In this episode, we dive into the science and strategies behind improvement egg quality with supplementation. Join Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Abby Eblen from Nashville Fertility Center, and Dr. Susan Hudson from Texas Fertility Center  as they review potential nutritional supplements and their roles in improving fertility. Dr. Mark Ratner, Chief Medical Officer of Theralogix, educates us on the well known effects of CoQ10 on egg quality, as well as shares insights on the impact of less recognized fertility supplements such as melatonin, iron, and others. Whether you’re preparing for pregnancy, undergoing fertility treatments, or simply looking to support your reproductive health, this episode offers practical advice, backed by research, to help you make informed choices. Tune in to learn which supplements could make a difference for you and how to incorporate them into your daily routine for better egg quality and a healthier reproductive system.

Episode Transcript:

Susan Hudson (00:01)

You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.

Carrie Bedient, MD (00:23)

Hello everyone and welcome to another episode of Fertility Docs Uncensored. I am joined by my two fantabulous co-hosts Dr. Susan Hudson from Texas Fertility Center and Dr. Abby Eblen from Nashville Fertility Center. And our guest today is Dr. Mark Ratner, who is the Chief Medical Officer of Theralogix. And so we are delighted to have Mark back again, because every time he’s on, just get, it’s not only continuing medical education for our patients, but it’s CME for us as well. So we are very appreciative.

Abby Eblen MD (00:37)

Hey everybody.

Carrie Bedient, MD (01:02)

Dr. Carrie Bedient from the Fertility Center of Las Vegas. So it’s so nice to see you guys all today.

Susan Hudson MD (01:07)

It’s good day when we have Mark. We get to learn so much!

Abby Eblen MD (01:10)

I know, it’s always exciting. We have so many questions saved up for him when he comes on.

Mark Ratner MD (01:10)

Wow. It’s great to be back with you guys. So this may be my third or fourth visit with you. You know, it’s great. I always enjoy it.

Abby Eblen MD (01:16)

Yeah, we love it. Keep it going.

Carrie Bedient, MD (01:18)

So Mark, the last time that we talked to you, you were in the process of moving from DC. And so now that you’re all settled, what are the hidden gems of Baltimore that you have?

Mark Ratner MD (01:32)

It’s so funny if I had a nickel for every time when I tell people, yeah, I moved to Baltimore, I get a lot of really what happened. Unfortunately, there was this HBO series, The Wire, which is already 20 years ago, but it has forever destroyed people’s impression of what Baltimore is like. Listen, it’s a city. It’s got its issues.

But it’s got a lot of charm. In fact, that’s the nickname, Charm City. So great food, great restaurants. It’s right on the water. So you get great seafood and crabs and everything else. And it’s reasonably safe for a big American city. And we’re enjoying it. So yeah.

Carrie Bedient, MD (02:18)

Have you been to the Charm City Bakery? I remember there used to be some TV like cooking.

Mark Ratner MD (02:25)

Right, right, right. There was that guy who, they did all these tremendous cakes, these really involved cakes. but I’ll have to take a look.

Susan Hudson MD (02:33)

I loved that show when it was on.

Mark Ratner MD (02:36)

Yeah, was Duff Goldman, right? Yep. That was the

Susan Hudson MD (02:38)

Yeah, that’s it, Duff.

Carrie Bedient, MD (02:38)

Yes. So Mark, before, because our annual meeting, ASRM is often held in Baltimore. So your homework before the next one is to tell us where all the best bakeries are in town so that when we come in for whenever the next meeting there is that we are fully supplied with where we should go.

Abby Eblen MD (02:51)

Yeah.

Mark Ratner MD (02:51)

Okay.

That sounds good. I think it may be a couple years off. I don’t know. Next year is what? San Antonio, right?

Carrie Bedient, MD (03:00)

Yeah, next year is San Antonio, so we’re going to go hang out with Susan.

Abby Eblen MD (03:04)

Susan’s town, Susan’s neck of the woods.

Carrie Bedient, MD (03:11)

Susan, do we have questions?

Susan Hudson MD (03:14)

Yes, we’ll do a question today. So our question for today is, Hi, I have been doing your podcast all week and it’s been super helpful. I’m currently undergoing IUI round three. I had an ectopic pregnancy 10 months ago. My doctor didn’t give me progesterone post insemination and I was wondering why that is.

