Hutchison’s Huddle: Optimizing Natural Fertility During Quarantine

This time is a great opportunity for patients to reevaluate their lifestyle and take extra measures to optimize their natural fertility. So, what can you do? In a Facebook Live event, Dr. Scot Hutchison answered patient questions and shared easy things patients and their partners can do to increase their fertility.

Watch the full video below or on Facebook.

Hello. Hi, this is Dr. Scot Hutchison in Tucson, Arizona doing another Hutchison’s huddle again with the help of my coworker, Kareena Bacame. And today’s topic is maximizing fertility while under quarantine. So, anyhow, we’ll get kind of started with that! Some of this ground we’ve kind of covered before and some of it we haven’t. So anyway, if you’re lucky enough to be in Tucson right now, our weather is absolutely gorgeous. Our hotel occupancy, like a lot of other places is really super low. I know if you’re from around the region, you could drive here. A lot of our really good hotels are super cheap right now and they’re spreading people out and sanitizing things really well. So you might even take a little vacation here in Tucson!

But anyway, there are a number of questions, we’ve got eight questions for this Huddle that patients sent in. And one of them said, What is the best way to track my cycles? And why is it important? Well, a couple things on that. I think that the main thing to remember about menstruation is that we don’t just care if you get pregnant or not. We don’t really care [inaudible] are you having a bleed. It’s usually a sign that you’re ovulating regularly. But there’s still 3 or 4% of the population who will have very nice, normal, regular cycles, and they’re not ovulating all the time. So it is a relatively good thing to know that your cycles are regular, but there’s other features that will also kind of be good bellwethers of whether or not you’re ovulating. So, normal menstrual flow is about 25-28cc total. So really about an ounce, most of it about 60 some percent of that is actually cellular stuff and endometrium and very little of it is actually blood. And so when you don’t have lots and lots of whole blood, you don’t get clots. So if people are clotting, it’s a sign that they’re really passing–they’re bleeding too much. So, you know, normal menstrual flow is kind of darkish colored, and may have little fragments of cellular debris in it. And so if you’re having–and the normal duration is about somewhere on the short side from a couple of days–three to even up to about seven days. Beyond seven days we start to worry. Certainly if people are having spotting that precedes bleeding, we worry that the uterine lining is breaking down too early to allow for good implantation and that can be from a relative deficiency of progesterone. Or, you know, so they may not be making enough for the or the effect on the uterine lining may not be strong enough. But if you have these lighter bleeds that are three to five days, consider yourself really lucky. Also, around mid-cycle, most people will start to see watery cervical mucus, the stuff that kind of looks like egg whites. And what’s happened there is the cervical mucus has kind of changed from sort of a net array to where the mucopolysaccharides are kind of arranged so that they’re actually a block to keep bacteria and things out of the uterus into where they sort of will form these little tubules that can allow the sperm to pass through. But that tubule formation means that the cervical mucus will be very stretchy. So if you see that around mid-cycle that’s a really good sign. Other people will notice that their cervix will change consistency. It may get softer or may get a little more firm in another part of the cycle. And actually how far down in the pelvis the cervix is riding can also change. So some people are really comfortable with being able to palpate their cervix and feel it and see if it has any changes. Also, around ovulation, there’s sometimes some mid-cycle pain. And there’s an old German word called mittelschmerz which just means mid pain and, and lots of times that’s perceived on one side or the other. And that’s actually a pretty good sign of ovulation as well. The basal body temperature will then also shift up about a whole degree Fahrenheit because the extra progesterone that you produce will actually ramp up your basal metabolic rate. And for some people, the basal body temperature thermometers will actually work. For a lot of people, they won’t, especially if you are using you’re called a lot at night. You know, my wife was on call a lot and was being woken up during the middle of the night all the time. And so it was really difficult for her to get a good BBT chart. 

