Rescripted S02E10_Preconception Prep: Audio automatically transcribed by Sonix

Rescripted S02E10_Preconception Prep: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi! I'm Kristyn Hodgdon, an IVF mom, current IVF patient, and co-founder of Rescripted.

Lucky Sekhon:
And I'm Dr. Lucky Sekhon, a board-certified reproductive endocrinologist at RMA of New York.

Kristyn Hodgdon:
Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for the millions of people globally who have trouble conceiving.

Lucky Sekhon:
We're here to answer real questions from real fertility patients about what to expect during each stage of the fertility journey and to provide you with the patient-centric advice and guidance you need to be your own advocate when trying becomes trying.

Kristyn Hodgdon:
Now, let's dive in and help you feel more empowered during this overwhelming process.

Kristyn Hodgdon:
Hi everyone, and welcome back to Dear Infertility. I'm your host, Kristyn, and I'm here with Dr. Lucky Sekhon. Hi, Lucky!

Lucky Sekhon:
Hi. How's it going?

Kristyn Hodgdon:
I'm doing well. How are you?

Lucky Sekhon:
I'm good. I'm excited to be here, talking about Pre-conception Prep, one of the most important steps.

Kristyn Hodgdon:
Yeah, absolutely. And, you know, so much of this journey can feel like you have no control, and some of these tips I'm sure we'll discuss related to nutrition and lifestyle changes can really help you feel like you're putting your best foot forward on this journey.

Lucky Sekhon:
Yeah, I think so much of the emphasis when it comes to education around our bodies and reproductive system is how to prevent pregnancy. And then we get to our maybe late twenties, thirties, or beyond, and you're ready to start this journey, and it can be very overwhelming because there can be a lot of advice out there and noise and some of it's conflicting with each other. And so, I think it's good to put it all in one place on how to prepare.

Kristyn Hodgdon:
Yeah, absolutely. So someone in the community asked why do fertility doctors often not address nutrition when discussing IVF or fertility treatment in general?

Lucky Sekhon:
So I can't really say because I guess everyone's having different conversations and it depends on the doctor they're speaking with, but I think it's just because we don't have specific things, a lot of times there's this tendency towards trying to think about superfoods, like, for example, pineapple core, right? But there are all these fertility superfoods that people talk about. And I think it's human nature and a very natural tendency to want to say, like, what are the foods that would be good for my fertility? But it's really more about a lifestyle. So I think we don't hone in on very specific things like you should eat this type of magic superfood because that doesn't really exist. It's more about when it comes to diet, nutrition, and your fertility, just like your general health, it's more of a holistic thing. It's, you know, everything is additive and pretty much anything that's good for your heart health, for your cardiovascular system and your general health and longevity is also going to be better for your fertility and is not something that hasn't been studied or, or looked at. And certainly as a, as a fertility doctor, I don't shy away from this discussion, but it's not like every patient who walks through the door, I tell them, like, you need to be eating these specific things because this is what's going to make you more fertile, because we don't really know that such a thing exists. We know that the best steady diet that's been most successful in terms of trends towards improved outcomes with treatment or improved pregnancy rates is the Mediterranean-style diet. And this is a very balanced approach to eating where you're basically trying to eat all the colors of the rainbow, you're trying to increase your intake of antioxidants, which can be found in a variety of healthy vegetables, fruits, and nuts, and things like that. And you're really trying to reduce the overall load of processed foods, of unhealthy sources of protein like red meat. And, you know, it's all about if you're going to consume fats, make it the healthy fats like avocado is a source of healthy fat. So it's not, I think it's sometimes a source of frustration for patients. They want a pamphlet that tells them exactly what to do because it's so much easier and you feel more in control when you can follow something very specifically. But I always like to say flip the coin. I think it's better that you have an endless number of options as long as you're kind of doing this overall theme of reducing processed foods and eating healthy carbs, eating healthy forms of fat, and trying to eat all the colors of the rainbow, you can't really go wrong. And it's really nice, I think, to not be limited because everyone has different tastes and different types of foods that they enjoy. And I don't think this has to be a painful thing that's overly restrictive and you're not able to eat foods that are delicious and also good for you. So my guidance would be vegetables, fruits, nuts, seeds, legumes, potatoes, whole grain,sources of protein like fish or seafood, lean cuts of chicken, eggs, cheese, yogurt. It's not about being restrictive, it's about having a wide and varied diet, but that's going to be actually healthy for your general well-being and for fertility. And I think that it's something that doesn't have to happen overnight, it's just something to work towards, it's all about balance and just not being too hard on yourself as well.

