Lifestyle and fertility
Lifestyle / Fertility / ED
Recent studies are uncovering many effects of lifestyle and nutrition on fertility in both partners. Also, sexual dysfunction is common in infertile couples and male sexual function is influenced by most of these same factors. You will have the maximum chance of success if you pay attention to these issues right from the beginning, but they become more important as the treatments become more complex, and particularly with IVF. You will find more detailed information in the book "survival of the Firmest" available on Amazon/kindle or itunes regarding ways to maximize your sexual relationship. References with a short description of the key findings are also provided (see "references").
Weight and fertility
Obesity (BMI over 30) decreases a woman’s fertility, increases the chance of miscarriage, and most importantly, increases the chance of premature birth with all of its attendant risks for the offspring. The higher the BMI the more pronounced these problems are and we generally recommend weight loss before attempting conception if your BMI is over 35. The effects of obesity on live birth are much more pronounced in non-white women; prematurity is even more pronounced for African American women. Exercise, even at a vigorous level, apparently does not have negative effects on obese women trying to conceive (Palomba, et al). In that study the chance of success with IVF was increased over three-fold, even without losing weight!
With a brisk walk for 30 minutes and only 200 fewer calories each day you will lose 30 pounds per year. If you start at the beginning of your attempts to conceive, by the time IVF would be considered you may have lost up to 60-90 pounds or more, which will have major benefits in reducing all of the above problems. Excess body weight also contributes to sexual dysfunction in both sexes, but particularly for the male partner. At Amazon/kindle or itunes you can download “Survival of the Firmest”, that has many helpful hints for losing weight and for healthy eating.
Obesity in the male partner reduces sperm quality. The effects are not great, but even one fewer embryo getting fertilized could be the one that would have implanted.
Low body weight can also cause infertility by stopping ovulation and menstrual periods, and low body weight increases the chance of poor fetal growth (small for dates); weight gain is highly advisable in these women before embarking on a pregnancy.
Exercise and fertility
Moderate exercise increases both male (Vaamonte, 2012) and female fertility (Wise, 2012). Moderate exercise (e.g. a brisk walk) for 30 minutes most days of the week is the current recommendation for all adults and this level is fine for fertility. Two studies have suggested more than 3-5 hours of vigorous exercise per week for the female partner may reduce fertility (Morris, 2006, Wise, 2012), hence the above guidelines. Moderate or even high exercise for the male will enhance erectile function and will help prevent any decline of that function with aging. However, in a very thorough and well controlled study, normal young men assigned to regular high intensity exercise had significant reductions of most semen parameters and gonadotropin and testosterone levels (Safarinejad, 2009). As it is likely that men with decreased semen quality would have similar or greater adverse effects, we do not recomment regular, high intensity exrecise for for the male partner. Biking for > or = 5 hours per week (Wise, 2011) has been reported to have negative effects on sperm. Overheating of the testicles may explain the effect of biking.
Nutrition and fertility
Recent studies have suggested that a “prudent” diet improves fertility for both partners, i.e less red meat and saturated fat, more seafood, and more fruits and vegetables, often referred to as the “Mediterranean diet” (Vujkovic, 2010, Twigt, 2012, Gaskins, 2012). Trans fats should be avoided entirely (Chavarro, 2011), for example, doughnuts, Danish pastries, French fries and fried foods in general. Studies point to antioxidants, monounsaturated oils, and omega-3’s as the factors involved in these benefits and these are therefore discussed in detail below.