Additionally, I’ve read about something called Mini-IVF, but not sure what it entails and if I should explore it if IUI fails or should I just go on to full IVF. Thank you for all you do in educating women and men on this. Well, thank you for listening.

Abby Eblen MD (03:49)

So progesterone, unless you really need it, there’s probably not a good reason to use it. It’s kind of like dumping water in the ocean. As Carrie says, that’s Carrieism. It doesn’t really hurt to get too much, but sometimes it can be confusing when to take it. Sometimes people take it incorrectly. Sometimes it can lengthen your menstrual cycle and you get excited because you think you’re pregnant.

It’s one of those things, unless you really need it, there’s probably not a great reason to use it. So, you your doctor probably believed that you were ovulating and making the correct amount of progesterone. And sort of the easy way to look at that is if your cycle is, 26 to 34 days, you probably don’t really need progesterone because you’re making plenty of your own progesterone.

Susan Hudson MD (04:27)

With the history of an ectopic pregnancy, actually kind of understand why your doctor does this, because if you have ovulated and you have an early ongoing pregnancy and it looks like it’s most likely going to be an intrauterine pregnancy, progesterone levels tend to be higher, whereas very, very, very low progesterone levels, like less than five, are often indicative of a possible ectopic pregnancy. So it could actually be a sign that you might have another ectopic pregnancy. And as we’ve talked about on the podcast, people who have had ectopic pregnancies are at risk for it again. And he or she might be looking for another biochemical marker to give reassurance of, do we think this is in the uterus before we can see it in the uterus? Or do we need to watch her super, super, super closely?

Carrie Bedient, MD (05:20)

With respect to the mini IVF versus full IVF question, in general, doing mini IVF tends not to be super beneficial for people because the goal of IVF and what makes it so successful is the ability to get as many eggs as possible. And in order to do that, you need the full set of drugs, typically. Mini IVF is oftentimes going just on either oral medications or very minimal doses of injectables, and you’re still having to incur a lot of the costs of both the lab work and the egg retrieval. And if you’re only ever gonna get one or two eggs, then Mini-IVF and Real-IVF are somewhat interchangeable. But if you are someone who has the potential for a lot of eggs and you’re only getting a couple, oftentimes that really doesn’t serve you very well in your goals. And so you end up having to do Mini-IVF more frequently in order to get the end result of good embryos in a live birth that you’re looking for. And so that’s certainly not true of everyone. There will be people who do mini IVF, who get just a couple of eggs and who get an embryo and a live birth out of that. But we’re playing the odds here and trying to figure out what is the best thing that we can do for you to get through this quickly, efficiently, and get to your goal. Because by the time people get to us, they’ve been through enough trauma, they don’t need to go through more. And so mini IVF, can extend out that process. And so there’s exceptions for everyone, but in general, for the most part, it tends not to serve a lot of people. We don’t know all the details about your case, but in general, that’s the way that a lot of us think about it.

Susan Hudson MD (06:59)

In general, if you’re going to go for the gold, go for it all the way.

Carrie Bedient, MD (07:03)

Yeah.

Abby Eblen MD (07:03)

Yeah, I say it’s like buying lottery tickets, the more lottery tickets you buy, the better chances you have of winning the lottery, the more eggs you get, the better chance you have of having a normal embryo at the end of it.

Carrie Bedient, MD (07:11)

Yeah, yeah. All right, so what we’re gonna talk about with Mark today is supplements to improve egg quality in general. We have talked about this a little bit in some of our prior episodes. We’ve covered a lot of CoQ10 and things like that. So let’s plan to go through CoQ10 a little bit and then move on to some of the other ones that we haven’t spent as much time on before and we can get our CME lecture.

Mark Ratner MD (07:41)

I’m going do my best. Okay. Good.

Carrie Bedient, MD (07:42)

What’s the short story on CoQ10 in terms of what it is and why we think about it in terms of egg quality and dosing?

Mark Ratner MD (07:51)

Okay, in order for an egg to be what we would call a good quality egg, the first criteria is that it has to have the correct number of chromosomes. So the cells in the rest of our body have 46 chromosomes. The egg and the sperm each have 23. The process by which the egg forms with half the number of chromosomes found elsewhere, takes a lot of energy. And there are several processes that go on in the egg to generate that energy so that it develops with the proper number of chromosomes, the 23. One of the most important metabolites in our cells is called coenzyme Q10. It actually is involved in producing energy inside what’s called the mitochondria. Anybody who remembers high school biology probably remembers this thing called the mitochondria, which is it’s a little organelle inside each of our cells where energy is produced. Sort of like the energy production center of the cell.