Kristyn Hodgdon:
Absolutely. And I want to touch on the restrictiveness for a second, because I remember when I got diagnosed with PCOS, there were so, there was so much information out there about like you need to give up gluten and dairy and all this crazy restrictive dieting. And I try to, knowing what I know now, I try to take it all with a grain of salt. But do you, you don't usually recommend any sort of restrictive. I just kind of want to like Mythbusters.

Lucky Sekhon:
Yeah, yeah, for sure. I mean, I think there's so many myths. Everyone is talking about the keto diet being better for women with PCOS. Keto is really harsh. You know, it's basically sending your body into a state of what it thinks is starvation and it is not something that I would advise. It's not that I have direct evidence to suggest that it's going to make you less likely to conceive. But I think the general theme and logic is that you should be taking a balanced approach and anything that's an extreme or fad diet I would stay away from in general for your health, but also for fertility. You don't want to be in a situation where you're depriving yourself of calories and your body isn't getting the source of energy that it needs to function. And when it comes to gluten-free, the only reason to avoid gluten is if you have a diagnosis of celiac disease, that is a legitimate medical problem where your condition will be improved if you avoid gluten. But, gluten should not be villainized for people that are able to break it down and don't have gluten intolerance. There's nothing wrong with consuming gluten and same with dairy. And for PCOS specifically, the reason why a diet even comes into play is because we know that certain women with PCOS have a tendency towards insulin resistance and this is like a pre-diabetic type of state where your body doesn't know how to utilize sugars effectively. Maybe your body produces insulin from its pancreatic gland, but the cells of the body don't know how to actually respond to it and store sugar properly. So definitely reducing carbohydrates from the diet can be helpful in that setting, but it's not a recommendation across the board for every patient who's trying to conceive.

Kristyn Hodgdon:
Right. And some women with PCOS, myself included, don't have the insulin resistance component, so it's individualized. Do you recommend, kind of want to go into supplements, but do you recommend inositol for women with PCOS typically?

Lucky Sekhon:
So I don't typically recommend it, but it's not to say that it might not be helpful. It's just not something that has been shown to be highly effective in the data. And there are so many different studies on this. I would say obviously talk to your doctor, if you are using it as part of an overall regimen to just try to help your body utilize sugars effectively, then that can be done under the direction and guidance of a doctor. Most people who have problems with insulin sensitivity and their glucose levels will be put on a drug called metformin, and that tends to sensitize their body cells to the effects of insulin, and it works really well. It can also help with weight loss in patients with PCOS who also are overweight, and that can also in turn help them to start ovulating more regularly. So we have a lot of really good data and metformin is very well studied for this purpose. Inositol is another compound that we know is found in our everyday diet. You can find it in fruits like cantaloupe and grapefruit, you can find it in things like lima beans, brown rice, whole wheat, and nuts. So it's not something that is synthetic, and the only way to consume it is by taking a pill. You can definitely get it from having a healthy diet, but basically, it may help to further sensitize your body to the effects of insulin. There are different studies that suggest there are two different types of inositol supplements and that it's important what ratio you're taking. So there's some studies that have shown that in healthy women, most of their body tissue has a ratio of Myo Inositol to de Chiro Inositol of about 40 to 1, and that women with PCOS might have a higher ratio of this and that this is a target that could be corrected. But all in all, I will say I think the overall effects aren't going to be harmful and perhaps it could be helpful, but I don't feel compelled to recommend it to all of my patients because I know of an alternative that is actually proven to be helpful. And this is not something that's really been supported in well-designed studies that have really shown a market benefit. And if you look at recommendations from societies like the American Society of Reproductive Medicine, when they've reviewed the different types of interventions and treatments that have been proposed over the years for women with PCOS, Inositol kind of falls into that category of very weak evidence, limited-to-no-evidence to really support its use to say that it could be helpful.

Kristyn Hodgdon:
Gotcha, that makes sense. What about other supplements? I know obviously prenatal vitamins for anyone who's trying to conceive, but are there any specific brands that you recommend or are there any other supplements you typically recommend right off the bat?

