Lorne Brown:

By listening to the Conscious Fertility Podcast, you agree to not use this podcast as medical advice to treat any medical condition in either yourself or others. Consult your own physician or healthcare provider for any medical issues that you may be having. This entire disclaimer also applies to any guest or contributors to the podcast. Welcome to Conscious Fertility, the show that listens to all of your fertility questions so that you can move from fear and suffering to peace of mind and joy. My name is Lorne Brown. I’m a doctor of traditional Chinese medicine and a clinical hypnotherapist. I’m on a mission to explore all the paths to peak fertility and joyful living. It’s time to learn how to be and receive so that you can create life on purpose. Welcome to the Conscious Fertility Podcast. Our expert guest today is Dr. Shaun Tregoning. He is a reproductive endocrinologist. He has his clinical practice at the Olive Fertility Center in Surrey, British Columbia. Now Sean, you’re originally from South Africa, if I recall.

Shaun Tregoning:

Yes, that is it.

Lorne Brown:

Correct. And I found it fascinating, kind of like just how the different cultures look in America, Canada versus South Africa, how we kind of view the body and look at the body. And so I was curious to know that when you, because you did your OBGYN in South Africa.

Shaun Tregoning:

That’s correct, yes. I did my residency training in OBGYN in South Africa. And then my fellowship training partly in South Africa and partly in the United States.

Lorne Brown:

So like you’re a reproductive endocrinologist, so yes. When you immigrated over to North America and did it go into the states first and then Canada or how did you Uh,

Shaun Tregoning:

Before I immigrated to Canada, so I, I did part of my, my fellowship in REI in Cape Town where I had done my medical training and residency and then I, uh, finished up part of my fellowship at Stanford, but then I went back to South Africa before I immigrate to Canada.

Lorne Brown:

But did they, do they require you to do more schooling when you came over or did they accept your medical background training?

Shaun Tregoning:

I did not have to do any more schooling, but any international medical graduate has to redo the Canadian exams, which is verbatim in most people’s lives, especially if you have a specialist because you have to redo the basic medical exam as well, the LMCC. And then you have to, you have to set your specialist exam

Lorne Brown:

Again. You know, I always found that interesting because when I think of doctors and South African doctors, I think people kind of trust how you’re trained and people kind of like it when they have a doctor that’s from South Africa. So it’s always interesting that they required you guys to jump more hoops but se la vie. Right?

Shaun Tregoning:

Exactly.

Lorne Brown:

And the reason I bring up your training background is because I was pleasantly surprised at one of my visits at your clinic in Surrey, BC when I learned that you have trained in homeopathy. because I just don’t think of a specialist as a reproductive endocrinologist finding that so much of an interest. But your program was for medical experts. It wasn’t for the general public, your homeopathy

Shaun Tregoning:

Program. That’s correct. So that, uh, that program wasn’t, uh, wasn’t part of what medical school training homeopathy as a, as an alternative form of, of medical treatment in South Africa is fairly ubiquitous. A lot of, uh, it’s quite easily accessible as it is in Europe. And so a lot of people will, will make use of, of homeopathy. So I didn’t have this huge antithesis towards it and didn’t know much about it. But constantly, I’m always on the lookout for more ways to expand my approach to a patient-centered care philosophy and personally have more of an integrative approach to my clinical practice. And so there is a diploma that can be done in clinical homeopathy, which really centers around physicians, registered nurses and allied health professionals who have an interest in trying to integrate homeocracy into their clinical practice. And that’s a year long diploma that you do through the center for uh, the development of homeocracy in clinical practice. So I did that that year. Longman particularly obviously was looking for strategies on how to integrate that into my practice in fertility.

Lorne Brown:

And is there certain, maybe for our listeners just explaining the homeopathy side because I think it’s aligned with how we think of it from a Chinese medicine perspective where we’re treating the person not the disease diagnosis that’s similar with homeopathy. And is there a certain chen still that you like to use it for in your reproductive practice?

Shaun Tregoning:

That’s exactly correct. I mean, homeopathy’s whole basis is that you, you don’t treat disease, which is very different to the way we trained in allopathic medicine where you make a diagnosis, you treat you very diseased focused, you pick up symptoms and you put together treatment plans to ameliorate and or treat the actual symptoms of a disease process. Homeopathy embraces the idea that disease processes are a manifestation of what’s going on in the entire entity of the body. And so you treat the person, so in homeopathy you would not necessarily treat a symptom of infertility. That infertility may be, or just even if you take an infertility symptom like endometriosis for example, or recurrent pregnancy loss. But somebody’s having recurrent pregnancy loss may be having it because there’s a variety of constitutional symptoms that have not been addressed and not necessarily because there’s a specific problem at the level of the endometrial. So it obviously takes this broader view of trying to treat the individual and use medi homeopathic medicines that try to allow or help and aid the body to heal itself. So it follows this philosophy, probably not unlike that in Chinese medicine, which intuitively says the body was really designed to cure itself. And what we do is to just push it gently and lodge it into the pathways that help it to do that.

Lorne Brown:

And I use that proverb parable from Chinese medicine where they say nourish the soil before you plant the seed. And that idea is to help create an environment on a cellular level for the organism to thrive. And so how as you, I liked how you put it, you gently nudge it into the pathways to support the healing and that’s, that is the Chinese medicine approach that for example, just like with homeopathy, you could have five individuals with a diagnosis of endometriosis and all five would get a different herbal acute prescription. Correct? Right. And then you could have five people with different disease diagnosis, but they get very similar herbal prescriptions based on their pattern imbalances or constitution. And again, similar to I think the homeopathy approach is rather than just attack like the pathogen, we’re trying to attack the pathogen and at the same time build up the body’s defense so it can deal with the pathogen. So we’re supporting the body. That’s correct. And I know in the west sometimes we just go to war and attack everything, right? The body and the pathogen we’re, we’re trying to treat the pathogen and support the body at the same time.

