The old fertility legend about a couple who had failed fertility treatments, adopts a baby and then all of a sudden gets pregnant is one we have all heard.

In fact, as a practicing reproductive endocrinologist over the past 25 years, I have experienced this with some of my own patients.

Those stories have led us to believe that it takes longer for women with high stress levels to conceive. Unfortunately, there has not been much research on this. Until now, the best evidence for the benefit of stress reduction comes from the wellness center at Boston IVF where they had shown higher IVF success rates for women who were involved in their Mind Body program.

Latest Research on Stress and Fertility

A new study in the current issue of the ASRM journal Fertility and Sterility (the primary research outlet for our national fertility society) lends credence to a link between stress and fertility. In the study, 274 British women, ages 18 to 40 years old, were examined to determine if using fertility-monitoring devices would improve their chances of conception.

They were followed for six menstrual cycles or until they got pregnant, whichever came first. On Day Six of each cycle, saliva samples were collected. Researchers measured their levels of alpha amylase and cortisol, two substances that reflect how the body reacts to stress.

Pregnancy rates were compared in women with the highest concentrations of alpha amylase in their first cycle to women with the lowest levels of the stress hormone marker. It was found that over the six-month period, the group of women with the highest alpha amylase (and hence stress) were 12 percent less likely to conceive than women with the lowest.

Cortisol levels were not associated with the women’s chances of conceiving. The alpha amylase and cortisol reflect two different components of the stress response and don’t necessarily correlate well. Alpha amylase reflects the “fight-or-flight” response to immediate stressors.

To confirm these findings, the research team conducted a larger and longer study of women trying to conceive. Evidence from these trials suggests that stress-reduction techniques can improve pregnancy rates in couples who use in vitro fertilization and related methods.

Applying the Findings

With such findings it appears that patients would benefit if they enroll in various stress reducing programs when trying to conceive. Mind-body programs, support groups, acupuncture and massage apparently offer the greatest benefit.

As a practitioner in the field of infertility for 25 years, I endorse these adjunctive therapies for my patients undergoing treatment, with the goal of reaping the fertility enhancing benefit of stress reduction before we submit them to multiple treatment cycles.

I grew up on baseball in the 1960’s with the likes of Mickey Mantle and Roger Maris.  A few years later Tom Seaver and the Miracle Mets held my fancy.  Over the years I have been intrigued by many baseball spectaculars such as Mark McGwire and his run to break Roger Maris’s homerun record and Barry Bonds’s overcoming Mark McGwire’s record.  Roger Clemens winning his 300^th game and pitching his 3000^th strikeout was unforgettable.  I was enchanted with these baseball heroes when they achieved their record breaking accomplishments.

Then the story about how modern day athletes were using steroids became public and the glory of those heroes from the past 20 years disappeared.  Many of us lost our youthful innocence with the discovery that steroids had intruded into the daily routines of professional baseball.  But as my bubby (my Russian grandma) used to say; c’est la vie.  At least that was the French translation.

This week someone’s little boy who was pitching in the big leagues for the first year had a perfect game, meaning no batter reached first base the entire game with only one out to go.  This is a rarity in baseball having previously occurred only 20 times in major league history.   The final out was weakly hit, a ground ball to the infield, the pitcher covering first base beat the batter, and the throw was caught before the batter reached the bag.  Replays documented the batter was out but unfortunately, the umpire mistakenly shot his arms out signifying a safe sign thus preventing the last out which would have made this a rare perfect game.

So why should I blog about a botched call ruining a perfect game?  This arbitrary wrong turn of events which prevented a perfect game crushed me emotionally the same day my patient who I wanted so much to have her baby, miscarried after 3 years of trying to conceive.  She, like the rookie, Galarraga, deserved to have their day, the perfect game, the perfect baby.  Randomly, both were denied.  How is an individual who has such hopes, dreams and aspirations focused on the denied event to deal with this catastrophic disappointment?

As an observer of both, I was feeling distraught, angry, pushing me to cry out for justice for some supernatural power to make things right again.

