embryos and the impact of using this method for selection on ongoing pregnancy rates. Needless to say, as always it seems in fertility research, more studies would be beneficial. Saying that though, all technologies and advances are new at some stage, so as long as your doctor isn’t concerned that there could be any disadvantages and if your clinic is one of the ones that provides the use of EmbryoScope free of charge, then surely there are not costs to trying?

6. It can cost more money.

If your clinic is not one of those clinics offering it to you free of charge, the extra costs on top of your normal IVF or ICSI charges can be significant. In Australia the extra costs to you can be between $0 to $800… a wide variation! Because there is no Medicare number for this you are also unable to claim any out of pocket expenses. In the UK I have seen quoted surcharges of between £400 –£600. The EmbryoScope, from what I have seen, doesn’t seem to be as widely advertised in America (please correct me if I am wrong!) but when it is used, the cost of it seems to be included into the cost of the IVF cycle and isn’t charged as an extra. Clearly, this is one of those things that needs to be discussed with your clinic.

7. May not be helpful to you if you are a ‘poor responder’.

You may already have the gist, but the idea of the EmbryoScope is to help laboratory staff chose the best embryo out of your batch for you to transfer. Ladies who traditionally don’t have success with IVF cycles generally don’t produce many viable embryos. (This is a big generalisation though!) Therefore if you don’t have many embryos the need to use the EmbryoScope to pick the best one isn’t necessary because you may only have one or two available anyway. In this case it doesn’t really matter what your embryo looked like at every stage because chances are you are going to transfer it regardless. Saying that though, even if you don’t have many embryos and its not going to help your treating team chose the best embryo it still might be helpful to them from a diagnostic point of view. That is they can see exactly where and when the embryo does (or doesn’t!) stop developing normally which might be helpful in planning future treatments.

8. May not be helpful if your clinic grows embryos to Day 5 as routine.

EmbryoScope is mostly used to pick the best embryo up to day 3. For clinics that routinely grow their embryos to blastocyst stage the EmbryoScope may not be considered as important. Though as discussed above, with studies showing that an embryos early development, development that is best seen in the EmbryoScope, having a positive impact on ongoing pregnancy rates, this seems to be a bit of a short sighted reason. Simply getting to blastocyst stage, in whatever shape or form, isn’t necessarily enough to go the distance. It would still be good to know what happened in those early days to chose the best one for transfer.

9. Its going to become more and more useful.

As the EmbryoScope is used more and more, laboratory staff and our doctors are going to be able to learn and collect much more data on embryo development than ever before. This will hopefully let them learn new things about how an embryo develops in the very early stages and its impact on implantation, ongoing pregnancy and the chances of the take home baby we always talk about. One journal article (4) suggests that by watching the appearance of the embryo very closely embryologists can watch out for distinct milestones and markers in the embryo development. By using this information they will then hopefully be able to develop more of a ‘predictive model’ for the embryos success. What they hopefully aim to do is identify by day 2 or 3 which embryos are those destined to become your take home baby by examining how it looks and behaves. By identifying the embryos at this much earlier stage this means that they don’t have to grow to blastocyst in an artificial environment – a situation which is sometimes associated with problems of its own.

Whether or not you chose to use the EmbryoScope is up to you in consultation with your doctor. By discussing things through with your doctor taking into account your own individual circumstances can you make the best informed decision.

References

1. Rubio I., Galan A., Larreategui Z., Ayerdi F., Bellver J., Herrero J. & Meseguer M. 2014. Clinical validation of embryo culture and selection by morphokinetic analysis: a randomized, controlled trial of the EmbryoScope. Fertility & Sterility. 102(5):1287-1294.e5.

2. Speksnijder, C. van de Werken, S.M. de Jong, A.J.A.M. Dons, J.S.E. Laven, E.B. Baart & Erasmus MC . 2011 Abstract: Improved embryo development in a time-lapse incubator system evaluated by randomized comparison of surplus embryo development to the blastocyst stage. Abstracts of the 27th Annual Meeting of ESHRE, Stockholm, Sweden, 3 July – 6 July, 2011 (doi: 10.1093/humrep/26.s1.26)

3. Racowsky, C., Kovacs, P. & Martins, W. 2015. A critical appraisal of time-lapse imaging for embryo selection: where are we and where do we need to go? Journal of Assisted Reproductive Genetics. 32: 1025 – 103

4. Milewski, R., Kuć, P., Kuczyńska, A., & Stankiewicz, B., Łukaszuk, K. & Kuczyński, W. 2015 A predictive model for blastocyst formation based on morphokinetic parameters in time-lapse monitoring of embryo development. Journal of Assisted Reproductive Genetics. 32:571–579