Integrative Approaches to Infertility DR JACLYN CHASSE ND

Integrative Approaches to Infertility DR. JACLYN CHASSE, ND

Trends in the percentage of women (aged 15 -44 years) with impaired fecundity by age group, 1982 -2002 CDC Report: “Fertility, Family Planning and Reproductive Health of US Women: Data from the 2002 National Survey of Family Growth” National Center for Health Statistics, Vital Health Stat 23(25) (2005). 1982 1988 1995 Fertility in the US Where are we and why? 2002 2012

Is fertility really declining? Review of 61 papers (14, 947) 1940 -1990 450 400 350 300 250 Sperm Conc (million/m. L) 200 Sperm Count (million) 150 100 50 0 1940 Carlsen et al. BMJ. 1992; 305(6854): 609. 1990 • Ave. sperm concentration decreased from 113 million/m. L to 66 million/m. L • Ave seminal volume decreased 3. 4 m. L to 2. 75 m. L • Ave sperm count decreased 384. 2 million to 181. 5 million (52. 8% decrease!!)

Contributors to Infertility- Lifestyle �Nutritional changes �Environmental exposures Pesticides Exogenous estrogens Heavy Metals �Stress

Potential for Integrative Medicine �Forsight Study, UK 367 couples (females age 22 -45, males age 25 -59) Couples had previous hx of � Infertility 37% � Miscarriage 38% � Therapeutic abortion 11% � Still birth 3% � LBW babies 15% � Malformations 2% � SIDS 1%

Potential for Integrative Medicine �Forsight Study, UK After basic preconception care (nutrition counseling, MV), � 0 miscarriages, perinatal deaths, malformations � Expected 70 miscarriages, 6 malformations � Couples with live births 89% � Infertile couples with live births 81% � Ave gestational age 38. 5 weeks � Average baby weight 7 lbs, 3 oz.

Challenges with Lack of Integration of Care Naturopathic - only Care Conventional - only Care � Emphasizes healthy � Fast timeline lifestyle � Treats the underlying cause � Many options available � Poor outcomes statistically � Long treatment time often required � Lack of advanced options, ie. laparoscopy � High cost, high parental stress � Possible epigenetic and genetic outcomes

Current Treatment Paradigms Integrative Conventional Treatment • Clomid-assisted cycles • IUI • IVF with ICSI

Conventional Fertility Treatments

Conventional Treatment Options “Fertility Enhancing” Medications Artificial Insemination/ IUI ART (Assisted Reproductive Technology) IVF: In-Vitro Fertilization ICSI: Intracytoplasmic sperm injection GIFT: Gamete Intrafallopian transfer ZIFT: Zygote Intrafallopian transfer

“Fertility Enhancing” Medications 2 Main Classes: Clomiphene/Serophine (Clomid) Gonadotropins

Clomid Clomiphene Citrate Interacts with estrogen-receptor containing tissues (hypothalamic, pituitary, vaginal, ovarian, endometrial, cervical) Increases pituitary gonadotropin release which increases steroidogenesis and folliculogenesis This causes growth of an ovarian follicle and increase in estradiol

Clomid (cont. ) Pharmacy: Dose 50 -100 mg qd x 5 days starting on day 5 of menstrual cycle Drug Interactions: None documented Contraindications: hypersensitivity, pregnancy (category X), liver disease, ovarian cysts (not due to PCOS), abnormal uterine bleeding of unknown origin, uncontrolled thyroid or adrenal disorders Toxicity: Unknown toxic dose in humans. S/Sx of overdose include: nausea, vomiting, vasomotor flushes, visual blurring, spots or flashes, scotomata, ovarian enlargement with pelvic or abdominal pain.