So the next question is would you recommend using angulation predictor kids or BBT charts? And I think that if you want to do those things, certainly, you’re welcome to. The population predictor kits are, I think they’re relatively ineffective. If you use them and you actually do get a good positive, like let’s say you have 28 day cycles, which is sort of the prototypical interval and then you’ve got your positive test on about cycle day 13 to 15, that’s plenty good. Then you know you usually are going to ovulate around there. And that means you really should start having intercourse, you should back that up to that cycle day eight or nine. And start having intercourse every day and go through that whole time period. And we’ll circle back and talk about frequency of intercourse and stuff in a little bit. But if you want to check kits, that’s fine–or BBT charting–but the worst thing is to try to use them to time intercourse. So all the time we see this where people are busy. You know, most of our couples are both working, a lot of them up until this point have been traveling. And it’s very difficult to have appropriately timed intercourse or you know, even every other day sometimes. So a lot of these couples are under the impression that you can use this ovulation predictor kit and it will tell you when you’re going to ovulate and that’s when you have sex. And that’s a little too late. I remember there was a study looking at failure of contraception. So like what was the chance of pregnancy for like a woman in her early 20s? If she called you up and said, Oh man, I had unprotected sex for three days in a row before ovulation versus Oh, I just had that unprotected sex of the day I probably ovulated and the difference was pretty stark. The people who had more unprotected intercourse over the time period before the pregnancy, about 20% of them got pregnant. Whereas only about 7% of the people who only had intercourse on the day that they ovulated. So it really is a big–cutting your chance of pregnancy down a lot if you’re just kind of trying to use those kits to time intercourse. So don’t do that. But if you want to do temperature charting, hey, there’s nothing else to do right now, so have at it! You do have to have what’s called the basal thermometer and that’s a thermometer that doesn’t have as many degrees on it, but it has the mid-degrees that we’re looking for from around 95 to 98 expanded so that you can tell you can read the increments and the differences a little bit better. You can probably order those online, I would imagine. Probably a popular item right now, so you probably aren’t going to be seeing them resold on eBay.

And then I’ve got another question. Are there any updates to starting a new cycle? I’ve heard that other states and clinics… I looked at the ASRM recommendations a couple hours ago and now they have not changed. They, what they’re saying is that for that all non-emergent fertility treatment should be stopped. Now, that is very controversial because we don’t really know the arc of what’s going to happen here. And certainly ASRM is not saying out there to people don’t try to get pregnant on your own. I think that the worry is, and we addressed this I think last week or the week before is that, just doing fertility treatment, especially with things where there’s even a small amount of risk, like doing egg retrievals, where you might get into bleeding and you might need to transport somebody to a hospital. Well, now, instead of being just something that, yeah, wouldn’t be fun to have complications, but now you’re actually putting the patient at pretty high risk of actually getting sick from COVID. But also, you’re overtaxing the system where we really don’t know what’s going to happen here. I know that our cases in our county here in Tucson are starting to plateau. However, we had a shortage of personal protective equipment. And I have to believe that that’s why the governor didn’t try to get a lot of that stuff to the prison guards and the nursing home workers. And so I think we’re bracing for another big round of hospitalizations coming from those two areas. And, of course, in those populations, those workers, either the prison workers or the nursing home workers, they’re going to get infected and then they’re going to drag that home to their kids and their families and then it’s going to go back into the into the system into the schools, most likely in the fall. So I don’t know really where we’re at with all this, but, you know, having been a Nurse Aide in a nursing home while I was in medical school, I can tell you that without a mask like this and without appropriate hand washing precautions and stuff, it would be impossible to shave or feed or bathe or change someone without infecting them. And so, yeah, we just don’t really know if–I think that when we talk about emergent fertility stuff, that’s people like having to go through breast cancer chemo or something like that, where we’re trying to hurry up and get those cycles done. We also–it gets into this gray area where there are a fair amount of our patients who have diminished ovarian reserves, they don’t have a lot of eggs, and/or they’re bumping up to 40 or 42. And really, if we wait too much longer, their chances of having a biologic offspring are going to be a lot lower. Now, what we are kind of dancing with right now is we’re waiting on ASRM. In the meantime, there’s talk that if we could make the environment as COVID-free as humanly possible for everybody, we might be actually able to go ahead with IVF, maybe inseminations, but what we’re talking about, certainly for the IVF patients, is doing testing before they start the cycle testing halfway through. And then if that test is negative as well, then proceeding on with egg retrieval, with the understanding that, you know, if they get infected, we don’t know what it’s going to do to–well, certainly if they get a fever, that hurts egg quality and it can just ruin the cycle. So, we may be able to do some of that here in our practice. For test kits, they’re not cheap, it’s going to add about another $400 to the cost of the cycle. Throwing into that on top of it is we don’t really know how good these test kits are. So you know, we’re just a little bit flying blind with it. And I really wish CDC would have gone with the WHO testing rather than trying to chart its own path, but it is what it is. And now we’re left with what we got. But we may be able to do egg retrievals, we’re certainly not going to be doing embryo transfers until ASRM says it’s kosher to. And then on top of that, I think that it’s very, it’s important for the patients to know that we’re following some pretty good guidelines of just single embryo transfers, because believe me, you do not want to head into a twin–you don’t want to go into pregnancy with a twin, and then in another few months and then have to have a baby in a place where you can’t have a C-section or anesthesiologist because all the anesthesiologists are tied up managing ventilator patients. So yeah so we need to make the pregnancies on the other side of this as uncomplicated as they can be. So practices that are chasing high pregnancy rates by transferring multiple embryos I think that’s a real mistake unless the patient has a history of repetitive IVF failure. Also, if practices around or just saying oh, we’re gonna do it anyway, well, man, that is, I think, that’s pretty unethical, personally. 