Susan Hudson MD (08:58)

The powerhouse.

Mark Ratner MD (08:59)

The powerhouse of the cell and it requires the presence of coenzyme Q10, CoQ10 to make energies. It requires other things as well and we’ll talk about one of those other things in a minute. But what happens is as we get older, the amount of coenzyme Q10 in our cells declines. And so if we can keep the amount of coenzyme Q10 at a good level, it’s going to increase the chances of the egg forming properly. And so that’s the underlying theory to support the use of CoQ10, coenzyme Q10 as a supplement.

Susan Hudson MD (09:37)

So we’ve always been told that you need to have CoQ10 in your system for about two to three months prior to it having its full effect. Does that have to do with the process of it was two to three months ago that my body selected which eggs we were going to be using now?

Mark Ratner MD (09:55)

Exactly.

Exactly. Yeah. I mean, it’s what we call and again, I don’t want to drag anybody back into high school biology, but it’s called the second meiosis. The second meiotic division is where the 46 chromosomes split into 23 and 23. 23 of them go off as what’s called the polar body and the other 23 form the egg or the oocyte.

And that happens in the last month or two prior to ovulation. So that’s really when you want to supplement the CoQ10.

Carrie Bedient, MD (10:25)

And how much of it do you need?

Mark Ratner MD (10:27)

The study is an interesting story in terms of looking at the published clinical trials with CoQ10. It’s been very, very difficult to do CoQ10 trials where you give some people placebo and some people CoQ10. Couples who are being treated for fertility issues, they don’t want to take the chance of getting placebo.

Especially if the intervention, CoQ10, is something they can buy over the counter. So getting couples to enroll in those studies has been very difficult. And in fact, it was just a, what we call a meta analysis published about six months ago, looking at the six controlled studies that have actually been done with Coenzyme Q10 in couples where the woman had what we would call diminished ovarian reserve.

All six studies were done in China. And I think it’s interesting. I think it’s because couples are being given IVF, it’s through maybe state programs or whatever it is, but it’s easier to enroll couples, I guess, there than it is here. Yeah. Yeah.

Susan Hudson MD (11:17)

interesting.

Mark Ratner MD (11:33)

And the interesting thing was that clinical pregnancy rate in this meta-analysis where they combine those six studies and they look at the statistical analysis of combining all six together increased by 84%. And so the data on CoQ10 is pretty solid. It really is. Now, the dose, you asked about the dose. The first study that was ever done with CoQ10 in women, was done up in Toronto. And the dose that was used was 600 milligrams of coenzyme Q10 per day. But the thing that’s tricky about coQ10 is that it’s a very hard substance to absorb from the stomach. That’s because it’s fat soluble. It’s a large fat soluble molecule, and it takes emulsification.

Meaning you have to make it water soluble in order for it to be absorbed well.

Carrie Bedient, MD (12:26)

Are sure you just can’t eat it with like a giant bowl of ice cream?

Abby Eblen MD (12:30)

Hahaha

Mark Ratner MD (12:30)

That helps. That helps. When we eat something that’s got a lot of fat in it, our body uses bile salts, to make that fat into an emulsification and make it easier to absorb. So yeah, if you take Coenzyme Q10 with a bowl of oatmeal without any fat at all, you’ll absorb very, little of it, okay. And the the carrier that they use, most CoQ10 is sold in soft gels. If the soft gel has an oil-based carrier, the absorption is typically in the range of 2 to 3%. That’s it. And so the first study that was done where they used 600 milligrams was an oil-based carrier. Absorption was pretty low. There are now products out there, which add the emulsification agents to help the CoQ10 be absorbed. So what we always say is it’s not what you ingest. It’s not how much you ingest. It’s how much you absorb, yeah.

Susan Hudson MD (13:22)

It’s what you absorb.

Two questions. So one, is CoQ10 helpful in individuals other than those with diminished ovarian reserve? So normal ovarian reserve or even extra ovarian reserve like women with PCOS.

Mark Ratner MD (13:39)

Yeah, I think all you can say is possibly. And the reason I say that is because when they do the studies, they choose subjects for their studies that are likely to show benefit. They want to, so they’re typically going to be women over the age of say 35, 36, or have very low AMHs. They’re looking for subjects where the possibility of benefit is greater. And so, I think the answer is unknown. Aneuploidy, which is the medical term for the wrong number of chromosomes in the egg. Women in their late 20s produce aneuploidy, right? What’s that?