Forty five minutes after the game after umpire, Jim Joyce, had the opportunity to review the play he went to the dugout to speak with pitcher, Armando Galarraga.  He apologized to the pitcher for spoiling his slice of fame. … There were few words, just a deep apology, as tears welled in Joyce’s eyes. “He feels really bad, probably worse than me,” said Galaragga, who began the season in the minors in Toledo. “I give a lot of credit to that guy, to say he’s sorry. I gave him a hug. His body English said more than the words. Nobody’s perfect, everybody’s human.”

We, in the field of infertility face disappointments as regularly and the menstrual cycle.  When a pregnancy is conceived, in our minds, the “perfect baby” is essentially created.  Miscarriage, the loss of one’s “perfect baby” seems to be a life crushing blow.  Perhaps, we can gain strength from the story about these two men, Armando Galarraga and Jim Joyce, who were able to reconcile this catastrophic schism in their path to obtaining their “perfect” goal and move forward to the next game.

Thank you, Armando and Jim for helping us to see the way.  After all, if you can get this close once only to miss because of a random mistake, then why can’t we expect that we have a good shot that it will work next time?

In the mean time, again as my Bubby would say, “Play ball”.

Sperm Meets Egg

Why me? My wife never had an infection, surgery or any other problem? I have no difficulty ejaculating and there’s plenty to work with so why can my friends, neighbors and coworkers get pregnant and we can’t?

I hear these questions daily and appreciate the frustrations, anger and stress felt by my patients expressing these feelings through such questions. There are many reasons why couples do not conceive. An infertility workup will identify some of these. A semen analysis will pick up a male factor in 50-60% of cases and in more than half of these cases the male has the only problem. An hysterosalpingogram will locate tubal disease in about 20% of cases. Another 20-25% of women do not ovulate or ovulate dysfunctionally preventing conception.

Even when a semen analysis is normal it is possible that a post coital test may identify that the problem is that the sperm is not reaching the egg. It may not be able to swim up the cervical canal into the womb and up the tubes where it should normally find an egg to fertilize. When these tests are normal a laparoscopy may be performed to identify the 20-25% of infertile women with endometriosis. However, even when the infertility workup is normal and there is no test that logically explains the lack of success in achieving a pregnancy; an IVF procedure may both identify the cause as failure of the egg to fertilize and treat it successfully by injecting sperm microscopically into the egg by a procedure called Intracytoplasmic Sperm Injection or ICSI.

What causes male factor infertility?

There are several potential causes of male factor infertility. Hormonal causes can be caused because of problems at the hypothalamic-pituitary level or at the testicular level. Normally, the hypothalamus regulates pituitary production of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). FSH and LH drive the testis to produce sperm and testosterone. Deficiency of FSH or LH can lead to lack of ability to drive the testicular production of sperm and testosterone just as lack of gas will prevent a car from being able to run. Today, the most common reason for a man to have FSH and LH production shut off is from his use of anabolic steroids such as testosterone, hcg (human chorionic gonadotropin) and clomiphene (clomid). These all may provide negative feedback on the pituitary turning off FSH and LH production. One can also see elevated testosterone shutting down the testis with congenital adrenal hyperplasia and adrenal tumors.

Pituitary tumors, infarction, surgery, radiation and infiltrative processes can also diminish FSH and LH production. In the presence of low FSH and LH it may be useful to check for elevated prolactin levels to rule out a pituitary prolactinoma and obtain an MRI to check for other tumors or pituitary pathology.

Isolated deficiency of LH and FSH can occur (Kallmann’s syndrome) and lead to diminished testis (hypogonadism). This occurs in 1 in 10,000 men. Less common defects are seen in hypothalamic stimulation of the pituitary and are usually associated with other congenital findings.

Abnormal thyroid and glucocorticoid (prednisone) excess can result in decreased spermatogenesis through effects on the hypothalamus and LH production or conversion of androgens (male hormone) to estrogens.

Testicular causes include the presence of tumor, chromosomal abnormalities, congenital absence of germ cells, drugs and radiation that are toxic to the testes, undescended testes and varicocoele.

Ten per cent of males with a sperm count under 10 million and 20% of men with azospermia have a chromosomal abnormality. Kleinfelter’s syndrome is a genetic disorder due to the presence of an extra x chromosome in the male. This occurs in 1 out of 500 males and is often seen in the mosaic form where some cells are 46 xy and some are 47 xxy. The testes tend to be small and these men have delayed sexual maturation, azospermia and gynecomastia (enlarged male breasts). There has been some success with ICSI of biopsied immature sperm cells.

