Lifestyle and infertility
Laura dracea, MD, PhD
Gynera Fertility Center Bucharest, Romania
We hope you enjoyed your coffee.
Don’t worry!
Up to 5 cups of coffee/day have
No demonstrable adverse effects on your health.
Higdon J, Frei B. Coffee and Health: a review of recent human research. Crit Rev Food Sci Nutr 2006; 46
Lifestyle and infertility
Laura dracea, MD, PhD
Gynera Fertility Center Bucharest, Romania
"Destiny is not a matter of chance, it is a matter of
choice."
Winston Churchill
What if
our choices or our patients’ choices
could make a difference?
What we do know?
One out of six couples have fertility challenges
Lifestyle choices may contribute to their infertility
Social trends lead to deferring childbearing and care
Most patients are not aware on potential consequences
No evidence-based guidelines available
Reduced counseling focused on lifestyle modification
What we do not know?
Infertility factors identified
in 80 % of the cases
Different results of the treatment
in patients with same causes
What about the other 20%
Why
?
?
Adjuvant medication
Why not adjuvant lifestyle
?
Patients underestimate the
influence of certain factors
What about professionals
?
Aren’t we missing something
?
Why is it relevant?
Modifiable factors!
Inexpensive modification!
• With appropriate counseling we may be able to:
Improve natural fertility
Improve reproductive treatment outcome
Reduce obstetric and neonatal complications
What to do?
Review current knowledge and recent meta-analysis
Provide updated evidence
Provide results of our recent awareness study
Make recommendations for appropriate counseling
main factors
Deferring childbearing and aging
Deferring treatment
Smoking
Obesity
Alcohol and caffeine
Environmental toxins
Psychological stress
Aging
Infertility Increases With Age
Age Group (years)
Percent Infertile
Percent chance
of remaining childless
20 - 24
7
6
25 - 29
9
9
30 - 34
15
15
35 - 39
22
30
40 - 44
29
64
Aging
•
Maternal Age (years)
Spontaneous Abortion (%)
15-19
10
20-24
10
25-29
10
30-34
12
35-39
18
40-44
34
≥45
53
Risk of Spontaneous Abortion with Advancing Age
•
Heffner L., Advanced, maternal age – how old is too old? New England Journal of Medicine 2004; 351(19):1927–29
Aging
Aging
Success rates of ART treatment by maternal age
The most recent United States IVF-monitoring U.S. 2007
(CDC online publication)
Average pregnancy rate per cycle:
Woman age
Fresh cycles
(nondonor)
< 35
40 %
35-37
38-40
41-42
43-44
31 %
21 %
12 %
5%
U.S. Department of Health and Human Services, Centers for Disease Control (CDC) at /www.cdc.gov/ART/ART2007
Success rates of ART treatment by maternal age
Review of data from the various IVF centers in the USA 2007 CDC Report
main factors
Deferring childbearing and aging
Deferring treatment
Smoking
Obesity
Alcohol and caffeine
Environmental toxins
Psychological stress
smoking
Smoking vs Nonsmoking women
Relative risk of infertility increased 60%
Increased miscarriage risk Natural conception
Assisted conception
Increased risk for ectopic pregnancy
Conception delay over 1 year
Clark et al., 1998
Augood et al., 1998
Winter et al., 2002
Saraiya et al., 1998
Augood et al., 1998
Hull et al., 2000
Require nearly twice the number of IVF cycles to conceive
Feithinger et al., 1997
Each year of smoking - 9% increased risk of unsuccessful ART Klonoff-Cohen et al.,2001
Decreased IVF pregnancy rate for passive smokers as well
Neal et al., 2005
Menopause occurs one to four years earlier
Mattison et al., 1989
Baron et al., 1990
Higher gonadotropin dose requirements
MacMahon et al., 1982
More diploid oocytes in the ovary
Zenzes et al., 1995
Lower sperm count in male progeny
Storgaard et al., 2003
Increased risk of trisomy 21 offspring
Yang et al., 1999
Increased transmission of modified DNA to embryo
Zenzes et al., 1999
Much of the risk may be reversed within a year of cessation
Hughes et al., 2000
smoking
Smoking as a risk factor for men
Most recent systematic review and meta-analysis
Li et al., Fertil Steril 2011
57 cross-sectional studies
29,914 participants from 26 countries/regions
Sperm parameter
effect
Pooled mean difference
IV
Sperm volume
Sperm density
Total sperm count
Sperm motility
Sperm normal morphology
Sperm abnormal morphology
-0.25
-7.07
-32.20
-1.85
-4.92
0.72
95 % CI
(-0.32,-0.18)
(-10.03,-4.10)
(-43.28,-21.11)
(-3.27,-0.43)
(-6.90,-2.94)
(0.15,1.29)
Test for overall
p value
< .00001
< .00001
< .00001
.01
< .00001
.01
obesity
30%–47% of overweight women have irregular menses
Castillo-Martinez et al., 2003
Obesity decreases fecundity, even in ovulatory women
Gesink Law et al., 2007
Ovulation and pregnancy rates improve after weight loss
Clark et al., 1995
Obesity decreases IVF pregnancy rate
Nichols et al., 2003
Obesity increases requirement for gonadotropins
Fedorcsac et al., 2004
The risk for spontaneous abortion increases in overweight