Gonadotropins Many choices available on the market Combination of LH and FSH which directly stimulate the ovaries to produce a follicle Brand names include Pergonal Repronex Fertinex Follistim Gonal F Novarel Ovidrel Pregnyl Profasi Megonon Puregon Menopur

Menopur (a menotropin) Pharmacy: Subcutaneous injection Dose 225 units qd for up to 20 days Once follicular development is adequate, dose 5, 000 -10, 000 units of h. CG the following day Drug Interactions: None documented

Menopur Contraindications Primary ovarian failure (high FSH) Uncontrolled thyroid and adrenal dysfunction Intracranial leision AUB of unknown origin Ovarian cysts not caused by PCOS Sex hormone-dependant tumor

Menopur- toxicity OHSS (Ovarian Hyperstimulation Syndrome) S/Sx: Abdominal pain and distention, nausea, diarrhea, dyspnea, oliguria, rapid weight gain, severe pelvic pain, vomiting Occurs in about 5 % of patients undergoing gonadotropin therapy. It is thought that stim. of ovary causes release of VEGF, causing capillaries to leak out vascular fluids- can lead to hypovolemia and leave patient more prone to circulatory, renal, and respiratory problems.

IUI Intra. Uterine Insemination (Artificial Insemination) Placement of ejaculate into the vagina/cervix/uterus/fallopian tubes (Fa. ST) and allowing conception to take place naturally within the fallopian tubes Helpful in cases of low sperm counts, low motility, sperm antibodies, hostile cervical mucous GIFT: A type of IUI where egg and sperm are deposited in fallopian tube

the ART of IVF First “test tube” baby conceived in 1978 in England Conception outside of the body and embryo(s) implanted Procedure used alongside medications (Lupron) Follicle stimulating meds (Follistim, Gonal-F) often with Humegon, Pergonal, or Repronex, and also often used with Clomid and h. CG Eggs retreived by transvaginal ultrasonic needle aspiration

More ART ICSI- Intracytoplasmic sperm injection Sperm is deposited directly into the egg and egg is then placed in uterus/fallopian tubes Often used for couples with low sperm count GIFT: Gametes are transferred into fallopian tube ZIFT: Zygote is transferred into fallopian tube

Establishing relationships with RE/Ob. Gyn �Letters summarizing treatment of patients also in their care �Refer to them when appropriate! �Reach out to them to perform testing/procedures you can not do Antral follicle count Ultrasound IUI Advanced lab testing

Address their needs �Most RE clinics are competing for the best outcomes in their area. You can offer them help! Treating obesity to get patients into healthier BMIs � BMI limits Improving egg quality/semen quality Offering an alternative for patients who are not interested in/not comfortable with their treatment options

Clinical Courtesies �Never disparage the clinic’s care to the patient. �If you disagree, reach out to the doctor directly through a phone call, letter, etc. �Understand that they have expertise as well, within a different paradigm �Remember that the patient always comes first! Ie. if they are undergoing IVF and you want them on herbs that their RE doesn’t want them on…

General Fertility support • MEDITERRANEAN DIET • ADDRESSING OBESITY • PRECONCEPTION SUPPORT AND FERTILITY OUTCOMES • STRESS MANAGEMENT • ACUPUNCTURE

Mediterranean Diet and Fertility �Greatest adherence to Mediterranean diet pattern (vs. western diet) showed lowest difficulty of getting pregnant in 2154 Spanish women aged 20 -45 years. �Netherlands study of 161 couples undergoing IVF/ICSI demonstrated that Mediterranean diet adherence increased the probability of pregnancy (odds ratio 1. 4). It was also associated with high folate and B 6 in red blood cells and follicular fluid Toledo E et al. Fertil Steril. 2011 Nov; 96(5): 1149 -53. Vujkovic M et al. Fertil Steril. 2010 Nov; 94(6): 2096 -101.