Susan Hudson MD (14:20)

Half of the embryos created from women in their 20s are going to be chromosomally abnormal. And it’s interesting because actually if they’re very young, so even in their teens, there’s even a higher risk of aneuploidy.

Mark Ratner MD (14:32)

Yeah, it’s like a U-shaped, what they call a U-shaped curve, right? And so they have not done studies using CoQ10 in younger women, okay, or women with what seems to be normal ovarian reserve, just because it’s hard enough to do these studies. So they want to study at-risk populations.

Susan Hudson MD (14:35)

Mm-hmm.

Abby Eblen MD (14:49)

So Mark, what should you look for if you’re a patient other than go to Theralogix and buy your brand since you have a good way for it to be absorbed? What are things that women should look for in the makeup of the coenzyme Q10 that will increase your chances of absorption?

Mark Ratner MD (15:01)

Sure.

A couple things. Any coenzyme Q10 that’s either in a dry tablet or in powder form, a dry tablet or powder in a capsule, you’re not going to absorb it. The absorption of that is going to be minimal. There’s also two different forms of CoQ10 that are sold as supplements. One is called ubiquinone and the other one is called ubiquinol.

Abby Eblen MD (15:11)

Okay.

Mark Ratner MD (15:26)

And those are actually interchangeable in the body. The body converts back and forth between ubiquinol and ubiquinone. One’s reduced and one’s oxidized. We don’t have to get too far into that. But the point is there’s no difference. You’ll see a lot of marketing stuff about, ubiquinol is body ready and ubiquinone is… Either one’s fine. But you definitely want, at the very least, a soft gel, which is…If it doesn’t have an emulsifier, it should at least be an oil-based carrier for the soft gel.

Susan Hudson MD (15:56)

Because it’s fat soluble, is there a concern about getting too much CoQ10?

Mark Ratner MD (16:03)

No, we make our own CoQ10. In other words, CoQ10 is not an essential nutrient that we have to get from our diet. We produce it in our cells naturally. And the interesting thing here is, and this is typically not a big issue for women in a reproductive timeframe, but the same enzyme that produces cholesterol in our body, is called HMG-CoA reductase, produces

coq10. So people who take statin drugs, Lipitor, Zocor, Provacol, you know, the drugs that lower cholesterol, right? The way they lower cholesterol is they block that enzyme, HMG-CoA reductase, and it stops cholesterol production, it drops it, but it also drops coq10 production. So people who are on daily statin, their coq10 levels tend to be lower.

Susan Hudson MD (16:56)

Hmm.

Mark Ratner MD (16:56)

So older folks who are taking statin drugs should probably supplement with CoQ10 because their tissue levels of CoQ10 are low. This probably isn’t a big issue for most women trying to conceive. They’re not on cholesterol drugs yet, typically.

Abby Eblen MD (17:10)

Plus we usually tell them to stop those drugs anyway.

Susan Hudson MD (17:13)

But if they’re coming in though, I mean we have a lot of women who come in and they’re on statins and if we’re instructing them to come off that might be a population of, your CoQ10 might be low because you’ve been taking a statin, let’s supplement to boost you back up. I hadn’t thought about that in the past.

Mark Ratner MD (17:19)

Yeah, it drops the typical number that you hear thrown around is about 30%. If you’re in a statin, on average, it drops your tissue CoQ10 levels about 30%. Yeah. CoQ10, mean, people with heart failure. And again, we’re getting off the reproductive stuff here, but there’s a study that was published, and it’s already six, seven years ago that this was published, by supplementing adults with heart failure with coenzyme Q10, you cut the risk of death in half and hospitalization risk cut in half because it helps the muscle produce more energy. So coQ10 is a very useful supplement in many different settings.

Susan Hudson MD (18:15)

What are some of the other supplements that we can use to boost ovary and egg function?

Mark Ratner MD (18:23)

So there’s another supplement which is, I would say it’s somewhat controversial. It’s called DHEA. Now that is a hormone and we need to just make sure that we don’t confuse it with DHA, which is the omega-3 fatty acid and that’s present in a lot of prenatals as well. But this is a hormone, DHEA, dehydroepiandrosterone, okay, it’s a really long name, which is why we just call it DHEA. And it’s controversial because there are probably just as many studies that show it provides benefit in terms of older women with egg quality issues and recurrent miscarriage. There’s just as many studies showing benefit as there are studies that have shown no benefit.

