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‘eggs, eggs, eggs.
eggs for breakfast,
eggs for dinner,
fried? poached? scrambled? chocolate?
how would I like my eggs??
fertilised.
(actually I'd just like to produce one from time to time)"
(an extract from a journal I started writing back in the dark ages)
I used to obsess over the word 'eggs' when I was struggling with infertility, so I know how emotive the word 'egg' can be to someo struggling to conceive. Today I have taken to my keyboard to express my frustration with how readily I accepted the idea that I had 'bad eggs'.
More than twenty years later, the tendency for women to shoulder responsibility for fertility issues is still alive and well. I have had conversations recently around the issue of egg quality in situations where I would now judge it to be premature to point the finger at the eggs without further investigation. Yet as a woman going through fertility issues we are still primed to take the blame, our inability to fall pregnant easily speaks to the very core of who we think we are.
MYTH: 'Over 35 Means Lower Egg Quality?
Aging is a factor that influences the chromosomal integrity of all of our cells, including our eggs. As we age, the integrity of the DNA in all of our cells is often lower as our bodies can accumulate toxins and environmental damage over the years. One of the reasons that it can take longer for a lady over 35 to conceive is that a larger proportion of our eggs may not be chromosomally perfect, and we may need to wait for one that is. However if you eat a diet rich in antioxidants, commit to reducing stress, have a healthy liver, a healthy microbiome and a system in which inflammation and blood sugar spikes are well controlled, it is very possible to create perfect eggs well into the 40's.
If someone has a past history of polycystic ovaries, it has even been shown that the older ovary can produce eggs with a chromosomal integrity of a much younger woman.
As long as you are ovulating, even if some eggs may be less than perfect, some eggs may be absolutely wonderful - and it only takes one.
QUESTION: Do You Really Have Diminished Ovarian Reserve?
'Diminished Ovarian Reserve' (DOH) is another term thrown about too readily - but I would urge caution with this diagnosis. DOH cannot be determined by measuring Anti-Mullerian Hormone alone, and low Anti-Mullerian Hormone (AMH) level is not the same thing as DOH. To determine DOH, you need to have a combination of low AMH, low antral follicle count and high Follicle Stimulating Hormone (FSH). If you have low AMH and low FSH, I would be cautious about accepting a diagnosis of DOH - your ovaries are simply producing a smaller number of follicles each month; low AMH and low FSH suggests that the ovaries are not straining to do this, and a lower number of follicles each month is not an indicator of egg quality.
Egg Quality Can Be Improved
Egg quality is not set in stone., This is one of the reasons that the 3 month preconception window for IVF and other assisted fertility routes is so important - it really is possible to improve your egg quality by improving the environment in which the eggs grow and mature. The minimum time to make a significant impact on egg quality is around 3 months, but it can take up to a year for eggs to slowly come out of deep storage so improving egg quality is a long game.
Acupuncture is an incredible therapy as it can improve your stress hormone balance, your menstrual hormones, your digestive health, sleep quality and help your body to regain control of any underlying inflammation.
MYTH: "Men's Sperm Don't Age . . . "
Age also has an impact on the chromosomal integrity of sperm. In some instances, a man can produce a perfectly healthy looking sperm test, but the sperm could still have underlying issues with high sperm DNA fragmentation. There are particular stages of early embryo development and stages of early pregnancy when the male factor DNA is thought to exert a particularly strong influence on proceedings.
MYTH: 'His Sperm Are Great, His Sperm Test Results Show That'
40% of infertile men would produce a sperm test within normal parameters. That means that just because the sperm test looks OK, it doesn't necessarily mean that the male contribution is not contributing to the problem. Research has linked increased levels of sperm DNA fragmentation with difficulty in conceiving both naturally and within the laboratory (Cho C & Agarwal A, 2017). Sperm DNA fragmentation has an impact on the chance of spontaneous conception, the chances start to decrease when sperm DNA fragmentation index values reach 20%, and beyond 40% the chances of spontaneous conception fall to nearly zero (Cissen M, 2016).
When Is It Worth Asking About Sperm DNA Fragmentation?
Higher than expected Day 3 to Day 5 embryo loss While sperm DNA fragmentation doesn't appear to impair initial embryo formation, it does have a strong influence on embryo development between day 3 and day 5. If you have had a successful egg collection, a good percentage of embryos reach day 3, but high or total losses between day 3 and day 5, it may be time to check whether there are any underlying issues with sperm DNA fragmentation (Alvarez Sedó C et al, 2017)
Recurrent Implantation Failure DNA information from the sperm has a strong influence on the development of the placenta. It therefore makes sense that if there may be an issue with implantation that could indicate it was time to dig a little deeper into sperm health. There are other factors in the woman that can impact this stage of the process, issues with the health of the lining of the endometrium, vitamin D deficiency, issues with a dysregulated immune system, underlying clotting disorders or erratic inflammation issues.
Recurrent Early Miscarriage If you have had recurrent early pregnancy loss, one of the possible contributing factor could be male DNA fragmentation (Esquerré-Lamare, C. 2018). DNA fragmentation issues have been shown to have an impact on early spontaneous pregnancy loss (Zheng WW et al, 2018; Cho C & Agarwal A, 2017). This is by no means the only cause of early pregnancy loss, other factors can also contribute to this, factors such as poor thyroid health, vitamin D deficiency, MTHFR issues, reproductive immunology issues.
Varicocele Research suggests that approximately 15% of normally fertile men, and 40% of subfertile men have either clinical or sub clinical varicocele (an abnormal dilation of testicular veins caused by missing or malfunctioning valves with the veins). There appears to be a correlation between the presence of varicocele and an increased risk of higher levels of sperm DNA fragmentation (Dieamant, F, 2017).