Shaun Tregoning:

That’s absolutely correct.

Lorne Brown:

And so that’s really refreshing that you have that thinking process because in training, because you’re trained in both styles. Like you have the obvious depth of training, you know, MD, OBGYN, REI. So you have years and years of study and then you have your homeopathy. But it’s kind of refreshing for me and I’m sure the people, the patients that see you, to know that you have that perspective, that there’s probably not one size fits all and you’re looking at all the different approaches that are available that you can offer. And why I think we see referrals from you is that integration seems to be something that’s important to you that you value.

Shaun Tregoning:

I mean obviously my bias in my medical training coming from an allopathic background was very, very scientifically biased. And yet throughout that old, one thing that I became so cognizant of is that science cannot answer every question. And that no matter what clinical trials you look at, there are always outliers in those clinical trials. So even if you take a trial looking at the efficacy of a drug, there will still be a small proportion of people that will not respond to the drug that will later be deemed to be highly efficacious, but yet in some people will just not work. And the corollary is also true that there will be some cases where you determine an intervention is of no value. And yet there were outliers within a study that derived great benefit from that intervention. And so I don’t necessarily believe we always have the final answer just because there’s been a randomized controlled trial because within the concept of that there are outliers on either side of the bell curve that don’t conform accordingly. And sometimes I think we are not totally honest with patients when we tell them something is or isn’t scientifically beneficial because we don’t often discuss the caveat that was in the boundaries where we arbitrarily chose to set the parameters for statistical significance. And it’s that group of people, especially in infertility, that we often deal with the people who just do not respond despite our best intentions. And yet we have to come up with something that offers them more than a wing and a prayer.

Lorne Brown:

And I think I’ve heard you say before, for those that have that poor prognosis, um, sometimes that one little tweak is the difference between having a baby or not having a baby. And you shared with me why you’re into integration, acupuncture, homeopathy, low level laser therapy. Yes. Using it all because although the studies may not be robust, you don’t know if that little tweak is gonna be the difference for that individual.

Shaun Tregoning:

That’s exactly right. You never know when that one small tweak will be the difference between success or no success. And sometimes that may also be just because you are offering the patient some hope and some form of intervention, which in the conflict system of the organism called the human being might have profound psychological appropriate positive features. So we all know that in randomized placebo controlled trials, placebos have efficacy. And so we need to remain cognizant of that. That does not mean that the placebo is a useless tool for management. It sometimes means that the tool that you gave the patient was the hope that something could get better. And we sometimes lose sight of the fact that small interventions, instead of saying to somebody, there is no hope, we’ve done the maximum we can see of you. When you actually prepare to sit down and say, let’s look at some alternatives. There may not be robust evidence for this, but let’s work at some of the things that we can do. That very act itself may change the outcome. And I think that’s important.

Lorne Brown:

And although they say the placebos in the herd as in this chemical, this substance has no chemical properties that we’re aware of. I find that the brain, and you kinda alluded to this, is the best pharmacy that exists. And so if somebody believes, we know now this is the Conscious fertility podcast, we’ve had a lot of experts on the mind body side that UR feelings can cause a chemical hormonal reaction in the body where dopamine and serotonin oxytocin Absolutely. Which have health benefits.

Shaun Tregoning:

Absolutely.

Lorne Brown:

And in the west we kind of, um, we’ve cut the head off from the body, right. And I think it was the cart, and I don’t know if this is true, but the story I heard is he was at risk of what he was doing with healing the body. Because it was the church’s domain for a lot of stuff. So he gave the church the spirit, the mind, the feeling stuff, and he just dealt with the body. But traditionally it was a, a bottom up, top down. So your physical affects your mental emotional and your mental emotional effects of physical. And we’re just getting back to that mind body aspect of medicine where we’re acknowledging that we can’t separate.

Shaun Tregoning:

That’s entirely correct. And even within the area of fertility studies, there have been some really good studies looking at the whole mind body interaction concept. And that’s, and the role that it plays in infertility. And I think you and I were both at, uh, at a conference recently where Ali Doman presented her work and she’s a fairly prolific writer in this area. She’s a clinical psychologist who spent most of her time working in, in fertility clinics. And some of the work that she’s done is quite amazing, quite staggering in terms of just understanding the link between the mind and the body and, and fertility and how small, small adjustments on a non-drug level, it can make a huge difference in terms of success and outcome. At the underappreciated thing, it’s the level of depression and anxiety that’s associated with infertility and uh, no matter how many drugs we give people and ovulation induction agents and how many Ivf cycles we do, our patients still don’t do as well as could do if we don’t address the underlying mind aspect of this.

Lorne Brown:

And thanks for mentioning Allie Domer. We have a podcast with her as well where she talks about the research and we were at that conference together where the question was does stress cause infertility? Does infertility cause stress? And the answer was yes. Right? Correct. It’s a vicious cycle. And uh, and so if you’re gonna go through these treatments, let’s make them as positive as possible so you don’t have to suffer through it. There’s an expression, I don’t know who said it, but the expression goes, pain is inevitable, suffering is not. And so going through the IVF process, or I should say the fertility journey that’s the pain is inevitable. That is not an easy process, but the amount of depression, anxiety, and suffering, um, I think there can be, uh, more resources and a better job done. So it’s not as challenging as it is right now.
And as we heard from that data, many people don’t end up having babies, not because of the financial stress of the fertility journey, but from the emotional and they drop out of the fertility journey, the I v s process. And if they just did one more cycle, they might’ve gotten that take home baby. Right. So it’s an important part to address. The other thing I’m interested in is talking about  PRP because I’m getting many patients asking me about it. And uh, so I’d love it if you could define it and how you see this as a potential for rejuvenation. You talked about, again, the data, where’s the data and the science at this point, it’s, it seems to be popular in Greece now in some parts of the states. And I also want to talk about, if you can, about the lining versus the ovary. because I do know that we have talked about mutual patients and you’re one of them. I know that I refer to you that you’re going to be talking with or I’ve talked with AOSIS and, and how you use it post-surgery and then for lining issues. So can you kind of give us a nice mind dump on uh, PRP, what it is and, and what is where it is today and what’s the potential?