Lucky Sekhon:
Yeah, I think any prenatal vitamin that you're taking should contain folic acid because the purpose of taking folic acid is to prevent the incidence of neural tube defects, problems like spina bifida. And for that reason, we recommend women in preconception ideally be taking folic acid for three months prior to getting pregnant. Now, don't panic if you got pregnant or you're in the midst of trying and you've only been on it for less than three months, for a month, or you're just starting it because most of the American diet is fortified with folic acid to really prevent this becoming a major public health issue. So most of us have good amounts, but just to be safe, we always say 400 micrograms of folic acid is what's important. And this is a controversial issue, believe it or not, something as simple as prenatal vitamins, which we've been recommending for decades, is now the center of a controversy, because there is a lot of misinformation and disagreement out there, especially on social media, about whether some women would benefit more from taking alternate forms of folate, like five methyl folate. But really, it's a message that should be heard loud and clear that the purpose to be taking folic acid is not to improve your fertility, is not to really impact anything other than ensuring that you have, you have a lower chance of having a child with a spinal problem like spina bifida, a neural tube defect. And it's the only form of supplementation that's been proven to effectively reduce the incidence of that problem. And so I think a lot of people are getting distracted because they're getting tested for something called MTHFR, which is a gene that you can have variants in that gene in a large, very significant proportion of the population, like 30 to 40% of people will have a variant in that gene, so if you test for it, oftentimes it's going to say you have a quote-unquote mutation in the gene. And so there's this whole industry that now, that's come out from this fact because people are saying, well, it's better to have a personalized prenatal vitamin for you and you don't know how to break down folic acid because you carry this mutation, you need fully. And none of that has ever been shown in the literature, it's a very old, antiquated idea in the field of reproductive medicine that taking a different form of folic acid might help to prevent miscarriages or improve fertility. We know that that's not true anymore, and that's why all of the major women's health organizations, including ACOG, ASRM, across the board they all recommend folic acid. And you can actually, I think that's a good place to point people to, looking at the American College of OBGYN website, they have patient education material, and if you look under nutrition, they very clearly list out what the nutritional recommendations are, pre-conception, and while you're pregnant. So I think that's always a good thing to look at when you're choosing a prenatal vitamin to use. And sometimes some of those things that they're recommending might not be all-encompassed by the vitamin that you're taking or that you want to take. So you can always add that in by taking a separate supplement. So I definitely would refer to their recommended list.

Kristyn Hodgdon:
Awesome. That's great advice.

Lucky Sekhon:
We're asking about other supplements too, right?

Kristyn Hodgdon:
Yeah, yeah. Are there any, like if someone's, if a patient is in for an initial consultation, is there anything in addition to a prenatal vitamin that you would recommend?

Lucky Sekhon:
Yeah. I mean, I think, you know, sometimes people will automatically assume that Western medicine doctors or those who are, tend to be very evidence-based are not going to be recommending things like supplements that maybe don't have the clearest data or studies to back them. But I always say if something is not going to be harmful and it could be helpful, then why not? So something that falls into that category that I think has shown some promising results in animal studies is coenzyme Q10, there, you know, this is an antioxidant, and it has been used as a supplement to improve heart health and other areas of well-being. So we know that this may help just slow down the aging process that affects our eggs and perhaps over time by taking supplements rather than thinking of it as a reversal effect, right? Where it's undoing quality, issues in quality that have cropped up over time, I like to look at it more as maybe by taking antioxidants and supplements, you're actually helping to slow the aging process, or perhaps this could lead to a slower rate of egg loss and quality issues over time. And like I said, this hasn't been well studied, in humans, there are some trials that have been done, but it's hard to really isolate out what the true effects are because there are so many other factors that go into egg quality and quantity and response to treatment. But they've done really well-designed studies in animals and the animal model, and I think that it's compelling enough to recommend it, and the dose that it's been studied at clinically is 600 milligrams per day, so I think that that's something that you could try. Another one that people will ask me a lot about and I'm not a huge believer in it at all, is DHEA. DHEA is a hormone that is found, coming from our adrenal glands. And we know that women who, as women age, older women, will have lower levels of this adrenal hormone. And so the thought process behind why people recommend women to take this for fertility purposes is that if you replace what's missing in these older women, that perhaps that can change the hormonal environment that's going to be more conducive to a better response to IVF treatment and maybe improved egg quality. But even just me explaining that right now, I mean, it doesn't really make logical sense how that would actually work. And I think that the studies that are done out there, they're mixed in terms of the quality, the number of patients that have been looked at and who's doing the study, right? And I think that it hasn't been shown by well-designed, large scale trials to be effective and there could be untoward side effects because it acts like a testosterone. So it's not uncommon to have greasy skin, breakouts, or for it to affect your liver enzymes. So I don't take it lightly and I don't recommend it, but I do have some patients that really are willing to try it. And I would say, talk to your doctor, the usual dose that is recommended is 75 milligrams per day.