But anyway. So when trying to get pregnant, when is the best day to have intercourse? Well, again, we don’t really know when the cervical mucus maximizes its stretchiness and its ability to allow the sperm through. So really, it’s better a day or two before your period stops is the best time to start having intercourse and daily is better than every other day. There was a January 2017 committee opinion in Fertility and Sterility, if you want to look that up, that I thought was very helpful. And other interesting things is–and it probably is helpful for a number of reasons to have that intercourse more frequently. First of all, you want your fresh eggs and sperm because older sperm have more DNA fragmentation and they’re going to give you worse embryos. So your chance of pregnancy may be lower and your chance of miscarriage may be higher. Secondly, we don’t really know when people ovulate or when the mucus gets better. Thirdly, there’s some transforming growth factors that are present in seminal plasma that actually make their way up into the uterine cavity somehow. And they get into the uterine cavity cells in the endometrium and a couple of really neat papers in both Nature and Science that showed that years ago, and so they really may be in that seminal plasma for a reason, so having more frequent intercourse is good. Also women who have more frequent intercourse–even if it was with condoms, it’s not a semen exposure–have decreased natural killer cell function. So they tend to be more immunotolerant, which is probably really what we’re shooting for tolerating implantation of an embryo that is half not your genetic material, but half your male partners. So, a bunch of reasons why that may be helpful. 

Now, one thing that committee opinion looked at was, is it important to stay down after intercourse? And the answer is no. It does not do any good. It only increases the chance of bladder infection, so there’s no need to stay down after intercourse whatsoever. Also, the position during ejaculation didn’t matter either–so, if the woman could be on top. Now, having been a fertility patient, I can tell you that it is trying to agave intercourse everyday can be a real chore. Sometimes it can feel like a real chore. All I can say is be nice to each other and try to help each other out. 

If someone was taking birth control and preparation and stimulation for IVF, should they continue on with the birth control? And I would say yes for right now. Because having been on birth control pills for a long, long period of time, potentially, while it can decrease uterine lining proliferation on the other side of that–and I’ve seen some people take a few months to come back to a good endometrium if they were on like continuous birth control pills for like, eight years or 10 years or something like that–but most of the time not. And on top of it, a lot of our patients have endometriosis, whether they know it or not. And there’s pretty good data out there that a couple of months of birth control instead of  one month ahead of IVF, at least for endometriosis patients, really improves their chances of getting pregnant. Plus, if you can rack up about three to five years of birth control pill use, either here or there or wherever, it decreases your risk of ovarian cancer by about 50 to 60%. So not a bad thing. 