Sertoli-cell only syndrome or germinal cell aphasia may have several causes including congenital absence of the germ cells, genetic defects or androgen resistance. Testicular biopsy shows complete absence of germinal elements. Men are azospermic yet virilize normally. Testes may have normal consistency but be slightly smaller in size. Testosterone and LH levels are normal but FSH is usually elevated. Men with testicular failure secondary to mumps, cryptorchidism or radiation/chemotherapy damage have smaller testes with a non uniform histologic pattern. The testes may have severe sclerosis and hyalinization. There is no treatment for this form of azospermia.

Gonadotoxic drugs like chemotherapy or radiation can effect the germinal epithelium because it is a rapidly dividing tissue and is susceptible to the interference imposed by these toxins on cell division. At radiation exposure below 600 rads, germ cell damage is reversible. Recovered spermatogenesis may take up to 2-3 years even when exposed to low doses of radiation. Elevated FSH levels reflect the impaired spermatogenesis and return to normal once the testes recover.

Orchitis occurs in 15-25% of males who contract mumps which is unilateral in 90% of cases. Testicular atrophy may take years to develop. At least two thirds of men with bilateral orchitis remain infertile for life.

Trauma either through accident or torsion of a testis is a relatively common cause of subsequent atrophy with potential diminished fertility.

Medical conditions such as renal failure, cirrhosis of the liver and sickle cell disease can all lead to low testosterone levels and decreased spermatogenesis.

Cryptorchidism occurs in 1 in 12 males. The undescended testis becomes abnormal after age 2. Even when unilateral, cryptorchid patients have reduced fertility potential.

The varicocoele is the most common finding in infertile men. It is the result of backflow of blood due to incompetent valves in the spermatic veins. 90% occur on the left and is found in 20% of males 40% of the infertile population. 50% of men with varicocoeles are fertile. It is thought that a varicocoele can cause infertility by elevating the temperature of the testis. Varicocoelectomies however are not universally helpful and remain somewhat controversial for many cases of infertility.

Unfortunately, at least 25-40% of infertile men have idiopathic infertility for which no cause may be identified.

Other causes of azospermia include congenital absence of the vas deferens or obstruction secondary to infection or surgery. These cases may be amenable to surgical reconstruction and/or ICSI with epididymal aspiration or testicular biopsy to obtain sperm. These are the most successful cases of ICSI associated with azospermia.

Sperm antibodies may be a relative cause of infertility in about 3-7% of cases. Treatment has been successful with intrauterine insemination and with ICSI.

Infections can affect sperm motility secondary to e coli, Chlamydia, mycoplasma, ureaplasma and trichomonas. Culture and treatment for asymptomatic infertile males remains controversial.

Sexual dysfunction is a presenting cause of male infertility in about 20% of cases. Decreased sexual drive, erectile dysfunction, premature ejaculation and failure of intromission are all potentially correctable causes of infertility.

Treatment of Male Infertility
Treatment depends on diagnosis. In cases where the FSH and LH are low with a normal head MRI, clomiphene may be of benefit. Clomiphene citrate (Clomid or Serophene) is one of the most widely used drugs in male infertility. It is a weak anti-estrogen that interferes with the normal feedback of circulating estrogens and results in an increase in GnRH that stimulates gonadotropin secretion. The resulting elevation in LH and FSH increases intratesticular testosterone levels and in theory should improve spermatogenesis. Gonadotropin therapy may be used if clomphene is unsuccessful in the face of low FSH and LH.

If a pituitary tumor is found, surgery or medications to lower prolactin may restore spermatogenesis to normal.

An obstructed vas may be microsurgically reconstructed. Surgery may also be performed in the presence of a varicocoele.

Intrauterine insemination may improve delivery of sperm to an egg or in the absence of any sperm, artificial insemination with donor sperm is often successful.

Intracytoplasmic sperm injection into the egg in an IVF procedure is highly successful when sperm may be obtained through the ejaculate and even through testicular biopsy. When normal mature sperm are rare such as in testicular failure, associated with elevated FSH, ICSI is much less likely to result in fertilization and pregnancy. Immature sperm cells rarely can result in a healthy pregnancy.

