People often wonder whether they can try to improve fertility. While some medical issues are beyond control, the science is clear that lifestyle choices have an effect, too. Here's how individuals can promote and protect fertility - and how that can lead to improved pregnancy rates.
About this special series
This month marks the launch of ELANZA Wellness’s Whole Patient Care Initiative, in which we are drawing together a combination of clinician commitments to build patient-centric experiences with patients’ personal stories that shed light on some of the big questions about how to improve fertility care.
As part of this initiative, ELANZA is looking at five key topics that relate to the strengths and weaknesses of existing fertility services, the state of access and inclusion, patient’s expectations of care and the potential of technology to change things for the better in future. This special series of articles includes:
2. Diversity, equity & inclusion
3. Lifestyle factors
4. Patient-centric operations
5. How clinics can improve patient care
This initiative and the reports we will produce are intended to inform the global conversation about the past, present and future of fertility care.
Pre-Pregnancy Lifestyle, Diet and Fertility
Lifestyle changes in the preconception period are all focused on making our bodies healthier and our emotional state happier. There are three scientifically identified factors that influence the ability of your ovaries to produce quality eggs as you age. These are: oxidative stress, hormonal balance and energy production. All of these three factors can be influenced by the foods we eat, what we put in, on and around our bodies and our mental and emotional wellbeing.
Let's take a look at these key factors for fertility in more detail:
Oxidative stress
Oxidative stress in your cells is caused by the overabundance of molecules called free
radicals, which can cause damage to the cells in your ovaries. It can impact fertility by dis-regulating hormones, causing damage to energy-producing centers in cells (mitochondria) and by causing DNA and cell damage.
Hormone balance
Reproduction as a whole is a finely tuned process run by a sophisticated balance of
interacting hormones. These hormones work like a symphony orchestra, each playing a subtle
role in concert with the others - so if one hormone plays out of tune, it can disrupt the entire
performance. In other words, if the signals hormones send are disrupted, left unsent, or are
unable to be received at any point while your eggs are growing, your ovaries won’t receive the message to carry on with the key phases of chromosomal processing. Meaning: they may not become quality eggs.
And, achieving the right balance of hormones needed to send the right signals is harder than
you think, especially as you get older. As you age, your ovaries become less responsive to
hormone messages from the brain, leaving more opportunities for disruption.
Energy production
Your growing eggs need an incredible amount of energy to get safely through all the stages
of chromosomal processing. They get this energy from mitochondria, which are the tiny “power
plants” in your cells. As you age, your mitochondria decline both in quantity and in power supply. When there isn’t enough energy to fuel egg maturation and chromosomal processing it can result in low quality eggs. Scientists think certain lifestyle habits may protect mitochondria from or expose them to damage.
“As a clinician, I've seen plenty of women who have had undesirable results from their first egg retrieval, and then take three months to focus on specific health and lifestyle modifications before going back for another cycle. Almost every single time, the woman gets more egg retrieved and the embryos are better quality." - Dr. Jenn Shulman, Jennifer Shulman Acupuncture, New York and Los Angeles
1. Is the Mediterranean diet really linked to fertility?
Diet can have a profound effect on the maturation, development and quality of eggs. In fact, what you eat is so instrumental that some scientists believe that nearly half of all cases of infertility are due to improper nutrition.
Hundreds of studies show that specific dietary patterns translate to better fertility treatment outcomes, such as higher quality eggs, higher number of eggs retrieved increased pregnancy rates and lower risks of miscarriage - and that certain lifestyle patterns can affect the menstrual cycle and reproduction. A Harvard study reported that women can decrease infertility risk due to ovulation disorders by 80% with healthy dietary changes).
There is resounding evidence that the right foods help:
● Maintain hormonal balance
Reproductive hormones are synthesized in the body by
proteins and fats from food.
● Limit oxidative stress
A poor diet with lots of fried and processed foods can cause
oxidative stress around your eggs and ovaries, while some foods have antioxidants that
can help protect against it.
● Supply essential nutrients
Key proteins oversee DNA processing during egg maturation, many of which can only come from dietary sources.
● Regulate sleep patterns
Dietary patterns may help regulate sleep and improve sleep quality, which can affect your hormones and ovulation.
● Boost cell energy:
Compounds in certain foods fuel your mitochondria.
● Help you maintain optimal weight
A balanced, nutrient-rich diet with healthy fats can help maintain fertility-friendly bodyweight (BMI of 20-25)
● Stabilize blood sugar levels
Elevated blood sugar levels caused by foods with a high glycemic load (GL) can cause ovulatory dysfunction.