What things can men do specifically to improve their fertility? So the main thing is take care of yourself. So the interesting thing I think, is that over the last hundred or so years, sperm counts have fallen five fold. That’s a huge number! And why, no one really knows. It probably is, in part due to pollution, lack of exercise, male obesity, which you know, if you have more adipose tissue in a man, then that man is going to make more estrogen. More estrogen production will pull down the ability of the testes to work and make good sperm. But other things are out there too, that are probably factors. I think a lot of us have noted–I was at a meeting this summer and we were talking about how men who drink a lot of energy drinks almost never had a normal semen analysis. And then when you get them off of those and just get them drinking coffee or tea, they come back quite nicely. So I’m a big fan of if guys want to drink caffeine up until noon, I don’t have a problem with it. So coffee or tea, but I would stay away from any of the energy drinks or sodas. For whatever they’re doing, there’s something in there that’s just bad for sperm and it may be just that it interferes with people’s sleep enough that then they don’t sleep as well and then they don’t cue their growth hormone production and their testosterone production as well. And so they’re just not getting good sperm production. But other stuff that I would do–I really believe that exercise  everyday to every other day is a good thing. You could do short high intensity workouts–you don’t have to be training for a marathon. I would definitely do some exercise of some kind. And then lots of sleep. The majority of people now in this quarantine–I think I’m sleeping more now, but before this, I would say well over 50% of men will say that they get six hours of sleep or less a night. And a lot of it is, they’re staying up playing games, they’re watching TV or doing whatever. And so they’re just not getting enough rest. And so, and then on top of it, a lot of our male partners have sleep apnea. So that has been a thing that, you know, I always try to remind myself to ask these guys because even normal weight men, a lot of the time they have pretty significant sleep apnea. And I’ve seen guys with really poor sperm production really turn around nicely with just getting on a CPAP machine. And let me reassure you the CPAP machines now usually are pretty comfortable and they’re very quiet and most people are going to tolerate them better and certainly for the men who are overweight.

[inaudiable]

So for both males and females, getting plenty of sleep is great. Also, on the male side of things, no saunas, no hot baths, no hot tubs. Because the testes need to live in about three degrees Fahrenheit cooler, so that they don’t get that DNA fragmentation and it’s classic to have–like I had a husband years ago who has a very stressful job and so his routine would be to get into the hot tub at 104 degrees, and then just stay there for about an hour. And then once he’d kind of decompress, then he would get out and rejoin his spouse and his sperm production was just in the basement and then within six weeks of stopping that they were pregnant. So it’s an important thing to remember. Hot showers are probably fine. But yeah, you just don’t want to immerse the testes. Not a big fan of road cycling either if people are trying to get pregnant unless they have a good semen analysis. I know that a lot of the Tour de France guys actually have perfectly normal semen parameters, and they get their wives pregnant and have kids and do just fine. But a lot of our patients who were really serious riders will either decrease their sperm production significantly or it’ll just drop off to near nothing.

So I encourage you to, if you’re going to go road cycle to at least follow those semen parameters every month or two to see what they’re doing. Because you really don’t want to long dig out with that. Again, that’s just a matter of holding the testes up to the trunk where they can’t drop away and be cooled. And then if you’re working hard on the bike, it’s just not really good for him. And also those bike shorts have pads in them that also retain a lot of heat. Icing the testes down after that would not help by the way. I always tell people don’t put the laptop on your lap. You know, unless it’s a really cool laptop, but if you’re working pretty hard, a lot of times it’ll heat up and that drive will be working, you’ll hear it and it’ll get more warm. Yeah, same thing with motorcycles too. I’m not a big fan of all of that. 

How long should things like vitamins, nutrition, no caffeine and no— For women, it probably is best to have no caffeine. The thought is that you want to hold it to 60 milligrams a day or under on the female side of things. And what is 60 milligrams? 60 milligrams is one cup of six ounces of regular brewed coffee, so not Starbucks or whatever where they put four tablespoons into a cup, but just like it’s two level tablespoons per six ounces of water. And you can have one of those. I’m a big fan of no processed stuff. So especially stuff that has corn syrup, so I would avoid any of the ones like CoffeeMate or things that have corn syrup and artificial flavors and things like that because those may be really bad for your gut bacteria and In turn really bad for the uterine cavity bacteria which promote implantation. 

I’m a big fan of everything being good for at least two months, but really probably more like three to six. So this is a golden opportunity during this quarantine to really, really maximize your potential on the other side of this. My one of my heroes is guy named David Meldrum, who is who was kind of the grandfather of West Coast fertility stuff and IVF and he’s retired now, but he devotes all of his time to really looking through papers. The guy reads just constantly. And together all of the evidence, he updates all the evidence every year for what lifestyle things make a difference. And, you know, he originally, a few years ago would say two months to do it to make everything be better. So decreasing your caffeine, exercising, eating really healthy food. And now he’s really three to six months, he really thinks it makes much more of a difference. 