Naturopathic Treatment

Naturopathic treatment for male infertility focuses on improving sperm quantity, sperm quality, and overall male reproductive health. There have been reports that sperm counts have fallen almost 50% since the 1930s. Although some dispute these findings, it is generally accepted that sperm counts are declining. The cause may be environmental and dietary and lifestyle changes may interfere with men’s sperm production. If this is so, improving diet and making healthy lifestyle choices should positively impact male reproductive health.

Nutrition

The importance of a healthy diet cannot be overstated. To function properly, the reproductive system requires the proper vitamins and minerals. Nutritional deficiencies can impair hormone function, inhibit sperm production, and contribute to the production of abnormal sperm

• Eat a natural foods diet that focuses on fresh vegetables, fruits, whole grains, fish, poultry, legumes, nuts, and seeds.
• Drink 50% of body weight in ounces of water daily (e.g., a 150 lb man would drink 75 oz of water).
• Eliminate processed and refined foods (e.g., white flour), junk food, sugars, alcohol, and caffeine.
• Avoid saturated fats and hydrogenated oils (e.g., margarine); use olive oil.
• Pumpkin seeds are naturally high in zinc and essential fatty acids which are vital to healthy functioning of the male reproductive system. Eat pumpkin seeds to help maintain a healthy reproductive system.

Supplements

The following supplements may increase sperm count and/or motility. Allow 3-4 months for the supplements to work. The following is a list of supplements with their supposed benefit.

• Arginine – Take 4 gr daily. Needed to produce sperm. If the sperm count is below 10 million per ml, arginine probably will not provide any benefit.
• Coenzyme Q10 – Take 10 mg daily. May increase sperm count and motility.
• Flaxseed oil – Take 1 tbsp daily. Is a source of essential fatty acids.
• L-carnitine – Take 3-4 grams daily. Required for normal sperm function.
• Multivitamin-mineral – Buy a high-quality product and take one serving size (differs from brand to brand).
• Selenium – Take 200 mcg daily. May improve sperm motility.
• Vitamin B-12 – Take 1000 mcg daily. A B-12 deficiency reduces sperm motility and sperm count. Even if no deficiency exists, B-12 supplementation may help men with a sperm count of less than 20 million per milliliter or a motility rate of less than 50%
• Vitamin C – Take 500 mg 2 times daily. Is an antioxidant.
• Vitamin E – Take 400 IUs 2 times daily. Is an antioxidant and may improve sperms’ ability to impregnate.
• Zinc – Take 30 mg 2 times daily. Required for a healthy male reproductive system and sperm production.

Herbal Medicine

Herbal remedies usually do not have side effects when used appropriately and at suggested doses. Occasionally, an herb at the prescribed dose causes stomach upset or headache. This may reflect the purity of the preparation or added ingredients, such as synthetic binders or fillers. For this reason, it is recommended that only high-quality products be used. As with all medications, more is not better and overdosing can lead to serious illness and death.

The following herbs may be used to treat male infertility:

• Ginseng (Panax ginseng) – Known as a male tonic (an agent that improves general health) and used to increase testosterone levels and sperm count. Siberian ginseng (Eleutherococcus senticosus) may also be used.
• Astragalus (Astragalus membranaceus) – May increase sperm motility.
• Sarsaparilla (>Smilax spp.) – Known as a male (and female) tonic.
• Saw palmetto (Serenoa repens) – Used for overall male reproductive health.

Other Recommendations:

Avoid alcohol. Alcohol consumption is associated with an increased number of defective sperm.
• Consider acupuncture.
• Do not smoke, or quit smoking. There is an association between smoking and low sperm count, poor sperm motility, and abnormal sperm.
• Proxeed – is a new nutritional supplement that may improve sperm health and fertility rates. The ingredients include L-carnitine and acetylcarnitine, two vitamin-like substances synthesized naturally by the body. These chemicals are involved in cellular metabolism and are found in semen at a rate that is proportionate to the amount of healthy sperm. Proxeed is purported to improve sperm count, concentration, and motility when taken orally for about 2 months. It is reported that approximately 30% of couples using it conceive. It is available without a prescription, although couples considering it should consult their physician.