Mediterranean Diet and Fertility

Addressing Obesity �In men, Lower sperm counts, sperm concentration, sperm morphology, motile sperm, and testosterone levels are associated with BMI and central adiposity. �In women, Lower pregnancy rates (20. 8% v 28. 3% p=0. 04) and live birth rates per cycle (15. 2% v 21. 5%) with IVF Increased risk of preterm birth in IVF couples �For couples, Higher rates of miscarraige in assisted reproduction AND spontaneous conception Sermondade N et al. Arch Intern Med. 2012; 172(5): 440 -2. Hakonsen LB et al. Reprod Health. 2011 Aug: 8 -24. Pinborg A et al. Reprod Biomed Online. 2011 Oct; 23(4): 490 -9. Dickey RP et al. Fertil Steril. 2012; 97(2): 349 -54 Boots C, Stephenson MD. Semin Reprod Med. 2011; 29(6): 507 -13.

Addressing Obesity �Huge factor fertility clinics! Many have BMI limits for patients Have a program you can offer a referral for Be successful- ensure proper patient follow up Even better if you can use a Mediterranean-diet style program

Preconception Support �Prenatal Vitamin �Fish Oil �Cal/Mag �other

Prenatal Vitamin �Provides key nutrient support Iron Calcium Folate Zinc �Studies have demonstrated significantly improved pregnancy rates in women on multiple micronutrient supplements compared to folic acid alone. (66. 7% vs 39. 3% after 3 clomid supported cycles, 60% vs 25% ongoing pg rate) Agrawal R et al. Reprod Biomed Online. 2012 Jan; 24(1): 54 -60.

Prenatal Vitamin �Also associated with better birth outcomes than folic acid and iron alone Birth weight Pregnancy outcome � Decreased rate of stillborn, miscarraige, and neonatal death (nonsignificant trend) Maternal micronutrient status Sunawang et al. Food Nutr Bull. 2009; 30(4 Suppl): S 488 -95.

Fish Oil and Men �Fertile men have higher blood and spermatozoa levels of omega-3 FA as well as lower serum omega 6/omega-3 ratios compared to infertile patients. �In men with oligoasthenoteratospermia (OAT), supplementation with omega-3 s Increased sperm count (from 38. 7 to 61. 7 million) and concentration (from 15. 6 to 28. 7 million/m. L) Increased SOD-like and catalase-like activity. � Positive correlation with increased sperm count, motility, and morphology. Safarinejad MR et al. Clin Nutr. 2010 Feb; 29(1): 100 -5. Sarafinejad MR. Andrologia. 2011 Feb; 43(1): 38 -47.

Fish Oil and Women �Increased dietary intake of omega-3 (esp. alpha- linolenic and DHA) improve embryo morphology with IVF/ICSI Hammiche F et al. Fertil Steril. 2011 Apr; 95(5): 1820 -3.

Stress Management �Stress mediators can be both protective and damaging. High levels of stress can lead to “allostatic overload”, meaning a chance in stability of physiological systems affecting fertility. �The link between stress and female fertility exists even independent of stress hormone levels �Selye observed ovarian atrophy in response to stress in rats. Additional studies have confirmed that stress inhibits HPG axis. Mc. Ewen BS. J Psychiatry Neurosci; 30: 315 -8. Sanders KA, Bruce NW. Hum Reprod 1999; 14: 1656 -1662. Berga SL. Reprod Endocrinol Surg Tech 1996. Lippencott-Raven, Philadelphia: 1061 -76.

Stress Management �Stress hormones and HPA axis directly interact with Gn. RH Prolactin LH FSH Cortisol Endogenous opoids Melatonin

Stress Management �In women, higher rates of infertility correlated with follicular cortisol/cortisone ratios �In men, increased stress has negative impact on sperm quality and motility Loss of glutathione and free sulphydral content of semen And/or inhibition of androstenedione into testosterone in Leydig cells due to high ACTH and cortisol levels Arcuri F et al. Endocrinology 1996; 137: 595 -600. Boivin SL. Reprod Endo Surg Tech. Lippencott-Raven, Philadelphia. Vol 1: 1061 -1076. Eskiocak S et al. Hum Reprod 2005; 20: 2595 -2600. Klimek M et al. Neur Endocrinol Lett 2005; 26: 347 -50.