Kristyn Hodgdon:
Okay. I didn't know all that about DHEA, it's interesting. So we received a ton of questions, as you can imagine, on exercise, caffeine, alcohol, so like, how much is too much of any of those things?

Lucky Sekhon:
So exercise is a hard one because so many people need it to maintain their sanity during this process, which can be stressful in and of itself, but there are some restrictions. So I think it's helpful if you break it into the different types of treatment. So if we're talking IUI, I don't really restrict my patients from exercising very much during an IUI, provided they don't have a crazy overresponse with tons of follicles. The concern about exercise when you're stimulating the ovaries is that if the ovaries get very enlarged and you're doing something high impact, like running or even spinning, if you're getting up and out of the saddle, SoulCycle style, you're putting yourself in a position where the, the ovary, which is very mobile in the pelvis, normally when it's small and at its pre-stimulation size because it's larger, if it twists around, it can actually get lodged into that position and it can be very hard for it to untwist easily and that can kink the blood supply to the ovary and leads to a surgical emergency called torsion. Surgical emergency meaning you would need surgery to untwist the ovary and salvage it, and if you wait too long to do that, the ovary may need to be removed. This is a very rare complication going through fertility treatment, and if it's going to happen, it's very unlikely to happen in the setting of an IUI because usually with IUIs you're doing an insemination of the sperm into the reproductive tract, either with one follicle or maybe two or three if that patient took Clomid or Letrozole. So it's usually not large enough to actually cause that type of an issue. And I don't really have concern that post-ovulation, it's better for you to avoid exercise for that egg to turn into an embryo and implant, there's no such data to support that idea, and I just think that it's needlessly disruptive to one's life and quality of life, if you're doing IUI cycles which take persistence and time to get to a positive outcome and restricting for at least half the month that patient's ability to exercise. I think, if anything, that might actually counteract what we're trying to achieve, which is a healthy outcome and a healthy patient. So I don't really restrict it for IUIs unless there's a special circumstance. For stimulation during IVF, I tell patients to avoid high-impact exercise, avoid sex, basically anything that could jostle the ovary on itself and put you in a position where it could twist and not untwist easily. And that restriction, a lot of doctors will say, right when you start the injectable medications, no exercise until you get your period after the retrieval, but it probably doesn't need to be that restrictive. But talk to your doctor. I usually tell my patients and obviously depends on how many eggs I think they're going to get and how big their ovaries might get, but I think you could probably exercise normally for the first 2 to 3 days because when you just start those injections, it's not like your ovary is going to blow up and grow overnight. It takes time for it to get bigger, so you could probably get in a few workouts right at the beginning. And then usually I say in the week leading up to the retrieval and for a week after the egg retrieval, at a minimum, no high-impact exercise, doesn't mean you can't move around, you could walk, you can still move your body. But even yoga, I would be careful because that's inversions and twisting of your core. And so I think that even that could be a little bit risky. So just be careful, usually a good rule of thumb is when you get your period because that's normally 1 to 2 weeks after the egg retrieval. And that's a sign that all your hormones are back to their baseline state, which means your ovaries are most likely shrunk to their pre-stimulation size and then for EPTs or transfers in general, there's really no data that shows a benefit to bed rest or avoiding exercise after a transfer. But I think that it's more so for your, it's more so one of those common-sense recommendations, quote-unquote, and more so for your mental sanity. If the transfer isn't successful or doesn't work, I don't want a patient looking back and saying, well, maybe I worked out too hard, or maybe it was this, or maybe it was that. So it's kind of just easier to take it easy. Again, that doesn't mean bedrest, but you don't want to take up CrossFit in that two-week wait. You don't want to do anything that's over the top strenuous. And you really shouldn't be taking up anything new or strenuous that your body wasn't initially used to doing because progesterone, which you're taking in the prep and during the two-week wait, can actually make your ligaments more relaxed. And so it is easier to get injured and you should be more careful about how you're stretching and, and the types of exercise that you're doing.

Kristyn Hodgdon:
Oh, wow, interesting! So low impact exercise is okay during the two-week wait.

Lucky Sekhon:
I think it's totally fine during the two-week wait. But I honestly go based off of the type of patient I'm speaking with. And I know some patients really need exercise for their mental health, and others it's going to be more anxiety-provoking for them, if they're doing anything that they, even though I'm telling them it probably isn't going to impact the outcome, it's hard to kind of shake that belief once it's firmly in your mind.

Kristyn Hodgdon:
It is, so, and then what about alcohol and caffeine? A lot of people ask, is it okay to have one glass of wine a week during IVF?