And because of the way it was developed, it was really one fertility doc who was based up in New York City who was responsible for publishing much of the early research. And there are issues sort of surrounding that. So the dose, if someone’s going to take DHEA is 25 milligrams three times a day. Okay. It’s actually a precursor to testosterone.

So it’s actually what we would call an androgen. It’s a form of male hormone. 25 milligrams three times a day is generally very well tolerated. There are some women for whom that may be a lot of male hormone and they could develop facial hair and sort of typical testosterone type of side effects. DHEA also used by some rheumatologists for patients with lupus. And typically those patients need 200 milligrams, 250 milligrams per day. And the way rheumatologists use it is they’ll start at a low dose and they keep dosing higher and higher and higher. And most patients with lupus are women, okay? And so what most rheumatologists who use the DHEA say, they just keep pushing the dose until the woman develops a mustache. And then they stop.

Abby Eblen MD (20:15)

That’s not good.

Mark Ratner MD (20:25)

Well, it’s, you know, a lot of women with lupus, one of the big side of, one of the big symptoms of lupus is fatigue. And the real benefit of DHEA in lupus is that it seems to dramatically reduce the fatigue. So yeah, I mean, obviously…

Abby Eblen MD (20:39)

So why does something that’s a precursor for a male hormone help women help with decreased ovarian reserve?

Mark Ratner MD (20:46)

Yeah, that’s, I’ll probably have to defer on that. I don’t know. I don’t really know. You there are, you do need basically androgenic stimulation in the ovary. Exactly what the pathway is, I’m not that familiar. So, okay.

Abby Eblen MD (20:49)

Okay. Fair.

Carrie Bedient, MD (21:02)

So what else besides DHEA? We were talking a little bit earlier about it’s not everything related to adding supplementation. There can also be subtractions as well. How does that factor into egg quality?

Are there supplements that, or micronutrients or things that you need to make sure you’re not getting and pulling back on and avoiding that would…

Mark Ratner MD (21:17)

Yeah. So there’s some very interesting new science that’s evolved about iron. The recommended daily allowance for iron for a woman who is not pregnant but is trying to conceive is 18 milligrams per day. And then once you’re pregnant, the RDA goes up by 50 % to 27 milligrams per day.

And so most of the prenatal vitamins that are being sold on Amazon or over the counter in drug stores, most of those are formulated for women that are already pregnant. Okay. And so they have 27 milligrams of iron. And for the most part, there hasn’t really been a lot of concern about that. That’s sort of, think in many instances, as long as you’re taking a prenatal for the most part, most docs are, that’s fine. So it turns out, and this is really pretty new science, 12 years ago, 2012, a new form of what’s called cell death was discovered at Columbia University in New York. Most docs are familiar with the term of apoptosis. Apoptosis is what we would call programmed cell death, okay, where in response to certain environmental changes, the cell releases enzymes called capases, which dissolve the cell, they basically kill the cell. So apoptosis is essentially cellular suicide, Theroptosis is basically murder. And the criminal, in the case of theroptosis, is iron.

Abby Eblen MD (22:57)

I hadn’t heard that one before.

Carrie Bedient, MD (23:06)

So this is now a true crime podcast

Mark Ratner MD (23:06)

Yeah. Okay.

So, ferroptosis, it’s F-E-R-R-O, right? Which is ferric, ferrous, right? Iron, right. And it turns out that excess levels of tissue iron cause oxidation of the mitochondria, damages the cell membranes of the mitochondria, and essentially destroys the cell. Okay. And ferroptosis, which has really only been 10, 12 years that it was understood,

If you Google ferroptosis, I mean, the amount of science that has now being published about it is incredible. And it has been implicated not only in egg quality, but in embryo cleavage, problems with embryo cleavage and implantation. Ferroptosis is a big player in neurodegenerative diseases.

At this point, up until about three, four months ago, this was really just a theoretical concern that you’d say, okay, well, that might mean that too much iron at a tissue level is a bad thing for fertility. And a study was just published three, four months ago, once again, from China, okay, because this is where they can do these studies really well. And this was a terrific study. What they did is they took 160 women.

Advanced maternal age, okay, so these were women, I think it was between 36 and 42, and they randomized them. Half of the women got melatonin, two milligrams per day, and the other half got placebo. And they then went through IVF. And at the time of the egg retrieval, they took the eggs obviously, but they also took what they call the cumulus cells. Those are the cells that surround the egg, okay.