Stress Management �Group mind/body intervention increased IVF pregnancy rates from 43% to 52% in women <40 about to start their first IVF cycle. �“Letting go” counseling associated with improved pregnancy rates with IVF (by 1. 9 times) �Many other psychological interventions showed benefit Psychotherapy accompanying IVF Benefit varied male/female Domar A et al. Fertil Steril. 2011 Jun; 95(7): 2269 -73. Rapoport-Hubschman N et al. Fertil Steril. 2009 Oct; 92(4): 1384 -8.

Acupuncture � 2012 Meta-Analysis of 24 trials (5, 807 patients) included Clinical pregnancy rate significantly higher in acupuncture treatment groups �Studies of RCTs have mixed results on outcomes, but consistently report positive patient experience and outlook �Typically treatment surrounds embryo transfer Zheng Ch et al. Fertil Steril. 2012; 97(3): 599 -611.

Patient Education �Eliminate/avoid teratogens and toxins which can impair fertility Alcohol Caffeine Cigarettes Pesticides Pollutants Endocrine-disrupting compounds � Environmental estrogens

Improving Male Factor Infertility

Semen Evaluation � Best to evaluate 2 samples � Samples obtained by masturbation after 2 -5 days of abstinence � Usually requires advance scheduling with the lab � Kept body temp until analyzed � Analyzed in under 2 hours, preferably under 1 hour

“Normal” semen parameters According to WHO Ejaculate Volume Sperm concentration Motility Morphology (WHO) (Kruger) Forward progression Other 1. 5 -5. 5 m. L >20 x 106 sperm >50% >60%, >30% >14% 2 (scale 1 -4) No agglutination No WBC Normal viscosity

Abnormal semen �Low ejaculate volume �Low sperm count (oligospermia, azoospermia) �Poor motility (asthenospermia) �Poor morphology �Leukocytospermia �Immunologic factors

Improving Semen Quality- conventional HCG 2 x/wk can stim cells within the testicles that produce testosterone Parlodel: Prolactin antagonist, can increase testosterone prod. Aromatase inhibitors: block conversion of test to estrogen Kallekrein: anti-inflamm protein can increase sperm motility �Usually, nothing is done- only one sperm is needed!

Sperm Health �Growing evidence indicates that oxidative stress can be a primary cause of male (and female? ) infertility �Oxidative stress Alters membrane fluidity Alters membrane permeability Impairs sperm’s functional competence �Correlations of semen/sperm quality with Superoxide dismutase (SOD) Catalase Glutathione (GSH) Atig F. BMC Urol. 2012 Mar; 12: 6. Shamsi MB et al. Indian J Biochem Biophys. 2010; 47(1): 38 -43.

Co. Q 10 and sperm parameters � 212 infertile men � 300 mg Kaneka Co. Q 10 vs placebo for 26 weeks �Significant improvement in motility, concentration, and morphology Greatest effect on motility �Co. Q 10 has effect as antioxidant, and mitochondrial energy production Safarinejad MR. J Urol. 2009; 182(1): 237 -46. Balercia G. J Endocrinol Invest. 2009; 32(7): 626 -32.

Carnitine and Acetyl-L-Carnitine �Demonstrated efficacy in improving sperm motility (total and forward) �Improved seminal free-radical scavenging ability �Carnitine and acetyl-L-carnitine both studied and have positive effect (usually at dose of 3 g/day)

Carnitine and Acetyl-L-Carnitine �PCDBR trial 60 infertile men, age 20 -40 with low sperm motility (normal count and morphology) LC 3 g/d, ALC 3 g/d, LC 2 g/d + ALC 1 g/d, or placebo x 6 months Motility significantly improved in ALC and LC+ALC groups �Review of 9 RCTs Improvement in pg rate (p<0. 0001) Total sperm motility (p=0. 04) Forward sperm motility (p=0. 04) Sperm morphology (p<0. 00001) Balercia, G et al. Fertil Steril. 2005; 84(3): 662 -71. Zhou X et al. Asia Pac J Clin Nutr. 2007; 16(1): 383 -90.