● Regulate stress
Diets low in sugar and junk food are linked to better moods. And the relationship goes the other way, too. The stress hormone cortisol triggers blood sugar and insulin levels to rise in order to give you the energy to “fight or flight” from a stressful situation. When you are chronically stressed, this can lead to insulin resistance, which disrupts the balance of hormones needed to properly mature your eggs.
So what should we eat?
The Fertility Diet created by Jorge Chavarro and Walter Willett from Harvard School of Public health is designed to boost ovulation and improve fertility. This is essentially a Mediterranean diet, focusing on vegetables, fruit, healthy fats, lean protein, nuts, seeds and whole grains, while avoiding sugars (including artificial sweeteners), simple carbohydrates, fast food, and packaged food. Try to fill half your plate with vegetables and some fruits, and avoid “empty” calories.
How to eat the Mediterranean way:
● Eat foods closest to their natural form.
● Try to get more of your protein from vegetables and fish, rather than red meat.
● Pick foods with a low glycemic load (GL).
● Mix up your meals your meals to make them richer in vitamins, minerals and
antioxidants for egg health.
● Consider taking a probiotic (namely lactobacillus acidophilus). New research is focusing on the role that vaginal bacteria could play in pregnancy and fertility treatment outcomes, too. So, it's worth making sure your diet is rich in pre and probiotic foods.
2. The "Goldilocks" body composition zone for fertility
While culturally, artistically and romantically, there’s no right or wrong amount of body fat, medically-speaking we’re on different territory. Scientists have pinpointed an optimal "Goldilocks" zone for fertility, and that's a body mass index (BMI) of 20-25.
High body fat percentage
30% of infertility has been associated with weight extremes, and infertility rates are 3 times higher in women with obesity.
The amount of body fat we have can impact reproductive systems because fat cells produce
and store estrogen, in addition to the estrogen already being produced in our ovaries. As such, the more fat cells the more excess estrogen. This can have a domino effect on other hormones, throwing them out of balance and leading to reproductive issues such as irregular ovulation. Being overweight also influences other factors that are problematic for reproduction, including stress, lack of sleep, oxidative stress and insulin resistance. Insulin resistance causes the body to release more insulin which can halt ovulation.
Research suggests that overweight and obese women are
much more likely to experience:
Anovulation
Menstrual disorders
Infertility
Lower IVF and egg freezing success rates
Higher rates of miscarriage
Pregnancy complications
Most studies show that obese women going through IVF tend to have fewer eggs retrieved, fewer mature eggs, and poorer egg quality compared to women who are not overweight or obese. The same is true for men: body fat can influence testosterone and other hormone levels that can affect sperm count and sperm mobility.
Low body fat percentage
Underweight women can often suffer with ovulation problems as well. The data suggests that having a BMI of 20 or less also comes with a higher risk of infertility and pregnancy complications.
Women with a BMI under 20 are more likely to have:
Ovulatory disorders
Higher risk of miscarriage
Ovarian dysfunction
Pregnancy complications such as preterm birth
This happens partly for the exact same reason as for high body fat percentage: key sex hormones like estrogen are produced and stored in fat cells. So, just as heavier women produce excess estrogen, women who have less of what’s been coined “sex fat” (tissue where sex hormones are stored) can experience lower-than-optimal estrogen levels.
Being very slim can also inhibit the production of other key fertility hormones such as
leptin, which is thought to give ovaries the green light to function. This is most likely because leptin plays a role in the regulation of energy balance (how many calories you eat, burn and store as fat) and is produced and stored in fat cells. So, when fat cells are in short supply, leptin signals to your body that the conditions are inadequate for reproduction.
Gradual changes are best
The good news is that even a 5% reduction in weight has been shown to improve fertility.. But It’s important not to try to make drastic lifestyle changes overnight, as this can put your body under a great deal of stress. For example, if you are severely overweight or underweight, a 20% rapid gain or loss in the opposite direction could cause menstrual irregularities and cause a hormonal imbalance. Taking your time to make healthy and steady lifestyle changes that are sustainable over time is by far your best strategy.
BMI
There are plenty of free online BMI measurement tools that can help see if you fall into a fertility-friendly bodyweight.
BMI is a notoriously tricky thing, of course, which is why sometimes it's more practical to talk about body fat percentage. You can discuss this with your own doctor, or you may wish to talk to a qualified nutritionist, dietician or naturopath.