And they took all the cumulus cells and they analyzed them for two things, for markers of theroptosis and mitochondrial function, energy production. And what they found was that the women who took melatonin had significantly less theroptosis and better mitochondrial energy production. Now that sounds, okay, great. That’s just sort of like a lab test, right? But they also looked at pregnancy rates and this was a great study because they actually looked at live birth rates. The women who took melatonin, the women who took placebo, they had a live birth rate of like 15, 16%. The women who took melatonin, it doubled. It was 33%. IVF study. Yeah, that’s how they got the cumulus cells.

Susan Hudson MD (25:30)

How much melatonin were they taking?

Mark Ratner MD (25:32)

Two milligrams at bedtime.

Yeah, you don’t need much melatonin. A lot of people, there’s a tendency to think if a little bit is good, more must be better, right? And that doesn’t apply with melatonin. Most of the studies have shown that a dose between two and five milligrams is probably optimal if you’re using it for sleep or potentially other things as well. Now, why does everybody thinks melatonin is just for sleep? But it is a very, very potent antioxidant. And the conclusion of this study was that it is essentially protecting the ovarian microenvironment from metal toxicity, primarily iron. Yeah, so go ahead.

Susan Hudson MD (26:10)

Interesting.

Abby Eblen MD (26:11)

Next question is, so we’re giving our patients, we tell them, you’ve got to take prenatal vitamins. And so they’re getting super dosed on iron. And I know Theralogix makes two different types of prenatal vitamins or three different types.

Mark Ratner MD (26:27)

Yeah. So we make a preconception prenatal, right? We have two different preconceptions, prenatals, fertility prenatals. They only have 18 milligrams. Then we have two gestational prenatals, meaning once you become pregnant, you switch to one of these, okay? And those have 27. But there are gestational prenatals out there that have 30 or even 50 milligrams of iron. And arguably, 27 is even too much if you’re trying to conceive.

Susan Hudson MD (26:56)

Now I would have to say though, for our listeners, because there are certain people out there who have fibroids or diet related things where they come in and they’re severely anemic, I would like to make a comment that I am pretty sure Mark is not talking to you.

Mark Ratner MD (27:14)

Absolutely. the point, the statistics are like, I think it’s somewhere in the range of 10 to 15 % of reproductive age women. If you take them off the street, just at random, they’re going to be iron deficient. That’s right. Okay. And for them, maybe the 18 milligrams, which is the RDA may not be enough. Okay. But that’s part of routine screening. I mean, most practices these days are going to be getting a panel of blood work, not only hormone testing, but things like, complete blood count, which is where you can see whether or not somebody is anemic. Many practices will throw in a vitamin D at this point. So yeah, no, absolutely. I’m glad you raised that point because it’s completely true. Yeah. There are some women who do need that much and more iron.

Carrie Bedient, MD (28:00)

And everybody needs at least some iron because that’s what’s helped building our hemoglobin. That’s what’s transferring oxygen throughout the body. So it’s not like you can go cold turkey and avoid absolutely everything with iron in your life because at that point you will become anemic, oxygen delivery will be compromised, and then you’ve got a different set of problems. So is this something where…

Mark Ratner MD (28:18)

Absolutely. I think the takeaway for me is that if your prenatal vitamin, if you’re not iron deficient, if your prenatal vitamin has more than 18 milligrams of iron, you probably don’t need to be taking that much, okay? As long as you’re not iron deficient, right? And if you look at the whole RDA, that even has some questions. The average iron losses for a woman who is getting her menses every month, is gonna be anywhere from 15 milligrams to 30 milligrams of iron per month, is what she’s losing. And the RDA at 18 milligrams times 30 days, that’s about 500 milligrams. So you’re getting 500 milligrams a month, okay, if you’re taking the RDA. But the RDA, is what you’re supposed to be getting not only from supplements, but from your diet as well. And most women are getting iron from their diet. So the whole question of whether or not that 18 milligrams of RDA, now again, you’re right. Some women, even at 18 milligrams, they need more. But…

Abby Eblen MD (29:15)

Yeah.

Mark Ratner MD (29:27)

The point is one size doesn’t fit, doesn’t fit all. 

Carrie Bedient, MD (29:30)

And the RDA, wasn’t that designed around men?

Susan Hudson MD (29:34)

during wartime.