Function of Carnitines �Mitochondrial metabolism Controls transport of acetyl and acyl groups across mitochondrial inner membrane �Found in high concentrations in the epididymis, where they exert antioxidant functions Protect spermatazoa from reactive oxygen species �Seminal carnitine concentration associated with Sperm concentration Total sperm count Total motility Rapid forward progression and linearity of movement Membrane function Nuclear DNA integrity Capacity for cervical mucous penetration (after 6 months of tx) De. Rosa M et al. Drugs R D. 2005; 6(1): 1 -9.

Antioxidants �Selenium �Zinc �Vitamin A, C, E �Pycnogenol Stanislavov R. et al. Phytotherapy Res. 2009; 23(3): 297 -302

Low sperm count �Multivitamin �Zinc �Selenium �Reduced glutathione �Fish Oil �Co. Q 10 (50 -300 mg/day) Atig F. BMC Urol. 2012 Mar; 12: 6. Singh AK et al. Indian J Physiol Pharmacol. 2010; 54(2): 157 -63. Shamsi MB et al. Indian J Biochem Biophys. 2010; 47(1): 38 -43.

Low sperm motility �Zinc �Reduced glutathione �Co. Q 10 (50 -300 mg/d) �Carnitine and Acetyl-L-Carnitine, 3 g/day total Atig F. BMC Urol. 2012 Mar; 12: 6. Shamsi MB et al. Indian J Biochem Biophys. 2010; 47(1): 38 -43.

Low sperm morphology �Glutathione �Co. Q 10 (50 -300 mg/d) �Theoretically, antioxidants Atig F. BMC Urol. 2012 Mar; 12: 6. Shamsi MB et al. Indian J Biochem Biophys. 2010; 47(1): 38 -43.

Other semen parameters �Leukocytospermia �Autoimmune reaction to sperm

Case Studies �Joe O. , Steven P.

Improving Female Factor Infertility POOR EGG QUALITY PCOS THIN UTERINE LINING IRREGULAR CYCLES RECURRENT MISCARRAIGE

Egg Quality �As you would predict, oxidative stress also plays a significant role in egg quality.

Poor Egg Quality �Melatonin and IVF Italian study, 65 women undergoing IVF randomized to receive myo-inositol and folate or the same combination plus melatonin. Significant increased number of mature oocytes and decreased number of immature oocytes (no difference in total number) after Gn. RH stimulation in the melatonin group Positive trends in clinical pregnancy rate and implantation rate (non-significant) �Many studies have mirrored these results Rizzo P et al. Eur Rev Med Pharmacol Sci. 2010; 14(6): 555 -61. Batioqlu AS et al. Gynecol Endocrinol. 2012; 28(2): 91 -3

Poor Egg Quality �Melatonin (cont. ) 115 women with history of failed IVF and low fertilization rate (<50%) in previous IVF cycle � Melatonin 3 mg/day or � No intervention Fertilization rate significantly improved in melatonin group only Tamura H. et al. J Pineal Res. 2008; 44(3): 280 -7. Unfer V et al. Gynecol Endocrinol. 2011; 27(11): 857 -61.

Poor Egg Quality �DHEA Used by 1/3 of all IVF centers worldwide Improves ovarian function and ovarian reserve � Promote preantral follicle growth and reduction in follicle atresia Increases pregnancy rates with IVF Lowers miscarriage rates by reducing aneuploidy, especially in women over age 35 Gleicher N. Reprod Biol Endocrinol. 2011; 9: 67. Gleicher N et al. Reprod Biol Endocrinol. 2009; 7: 108.