Men having reduced semen quality have a significantly lower intake of dietary antioxidants (Mediola, 2010). Antioxidants improve sperm motility and oxidative stress has been shown to be increased in the semen of men whose sperm don't move well and have increased fragmentation of their DNA (Shamsi, 2009). Sperm are very sensitive to oxidation because they have to shed their cytoplasm in order to be able to move rapidly. The cytoplasm (all of the cell’s bulk except the nucleus carrying the chromosomes) contains the cell’s natural antioxidant defenses. In men with increased fragmentation of their sperm DNA, 1,000 mg of vitamin C and vitamin E decreased the proportion of sperm with fragmented DNA (from 22 to 9 %) (Greco, 2005). We do not currently recommend vitamin E because it has been linked to all-cause mortality and a recent study associated it with increased prostate cancer. Most likely any strong level of antioxidant will have a similar impact, such as a small bowl of berries each day, or 1,000 mg of vitamin C and 2 cups of green tea daily. A commercial antioxidant, pycnogenol, has been shown to improve semen quality (Stanislavov, 2009); two 40-60 mg capsules daily would also provide a good antioxidant dose. All fruits and vegetables contain antioxidants but berries have the most with blackberries having almost twice as much as blueberries (Halvorsen, 2006). Dark chocolate is also an excellent source of antioxidants. Carotenoids, particularly lycopene (which is particularly high in tomatoes) has been positively correlated to sperm motility (Zareba, 2013).
As women get older, the amount of antioxidant in the fluid around the egg decreases. Without antioxidant protection, the cells surrounding the egg are less able to provide nutrition for the egg as it matures. The resulting poor function of those cells correlates with reduced embryo quality and the chance of pregnancy (Suh, 2002, Elgindy, 2008). The same suggestions for increasing antioxidant intake given above for the male also apply for the female, except women should not take vitamin E during the IVF cycle if they are also taking low dose aspirin, as it could increase the chance of bleeding with the egg retrieval, and, although recent studies are conflicting, we recommend no caffeine except one cup of decaf tea or coffee (therefore no chocolate, which has caffeine). Soy may be a particularly good source of antioxidants. A recent study found soy intake was significantly related to live birth in women having IVF (Vanegas, 2015).
Omega-3 fatty acids:
Omega-3’s, as well as antioxidants, increase blood flow by increasing a chemical called nitric oxide. Blood flow is very important for ovarian response to stimulation (Jadaon, 2012), and blood flow around the mature egg has been correlated with improved egg and embryo quality (Lozano, 2007). Higher dietary intake has been associated with improved embryo morphology (Hammiche, 2011, and implantation, fertility, and live birth. (HSI, 2016) (Gaskins, 2018).) (Ciu, 2018)
Blood flow presumably is also very important for function of the testicles. In one study two agents known to increase nitric oxide increased sperm count and motility as well as the circulating level of testosterone. Omega-3’s are also important in the make-up of sperm membranes. In various recent studies, fish intake (Afeiche, 2014), and omega-3’s have been associated with improved sperm quality (Chavarro, 2009, Safarinejad, 2011, Attaman, 2012).
A recent study associated minor increases of circulating omega-3 levels with increased prostate cancer. Other studies have shown associations with reduced prostate cancer and suppressive effects on prostate cancer tissue. Associations do not show cause and effect relationships. The small increase of omega-3 levels could have been associated with other factors that increase prostate cancer. For example, overcooking of meat and fish has been associated with increased prostate cancer risk. People who don't eat fish regularly complain that it is bland and lacking in taste. If men in the above study who were accustomed to overcooking foods simply had a minor increase of fish intake because they found that fish had sufficient flavor when it was fried or grilled, a false association of omega-3 levels with increased prostate cancer could be created.
An easy and inexpensive way to get omega-3’s is from fish oil. A reasonable dose is 500 to 1,000 mg, but make sure that is the amount of EPA and DHA (the two principal omega-3’s) and not just the amount of oil. They are listed on the nutrition label on the back of the bottle. If you take this amount you will not need a more expensive prenatal vitamin containing DHA. There are some early indications that omega-3’s may decrease premature birth. DHA has been added to some prenatal vitamins as it may aid fetal brain development, although a study at age 4 did not confirm any benefit. Because omega-3's may improve sperm morphology, 1,000 to 2,000 mg may be considered for men with low sperm strict morphology. In one study of 1,840 mg given for 8 months, strict morphology increased from 7.4 to 12.8%. Lesser doses or durations of treatment have not been examined, but there could be a need for loading to have maximal benefits. Also significant increases of sperm numbers (16 to 29 million per ml) and motility (19 to 27%) were seen in this study (Safarinejad, 2011).