Before I forget, I do want to go over the things I want both parties to do, which are take some vitamins. So male like a men’s multi would be great. For the women, a prenatal. I’d like both to take 2000 international units of Vitamin D3 a day, unless you’ve been tested and your normal on whatever you’re on right now. The vast majority–I stopped testing people routinely because a recommendation came out a few years ago, and I tested every new patient for a year and a half and no one passed. So no one got to that level of 30 or above. So even here in sunny Arizona, I think that the lack of people eating organ meat, which they used to do, is a big factor in vitamin D deficiency, but we’re pretty all vitamin D deficient unless you’re taking supplementation. That can make you much more insulin resistant for polycystic ovary syndrome patients, that can make their ovulation most likely harder to come by. And also for guys, again, you know,you make people insulin resistant, you make them gain weight. So, for that reason, I think that it’s probably good. There was also a randomized study from a few years ago where they looked at pregnant diabetic women, and the gestational diabetics or pregnant diabetics who got a big injection of it every week actually had easier blood sugars to manage. So vitamin D deficiency is something I think we need to be worried about. Also Coenzyme Q10. And I’m telling everybody to do this now. So both the males and the females, 100 to 125 milligrams, twice a day. It has to be an immediate chain triglyceride form or you will not absorb it very well unless you want to get your CoQ10 from sardines which have the best, the most of anything, or liver, and those are both really good sources of CoQ10. CoQ10 helps the cells make more energy. The sperm mitochondria, which are little power plants, don’t actually make it into the embryo, they get discarded, but you need those mitochondria to get the sperm to swim. And so taking the CoQ10 on the male side of things can help the sperm. So the brands that I recommend there’s one at Whole Foods called Jarrow that’s legit. There’s one from Costco that’s called Qunoll and then there’s one at an online merchant called Theralogix.com that is also legit. And by legit I mean they, they send their stuff out for independent verification because in the United States, as far as I know that you can sell all kinds of fraudulent stuff and no one even cares.The Cornell group had done a DNA study, looking at the DNA to figure out whether these herbal supplements even had the actual plant in them. And for example, only 3% of the Walmart herbal supplements even had the plant that was on the label. So, I mean, I think you just need to be–its buyer beware out there when it comes to supplements, so be really careful with that.

Oh, and the fermented vegetables hitting on this again, sounds bat crazy, but, you know, it’s probably the best way to get those good lactobacillus into your gut and then eventually into the uterine cavity. And that’s really important and if you want to [inaudible]. But those lactobacilli that ferment those vegetables, as they make acid as a byproduct of their metabolism, they make life difficult for other bacteria that are around them that are not going to help with implantation. And the interesting thing is, or one of the interesting things is that that group research group in Spain that came up with the DNA fingerprinting test, which is pending approval here, show that if you don’t have about two thirds of the three dozen or so species of bacteria in your uterine cavity, like lactobacillus, it was really difficult for those people to get pregnant. So, kimchi or active culture sauerkraut or active culture pickles. Costco carries an active culture sauerkraut called Wild Brine. My Safeway carries one active culture pickle called Bubbie’s. They’re kind of mushy sometimes but they’re okay. And then Sonoma Brinary, those pickles are awesome. And the places where we were getting them here, now they’re shut down, but you may be able to order those online. If you’re a pickle fancier. Kimchi though, I will tell you from personal experience because my spouse makes it, and you can make it better than–it’s way tastier if you make it yourself, test it to make it how you like it. It’s easy and really inexpensive.  You just need some mason jars and salt and water and a little bit of thyme and kimchi is good to go in about three days.

I think we have covered our list. So I appreciate you being with us for this session. If you have other questions, give us a call. If you are a patient who’s anxious to get started with some sort of fertility treatment, feel free to look at the ASRM website every day or two–where I pulled it up was in the side for professionals. It was pretty easy to find it was on the far left side and it was like an update for COVID-19 and then you can click on that and you can kind of take a look at it.

If you have other questions, feel free to call in. And I think in a couple of our future ones we’re going to have some different kinds of patients who are going to do the Huddle with me, which I think will be really interesting because they’re all different. Their journeys were all different. So it’s not just like this mono–Oh, I had blocked tubes, I had to do IVF kind of thing–but they’re all they’re all different and so it’ll be really interesting, different perspectives on the whole fertility journey. But anyway, thanks for tuning in and we’ll see you down the road!