Poor Egg Quality �DHEA Supplementation with 25 mg three times daily significantly improved AMH (Anti-mulerian hormone) (p=0. 002), especially for women under age 38. Improvement of AMH was about 60% (p<0. 0002) Longer use showed greater improvement up to 120 days. Significant increases in fertilized oocytes (P<0. 001), normal day 3 embryos (P=0. 001), transferred embryos (P=0. 005), and improved embryo scores (P<0. 001). Gleicher N. Reprod biomed Online. 2010; 21(3): 360 -5. Barad D et al. Hum Reprod. 2006; 21(11): 2845 -9.

PCOS �Affects 10% of women of reproductive age Anovulation or irregular menses Elevated LH/FSH, elevated testosterone, elevated prolactin �Current standard of care is insulin sensitizing agents such as metformin, but metformin doesn’t enhance ovulation in many patients. �Studies have demonstrated superior effect of inositol in: Sensitizing cells to insulin in PCOS patients Restoring ovulation Nestler JE. NEJM. 1998; 338(26): 1876 -80. Sturrock ND. Br J Clin Pharmacol. 2002; 53(5): 469 -73.

Inositol and PCOS �Phosphoglycan that mediates insulin action contains d-chiro-inositol �This phosphoglycan is deficient in PCOS patients �Administration of inositol Improves insulin sensitivity Improves ovulatory function Decreases serum androgens Decreases elevated blood pressure Decreases elevated plasma triglycerides Improves oocyte quality in women with PCOS Galletta M. et al. Eur Rev Med Pharmacol Sci. 2011; 15(10): 1212 -4. Nestler JE et al. NEJM. 1999; 340(17): 1314 -20. Ciotta L. Eur Rev Med Pharmacol Sci. 2011; 15(5): 509 -14.

PCOS �Myo-inositol seems to perform better then d-chiro inositol �Standard dosage 4 g/day Galletta M. et al. Eur Rev Med Pharmacol Sci. 2011; 15(10): 1212 -4.

PCOS �Other useful therapeutics: vitex, licorice/peony combination (shakuyaki-kanzo-to) �In women undergoing clomid-supported cycles, coadministration of N-acetyl-cysteine 1200 mg/day cd 3 -8 showed improvement in ovulation rate (52. 1% vs. 17. 9%), mature follicles, endometrial thickness, follicular E 2 levels, and luteal P levels. Badawy A et al. Acta Obstet Gynecol Scand. 2007; 86(2): 218 -22.

Thin Uterine Lining �Common side effect of clomid, letrozole, and other ovulation induction meds is a thinner endometrial lining �This can prevent proper implantation �No research to support, but Shatavari can be helpful to mitigate this effect.

Thin Uterine Lining �Black Cohosh Studied in CC induction cycles 134 women randomized to receive black cohosh (120 mg/day of extract cd 1 -12 or ethinyl estradiol (EE) Black cohosh group needed fewer days for follicular maturation, had a thicker endometrium, and had higher estrogen levels (P<0. 001). Also, higher luteal phase progesterone levels compared to EE group. Clinical pregnancy rates 36. 7% compared to 13. 6% in EE group Shahin AY et al. Reprod Biomed Online. 2009; 19(4): 501 -7. Shahin AY et al. Reprod Biomed Online. 2008; 16(4): 580 -8.

Cycle Abnormalaties: Luteal Phase Defect �Defined by shortened luteal phase or inadequate production of progesterone �Timing is vital for proper implantation! Egg/embryo takes 7 days to get from ovary to implantation in the uterus Cytokine/prostaglandin cascade triggering menstruation begins 3 -4 days before menstruation onset Need long enough luteal phase to allow for implantation and continuation of progesterone synthesis by corpus luteum.