Other factors that increase the possibility of DNA Fragmentation issues There are certain diet and lifestyle choices that increase the possibility of sperm fragmentation issues. Smoking is very toxic for sperm development, as is binge drinking and a poor diet - but did you know that regular long haul flights have also been assocaiated with higher rates of DNA fragmentation. Environmental toxins also play a part - does your other half work with toxic chemicals on a regular basis, toxic lab chemicals, cleaning chemicals, dental, veterinary or medical chemicals? If your other half works in any of these toxic environments, or frequently takes long haul flights, it is worth checking his sperm for DNA fragmentation.
Some studies suggest that ICSI negates the impact of sperm DNA fragmentation and improves the chances of a live birth (Osman A et al, 2015). The reasoning for this is that the sperm spend less time in contact with the lab culture, which can be particularly stressful for less robust sperm (Cho C & Agarwal A, 2017). Confusingly, other studies suggest that ICSI doesn't make a difference to live birth rates - the science is still developing, but it is definitely worth having an open mind about this.
It is worth noting that the relationship between sperm health and infertility is not a certain science, there are studies that have concluded that sperm issues have no relationship to either recurrent implantation failure or recurrent miscarriage (Coughlan C et al, 2015). However deeper, more detailed analysis of sperm health is an emerging science and progress is still being made towards identifying which aspects of male sperm may be playing a part in embryo failure or early pregnancy loss (Mohanty G et al, 2020). A healthy embryo and healthy pregnancy depends on three key factors, the egg, the sperm and the uterine envionment - just don't assume egg quality is the controlling factor.
What if it isn't the Egg OR the Sperm?
The other question that is rarely asked is about if you have had issues with disintegrating eggs, embryo development, implantation failure or early losses is whether the processes used in IVF could have been part of the problem. If eggs are harvested in an immature, or over mature state, they are more likely to disintegrate. If a significant number of eggs disintegrate, it may be something to do with the eggs, or it could be something to do with the process involved. Different clinics can use different procedures, different cultures, different stimulation regimes. It is definitely worth having that conversation and seeking a second opinion if you are not totally satisfied with the response. Think carefully about re-running the same protocol with the same lab and expect to get a different result (even if you do really like your consultant!).
Keep An Open Mind
This is not an attempt to worry anyone unnecessarily about sperm DNA issues, or create concern about any particular IVF process, but my frustration is that in many cases sperm health just doesn't seem to factor into the debate and lab techniques are rarely questioned at all. Too often, neither of these areas are properly explored and the problem is too readily labelled as an issue with the egg which can mean another issue is not uncovered.
Making a baby may seem like a simple thing to do, but when it doesn't work as expected we need to have a really open mind about why. For too long it has been up to the woman to carry the bulk of the responsibility - too often women feel that they are somehow at fault, even in a situation when the male input has not been thoroughly investigated.
In the pursuit of fertility, leave no stone unturned, and don’t be too quick to write off those eggs.
Alvarez Sedó C, Bilinski M, Lorenzi D, et al. Effect of sperm DNA fragmentation on embryo development: clinical and biological aspects. JBRA Assist Reprod. 2017;21(4):343‐350. Published 2017 Dec 1. doi:10.5935/1518-0557.20170061
Esquerré-Lamare, C., Walschaerts, M., Chansel Debordeaux, L.et al.Sperm aneuploidy and DNA fragmentation in unexplained recurrent pregnancy loss: a multicenter case-control study.Basic Clin. Androl.28,4 (2018). https://doi.org/10.1186/s12610-018-0070-6
Cho CL, Agarwal A. Role of sperm DNA fragmentation in male factor infertility: A systematic review. Arab J Urol. 2017;16(1):21‐34. Published 2017 Dec 6. doi:10.1016/j.aju.2017.11.002
Cissen M, Wely MV, Scholten I, et al. Measuring Sperm DNA Fragmentation and Clinical Outcomes of Medically Assisted Reproduction: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(11):e0165125. Published 2016 Nov 10. doi:10.1371/journal.pone.0165125
Colaco S, Sakkas D. Paternal factors contributing to embryo quality. J Assist Reprod Genet. 2018;35(11):1953‐1968. doi:10.1007/s10815-018-1304-4
Coughlan C, Clarke H, Cutting R, et al. Sperm DNA fragmentation, recurrent implantation failure and recurrent miscarriage. Asian J Androl. 2015;17(4):681‐685. doi:10.4103/1008-682X.144946
Dieamant F, Petersen CG, Mauri AL, et al. Semen parameters in men with varicocele: DNA fragmentation, chromatin packaging, mitochondrial membrane potential, and apoptosis.JBRA Assist Reprod. 2017;21(4):295‐301. Published 2017 Dec 1. doi:10.5935/1518-0557.20170053
Mohanty G, Jena SR, Nayak J, Kar S, Samanta L. Proteomic Signatures in Spermatozoa Reveal the Role of Paternal Factors in Recurrent Pregnancy Loss. World J Mens Health. 2020;38(1):103‐114. doi:10.5534/wjmh.190034
Osman A, Alsomait H, Seshadri S, El-Toukhy T, Khalaf Y. The effect of sperm DNA fragmentation on live birth rate after IVF or ICSI: a systematic review and meta-analysis. Reprod Biomed Online. 2015;30(2):120‐127. doi:10.1016/j.rbmo.2014.10.018
Zheng WW, Song G, Wang QL, et al. Sperm DNA damage has a negative effect on early embryonic development following in vitro fertilization. Asian J Androl. 2018;20(1):75‐79. doi:10.4103/aja.aja_19_17