Wang et al., 2002
The risks for preeclampsia, gestational diabetes increase
Dokras et al., 2006
The effect of BMI on sperm parameters is uncertain
Li et al., 2011
alcohol
Moderate alcohol consumption
Detrimental effects on fetal development
American Academy of Pediatrics, 2001
N
o evidence to indicate that adversely affects fertility
Parrazini et al., 1999
Higher alcohol consumption (> 2 drinks/day)
Decreases fecundity
Can reduce semen volume
Williams et al., 2009
Li et al., 2011
caffeine
High levels of caffeine consumption (> 5 cups/day)
Decrease fertility
Increase the risk for miscarriage
Bolumar et al., 1997
Signorello et al., 2004
Mild consumption of up to 200 mg caffeine per day
( 2 cups)
Not associated with any apparent adverse effect on reproduction
environmental toxins
Have been shown to have a negative effect on
fertility:
Toxins and solvents used in the dry cleaning and printing industries
Heavy metals
Pesticide exposure for agricultural workers
Lead
Industrial microwaves
Radiations
Psychological stress
The most common reason for discontinuation of fertility treatment
Inversely related to pregnancy and life birth rate in IVF
No convincing evidence demonstrates a direct adverse effect on fertility
More often an effect than a cause for infertility:
Prolonged infertility
Too many treatment cycles
High psychological impact
other possible threats
Sexual behavior
Multiple partners
Unprotected intercourse
via
Sexual transmitted diseases
Recreational drugs
Cannabinoids
Cause hormonal dysregulation in women
Reduce testosterone level, sperm motility and capacitation
Medication
Anabolic androgenic steroids
Methadone
NSAI
Calcium channel blockers
Suppression of hypotalamo-gonadal axis
Depress spermatogenesis
Impairment of follicle rupture and tubal function
Fertilization failure
Anderson K et al. Lifestyle factors in people seeking infertility treatment - A review. Aust N Z J Obstet Gynecol 2010
Further clinical trials needed
To Investigate:
Environmental pollutants
Oxidative stress and role of
antioxidants
Diet
Excessive physical activity
Medication
Awareness among professionals
Roth et al., 2001
Awareness among patients
Factor
•
Knowledge of risk
Age related miscarriage risk
42%
Age related aneuploidy risk
18%
Age related IVF success rate
20%
Smoking
63%
Obesity
58%
Caffeine
74%
Gynera Fertility Center, Bucharest, 2010 - 2011
What to do?
Review current knowledge and recent meta-analysis
Provide up-dated evidence
Provide results of our recent awareness study
Make recommendations for appropriate counseling
Tool: Provide convincing evidence !
practical recommendations
Aging
For patients:
Do not defer childbearing!
For professionals:
Do not defer fertility treatment!
Do not defer IVF treatment for women over 38!
practical recommendations
Aging
How relevant is this choice?
35
Percent of infertile women
42
< 15 %
29 %
Risk of spontaneous abortion
15 %
30 %
Risk of genetic defects in newborn
1/192
1/42
Average success rate of IVF
30-40 %
< 12 %
practical recommendations
Smoking
•
•
Quit smoking!
Avoid passive smoking!
How relevant is this choice?
You will:
•Reduce the conception delay by 1 year
•Reduce the risk for miscarriage and ectopic pregnancy
•Reduce to half the number of IVF attempts required to conceive
•Delay menopause (by one to four years)
•Be healthier
practical recommendations
Obesity
Loose weight to:
•Improve ovulation
•Reduce requirement for fertility drugs
•Reduce the risk for miscarriage and other complications during pregnancy
•Look and feel better
Dilemma: Delaying treatment to allow loss of weight
practical recommendations
Alcohol
Stop drinking alcohol during pregnancy!
No safe level of consumption to avoid detrimental effect on fetal development
Avoid high consumption (>2 drinks/day) when attempting pregnancy!
No evidence to indicate that moderate consumption adversely affects fertility
practical recommendations
Coffee
Quit drinking coffee?
Not necessarily.
Just do not exaggerate!
practical recommendations
Psychological stress
Do not blame the psychological stress for everything.
This is not supported by evidence.
Add some psychologic therapy during fertility visits
Refer to professional counseling where appropriate
Avoid persisting too long with low chance treatments
Move quicker to IVF if woman is over 38 years old
What is the trend of modern lifestyle?
Older, fatter, stressed, tobacco intoxicated and infertile
but having a career and affording assisted reproduction?
conclusion
Apparently, the lifestyle factor that has the most detrimental
effect on fertility potential seems to be the social trend of
having a career before a family
We need to make people aware of the consequences
!
They could deal with both goals in a much more efficient way.
We should be able to slow down this trend.
We could do better.
Thank you