At East Coast Fertility, we understand the emotional aspect that accompanies infertility, and we believe it is equally important to support our patients emotionally as well as physically. It is important to understand fertility holistically. In addition to treating the various physical etiologies of infertility, we must take into account the effects of stress and anxiety. Your mind and body work together, not separately. Therefore your thoughts have a direct effect on yourphysiology. When you are experiencing stress, your brain releases stress hormones. These stress hormones function in many ways. One of the stress hormones, cortisol, has been documented to interfere with the release of the reproductive hormones, GnRH (gonadatropin releasing hormone), LH (luteinizing hormone), FSH (follicle stimulating hormone), estrogen, and progesterone. In fact, severe enough stress can completely inhibit the reproductive system. Cortisol levels have also been linked to very early pregnancy loss. For this reason, it has been found extremely helpful when treating infertility, to include mind/body methods and strategies which help to alleviate the stress response that sets off a cascade of hormonal responses which may inhibit fertility.

The mind/body work we teach here at East Coast Fertility includes methods that allow the body to return to a calm and relaxed state, thereby turning off the biochemical stress response and allowing our hormonal physiology to function optimally.  Feelings of anxiety, depression, isolation, and anger are common themes in infertility.  Often, anger masks the feelings of loss experienced month after month of trying to conceive without success. Infertility impacts on one’s marriage, self-esteem, sexual relationship, family, friends, job, and financial security.

One study showed that women going through infertility experience as much depression as women who have been diagnosed with life-threatening illnesses such as metastatic cancer, heart disease, or HIV. When women face these other illnesses, they are likely to seek out the support of their friends and family. The sad aspect of infertility is that although these women are as depressed as those facing life-threatening illnesses, they are far less likely to seek out support from friends and family. Often, thoughts of not living up to the expectation to become pregnant, thoughts such as “why is this happening to me?!”, and the intense emotions of loss related to the thought that one may never have a child, lead to feelings of isolation, anger, and depression.

Although there is a correlation between stress and infertility, the relationship remains complex. However, the research does in fact suggest that psychosocial factors such as depression and anxiety correlate with
lower pregnancy rates following IVF. In addition, of the women who participated in Alice Domar’s Mind/Body program at the Mind/Body institute in Boston, 55% conceived pregnancies that resulted in the birth of a full term baby compared with 20% of the control group.

~ Mind/Body Support Group at East Coast Fertility ~

In our Mind/Body support group, patients experience the opportunity to share information, feelings, or their own personal stories. You may be surprised to see how your support can help others or you may be relieved
to hear others experiencing the same type of thoughts and feelings as you experience. Often, the supportive nature of this group, and the connection that develops between members, fosters a healing process.
Feelings of isolation, anger, and stress are slowly relieved.

Our Mind/Body program focuses on symptom reduction and developing a sense of control over one’s life by utilizing Mind/Body strategies and interventions which elicit the relaxation response. The relaxation
response is actually a physical state that counteracts the stress response. You can think of it as the physiological opposite of the body’s stress response. We cannot be stressed and relaxed at the same time.
Therefore when a person elicits the relaxation response, the body’s stress response is halted, stress hormones diminish. Stress responses such as heart rate, metabolic rate, blood pressure, and shallow breathing decrease. Breathing becomes slower and deeper, so we have more oxygen being delivered to all the cells in the body. The way in which you are taught to elicit the relaxation response is through methods such as: breath focus, guided visual imagery, muscle Relaxation and learned mindfulness, and meditation.

In Mind/Body work, we also work with “cognitive restructuring” which is examining our negative thoughts, seeing where there is distortion, and reframing our thoughts positively and realistically. Often, we have held on to certain negative thoughts and feelings we may have developed years ago. The thought pattern becomes so ingrained in us, that we take it for truth, when in fact, it is a distortion. Cognitive restructuring will help you examine your thoughts and see which are distorted, causing you needless worry, anxiety, or depression. Once you understand how a thought is distorted, you can change those thoughts and alleviate the anxiety attached to them.

Awareness of the mind/body connection allows us to use our minds to make changes in our physiology. This holistic treatment – combining bio-medical science with mind/body medicine deals with the treatment of the whole individual rather than looking only at the physical aspect.  The fact is, body and mind work together. We invite you to take advantage of this unique area of support provided at East Coast Fertility and join our Mind/Body group.