Shaun Tregoning:

So PRP stands for platelet-rich plasmid and it is derived from taking blood from a patient, spinning down that blood, separating out the white and red blood cells from the serum and the platelets, so the platelets of the cells within the blood that actually allow clotting to take place. The platelets, however, also contain multiple other granules in them. Most notably a whole bunch of cytokines growth factors, which have huge healing properties. And so finding a way to concentrate that portion of the blood without, without any of the other cells that we don’t need was something that was manipulated and explored way back by really in the setting of a rejuvenative joint recovery. So a lot of rheumatologists, um, and orthopedic surgeons had an interest in looking initially at the use of PRP in, in the setting of injecting into, into degenerative joints and showed fairly promising results there.

Then dental and oral, uh, or maxillofacial oral surgeons picked up on this when they do extensive mouth work and they use PPR ports or PRF, it’s the, the instead of the plate, uh, platelet rich plasma, it’s platelet rich fibrin. So you, you allow it to actually clock, um, and can be used as a healing tool when they drill deep into bone. And then it kind of extended over from there into plastic surgery and aesthetic medicine where p p is used for regenerative and regenerative things in the aesthetic industry such as improving fine lines and wrinkles within the face stimulating collagen production. It can be used to be injected in people who have thinning of the head to try and stimulate the follicles to improve. And so that’s where PRP was. But then obviously PRP’S PRP and it doesn’t know where in the body it’s going to be utilized in any area which may benefit from rejuvenation by injecting growth factors is a potential for PRP use.

And so within the area of fertility where it’s really, there really three big areas where there’s been some interest. And the one is in the setting of patients who have embryos who are doing embryo transfers, but where we cannot get the end, the endometrial lining to thicken up adequately enough despite using tons of estrogen, which is what we usually do, or even align them to try a natural cycle, they have a chronically thin endometrium, which is usually not a good sign for the likelihood of the embryo to attach. And so this is one area where PRP has been used to do a PRP infusion in the hopes of trying to stimulate the endometrium to whatever that little blockage is that may exist there to now actually stop responding to the estrogen and stick it up. So that’s the one area. The other area kind of akin to that is in patients who had trauma at the level of the endometrium, such as if they’ve had an Ashland syndrome from a vigorous DNC or surgical interventions of the uterus lining, or in patients who may have, um, significant adenomyosis where you may actually have some kind of structural disruption to the endometrial lining in using the PRP may facilitate healing of that area and lead to a more normalized endometrial environment.

And then again, staying with the endometrial is also in patients who’ve had, uh, what’s called recurrent implantation failure term. We in fertility really struggled to define, but broadly speaking, a consensus of if we’ve transferred two consecutive chromosomally normal embryos without any evidence of attachment, that would be one patient who attaches but has very early chemical pregnancies in a repeated fashion. But the infusion of PRP in that setting may also normalize the endometrial environment. There’s not a whole bunch of data to support the use of PRP in the settings and the trials that have been published are very mixed. And I think the reason for this is one that the patient numbers have been quite small and so we are looking for really good big trials, but more importantly, there has been no consistency in terms of how the PRP is prepared.

And so we don’t, we don’t know that the product called PRP that’s been used in the various trials can actually be compared head to head from one trial to another. And so if you haven’t prepared the PRP well, and you’ve used the substance, you’ve called PRP and you get zero results, have you really used PRP? So this is some of the problems with the methodology of the trials that have looked at this, but the trials in good trials all suggest that there may be a tendency towards improvement. And again, because this certainly is not something that can harm anybody, what you are doing is infusing your own blood back into you. And when you’re, when you’re stuck with having had low response to anything else or full failed embryo transfers, most people will grasp at any straw that’s not gonna harm them.

And so I have a low threshold to try p setting. And then the last big area, which you mentioned is the ovary. And what has been looked at here is the term of ovarian rejuvenation. That injecting p r p under the capsule area of the ovary might help in women who have decreased egg reserve or, or starting to lose their egg quality that you may be able to rejuvenate the ovary by pumping back the, your own natural growth factors. And so it’s usually done the same way we would do an egg retrieval with the same needle you go subcapsular under the ovary and inject the opry into the ovary. And then a lot of studies, particularly the grease, which you alluded to, the pe uh, the group of people who did a lot of the initial work on this have now spoken about doing both the injection under the ovary as well as then infusing a large volume through the uterus in the hopes of bathing the ovary in the pelvis in the PRP straight after the procedure as well.