"Having structure with meal planning will help you if you are struggling with weight gain and weight loss. This will be a great way to create a foundation for if and when you do seek to get pregnant. I also encourage women who struggle with eating too much and too little to adopt a few techniques that stem from the practice of mindful eating on listening to hunger cues (feeling full or hungry), eating slowly without distractions, and appreciating your food.” - Elizabeth Stanway-Mayers, Clinical Dietitian, Stanford University Medical Center
3. Smoking, Drugs, Caffeine & Alcohol
Alcohol
When it comes to the impact that alcohol can have on IVF success rates, most studies
indicate that alcohol is fine to a point. However, the point at which negative repercussions appear varies from study to study: one study indicates that up to 12 grams of alcohol per day is fine (the standard American drink is 14 grams!) and others say that fewer than four drinks per week is ok. Another concluded that women who drank more than seven drinks per week were just two percent less likely to have a live birth per cycle than non-drinkers, so the difference may not be big enough to be significant.
Smoking
One of the most colossal changes you can make for your short and long-term fertility is to
quit smoking. It can reduce fertility by 60%. It’s linked to:
Irregular periods
Diminished ovarian reserve
Earlier menopause (one to four years earlier)
Every year of smoking has been shown to increase the risk of unsuccessful IVF by up to 9%
Risk of miscarriage increases by 1% per cigarette smoked per day.
Lower egg quality in IVF
Lower implantation rates
More cycles with failed fertilization compared to non-smokers. This is also supported by research showing that women who smoke are more likely to conceive a chromosomally unhealthy pregnancy (such as a pregnancy affected by Down syndrome) than non-smoking mothers.
One culprit is a group of chemicals called polycyclic aromatic hydrocarbons (PAHs) found in
cigarette smoke are known to accelerate the destruction of your eggs by causing DNA damage to the ovarian follicles, where the eggs normally develop to maturity.
It’s unclear how much of the damage is reversible but one large study showed that when
women stopped smoking, the risk of earlier menopause decreased. What is clear is that the sooner you quit, the better it is for your fertility.
The same goes - to a lesser degree - for secondhand smoke, vaping and e-cigarettes.
DOCTOR INSIGHT: “Smoking is one of the worst things for egg quality. Stop sucking on the egg killers is what I tell my patients. Describing how nicotine levels can literally be measured in a smoking woman's ovaries is a quick way to get someone to quit.” - Dr. Aimee Eyvazzadeh, Private Practice Physician, San Ramon
Caffeine
It used to be thought that caffeine had a purely harmful effect on fertility, but as more data
from large studies has emerged, conflicting results have made the link less clear - with some
showing no negative impact at all.
The key might lie in the amount of caffeine consumed. The present thinking is that while
low to moderate caffeine consumption has not been shown to have a negative effect on fertility
treatments, moderate to high intake could be harmful to your eggs. Support for this comes from studies in which women who consume large amounts of caffeine have been shown to experience:
Longer time to get pregnant
Increased rates of miscarriage
Higher rate of spontaneous abortion
Higher rate of fetal death and stillbirth
Decrease in quality embryos.
The rates seem to rise the more we drink - over four cups being problematic.
The exact biomechanics of caffeine’s impact on fertility are still unknown; however, there
are a few passageways that can offer us clues. First, caffeine magnifies your body’s stress
response, raising blood pressure and noradrenaline even at rest, which could have a knock on
effect to reproductive hormones. Second, when you drink caffeine close to mealtime, it can interfere with your body’s ability to absorb key minerals like zinc and iron from your food. It’s also theorized that high amounts of caffeine could restrict blood flow to the ovaries and womb, though this could also be due to some other substance present in coffee but not in other caffeine sources such as green tea.
Cutting it out completely is not considered necessary. Instead, doctors commonly advise to limit caffeine consumption to one to two cups per day - around 200mg of caffeine.
Overall:
Quitting smoking will likely have benefits for fertility outcomes
There's evidence to suggest limiting caffeine consumption, try naturally caffeine free teas.
There's also evidence to suggest limiting alcohol consumption - if you do drink, opt for red wine with a low GL meal.
4. Toxins
Many scientists now believe that the vast and growing use of noxious substances in the typical modern home and workplace could be partly to blame for the widespread decline in fertility for both women and men. These so caled "endocrine disrupting chemicals" (EDCs) have the ability to disrupt reproductive
hormones and to damage maturing eggs.
Hazardous chemicals to your fertility can be found in your cleaning products, kitchen
tools and beauty products. There are also strong links made between pesticides, preservatives and other chemicals in our daily environment.
Some of the most well known chemicals to cause reproductive damage are:
○ BPA - found in plastics, canned food containers, feminine hygiene products
○ Phthalates - found in plastics, medication coatings, cosmetics with fragrance
○ Parabens - found in cosmetics, toothpaste, processed food, face and hair care
products
○ Pesticides - found in drinking water, “dirty” foods, air supply near agricultural
areas
○ Heavy metals - Found in cigarettes, pollution, high mercury fish, household dust
BPA
One example is BPA - most famously known as the “gender-bending” chemical due to its effects on male breast growth (or, as you might know them, “man boobs”) and reduced penis size in newborn male infants. But more on the subject of you, BPA exposure is consistently linked to negative reproductive outcomes such as fewer eggs retrieved, fewer mature eggs and fewer fertilized eggs for women undergoing IVF. In fact, 139 different research studies indicate that BPA disrupts the egg maturation process and reduces egg quality.
Here are some simple changes to make to start reducing exposure:
● Get a water filter
● Throw out old and scratched plastic items
● Replace plastic Tupperware with glass
● Don’t heat up plastic
● Don’t consume foods from cans - BPA is often found in the lining of cans.
● Say no to printed receipts - Thermal paper is often coated with BPA.
Avoid products with fragrance or perfum - look for labels that say “phthalate-free”
or “no synthetic fragrance” instead.
● Ditch fast food
● Reduce consumption of foods packaged and stored in plastic - and swap out plastic containers for glass or stainless steel
● Buy organic food, if possible
5. Sleep
Getting enough good quality sleep is important in the buildup to your egg freezing
procedure because of the direct and indirect impact it can have on reproduction. You’ve
probably read quite a lot about poor sleep affecting all sorts of things from your likelihood of
developing diseases like Alzheimer’s, to your productivity at work, even how long you’re likely
to live! We all know that feeling of being “drunk at the wheel” at our desk if we spent the night
tossing and turning.
Sleep disorders are linked to:
Menstrual irregularities
Heighted PMS symptoms
Increased time to conception
Reduced likelihood of
conception
Increased chance of miscarriage
Lower birth weights in newborns.
The main reason scientists deem sleep so important for reproduction is that sleep is a
hormonal process. The same area of the brain that regulates sleep-wake hormones (including
melatonin and cortisol) also triggers reproductive hormones. For example, progesterone,
estrogen, leptin, and follicle stimulating hormone (FSH), which are involved in processes
required for egg quality, are among the hormones released during sleep. In fact, luteinizing
hormone (LH) - the production of which is thought to be the event that initiates puberty - is only
released during sleep.
Getting 7-9 hours per night is ideal, but scientists say it's not necessary to be asleep consistently during that time in order to be getting good quality sleep, contrary to common assumptions.
6. Exercise
No matter what your current fitness level, moderate exercise is thought to benefit your
hormone profile and reproductive function. People who exercise moderately have been found to have better fertility treatment outcomes than those that do too much exercise without replacing the calories they expend or people who never or rarely exercise.
How moderate exercise helps boost fertility:
● Improves blood flow to your reproductive organs
During the ovarian stimulation
phase, blood flow is one of the things your doctor will assess when scanning your
ovaries. That’s because good, oxygen-rich blood flow is vital for the growth process of
the follicles that contain your maturing eggs. Good circulation is thought to have a
positive effect on egg quality and success rates in ovarian stimulation. Experimental data
has linked the number of eggs retrieved and the quality of eggs retrieved to ovaries with
good blood flow.
● Reduces oxidative stress
Intense exercise generates a lot of free radicals, more than
your body’s antioxidant levels can balance out. But when you exercise in moderation,
your body’s antioxidant levels are able to rise enough to neutralize the damaging effects
of free radicals and to protect against future attacks, particularly within the ovaries.
● Helps maintain a healthy level of body fat
Women who are on the heavier side have a pregnancy rate that is 30%-75%
below that of women who are not.
● Helps manage insulin levels
High blood sugar levels can significantly decrease both the quantity and quality of eggs retrieved in your egg freezing cycle. But research shows that moderate exercise can help improve insulin sensitivity and glycemic control.If you fall into the obese category, even a modest session of exercise is shown to improve insulin sensitivity.
● Helps manage stress hormones
First of all, the process of egg freezing itself can be stressful so anything you can do to regulate that will help. In addition, moderate exercise can help you manage the hormonal shifts that occur as a result of chronic stress. This is important because it can interfere with normal reproductive hormones required during the egg maturation process.
● Acts as a counter to depression, and enhances mood
When you exercise, your brain chemistry changes through the release of endorphins, which can quell anxiety and can help counter depression. Experts have even likened it to a form of meditation, giving you a sense of optimism, calmness, and clarity. All of which will support your psychological wellbeing throughout the egg freezing process. Even just going for brisk
walks can help you reap many mental health and mood enhancement benefits.