Omega-3’s themselves are very sensitive to oxidation so always take a good level of antioxidants along with boosting your omega-3 intake. Also, they work together to increase blood flow for fertility or male sexual function.
Best fat sources
In an extensive analysis of fat intake from Harvard, the authors suggested that women trying to achieve pregnancy should be encouraged to increase consumption of whole grains, omega-3 fatty acids, fish, and soy and to reduce consumption of trans fats and red meat (Chiu, 2018). This study suggests strongly that the best outcome will occur by limiting meat intake and substituting with fish, and by choosing olive oil for all salads and cooking. For snacks, choose nuts. Avocado is great on salads and omelettes, and try some on multigrain bread having lots of nuts and seeds, with olive oil instead of butter. When dining out have any bread with olive oil and balsamic. Trans fats should be avoided entirely, for example, doughnuts, Danish pastries, French fries and fried foods in general. The bonus will be if you stick with this diet for good, you will also live a longer and healthier life. Infertility is turning out to be a wake-up call for general health!
Cook foods less
When foods are overcooked, such as with barbequing, broiling, grilling, and frying, toxic compounds called advanced glycation end products (AGE's), are produced that accumulate in the body as people age, cause oxidative stress, and are thought to be involved in diabetic vascular disease and aging. In a study measuring levels in the circulation and in the fluid surrounding the eggs, higher levels of AGE's were associated with poor follicular and embryonic development and with a lower likelihood of ongoing pregnancy (Jinno, 2011). In this picture from a supermarket supposedly specializing in wholesome food choices, note the prominent grill marks on these otherwise healthy salmon filets! Besides increasing AGE's, the char contains cancer-causing chemicals. For more ways to limit intake of these toxic chemicals, see this article published by the American Dietetic Association (Goldberg, 2004).
A Canadian team has done some intriguing studies on egg quality in the aging rat (the older female rat’s eggs show very similar changes compared to eggs from older women), and most of those changes were reversed with co-enzyme Q-10 (Ben-Meir, 2015). As yet there is only a small study in humans (Bentov, 2014). The dose suggested based on the amount given in the animal model is 600 mg per day. That study was discontinued before enough subjects had been studied because of concerns regarding a technique they were using to assess the egg's chromosomes. However, there were strong trends toward a lower rate of chromosome abnormality (47 vs 63%) and higher clinical pregnancy (33 vs 27%). We can’t recommend it because of the limited experience of CoQ10 as yet in humans given for this purpose. Individual patients over age 37 may elect to take it, accepting any unknown risk. It has been taken for other reasons without apparent problems observed, but usually at lower doses. It should be stopped with a positive pregnancy test.
Smoking by the female decreases the chance of success by 50% (Hughes, 1994) and increases miscarriage. It is absurd for a woman to not stop smoking before fertility treatments, particularly IVF. Second-hand smoke causes a similar reduction in the chance of pregnancy (Neal, 2005) and also decreases ovarian reserve. Menopause occurs four years early in women who smoke. The effect of smoking is also seen in egg donation recipients (Soares, 2007), showing that smoking also influences the ability of the uterus to support implantation. Smoking by the male partner reduces success with IVF and ICSI (Zitzmann, 2003), decreases semen quality and increases DNA fragmentation. Of course the serious health risks of smoking are more important reasons to quit. However, if the female or male partner is unable to quit, she/he should take high amounts of antioxidants (above), which may counteract some of the adverse effects on sperm and on the cardiovascular system.