And then there is a group in New York who’ve also done quite a bit of work on this and they have a, a clinical trial ongoing at the moment that they’re recruiting for, but their preliminary data also suggests that this might be useful in the setting of early ovarian failure, um, people with significant diminished ovarian reserves. So I think we haven’t seen the end of this yet. I think there is hope on the horizon for this. And I use certainly, again, I offer this to patients when we have nothing else to offer because I, I think the data is early, but, but it’s a potential, you

Lorne Brown:

Know, it’s the expression leave no stone unturned. And for this population where they don’t have the luxury of five years from now when the study’s published and there’s lots of data to wait for, I can see why people are seeking this out before there’s robust data. It reminds me of the photobiomodulation low level laser therapy, just like the PRP you said it is, it’s safe. And so there’s not a big down, there’s not a real downside except for time and money to do this. And maybe it’s a little invasive or uncomfortable low level laser therapy, same idea. There’s a little bit of dab, but it’s not robust. But when you think of the mechanism of increasing mitochondrial function, increasing blood flow, lowering irregular inflammation, oxidative stress, this is why I want people want to try it because maybe, maybe that’s that one little tweak that’s going to be the difference between a baby or no baby. A couple of questions for you regarding the PRP in Canada right now are, are all of our centers doing the ovarian PRP or just the lining PRP right now?

Shaun Tregoning:

Uh, just the lining PRP, I’m not aware of any centers in Canada that are doing the ovarian PRP per se

Lorne Brown:

Though. And then with the lining, like somebody that’s got the asherman’s and scar tissue, is this like a treatment for aosis or asherman’s or is this the treatment that you would do post-surgery or both? So,

Shaun Tregoning:

So probably both. No one really knows the right answer to that. Certainly in patients who’ve been diagnosed with this before who have gone through a failed embryo transfer, it’s one of the tools you could think about prior to doing or in the next embryo transfer cycle to try and improve the likelihood of a good outcome. But really that’s probably one step too late. Again, just on the basis of how we know PRP works and we know for example, when people do extensive ablated laser treatments on their face, for example, these studies have been well done in aesthetic and plastic surgery. If you apply PRP once you’ve had an ABL laser, the healing phase is much faster than if you just let the body recover on its own. And that’s because you’ve replaced all the regenerative healing properties from PRP.

So it makes sense that if you were to do some kind of surgical intervention in a patient that may result in scarring of the endometrium, that infusing PRP in that sitting might reduce the chance of developments or adhesions or damage to the endometrial lining. The other area, which I often wonder and surmise about myself is patients who’ve had chronic ovis infections such as TB of the endometrial. We don’t see a lot of that in Canada in the first world, but certainly in the third world where I trained it would be considered an anas not to check every patient for TB because TB is so endemic in the third world, that’s it and done. Where I work in Surrey, there is a large immigrant population. And so we often forget that just because someone who lives in Canada now carries a Canadian place, does not make them a first world person in terms of their risks that they bring from a country of origin. And so we actually do pick up a fair amount of tuberculous endometritis in patients that have come from areas in the world where it’s endemic. And so that led me to wonder whether PRP may have some benefit in the setting of, uh, healing post TB as well.

Lorne Brown:

And I’m gonna ask some questions about the PRP, which you may or may not have the answer to, but based on your experience of using it in your clinical practice, and I know you are affiliated with another cosmetic clinic where you use a lot of PRP, so I know you have knowledge around this. I’m gonna tie to where I have knowledge on photo bi modulation, low level laser therapy and how I, I think it for fertility is there are studies where they show that if you’re doing the PBM, the laser treatments leading up to surgery and post-surgery, there is less pain, inflammation, swelling and quicker recovery. So they don’t just do it post-surgery, but they also prepare the body. So leading up there’s some treatments and then immediately after surgery there’s treatments, which is why I often encourage our patients that we’re seeing through your clinic leading up to retrieval that we are doing the treatment to support the egg quality.

That’s our goal, but immediately after the retrieval with blood flow edema, right? We wanna do it just for the recovery area. So here’s my question: why I, I, brought up the research of laser therapy wondering with PRP, because it sounds like they’re doing it mostly post-treatment versus leading up to IT, patients educate us when they’re doing new things that are not totally standard, uh, treatment. So PRP right now is not a standard treatment for a quality. And I have patients that have researched this and they looked at the American way and degree, the way they’re doing it in Greece in the states, they say have your IVF within three months of the PRP because they will lose the effect apparently in Greece. They don’t want you to do the IVF until three months after they’ve done PRP. Can you think about what you know from, as a reproductive endocrinologist and how you understand the mechanism behind PRP theoretically, when do you think people should do IVF based around PRP based on how you understand follicular genesis and the effective PRP?

Shaun Tregoning:

I mean, I think the original word that came out from the Greeks was really based on the early studies that showed, they started to see traction and effect on improvement in antral follicle counts and an AMH antral and, and malian hormone levels three months after the PRP was injected. And that kind of informed the decision making around the big group in New York that’s doing their studies. Uh, and maybe it’s because the protocols are a little different, started seeing an effect quite quickly after the first PRP. So I think that it’s a difficult one to tease out because again, we don’t have a standardized approach to when we do it, how much we inject, where you inject it, whether you do just the subcapsular injection or whether you do that plus be the ovaries in a vis of PRP and what that exact may be.

And I, I just don’t think we have the numbers in the study to know for certain personally, I think that if somebody’s had p r p done for ovarian rejuvenation, I think I would watch the biomarkers very closely and suggest I, I probably would not suggest doing IVF immediately I would hold off until I start seeing some improvement in either the, the number of antral follicles or the AMH. And when you see those starting to improve, then you know that your p ps had some effect. But intuitively for me, the three month mark makes more sense than immediate.

Lorne Brown:

And you know, I think about it, uh, again, how we’re playing with it with the low level laser therapy and just our, our preconception nourishes the soil at Acubalance using the diet, lifestyle, herbs, acupuncture, and low level laser therapy. Because follicular genesis on average is about a hundred days. Right, right. That from the primordial follicle to egg retrieval or ovulation, right. If I went abracadabra, so I injected with PRP, I would expect the most benefit those follicles would be experiencing is a hundred days after abbra. So that’s why I thought three months later, because the follicles have bathed in that environment for a hundred days versus they only had a week off. But again, the research will tease that out. There’s what I think and then there’s what we know and thinking is that right now we’re just speculating on theory, which we know doesn’t always translate into clinical outcomes.