Abby Eblen MD (29:35)

Yeah.

Mark Ratner MD (29:36)

No. So the RDA, the way that these nutritional recommendations get made, there’s something called the daily value. And then there’s something called the RDA. The RDAs are stratified by sex and age. So there’s a different RDA for men. There’s a different than premenopausal women. Women who are pregnant have a different RDA. Women who are nursing have a different RDA. Yeah. So the RDA, the daily value is across the board.

That’s the one which is not stratified by age or sex.

Carrie Bedient, MD (30:05)

If we go through everything that we’ve talked about and summarize it in recommendations, it sounds like a recommendation for CoQ10 is helpful, particularly if it’s in a micronized or oil soluble delivery system, soluble form. And then it seems like DHEA may or may not be helpful. If you’re getting a mustache, don’t.

Abby Eblen MD (30:30)

Lower the value. Lower the amount.

Carrie Bedient, MD (30:32)

It sounds like iron is kind of a mixed bag in the sense that you need it in general, but you want to make sure you’re not getting too much. And it may be more protective if you’re taking the iron, which is likely to be in a prenatal one way or the other. If you’re taking that with the melatonin of two milligrams a day and that you need to be in in mind of what you’re eating and taking in your body in general, because you’re getting a lot of these things just through diet and nutrition in addition to the supplements. And more is not always the answer, as we see here with some of these questions.

Mark Ratner MD (31:09)

Correct, correct, correct, correct. If we have another five minutes, I’ll tell you about this one new kind of nutrient that getting a lot of attention.

Abby Eblen MD (31:16)

Yes, I was just going to ask you that. I didn’t want you to leave until you tell us what the mystery supplement is that we need to tell our patients about.

Mark Ratner MD (31:21)

Okay, so you’ve heard of NAD +, right? NAD, okay. So NAD is another one of those metabolites that’s in our cells. It’s what’s called a cofactor. Much like CoQ10, it’s involved in energy production and it works in a lot of different mechanisms inside the cell. And it was discovered that if you increase, they started off doing this research in roundworms. And they realized that if they increased the amount of NAD in the roundworms cells, they could double their lifespan. Okay. Instead of living for 18 days, they would live for 36 days or something. I don’t know. And so they then got very excited about this science. And this is back over the last 12 to 15 years, they’ve started doing studies trying to increase NAD plus levels, NAD levels in the cells of more and more complex organisms. Okay, they went from earthworms to mice, and then from mice to something bigger, and then they went to monkeys, and then finally the people, okay? But the people studies are still evolving because they take a long time to do. There are some studies with people which show that, and by the way, NAD in…terms of egg quality has been shown in mice to dramatically improve egg quality in old mice. An old mouse is, think, a year old. But they haven’t done any studies in people yet. There’s a lot of excitement about NAD as a longevity factor. But there’s also some excitement about possibility of it being beneficial in terms of preserving fertility for women as they get older. So how do you increase NAD in the cells using a supplement? Well, you can’t just give NAD. I mean, it exists as a supplement, but you don’t absorb it. It won’t work to actually increase cellular levels. What you need to do is you need to take a precursor. And up until three years ago, the precursor that was most widely being sold was called NMN, which stood for very long chemical name. And then the FDA stopped the sale of that. So the FDA said, you’re not allowed to sell that anymore. And the reason was because there’s actually a drug company that has patented it and is developing it as a drug so it can’t be sold as a supplement. So now everybody in this world has switched to something called NR, which stands for nicotinamide riboside.

And the company that makes the most widely sold nicotinamide riboside is called, the product is called Tru Niagen. N-I-A-G-E-N. You can buy it on Amazon. And Tru Niagen is NR chloride, nicotinamide riboside chloride. And it has been shown to significantly improve NAD levels in human tissue. There is no data yet in people to show that egg quality improves the same way it does, we know it does in mice. So, but it’s safe to use. I think they sell Tru Niagen, I think it’s 300 milligrams a day. And they’ve used Tru Niagen, nicotinamide riboside in a bunch of other studies, so for instance, there was a study published last year. They looked at people who had peripheral artery disease. In other words, bad circulation in their legs. So they had a hard time walking a far distance and they placebo versus nicotinamide riboside. And so a blinded study, nobody knew who was getting what. The people who got the NR, the nicotinamide, they ended up walking much further.