Cycle Abnormalaties: Luteal Phase Defect �Animal models have suggested that oxidative stress can impair ovarian development of corpus luteum, leading to low progesterone. �In humans, melatonin treatment (3 mg/day at 10 pm) through the luteal phase increased serum progesterone concentrations compared to unmedicated group. Noda Y. et al. Biol Reprod. 2012; 86(1): 1 -8. Taketani T. J Pineal Res. 2011; 51(2): 207 -13.

Pregnancy Loss Undisputed causes: Parental chromosomal structural abnormalaties Antiphospholipid antibody syndrome Frequently cited causes: Advanced maternal age Luteal phase insufficiency Untreated hypothyroidism Hyperprolactinemia PCOS Diabetes mellitus Uterine anatomic abnormalities Unknown (likely immunologic)

Managing Miscarriage �Many patients want workup sooner than medical standard After 1 miscarriage, likelihood of next pregnancy healthy is 76% After 2, 70% After 3, 65% After 4, 60% Work-up after 2 consecutive losses if no prior term pregnancies, after 3 if prior term-pregnancy

Miscarriage Fetal Stage Timing Key milestones Contributing factors Preembryonic LMP to week 4 Implantation Genetic, implantation-related (thrombotic, thin uterine lining, low P) Embryonic Week 5 -9 Organogenesis O 2 and nutrients through placenta Genetic, hormonal (low P) Fetal Week 10 delivery Autoimmune, thrombotic, anatomic

Miscarriage �No research supporting specific clinical interventions for pregnancy loss, but consider your naturopathic therapeutics Suspected Cause Considerations Genetic Oxidative stress, toxic burden, etc Thrombotic Aspirin, blood-thinning herbs, omega 3 s, etc Immune Evaluate possibility of food intolerance, manage with favorite auto -immune protocol

Unexplained Infertility TAKING A NATUROPATHIC LOOK INTEGRATIVE TREATMENT OPTIONS

Unexplained Infertility �Consider other compounding factors Food intolerance/celiac disease Chronic inflammation Toxicity (heavy metal or otherwise) Exposure to endocrine-disrupting compounds Stress Low nutrient status Emotional/spiritual state �Institute the classic naturopathic tools!

Heavy Metals and Fertility/IVF �UK study of 30 women with failed IVF history �Hair mineral/metal analysis completed. �Hair mercury concentration negatively correlated with oocyte yield (p<0. 05) and follicle number (p<0. 03) �Hair zinc and selenium positively correlated with oocyte yield (p<0. 05) and follicle number (p=0. 03). Dickerson EH et al. J Assist Reprod Genet. 2011; 28(12): 1223 -8.

It’s not just about getting pregnant… KNOWN AND SUSPECTED RISKS OF ADVANCED FERTILITY TREATMENT LOWERING THE RISK

Are there risks of fertility technologies? �Most risk associated with greatest level of intervention IVF with ICSI � Bypassing mother nature’s limitations around who can conceive � Manual selection of sperm based on gross morphology � Either egg or sperm (or both) may not have been good enough quality to conceive on own

Are there risks of fertility technologies? �Obesity Female teens born through ICSI have significantly higher rates of obesity (compared to spontaneous conception group). � Measured higher peripheral adiposity (skin fold measurement, upper arm circumference) and central adiposity (skin fold measurement, waist circumference), and total adiposity (BMI) (p<0. 05) � Neither parental or early life factors could explain the differences � Same trend not observed in males Belva F et al. Hum Reprod. 2012 Jan; 27(1): 257 -64.

Risk of ART, especially ICSI, alters natural selection. Increased rates of chromosomal abnormalaties Increased rates of hypospadias, Angelman syndrome, Beckwith-Wiedemann syndrome Developmental delays and defects (subtle) have been reported. Increased rates of ADHD, Autism. Could there be more?

The Bottom Line

Integration is KEY for Fertility! �Naturopathic medicine provides effective fertility support for most couples on its own; however, Most couples are pursuing advanced fertility support Success rates are low Many safe and effective adjunct therapies exist that can allow NDs to safely work with these couples.