Shaun Tregoning:

That’s actually right. And with the ovaries, the other question is do you do one treatment? Do you do one a month? Do you do three treatments? No one really knows. It is one, is two better than one or is three better than one?

Lorne Brown:

And two, and I, I would again speculate what I’m seeing with the low level laser data and what I’m seeing with acupuncture, it’s cumulative, it’s momentum. So you keep bathing. It’s like, because again, going back to our soil, I don’t water the plant and say now it’s good. I continually water the plant. And so I would suspect that it’s one of those things that you’re doing over that hundred days. And I don’t know how often it would be for PRP, but it sounds like you want to keep bathing the ovaries rugs in this beautiful soup of rejuvenation. Right. You give somebody one pill of ch Clomid if that was somebody’s thinking, all the researchers show that ch Clomid is a very poor ovulation drug. Right, right. But you found that dosage. I just, it’s just, again, thinking speculating, I would imagine you would need several doses of the PRP to get a dramatic result. Correct. Are you guys, because again, our role when we think about it with the acupuncture herbs is we feel that we’re somehow supporting the follicular the follicles, which are like the baby health search. It’s the follicles, mitochondria and blood flow, which is then going to support the maturation of the egg. When you’re doing the PRP, are they just doing it to the ovary or are they actually injected into the, like are they reaching, how are they reaching the follicle? Like is it

Shaun Tregoning:

So the protocols all just called flow immediate subcapsular injection. So that’s where the peripherally cited, um, primordial follicles are and and obviously there will be some absorption of the PRP from a very vascular stretch, which the ovary is into the deeper layers. Yeah. But again, that’s the same idea. You know, the protocols are not, are not ubiquitous and they’re not all the same. They don’t all inject in the same place, but they don’t all do the same amount. And the one interesting one I think to watch out for is a split study where they inject in one side and not the other to see, I think that would be really interesting where the patient accesses their own control to see if there’s improvement.

Lorne Brown:

I’m smiling because there was a study in rats where they did the low level laser therapy. And so what they did is they did one ovary. So they did the incision, pulled the ovary out, lasered the ovary, then sutured up and then put the rat or a mouse through an IVF cycle. And the mouse that had the side, um, treated had better everything and quality and real quality et cetera. But when you compare it amongst other rats that the controls also. But my understanding is even the other ovary did better, and I know this from laser studies, that it has a systemic effect. So they did with burns, if they burned two sides of the rat and only lased one side, that one side did better than the other side. But when you looked at the rats that got burned with no laser, the side that didn’t get lasered did better. Better. Yeah. And so there is a systemic effect.

Shaun Tregoning:

Right.

Lorne Brown:

So who knows? I don’t know how that works, because I know lasers have a systemic effect. And again, we think sometimes things are isolated or very separate, but we start to realize when you treat one area it has a cascade of events that affects everything, but I think that’s a really interesting study and I would expect one side would do better than the other. I just hope there was a control that got nothing. Right. Yeah. So I could see that. because it could be that systemic effect. So in general, in your practice, in your, in your clinic, again you guys do IVF, you’re seeing a lot. I think you have an interest in a lot of experience with endometriosis and PCOS. Yes. And again, now we’re learning you’ll use your medical protocols, so drugs and surgery.
But you also are interested in homeopathy. I know you like naturopathic medicine like we have at our clinic. Yes. IV therapy and low level laser therapy. Yes. I’m always a fan of adjunctive therapies. Like Acubalance, naturopathy, Chinese medicine laser. We like to use them on ourselves because they’re about health prompt, you don’t have to be sick to use them. Like I wouldn’t volunteer for an egg retrieval or for a heart surgery. Right. Just for the hell of it, you know. So I’m curious, do you use homeopathy for yourself? Do you get IV therapy for nutritional IV therapy for yourself? Are you one, are you a user of the, of the medicine that you tend to refer and to

Shaun Tregoning:

Your patients? Yes, absolutely. Particularly supplements. Like I’m a strong believer in doing a lot of things. I have uh, I have insulin resistance personally. And so I like to use things like myosis, AOL and ine, which is a step to try and avoid having to use a drug like metformin. Ultimately they both had fairly profound effects on me anecdotally in improving my insulin resistance, which we shouldn’t be really surprised about. because there’s actually good published evidence on both of those supplements in the settings I use like NMN, which I will often recommend to patients with reduced egg reserves. You know, based on a lot of the work that’s coming out of David Sinclair’s lab at Harvard. He’s a molecular geneticist who’s shown, who’s shown quite, he’s done quite a lot of work on the tuan or the, or the use of genes, the anti-aging genes showing, you know, that as we age, we we, we drop in levels of NAD. Um, and so using NAD supply agents like NME can be beneficial in reducing the signs of aging. And there’s quite a bit of research that’s been done on animal models showing improvement in, in egg quality, uh, as used stuff like N men and it has profound anti-aging effects on, on human cells. So all of that kind of stuff I’d absolutely use for myself because there would be little points recommending patients use it if I didn’t, if I didn’t actually believe it worked.

Lorne Brown:

I agree with that. And you know, there’s times where we have our staff meetings in my clinic and there’s a whole bunch of us hooked up to IV nutritional IV therapy and getting our glutathione

Shaun Tregoning:

Sorry. And yeah, glutathione and, and NAC and that. Yeah.

Lorne Brown:

Yeah. Those are some of our favorites. And again, our patients coming in for the IV with the glutathione, sometimes vitamin D injections that you have products with the NAD in our practice, our naturopathic physicians have been washing it closely because our patients are wanting and you know, they’re searching the internet and um, there’s some, so far the supplements have been unstable. So we, until just recently we haven’t carried, uh, an NAD supplement and the IV form of it is just a long process.

Shaun Tregoning:

Little bit risky

Lorne Brown:

Comfortable and super expensive. So we thought marketing was more than science at this point. We just hadn’t gone forward. Right. Although the patients asked

Shaun Tregoning:

There, there is a, there are a lot of quality supplements out there. My um, my understanding again from David Sinclair’s work, and looking at a lot of this myself, is that the one supplement update, it’s gonna use a brand which comes from an organization called do not age.org. That’s the UK, it’s a British company and they actually did allow themselves to be subjected to third party testing and monitoring and the results were fairly reasonably representative. So this is one of the biggest problems with, as you would know with the supplements and and naturopathic supplements and medicines in general is the lack of control over the companies that manufacture these things. So you could put 30 grams of nothing in a capsule and a legal getaway was pulling at 30 grams of something.

Lorne Brown:

Yeah.

Shaun Tregoning:

Um, and charge the earth for it and no one would be any wiser.

Lorne Brown:

Agreed. And we are, we’re for years we’ve been looking nor we’re not doing the research, we’ve been looking at the research and naturopath physicians have found an NAD supplement that kind of meets their criteria and the people behind it with the science and the rigor and the biochemistry. So I’ll share that with you as well because Yes, ly and I’ll look, I’ll look at the one that you have because it took us a while we do the glutathione injection because that Yes. Works well. Yes. And it took us a while to find a stable glutathione supplement because it just wasn’t stable, you know? Correct. And so we have that. But again, because we have the ability to do the injection either through the IV into the tube or we can do it in muscular, most of our patients just come in and get the injection, although we do have the supplement.

And now the NAD is again, that first seen or slowing down that biological aging. So I’m gonna look at the one that you mentioned and I’ll share with you the one that we’ve been looking at and, and maybe they’re both great but um, it’d be good to know that we have some, uh, NAD options to, to help our patients and ourselves. because I’ll take it too. . Well, Sean, at the conference that we attended together, there was an interesting discussion about pre genetic, um, screening the PGT a and uh, the value and the benefit of it. Can you share your takeaway and how you’re counseling your patients, whether they, you think it’s beneficial or whether they should or should not do the pg d a And I’m asking you this because I know you don’t think there’s a one size fits all. And so I know there’s not a simple answer to this and it depends on the person sitting across from you. But I’m curious what your takeaway was from that talk that we both sat in and how they were, what, what they were saying about PGT A. Yeah. And what it is and what it is. Maybe, maybe

Shaun Tregoning:

Explain what it’s Well, so preimplantation genetic testing for aneuploidy is when an embryo grows to the blastocyst stage the stage ready for implantation in the uterus. And then our embryologist will take a biopsy from the outer cell area of the embryo, not the inner cell area that becomes the, the fetus but the outer cell area that ultimately becomes the placenta and send that away from chromosomal testing to see whether they are chromosomal abnormalities. So oftentimes people will confuse us and think that P GT looks for genetic abnormalities. It is not, it’s not looking for things like Sachs disease or cystic fibrosis or congenital deafness or blindness. It’s definitely not looking at autism, which is not a single gene defect. What we are looking for are numerical differences such as trisomy 21, which is down syndrome and is the ES of all of the abnormalities.

So we are looking for an extra or a missing chromosome. We know that all human beings have 46 chromosomes throughout their body and then 23 ultrasounds. So the sperm and the egg contain half the number of chromosomes because when the two come together, that makes up the 46 chromosome complement of a normal human being. However, during cell division you can sometimes get abnormalities in that process in which a cell will either lose or gain a chromosome and then that leads to chromosomal abnormalities, many of which are lethal or not compatible with life or can lead to severe impairment. And so screening those out is attractive because in the first place, if you put back a chromosomally abnormal embryo, the body’s first line of defense is just to not allow implantation to occur. So most chromosomal abnormalities don’t attach; the second line of defense is that they do, but the body will surveil pick up the abnormality and boot up the pregnancy in the form of an early first trimester miscarriage.

And then very few of those abnormalities actually make it through to the second trimester where you then diagnose ’em as an abnormality and have to deal with them. So the attraction behind doing PGTA is that you would know upfront which of your embryos are abnormal. So you only put back normal embryos, which ostensibly gives you a higher chance at pregnancy because the embryo is normal, a lower chance of miscarriage and then almost taking away the chance that you’re gonna later on discover you have an abnormality. And in an ideal world that would be so, however, the oxygen caveats with PGTA and one of them is that when you do the biopsy from the arter cell mass, you’re not biopsying all of the cells. You are only biopsying a sample of them. And if you get an area of the arter cell mass that has a, that has a higher constituency of abnormal cells, you may actually call this embryo abnormal when in fact it’s not truly and vice versa. So you may get false positives and false negatives around this. And then you get the, this very difficult clinical scenario of a mosaic embryo, which is an embryo that has both normal and abnormal cells found. And in the beginning we used to consider mosaics completely abnormal. Now we know that they’re not, a lot of the mosaics if you put them back, will actually lead to a healthy pregnancy.

Lorne Brown:

Is that because going back to our earlier conversation we talked about how the body has an innate ability to heal

Lorne Brown:

Yes you’re seeing that these embryos that don’t look normal self-correct.

Shaun Tregoning:

Correct. They self-correct. Um, so the drive and the propensity for the given organism is to survive at all costs. And so you put back the embryo and if there’s some abnormal cells, it’ll try to extrude them so that the normal cells will survive. And our clinics experience along putting back mosaic embryos has been very much the findings of everyone else in the world. If you put back a mosaic, the embryo tends to be normal, nothing is either they don’t attach because they’re abnormal and and all get pregnant or they do attach and the pregnancy tends to be a completely normal pregnancy. We’ve had very, very few mosaic embryos that go into the second trimester. What we’ve discovered in abnormality, it does happen and obviously the surveillance is very high if you’re putting back a mosaic. However many of us might have started off in lysis mosaics and we wouldn’t be any other wiser.

Lorne Brown:

And IVF before the age, the genetic screening, you are putting back mosaics all the time.

Shaun Tregoning:

Correct. Putting back untested embryos all the time. And in fact everybody who doesn’t require fertility treatment is probably having a just natural conception. There may be lots of mosaics happening out there. It’s just because we’re doing a test now that we’ve created a group of embryos that we now are concerned about because they don’t meet our definition of totally normal. But we are not totally sure what those abnormalities indications are long term. The irony of PGTA however is that the very group who needs PGTA, which is older women are also the group of women, most likely not to make an abundance of embryos or blasters to test the group of people who young, who more likely to make lots of embryos are the ones that are not likely to need PGTA because they, they probably are going to have enough normal embryos amongst them.

And so this makes the tape on it really difficult because if you look at a lot of the data, and this is what Bob Casper was talking about at the conference, really if you’re sitting in a situation where you’ve got three blasts and you put back one after the next, after the next untested, the live birth rate, the cumulative live birth rate in that group of patients is actually higher than if you test those embryos and put back selected because you may be throwing out embryos that aren’t actually normal. And so it becomes a little bit controversial that we may actually be discarding embryos that are okay and there’s no great evidence in all of the PGTA literature at the moment that we actually have done anything to improve live birth rates by doing this. So we have sage fears, but I’m not really, I’m not convinced in my own mind I have a lot of the same reservations Bob Casper has and I have a lot of the same biases.

So it’s a long, short and difficult discussion to have with patients. But generally speaking, if I have patients who have less than three blasts, I’ll often advise them just to do an embryo transfer. That’s the one aspect you’re just looking at scientifically. If you take in a more of a broader aerial view of this, many patients need to have an embryo transfer in order to feel like they have psychologically completed their treatment. So you have a patient with significantly diminished egg reserve who’s maybe 42 and they’re doing an IVF cycle because they feel they need psychological closure before they move on to a donor egg. If you get one embryo from that patient and you do PGTA and the embryo comes back abnormal, that patient is often driven to feel like, well I got one embryo, maybe I should give this another kick at the can because maybe the next one will be long or worse.

Yet they have a an or they have a mosaic embryo and they transfer it and they don’t get pregnant. They feel I really should do this again. And so you start getting into this never ending spiral of just one more time. One more time. What I like to call the infertility addiction syndrome. Because it’s very much like watching a slot player at the casino who thinks that that one more dollar in the machine is the one that hits the million bucks. No one can tell you it’s not. Statistically the likelihood is quite small but it’s not zero. And so you start becoming obsessed with the notion of chasing a positive pregnancy test rather than actually completing your goal, which was to have a baby. Um, and I often find that you can stop that full bullet train by just putting back an embryo in a patient and if they don’t get pregnant they feel like they have done everything that they can and they move on to closure a lot easier. So again, it’s not just always about what the papers say and what the scientific correct or incorrect thing to do is we actually treat the whole human being. And sometimes I think we lose sight of that. What a lot of patients need is to be able to take that process to conclusion, have an embryo trans mourn, the loss of their own ability to get pregnant and move up. And we sometimes take that away from them by not giving them an embryo.

Lorne Brown:

I  appreciate you sharing that because that is the psychological part of it of people moving on to donor eggs because the donor egg, they wanted to parent, that’s how you said it and that’s where I’m resonating with their goal wasn’t to do IVF. Their goal wasn’t to get a positive pregnancy. Obviously, they wanted to do it ideally with their own eggs, however they wanted to parent. And sometimes what, how’d you call it the infertility addiction train? Is that what it’s called?

Shaun Tregoning:

The Infertility addiction cycle? Yes.

Lorne Brown:

Yeah, the infertility addiction cycle. So you feel that you’re enabling that sometimes by doing the genetic testing on these women that only have a few embryos so they don’t get the closure. Because I’ve shared on past podcasts, I’ve only seen one regret that is shared when somebody’s done a donor egg cycle and it works is that they waited so long to meet this baby, right? They wish they could have done this. They could have held this baby two years earlier. Right.

Shaun Tregoning:

There was a very large Scandinavian paper a little while back that was published on this exact, which was the largest evaluation of donating programs. And really they set out to answer the simple question, do people who donate cycles actually are content with their decision afterwards? Yes or no to break it down? And really the data was staggering that this is exactly what emerged. The only regret people have is that they didn’t do this sooner. It’s a minuscule single point, pointing to the numbers of people who really wish they had not donated. Right. Vast majority of people were over the moon ecstatic with their decision to do it because again, everybody enters into this wanting to have a baby, wanting to parent and then they become obsessed with the need for their own gamuts to parent. And then when they lose that obsession and they actually have a baby they realize that biology doesn’t define parenting and they are as pleased as anything with the outcome and the data is there because this is how people will ultimately feel. And that’s why I have a great deal of confidence to counsel people in the direction of Dollar Egg when they are struggling with their own gummies rather than throwing down another 20, $30,000 on a cycle. We know, we know it is unlikely to be successful.

Lorne Brown:

And as you shared, having the transfer gives them that closure so they don’t have to sit with, I should have could have and have doubt. So they really feel

Shaun Tregoning:

That’s right that they . But on a daily basis, I have this discussion with patients that the worst case scenario you can ever be in is the double guessing yourself scenario because it’s a never, it’s a question to which there is no answer. The what if, what if I’d only done what if, what if, what if, what if? And nobody wants what if one day 50 or 60 and looking back on their last, what you want to do is to be able to answer the question I did and I know, so I did a cycle and I put back an embryo and I never got pregnant and I moved on. And you can just come to closure with that. But if you sit with the what if, what if that one embryo, what if we put it back? What if we did what if, what if it, it’ll drive you crazy.

Lorne Brown:

And on the genetic screening, what I think I heard from you is that like five, 10 years ago, at least five years ago, everybody thought it was the holy grail we solved. Right? We solved it. And like everything and everything seems to be too good to be true. We always get excited and then we realize it’s a little bit more complicated. And now it’s one of those things that in most cases, um, if somebody’s older and having less embryos, your take is it’s probably you don’t see the benefit of testing them because put in the three. Because if you test them and you get a mosaic, you may accidentally toss away an embryo that could have self-corrected. And so you actually have three chances versus one chance if you throw away two outta the three.

Shaun Tregoning:

That’s right. And you give people an opportunity and I don’t know, I mean everyone has their own take on this. The ardent PGTA converts and acolytes would, would have a conniption at the thought that you not test a 40 plus year old woman. I have a different take on this and I think that the data is quite clear that uh, live birth rates in that group of people is not higher. It’s not made higher by testing them.

Lorne Brown:

And then there’s always certain situations. So I’m thinking of somebody that’s having recurrent pregnancy losses and it’s physically and emotionally traumatic and draining. This is where maybe you would consider this type of testing.

Shaun Tregoning:

Absolutely. And sometimes, you know, I can share, I have a patient, I have a couple who, um, were both in their late twenties who came specifically to see us because they wanted PGTA, not ’cause they had infertility. And it was an interesting story because both of them actually had a down syndrome sibling. They had grown up in a family with a Down syndrome sibling that was older than them. And both of them, as much as they loved their siblings, felt like they had for their entire life put their lives on hold for their sibling. And, and they just felt that when they had a child, they couldn’t do this again. Not because they didn’t love their siblings, but because they had a choice, they would not choose to do this. They understood and realized that the likelihood of them having a downs was quite small, but they wanted a hundred percent assurance and so they did PGKA for that. So that is a very different reason. But certainly one can see the rationale from their point of view for wanting to do that.

Lorne Brown:

And that, and that’s where again, going to the beginning of our conversation where, you know, you’re looking at the individual and you’re not saying not to do this test. You need to see what people’s needs and what their history is. That’s exactly right. And when you can make a recommendation. But in general, you’re not as excited about this testing as we were five years ago. Correct. because of the data.

Shaun Tregoning:

Because of the data. Okay.

Lorne Brown:

And as you said, you follow the data and you’re also open to integration because of your background growing up in South Africa where it’s different to our listeners because they’re all over the world. But in Canada, the US naturopathy, Chinese medicine, homeopathy, most physicians, conventional trained, just not as open to it. Much more today as at the time we’re recording this than it was when I started practicing in 2000. But you grew up in an environment where this was kind of the norm in South Africa and Europe where people sought out homeopathy and supplements from conventional or not. Am I understanding that correctly?

Shaun Tregoning:

Yeah. Yes. There was a lot more openness to alternative, complimentary, um, approaches.

Lorne Brown:

Yeah. And so if that was your background and how you grew up with the system then that’s why you are the kind of doctor you are. That’s very open and integrative. And I think I know, because I get the feedback from your patients all the time, how much they adore you and appreciate the time you spend with them and the option you make available to, um, I hear it all the time. So thank you for being that kind of doctor.

Shaun Tregoning:

Well that’s great. Thanks.

Lorne Brown:

Alright, so Shaun, if they can find you through the Olive fertility website, obviously, so they can go to olivefertility.com. Do you have anything for if on Instagram or social media for yourself that you wanna share and I can put in the show notes or is all the best way to reach you? 

Shaun Tregoning:

I don’t have anything personally on social media. I tend to be shy of social media myself, so the best way to bug me is through the clinic.

Lorne Brown:

Perfect. So that’s all fertility and, um, Sean’s practice is in Surrey, British Columbia, Canada, and I’ll remind our listeners that are here locally, that Acubalance goes on site to Olive to do the IVF and laser acupuncture before and after onsite at Olive for your transfer day. And, uh, we have that integrative approach where we cross refer to the Olive fertility clinic and we see their patients as well for, and as Shaun was sharing the adjunctive therapies to leave no stone unturned and see if we can tweak something to help make the difference between baby versus no baby going towards the baby. So we enjoy that integrative approach that we’ve been doing for many years, Shaun.

Shaun Tregoning:

Yes. Yes. And, uh, so do we. I I think it’s a good holistic approach to treating patients. You know, I’m obviously, well, well versed in all the allopathic stuff that I need to do, but I’m a strong believer in more of a holistic approach with not necessarily the most knowledgeable about those options. And that’s why I have low, a low threshold, as you know, to refer to naturopathic colleagues and to yourself, like TCM docs and acupuncturists.

Lorne Brown:

I get a letter out, his low threshold means he does refer to naturopathic

Shaun Tregoning:

Yes, that’s right. Low threshold means I do it. I do it almost every time. Yeah.

Lorne Brown:

Shaun, wishing you well. And again, thank you for joining us on the Conscious Fertility Podcast.

Shaun Tregoning:

Thank you Lorne, take care.