At the end of this, by the end of the study, could walk much further. So energy production and muscular function in their legs was dramatically improved by nicotinamide riboside. So there’s evidence that its benefits extend to people in certain respects, but we still don’t really know the data on fertility yet.

Carrie Bedient, MD (35:10)

Huh. We’ll have to add that to the arsenal of things. when people are anything else.

Mark Ratner MD (35:15)

Yeah, mean, listen, it doesn’t stop a lot of people because you can buy this stuff. It doesn’t stop a lot of people from recommending it or using it. And it’s just, you know, if it doesn’t work, then you just wasted money.

Susan Hudson MD (35:31)

It’s good to know that when it comes in the pure form to know that that is actually not what you need, that you need the precursor because I have plenty of people who you know bring their bathroom cabinet with them to the office and that’s one of the things that’s there and I’ve so far been being like well I’m not sure if that’s actually helpful and now I know that actually may not be helpful but if you’re thinking along that here’s what may be.

Mark Ratner MD (35:55)

Yeah, yeah, you want to the precursor, either NMN, which doesn’t get sold anymore in the States, but NR, nicotinamide riboside, is very effective as a precursor. It helps the tissues produce more NAD+.

Abby Eblen MD (36:09)

So Mark, from a practical standpoint, is there a product that Theralogix makes that has antioxidants, has all these things that are good for decreased ovarian reserve?

Mark Ratner MD (36:17)

Yeah, one of the things that we’ve tried to avoid is these kitchen sink type of formulations where you throw everything you can possibly throw into one pill or a set of pills because there’s so many different situations, especially in a fertility setting. You’ll see these prenatals now that are sold with 50 milligrams of inositol in a daily dose.

It’s a meaningless dose. But they throw it in and they say it contains a inositol. So our focus has really been on trying to provide clinicians, fertility docs and their practices, the tools that allow them to fine tune their recommendations. There are practices that we’re familiar with that hand every couple, here’s the products we want the guy to take and here’s the products we want the women to take, no matter what your situation is. Everybody is given a list of six or eight different supplements, get on everything. That’s one approach, we have basically prenatals and then we’ve got things you can add to the prenatals.

We’ve got a standalone coenzyme Q10 product, is called Neo Q10. So if somebody comes in and they’re taking a prenatal and they love their prenatal, they tried different ones and half of them made them queasy. And so they finally found a prenatal where they could swallow and they like this prenatal, they don’t want to switch. As long as they’re not taking too much iron, okay, as long as they’re getting enough vitamin D, great, stay on your prenatal. If you want to add CoQ10, you can use a standalone CoQ10. We do have the prenatal that contains, that includes the CoQ10. But other than that, we have a standalone DHEA, we have standalone melatonin. We don’t have an NAD product yet, an NR product, but we’re looking at that because, again, we generally try to build a better mousetrap when we can. But if we can’t, then we typically will say, okay, you know.

Maybe not. So we’ll see.

Carrie Bedient, MD (38:15)

Yeah. Thank you so much, Mark. We will talk to you every time. And I’ve got my list of notes next to me that will all get switched over into my standard notepad. So thank you.

Susan Hudson MD (38:16)

Awesome.

Abby Eblen MD (38:17)

Very good.

Mark Ratner MD (38:19)

My pleasure.

Abby Eblen MD (38:24)

Thank you.

Mark Ratner MD (38:29)

And look up ferroptosis. You’re going to be shocked. I kept seeing these, I get, I get a lot of stuff, put Google scholar, if you put search terms in, I probably have about 30 search terms. And so two, three times a week, I’ll just get tons of links sent to me. And I just kept seeing this term, ferroptosis. It’s like, finally I said, there’s gotta be something here I should know about. So I started reading about it. it’s fascinating. And I think we’re to learn more and more about its impact on reproductive health as well.

Susan Hudson MD (38:58)

This is just a great example of how every day we’re learning and growing as a specialty to hopefully brin better and better care to those who need it.

Mark Ratner MD (39:07)

All for that. All right guys, my pleasure.

Carrie Bedient, MD (39:07)

Well, thank you so very much.

To our audience, thank you for listening. Subscribe to Apple Podcasts to have next Tuesday’s episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us to spread reliable information and help as many people as possible.

Abby Eblen MD (39:26)

Visit fertility.suncensor.com to submit specific questions that you have and sign up for our email list. Our email subscribers hopefully will get some interesting information in the coming year as we start to get ready to put our book out.

Susan Hudson MD (39:39)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye!