IVF

Surviving Inborn Errors of Metabolism with Diet: Multiple Acyl CoA Dehydrogenase Deficiency

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For DES Daughters, Conception and Pregnancy Are Difficult

My first pregnancy, now 30 years back, was difficult. I am a DES daughter and after years of trying to conceive naturally, we tried in-vitro fertilization (IVF), which was pretty new at the time. The first IVF attempt led to a miscarriage. The second IVF attempt was successful and I gave birth to triplets. The pregnancy was difficult. I was on bed rest throughout the pregnancy and in hospital from week 26 through 30 when the babies were born prematurely. Although they were preemies and had to stay in the NICU for five weeks before coming home, they had few problems once they were home. They were all good nursers after they developed the sucking reflex at about thirty two weeks of age – two weeks after delivery. I nursed all three of them for the first six months and when they went onto solids they were great eaters.

A Miracle Baby but Something Was Wrong

Fast forward eight years, I became pregnant naturally. Something I NEVER in the world expected. This baby was such a miracle. To my surprise, the pregnancy was normal. I delivered what appeared to be a healthy baby boy via c-section. Early on, however, it became obvious that something was wrong.

My son, Austen had no interest in breast feeding and although the nurses said it was not an uncommon thing for a baby not to eat for the first few days. I remember being very concerned about his crying. Since, I had c-section, I stayed on at the hospital to get back on my feet. Austen wailed like only a hungry baby could. When he was taken from my room so I could get some rest, I could hear his cries in the little nursery down the hall, louder than all the others. The second day was like the first. Now I was worried. The staff seemed indifferent. He still wouldn’t eat and he was clearly unhappy.

That evening lying next to my bed in his little bassinet, his wailing forced me to get out of my bed to pick him up. The nurses were all busy and because it was a Friday there were a lot of visitors, noise, and rejoicing the birth of all the new babies.

Once I got Austen settled in my arms and I was comfortable, I tried once again to nurse him. Nothing. His crying turned to a sound that a little kitten would make. The light was low and I held him and tried to soothe my sweet little man. I don’t know if I fell asleep or we both became one again and my breaths were his and finally he was at peace. Suddenly my dream turned into a nightmare. I stroked his head and it was cold. I called his name and he didn’t move. I screamed at the top of my lungs for help and my baby didn’t flinch. I recall screaming forever until the room was full of people and lights and the hallway was silent. Austen was a strange blue color. They took him away and I knew he was dead and I still kept screaming.

My writer’s block is kicking in. This is where I always stop the scene running in my head. I can’t keep writing because I feel sick and clammy and the tears make it hard to see. I need to finish this story because maybe it could have a happy ending.

Austen was eventually revived. The nurses said he was without oxygen for twenty minutes. I think it was longer because no one came to my room to tell me anything and I was very hoarse from wailing. He was transported by ambulance to New England Medical Center, (also known at the time as The Floating Hospital for historical Boston reasons), where he was stabilized from the seizures and put under oxygen. Once again I had a baby hooked up to wires and tubes, but there was no excitement this time. He had suffered serious brain damage and on the third day of his stay in the NICU. I was asked to sit down with the doctors who had been following him.

The Diagnosis: Multiple Acyl CoA Dehydrogenase Deficiency (MADD)

Dr. A, the metabolic doctor who had been spending a lot of time with him, told me that he had a serious genetic defect. She called it Glutaric Acidemia type II or otherwise known as Multiple Acyl CoA Dehydrogenase Deficiency (MADD). She told me that it was a fatal disease and explained that he could not metabolize fats or proteins. She said that no other child born with this disease had lived for longer than six to eight months. She was patient with me when I cried. She said that she wanted to send a muscle fibroblast to a doctor in Iowa who would confirm the disease. She said that he could be brought home once he was taken off the tube feeding him through his nose and suck on his own. He should be given the best life possible in the next few months. It was “best not to resuscitate” should he stop breathing again, because of all the damage that he had already sustained. He was not to drink breast milk, too much fat and protein, so he needed a special formula.

The Power of a Mom Fighting for Her Child

Up to this point, I was in shock and depressed and felt very alone and defeated. But as I spent days with him watching as he came out of his long sleep and when he finally looked up at me and took formula from a bottle, something changed in my attitude. On the day we were told we could go home I became an angry, assertive woman, a person I had never been in my whole life. I demanded an apnea monitor to have at home in case he stopped breathing. I insisted that I would breastfeed him and I didn’t want the formula. After all if he was to be given the best life in six quick months, shouldn’t he be allowed to breastfeed?

He went home and I pumped and he learned how to nurse. I got in touch with the FOO (Fatty Oxidation Disorder) Family Support Group and the Organic Acidemia Support group and got a home computer. Austen grew. He gained weight and I became more determined not to let the diagnosis defeat us. We got the confirmation from the fibroblast that he had “2% of controls… as low as enzymes get.” It was a mitochondrial disease and there was no cure except to continue with the carnitine and B2 supplements that were supposed to sustain him.

I read Dr. Andrew Weil’s book, “Spontaneous Healing” and was particularly affected by the chapter that addressed malfunctions in DNA. He says that it can be reversed through diet especially by ingesting natural enzymes. I changed my diet radically after going to see a naturopathic doctor who put me on a meat-free, dairy-free diet which included mostly raw fruits and vegetables and whole grains, (both Austen and myself still follow this diet). I didn’t stop there, I sought out a Native American shaman, a Catholic priest who was a faith healer, a chiropractor… and a second opinion from another metabolic doctor.

A New Doctor and New Hope

From the first time I met Dr.K , I knew that we would be in good hands. He believed in treating Austen the individual, not the disease. His approach was much more hopeful and that is what I needed to keep going, especially since I was a single parent at this point. He marveled at his weight gain and cognitive abilities. He was delayed but he seemed to be progressing. The one concern was that his head circumference had come to a halt. Dr. K prescribed CoQ10 and in the next few months after starting it, his little head started growing again. Although he is still considered to be microcephalic.

When we started with solid foods each meal was traumatic, because he would throw it up from reflux. I had to clean up the mess and start all over again. I knew if he didn’t eat we would end up in the ER. He came to recognize that he had no choice in this food business, he had to keep it down!

I weaned him very gradually off of the barbiturates that he had to take for seizures and he has never had another one since. Ear1y on I recognized that Austen had a severe visual impairment and hooking up with Perkins School for the Blind got us involved with the infant toddler program, preschool, the ‘Lower School’ and last June he graduated to the ‘Secondary Program’. Social skills, PT, OT, sensory integration, mobility, music therapy, gym, arts, swimming and of course academics are only part of the total program. We had a skilled health care clinic on the grounds and were very lucky to live so close to the school and be part of this wonderful community.

Surviving Genetic Errors of Metabolism Through Diet

Today, at almost 22 years old, he is of normal height and weight, a handsome devil who is devoted to his older siblings, Nathan, Sasha and Taylor, and his loving stepfather, Joe. It has not been an easy road. We have had many bumps and starts. He stopped sleeping, (night and day) at about age three. Several trips to the ER after a vomiting bouts, severe sinusitis and airborne allergies, incontinence still to this day, but we persisted.

He has many food allergies which have been hard to decipher since he can’t really tell us ‘where it hurts’ and displays his discomfort through tantrums or negative behavior. Although once we got the nuts, legumes and lentils, etc., out of his diet, we have seen much less confusion and better spirits. The change in diet and recognizing that his behavior was on the autistic spectrum, (and getting the diagnosis of Asperger’s syndrome), has afforded me with much more knowledge of how to help my son deal with this world that he doesn’t really understand, and help others to understand his world. He is about to graduate from the Guild School for Human Behaviors where he has learned so much about how to express himself and keep his meltdowns to a minimum.

I feel strongly that the choices I have made for my son have been the right ones, but I could not have done it without the help of all the wonderful people I have met along the way, who now share a part of Austen’s world. Without them, I might not have made some of the connections that have made such a big difference in the quality of my son’s life. I cannot stress enough how important diet has been. The physicians in the NICU suggested that he would not live beyond 6 months and that we should not resuscitate should he stop breathing. I ignored them and with diet and persistence, he has lived and we have loved him for 22 years.

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Assisted Reproductive Technologies, Birth Defects and Epigenetics

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Assisted reproductive technologies (ART) have grown in popularity and success over the recent decade. According to the CDC, in 2011 there were 61,610 babies born via ART, representing 1% of the US newborn population, nearly doubling ART use in just one decade. ART can be a blessing for the nearly 6% of US couples struggling with fertility issues. In the 30 years since ART began, there have been over 3.5 million children conceived using ART, many of whom are now adults of reproductive age. One wonders, what long-term, transgenerational effects might exist from ART; will those conceived via an assisted reproductive technology, also require reproductive assistance? Are the rates of cancer, especially reproductive cancers and hormone dependent cancers known to be epigenetic in nature, increased? Each of these questions remains to be addressed fully, but here is what is known so far.

The Basics – What is ART?

Assisted reproductive technologies refer to the techniques used to bring sperm and egg together in order to achieve pregnancy. The methods of assisted reproductive technologies include: in vitro fertilization – embryo transfer (IVF-ET), gamete intrafallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and frozen embryo transfer (FET). By far the most common is IVF- ET with fully 99% of couples using this method of assisted reproductive technology. IVF begins with intense hormone treatment to stimulate maternal oocyte production. Those eggs are removed and fertilized with the donor or partner’s sperm.  In most cases, eggs and sperm are placed in a petri dish and allowed to mix freely. In some cases, additional manipulation is required and the sperm is injected into the egg. This is called intracytoplasmic sperm injection or ICSI. IVF plus ICSI appears to account for a large subset of the birth defects associated with IVF.

Early Indicators of Birth Defects with Assisted Reproductive Technologies

A 2007 study of California couples found that children conceived using ART, especially those conceived with ICSI, had a 35% increase in risk for birth defects compared to those conceived naturally. Most common among them were eye abnormalities, heart defects and malformations of the genitourinary tract. Other studies have linked ART to an increased risk major structural malformations of the heart, cleft lip and palate, esophogeal atresia (the esophogus dead-ends in a pouch rather than into the stomach where it should be) and anorecto atresia – (a malformed anal opening).

Among the few studies addressing birth defects and developmental anomalies post infancy, a Chinese study found an increase in observed birth defects in ART males as time progressed, compared to females and compared to those observed at birth. In fact the rate of observed birth defects doubled over the course of the 3 years. Similarly, a study looking at one year olds conceived via ART found a doubling of the rate of multiple major birth defects including chromosomal and musculoskeletal defects.

Long Term Consequences of ART

Studies looking at longer-term difficulties, whether health or developmentally related are few and have had mixed results, always ending with the caveat that it is unclear whether the assisted reproductive technology or the original infertility itself was to blame for the defect. There does seem to be a near doubling of the risk of some rare cancers children conceived via ART, but again the data sets are small and the risk of theses cancers in general is low.

A more recent study compared cardiac function between children and young adults conceived naturally versus those conceived with ART. What they found was striking. The apparently healthy individuals with no visible malformations who were conceived by ART had significant decreases in cardiac and pulmonary functioning by a number of parameters. There was marked vascular dysfunction of the systemic and pulmonary circulation, to which the authors of the study suggest may lead to premature cardiac morbidity at a rate similar to rates seen in type 1 diabetes.

ART and Imprinting Errors

A number of ART epigenetic studies published have assessed the risk or rate of what are called imprinting errors. Imprinting errors occur when genes are incorrectly silenced. A individual normally gets one active imprinted gene, either from mom or dad. When errors occur, they may get two active or two inactive copies. Children born from assisted reproductive technologies have an increased risk of imprinting errors compared to the rest of the population. The common conditions that arise include:

As with the some of the other birth defects observed with ART, those using ICSI – the forcible injection of the sperm into the egg, seem to proffer higher risks and seem to affect males more than females (or perhaps, as is the case with most research, it is the male offspring that are studied more frequently). Of note, the combination of ICSI and environmental endocrine disrupting chemical exposures is linked to trends in demasculization and potential sterility.

Epigenetics and Assisted Reproductive Technologies

Thus far the notion of epigenetic changes in children conceived via assisted reproductive technologies has been limited to research on the aforementioned imprinting errors, also called epimutations. Research on the broader consequences ART, particularly in general health and reproductive health is lacking. The exposure to hyper hormonal states common in many assisted reproductive technologies has the possibility of disrupting critical hormone pathways across the lifespan of the offspring and may impact his/her reproductive health in subtle, and not so subtle, ways. Some effects may not appear until much later in life and certainly there is the possibility of transgenerational changes as those observed with DES, dexamethasone and other hormone exposures during embryonic and fetal development. Additionally, as evidenced by the study on cardiac-pulmonary function, it is conceivable that many of the epigenetic effects will be functional in nature versus more obvious structural malformations. However, because ART bypasses the natural buffers in human reproduction that might have otherwise selected out for specific traits, it is difficult to disentangle native ‘deficits’ – those of the mom and dad – versus those directly linked to the procedure itself. Only time will tell what the effects of ART are on the health and functioning of subsequent generations.

BPA Exposure Linked to Egg Maturation Errors and Infertility

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Bisphenol A (BPA), the polycarbonate, endocrine disrupting plastic is pervasive in the environment.  A recent National Health and Nutrition Examination Survey detected BPA in the urine of 95% of the participants. Along with other toxins, BPA has been found in the placenta and follicular fluid of pregnant women.  Given its estrogenic actions and its ability to disrupt the normal equilibrium of maternal and placental hormones, scientists have begun to investigate what role BPA might have on infertility, pregnancy complications and fetal development. What they are finding is not good.

In the most recent set of experiments, researchers from Brigham and Women’s in Boston, found that in vitro BPA exposure to human eggs – oocytes, prevented the egg’s ability to mature and disrupted chromosome alignment and organization at the lowest dose possible; a dose lower than levels normally found in women’s ovaries.

The experiment used eggs discarded from patients undergoing IVF/ICSI cycles. The eggs were divided into two groups, those to be exposed to varying doses of BPA and a control group. Sibling pairs, eggs from the same mom, were placed into both the BPA and the control groups equally to reduce the possibility that any maturation errors in egg development might be linked other factors related to maternal infertility, such as age, weight or general health.

The eggs exposed to even the lowest doses of BPA failed to mature appropriately and higher doses were linked to an increased rate of error and maturation failure. Researchers note that this was preliminary study, but that their findings indicate BPA exposure might be linked into infertility at the most basic level – egg health and maturation.

From our perspective, this study suggests that couples contemplating pregnancy should eliminate BPA and other environmental toxicant exposure well before attempting to conceive. For couples having difficulties conceiving, it might be worth testing urinary BPA and other endocrine disruptors such as phthalates and reducing exposure to these chemicals prior to undergoing costly fertility treatments. Here are the four most effective ways you can minimize your exposure to BPA:

  1. Drink filtered tap water. This helps avoid water that has leached BPA from plastic containers.
  2. Use stainless steel water bottles or certified “BPA-free” containers.
  3. Avoid all canned foods, which are often lined with BPA containing resins. Eat fresh, non-processed, organic foods and avoid storing in plastic bags.
  4. Avoid the use of plastic utensils and dishes.

BPA is likely not the only source of endocrine disruptors. All plastics under normal conditions release estrogenic compounds. It may be wise to avoid plastics in general. Additional research on removing BPA and other chemicals from your diet can be found here.

The Road to Baby: Fertility and Endometriosis Treatment

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Waning Fertility

I have always wanted to be a mother. Growing up around my grandmother’s day care, I relished taking on nurturing roles from a young age. I have always enjoyed spending time with children, reading to my younger cousins, and making up games for us play. I even earned my degree as an Early Childhood Educator, and have dreams of someday writing children’s books. My decision to work as a nanny while I finish my graduate degree has changed my outlook on my career goals, and I now hope to open my own preschool in the future. Caring for children has always come naturally to me, and has become my passion. At the age of 28, I am now four years past my peak fertility, according to several reproductive endocrinologists I have seen. Even though I am young, in the area of reproductive medicine, I have already lost the most fertile years of my life. This comes as no surprise to me. Knowing I have endometriosis, I expected that I would have trouble getting pregnant. I never expected how intense my road toward baby would be.

Endometriosis and Fertility

My husband and I were already together when I was first given my tentative diagnosis of endometriosis at the age of 22. In the same breath, my doctor assured me that she would get me pregnant, “even if we have to do in-vitro fertilization (IVF)!” I nearly fainted. Right then and there. I had barely graduated from college, and was still years away from starting a family! My fertility loomed over my relationship with my husband for nearly 5 years before it became a tangible part of our life together. My first laparoscopic surgeon informed us at my post-operative appointment that after trying birth control pills, progesterone, Lupron, and surgery to manage my then-stage III endometriosis, I was out of options and needed to get pregnant immediately.

My husband and I were given the choice to start trying for a baby, or go back on suppressive therapy, meant to eliminate estrogen and stall the growth of the disease. Pregnancy and breast feeding can offer a period of relief from endometriosis pain, since the body does not menstruate. For me, suppressive therapy options were Lupron or Mirena, both invasive and potentially dangerous treatments. I did not want to go back on easier methods, including progesterone pills, which my body could not tolerate. I had already tried progesterone for four years, and had suffered medical and emotional side effects. There was no easy choice.

I had wanted to start a family for years, but my husband and I were not in a place financially or otherwise to get pregnant, so we chose to go with Lupron while we got our ducks in a row, and told our families. Unlike my first experience with Lupron injections, this time, the Lupron did not help; I was still in excruciating pain during my period, and I even lost some hair and bone density. With our options at an end three months later, we started trying to conceive.

Although I was excited about becoming a mother, the following months were some of the most stressful of my life. With the looming return of my disease while being “untreated,” the immediacy of our need to conceive was overwhelming. When most couples decide to start a family, there might be a period of excitement, some adjustment, and taking the process slowly, while hoping that a positive pregnancy test (or Big Fat Positive to us online groupies) might happen easily. I jumped straight into charting my basal body temperature, cervical mucus, and peeing on sticks to see if my luteinizing hormone had triggered ovulation. I bought a stack of pregnancy books, and a few hard-to-come-by infertility books. So much for romance! I soon began using an app on my smart phone to track all the data for me, which sent me into an obsession with checking my chart every hour (for no reason whatsoever), in the hopes that today might be the day my precious egg would pop. But it never did.

Trying to Conceive: The Complications

Two months into my trying to conceive (TTC) journey, my obgyn suggested a reproductive endocrinologist. Most women get 6 months to a year before seeing a fertility specialist, but my doctor wanted me on the fast track. We were using a pregnancy as a treatment, a chunk of time without period pain, so we had no time to delay. One late evening visit later to a specialist at Brigham & Women’s, I was diagnosed with an anovulatory cycle (no ovulation), and given 5 days worth of the fertility drug Clomid to begin taking once my next period arrived. Five days after my 28th birthday, I started my first fertility treatment.

Unfortunately for me, the RE who prescribed these drugs did not monitor my hormone levels or the size of my follicles. I was told how to time intercourse, and to call the office when I got a positive pregnancy test or started my period. I ended up developing right side abdominal pain, something I was fairly accustomed to, and which the resident in my RE’s office found to be a nearly 5cm complex cyst. To my dismay, the RE could not fit me into her schedule for over a month. I was left to wait and see what happened. When my next period arrived (no BFP for me), so did the most intense pain and bleeding I had ever experienced. After nearly fainting from the blood loss, and doubling over in pain, a trip to the ER confirmed that the cyst had ruptured. The nurse at my RE’s office suggested taking a month off of fertility drugs to heal, then starting up again, but could not fit me in for an appointment for several more weeks.

I was shocked by how unimportant I seemed to this doctor. Why didn’t she feel like a ruptured endometrioma might warrant squeezing me into her schedule? Wasn’t my advanced disease serious enough? I guess she figured that was my obgyn’s job, but she had prescribed the fertility drugs that sent my hormone levels soaring, likely causing a flare in my endometriosis. Did she not feel she was somewhat responsible for my care? I felt abandoned. I never went back to that RE.

I decided to take that month, and do some research of my own. My obgyn suggested IVF when I saw her to follow up about the cyst. It was all happening too fast! I had always wanted to avoid IVF, which I found too invasive and highly taxing. Not to mention I was in my last semester of graduate school, and doing an internship. At this point, my husband and I had only been trying for four months. Most couples get three times that amount of time before considering daily injections, multiple embryos, and possibly life-threatening complications. Tears rolled down my face as I read books about other women’s experiences with IVF, and spoke to others like me on fertility forums about the process. I was not ready for this.

Excision Surgery

I began researching endometriosis and excision surgery, a technique few gynecological surgeons can perform adequately. It involves cutting the endometriosis out like a cancer to ensure that all of the disease is completely removed. After immersing myself in endometriosis literature and surgical sites, I considered several excision specialists from all over the US. Eventually, I found a plan that would work for me, and a doctor I felt I could trust.

I flew to St. Louis in June to have an excision surgery, despite obvious contention from my obgyn and the IVF specialist she recommended in her practice. They could not understand why I would fly halfway across the country when there were plenty of doctors here. My obgyn’s argument was that my first surgery had complications, and my recovery period was long. However, my gut told me that I had made the right choice. In the end, my surgeon found that my disease had progressed rapidly in the 11 months since my first surgery, far beyond anyone’s expectations. Besides the involvement of my bladder, bowel, ureters, rectum, appendix, and pelvic lining, the disease had ravaged my reproductive organs. Both of my ovaries had endometriomas, were being pulled behind my uterus, and attached to the back of my pelvis. My left fallopian tube was kinked shut. Adhesions, sticky bands of scar tissue, had distorted my anatomy to the point where nearly all of my pelvic organs were stuck together. My surgeon worked for six hours, even reconstructing my ovaries to avoid leaving raw tissue exposed and vulnerable to more damage. At my post-operative appointment, we discussed my options for fertility, and made a plan.

Road to Baby – Back on Track

Now, 10 months after starting on the Road to Baby, we are trying on our own naturally, without the help of fertility drugs. My first and only experience with pumping my body full of hormones was enough to turn me off of it completely! For me, the experience caused real damage to my body, and I am not eager to do it again. It feels like we are starting over, with a fresh canvas. We found a local fertility specialist who comes recommended by endometriosis patients like me who believe excision is the answer to this disease. He seems on board with our decision to wait a little longer before considering drastic measures. IVF may still be an option for us if we continue to struggle, or if there is any male factor infertility, something none of my previous doctors even bothered to test for. But for now, no one is pressuring us to jump in a race car and speed toward the finish line. We have time to take in the scenery and enjoy the ride together.

And that’s exactly how it should have been all along.

 

About the Author: Kelsey is an Early Childhood Educator and blogger from the Boston area. She chronicles her journey using sewing as a positive outlet while living with chronic pain and Stage IV Endometriosis. Diagnosed at 22, Kelsey has spent six years learning about her disease, and has recently become active in Endometriosis research and advocacy. She is a published poet who dreams of writing children’s books, and opening her own preschool that supports reading development. To read more about Kelsey’s daily dabblings in sewing, as well as recipes, preschool curriculum ideas, and information about endometriosis, visit her blog at www.silverrosewing.blogspot.com