One old, limited quality study suggested the female partner should not have more caffeine than one cup of decaf coffee or tea (5 mg or less) before and during an IVF cycle (Klonoff-Cohen, 2002). However, three other studies showed no effect of caffeine in women simply attempting conception (Hatch, 2012) or with IVF (Choi, 2011). The most recent large study found no effect on IVF or ICSI success of 1-5 cups of coffee per day compared with no coffee (Lyngso, 2019). That study did find a positive effect on live birth following IUI, which should be further verified. The sperm are also not sensitive to caffeine, but the male should not drink more than the equivalent of 3 cups of coffee (one cup contains about 150 mg). Larger amounts have been reported to increase sperm DNA fragmentation.
Neither partner should drink alcohol during an IVF cycle; studies have shown a decreased pregnancy rate (Hakim, 1998, Rossi, 2009), IVF Failure (Nicolau, 2014) and possibly an increased rate of miscarriage (Klonoff-Cohen, 2003). However, when first attempting to conceive, in one study drinking 5-6 glasses of wine per week by the female partner reduced the time to become pregnant (with most adverse lifestyle factors a greater reduction of pregnancy outcome is observed with more advanced treatments). However, two recent studies showed no impact of alcohol on outcomes, leaving the role of alcohol somewhat controversial.
Men should avoid significant heat exposure to the testicles (hot tubs, Jacuzzi’s, steam baths) and they should not use a lap top directly on the lap (hot showers are OK). The testicles are outside of the body because sperm production and movement require a lower temperature. It is probably better to wear boxer rather than jockey shorts, although one study did not show any change in sperm function. Recent studies have also suggested that extensive use of a cell phone transmitting from a front pocket should be avoided (Agarwal, 2009). Trans fats also adversely affect sperm, so avoid doughnuts, French fries and Danish pastries and anything without a nutrition label that says no trans fats. Plastic recycle number 7 (polycarbonate and “other”) should be avoided. Polycarbonate releases the hormone disruptor Bisphenol A. BPA is also in food can linings and the heat activated receipts we all handle (wash your hands). BPA levels have been associated with reduced sperm count and motility, decreased testosterone levels, poor ovarian response (Mok-Lin, 2010), lower follicle count, decreased egg quality, decreased fertilization, increased chance of implantation failure (Karwacky, 2017) (Erlich, 2012) , and increased miscarriage (Lathi, 2014).
Finally, any discussion of life choices and fertility would be incomplete without discussing the effects of anxiety, stress, and depression. Various studies have shown a reduced success rate in achieving pregnancy in women experiencing these symptoms (Sanders, 1999, Smeenk, 2001, Ebbesen, 2009), and an intensive stress reduction program (Mind/Body) has been shown in controlled studies to reduce the time to achieve a pregnancy in couples just beginning to attempt conception and to increase the pregnancy rate with IVF (Domar, 2009). One study showed that certain individuals are more vulnerable to stress (Facchinetti, 1997). When exposed to stressful visual and auditory stimuli, those exhibiting greater increases of their pulse and blood pressure had a reduced chance of pregnancy with IVF. This study also indicated that reduced blood flow may be the mechanism through which such an effect is manifested. Stress can also be reduced by taking on fewer tasks, by relaxation techniques such as yoga, or even by taking off time from work during the ovarian stimulation through until well after embryo transfer, as full-time employment has been correlated with a lower pregnancy rate with IVF. Most importantly, reducing stress may help couples better cope with failed cycles. In countries or states that cover the costs of IVF, the primary reason for failing to be successful is giving up because they just can't tolerate another failed cycle.
Actually, luck has relatively little to do with it. One of the most insighteful sayings is “it doesn’t matter so much what happens to you as much as how you handle it”. If you pay attention to the factors outlined above, and if you are persistent, you will be very likely to be successful. Even more important is to not let the infertility wear away at your relationship, including your sexual enjoyment. Challenges can strengthen the bond between you and your partner if you support each other and handle them together, and if you pay attention to all of our recommendations outlined in detail in the book "Survival of the Firmest" available on Amazon/Kindle or itunes, you might well find your sexual relationship better than at any time in the past.