● Promotes better sleep
Engaging in low to moderate intensity exercise can help you improve both the quality and quantity of your sleep. A meta-analytical review of 66 research studies revealed that even just one moderate workout session can increase total sleep time, reduce the time spent getting to sleep, increase overall sleep efficiency and can increase the amount of REM sleep you get at night. As you’ll discover in the next chapter, a sufficient amount of good quality sleep offers a host of reproductive benefits.
The key word is moderation. Over-exercising (too frequently, intensively or for long periods of time) can impact fertility, as can no exercise at all.
Exercising moderately for three to five times a week for 30-60 minutes can support your
reproductive functions, especially if you are overweight.
● Make sure you are consuming more than enough healthy calories offset your daily
energy expenditure.
● Extreme exercise can have a negative effect on your fertility, especially if you have a
low bodyweight or if you are suddenly increasing the duration, frequency or intensity of
physical activity.
● Remember to run your exercise regimen past your doctor, in particular if you are very
active or if you are going to start introducing physical activity after a period of being
sedentary.
7. Inflammation, Infection & Medications
The CDC estimates that nearly half of American adults have mild, moderate or severe periodontitis, a gum condition that damages the soft tissue and destroys the bone that supports your teeth. Gum disease could mean deeper problems than just the superficial: it's been suggested that certain dental problems could equal inflammation, which could equal fertility issues. Researchers recommend that women of child bearing age should have regular
preventive dental check-ups in order to maintain good oral and periodontal health.
Some medications, infections and chronic diseases can impact fertility - especially inflammatory diseases. However, it's not as simple as solving that with an anti-inflammatory! Preliminary research shows that anti-inflammatories like ibuprofen are capable of disrupting ovulation. If you are currently taking a medication, particularly a prescription drug, never stop taking it without talking to your doctor first. Make sure to review your entire medication list with your fertility doctor in case anything may interfere with the fertility drugs and your hormones and impact the success of your cycle. It's generally advised to avoid recreational drug use because the harmful effects are not fully understood.
Note that there are some supplements that have shown a link to improved fertility, hormone balance and a reduction in oxidative stress caused by free radicals. Read more about these supplements here.
In summary:
Three to four months before starting an ovarian stimulation cycle is a good, solid
amount of time to get fertility fit and get your ovaries in peak performance.
In general, the sooner you start making these changes the better. Even if you only have a
short period of time, doing something is better than doing nothing.
If you’re medically considered overweight or underweight, or if you’re a smoker,
consider addressing these key lifestyle factors in good time before your egg freezing
cycle.
Focus on sustained changes over time rather than sudden, drastic ones, as these could
even be counter-productive for your fertility. i.e. don’t launch into the cabbage soup
diet!
Fertility doctors are working with ELANZA to improve lifestyle education during fertility treatment
Several clinical studies have assessed the efficacy of interventions designed to help people better prepare for fertility treatments with beneficial lifestyle changes:
Making some healthy lifestyle switches may improve fertility as observed by several research teams
However, lifestyle changes are difficult to achieve and to maintain due notably to behavioural factors.
ELANZA's digital coaching platform blends a proprietary combination of behavioral coaching, cognitive behavioral therapy tools and support groups that aim to benefit patients in similar ways. It helps patients with problem-solving strategies in a supportive environment and helps with daily habit building to make the process of making beneficial lifestyle changes easier.
As an independent source of support – working in respectful parallel with clinical teams, but also separate from them – ELANZA makes it easier to see counseling and community as a separate entity to turn to with non-clinical questions in their journey of coping with infertility and makes it easier to convey confidentiality to patients.
Additionally, our exclusive Clinic Directory listings provide patients with an easy and reliable way to connect with clinics that have committed to a Whole Patient Care philosophy.
Fertility clinic? Learn more about getting listed on the directory here.
More Resources on Diet, Lifestyle and Fertility
Key researchers and leaders in this area:
Dr. Jorge Chavarro, Harvard Medical School
Media on the Patient Experience of Fertility Care:
Read this article titled "Follow the Fertility Diet?" by Harvard Health Publishing
Watch this video "Nutrition and Fertility: What's the link?" - ELANZA interviewing Professor Greg Anderson
Watch this video on "Environmental Toxins: 1 Simple Way to Improve Fertility" - ELANZA and Dr. Diana Chavkin in conversation
Have you signed the Whole Patient Care Pledge?
Celebrate your commitment to patient wellbeing - take five minutes today to join the free ELANZA Wellness Whole Patient Care Initiative. Sign the pledge to unlock your certificate and opportunities to list your services on the ELANZA directory.