Lucky Sekhon:
Yeah, I think it's fine. It depends on what you're doing. I would say no alcohol after the transfer because we want to pretend you're pregnant, we're hoping you are going to be pregnant. And so it's just best to have all those restrictions in effect after the transfer. During stimulation for IVF, for an IUI, I think it's fine to drink in moderation. It's hard to study, like I said, when whenever we're studying outcomes with fertility treatment, there are so many different factors that will influence outcome. But there tends to be a trend towards better pregnancy rates and better outcomes when you're reducing the number of drinks to less than four per week. And that's coming directly from recommendations from the American Society of Reproductive Medicine. They did a great review, which I recommend everyone read about how to optimize natural fertility. And this is something you can Google and have access to this amazing document that is basically a wonderful summary of all the studies that have been done out there, and it really points to how much evidence there is behind all of these types of recommendations. So they talk about some studies showing a trend towards better outcomes if you limit it to less than four a week. And then some studies where they looked at people that drink less than two drinks per day versus those that consistently have more than two a day. And that was also a significant threshold above and below which there were significantly different outcomes. So I think that's a good guide, and in terms of caffeine, I would say during the stimulation, if you're doing a freeze-all cycle, I don't really mind if patients have more than two cups of coffee, it doesn't really affect egg quality or the outcome of a stimulation cycle, there is no data that suggests that. But when you're doing an embryo transfer or an IUI cycle, it's ideal to keep it to less than 200 to 300 milligrams per day. Caffeine, which is the active ingredient in a regular coffee can vaso-constrict blood vessels. So we don't really know what the exact mechanism is, but there are some studies of extreme examples drinking more than five cups of coffee a day. There tends to be an association between that and lower pregnancy rates and miscarriage risk and things like that. But most people aren't having extreme amounts of coffee or caffeine, but it's just a loose guide. And I would say if you're saying less than 200 to 300 milligrams per day, that means having one cup of coffee a day would be totally fine.

Kristyn Hodgdon:
Is that before transfer too?

Lucky Sekhon:
Yeah, I think in the lead up it's always easier if you're gearing up for your behaviors and lifestyle that you're hoping to achieve post-transfer, I think it's hard to just quit cold turkey, going from 3 to 1, so I think it's just helpful to kind of work yourself towards that. But really the concern is mainly after transfer, I think. And before, I mean, theoretically, anything that decreases blood flow to the uterus is not something you want to be doing. So I don't think we have good data to really talk about the temporal relationship and when the restrictions should take place. But I think it's really more concerning around the time of implantation and during pregnancy.

Kristyn Hodgdon:
That makes sense. So lastly, I wanted to get your take on acupuncture because I think there's a lot of talk about how it can help fertility. For some people, it's like a great stress reliever during the process, for some, it's like an extra appointment that, that can kind of add to the overall to-do list. So I'm somewhere in between those two, I think. So what do you typically recommend that your patients do acupuncture?

Lucky Sekhon:
I always bring it up and I think that if they're open to it could be a good thing to try. I think it can sometimes help with side effects of treatment and make it more tolerable. I think it does help with stress relief. For those oatients who are really squeamish and don't enjoy the process, maybe it heightens their anxiety to be lying there with a bunch of needles in them. I always say, you know, try it out. If it helps you, if you find it enjoyable, and it's something you want to continue, go for it. If you don't enjoy it, I don't think it's a big deal to forgo it. I think it's not going to make or break your cycle. When you look at the studies that have been done, it's not like something that we feel is essential and without it you're not going to be successful obviously, the studies have mixed results and some show a trend towards better outcomes, others show no difference, but there's certainly no harm. So why not try it?

Kristyn Hodgdon:
Absolutely. Well, thank you, Dr. Sekhon, this was so helpful and we might have to do a follow-up episode on more of these tips, because I think we had, we got just so many questions. So always appreciate your advice and chat next time.

Lucky Sekhon:
Thanks so much for having me. And I agree with you, I feel like we should have a part two, because there were just so many good questions about it.

Kristyn Hodgdon:
Absolutely. Well, thank you. And we'll chat on the next episode.

Lucky Sekhon:
All right. See you soon.

Kristyn Hodgdon:
Thank you for tuning in to this episode of Dear Infertility. We hope it helps you feel more empowered to be your own advocate on your fertility journey. Whatever you're currently struggling with, Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click subscribe. To find this episode, show notes, resources, and more, head to Rescripted.com and be sure to join our free fertility support community while you're there.

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