Fertility requires the sperm and eggs to be very healthy. Let's look at factors which can influence the health of eggs and sperm. Some factors can be modified by changing behaviors; others can't.
Unfortunately as men and women age, both the sperm and the eggs are less able to form an embryo that can implant and form a normal offspring. A poor diet and poor lifestyle habits can worsen this process, or even cause poor egg and sperm quality in younger individuals. In the past, the marked reduction of fertility with age was attributed only to the female, but in large studies in which it has been possible to control for female age, and in studies of recipients of eggs from young egg donors, successful pregnancy was found to occur less often as the age of the male partner increases. Some exciting new findings outlined below indicate possible ways that judicious use of supplements may rejuvenate older sperm and eggs.
The testicles and ovaries need a good blood supply, which brings more nutrients, oxygen and hormones so that their functions can be optimized. For example, in the male, two agents known to increase nitric oxide, and therefore blood flow, increased the level of testosterone in the bloodstream and also significantly improved semen volume, sperm numbers, sperm motility, and sperm morphology. Testosterone production within the testicles is an important stimulator of normal sperm production. In the female, blood flow to the ovary correlates with the number of eggs that develop when the ovary is stimulated as well as the quality of the egg. Thus the chance of it initiating a pregnancy has been correlated with the blood supply surrounding the structure containing the egg and its nourishing cells, the granulosa cells.
The specific regimen that improved testicular function was a combination of 3 grams daily of L-arginine and 80 mg of pycnogenol. L-citrulline at a dose of 2 grams per day raises the circulating levels of L-arginine more than 3 grams of L-arginine and therefore should have the same or a greater effect because it also acts as an intracellular source of L-arginine. These two agents increase the production of nitric oxide, which increases blood flow by relaxing the arteries supplying nutrients, oxygen, and hormones to the testicles.
The antioxidant capacity of the semen and of the fluid and cells surrounding the egg decreases with age and is lower in individuals with poor sperm and egg quality. Potent oxidants increase with age and accumulate from eating foods cooked at a high heat such as with grilling and barbecuing and with higher blood sugar levels, as with obesity or excessive sugar consumption.
In the male, oxidation products correlate with poor semen parameters, particularly motility, and also correlate with fragmentation of the sperm DNA. Sperm require high levels of antioxidants in the surrounding seminal fluid because as they shed most of their cytoplasm to make them more motile, they lose their normal intracellular antioxidant defenses.
In the female, oxidation products correlate with less viability of the granulosa cells which surround and nourish the egg. In studies of in vitro fertilization, poor viability of those cells correlates very strongly with poor egg and embryo quality and pregnancy outcome.
Examples of potent antioxidants are berries, green tea, red wine, chocolate, and a commercial antioxidant called pycnogenol. However, for the female, we do not recommend chocolate, because of its content of caffeine, or wine due to the alcohol. Men desiring fertility also would be best to avoid or minimize alcohol intake. For the female we suggest only one cup of decaffeinated green tea per day, but the absorption of antioxidants can be markedly enhanced by adding 50 mg of Vitamin C to each cup. In the male, high doses of vitamin C and vitamin E may be helpful to minimize fragmentation of the DNA of the sperm. Sperm fragmentation increases with age, particularly over age 40, and is correlated with low antioxidant capacity of the semen. In a well-designed study, 1000 mg of Vitamin C and 1000 mg of Vitamin E decreased the percentage of the sperm having fragmented DNA from 22% to 9%, whereas it was unchanged with placebo. Most likely these benefits would also be seen with other potent antioxidants such as pycnogenol. Because the antioxidant capacity of 1000 mg of vitamin C is similar to that of 40 mg of pycnogenol, a dose of 40-60 mg of pycnogenol could logically be substituted if someone prefers not to take this large dose of vitamin C or experiences heartburn with such a high dose. Long term ingestion of 400 IU or more of vitamin E has been implicated in reduced overall health. Although no short term adverse effects would be expected with 1,000 IU, one could reduce the vitamin E dose to 200 IU and substitute 40-60 mg of pycnogenol.
CAUTION: If you are taking aspirin at any dose we do not suggest taking vitamin E. Vitamin E increases the effects of aspirin on blood clotting (women are often advised to take a baby aspirin per day during an IVF cycle and older men sometimes take aspirin for protection against heart attacks). A better diet with more antioxidants, fruits and vegetables and less meat, dairy and processed products has also been correlated with better semen quality.
Both the sperm and the eggs require a very high level of energy production. For the sperm, energy is needed for motility. For the egg, energy is needed for the proper segregation of the chromosomes and to expel one of each pair so that they can match up with the 23 chromosomes of the sperm to yield the 46 chromosomes of the adult cell. Disruptions of that process result in a higher miscarriage rate and contribute to the lower success rate of older couples. A high level of energy is also required for cell division into an embryo and by the rapidly dividing embryo. The egg has very high levels of energy-producing mitochondria, and oocyte mitochondrial DNA increases enormously during follicular growth. Co-enzyme Q-10 is critical to the transport of electrons and protons involved in the chemical reactions that drive ATP and therefore energy production by the mitochondria. This mitochondrial nutrient has been shown to reverse the effects of aging on eggs of older female rats, including leading to improved chromosome segregation. Although not yet evaluated in the older female to improve fertility, supplements of Q-10 have been used in a number of other studies with no side effects or adverse events being reported. Q-10 has also been reported to increase sperm motility. However, a recent study on older animals has shown that the defect of the mitochondria of their older eggs was passed on to their offspring. This indicates that there could be metabolic consequences for the offspring of achieving pregnancy at an advanced age.
Excess body weight has major effects on ovulation but relatively minor effects on sperm quality. Only recently has it been fully realized that weight also decreases the chance of pregnancy and increases the chance of miscarriage even if a woman is ovulating. In a study of almost 50,000 cycles of IVF, women were classified as overweight, or having class I, II, or III obesity. The odds of pregnancy, live birth and preterm birth were:
BMI > 39.9
< 32 weeks
*1.0=normal rate of pregnancy, live birth and preterm birth
**proportion of pregnancies resulting in live birth
Excess weight is a factor that should be attended to when you first start to attempt conception. If you do a brisk 30 minute walk every day and eliminate 200 calories from your food intake, you will lose 30 pounds per year. At lifechoicesandfertility.com you can download "Learning to Survive in a Health-Hostile Environment" and it will have many helpful hints regarding weight control. If you do require fertility treatments your chance of success will be higher. By the time you might need IVF you will have lost 60-90 pounds and your success rate could be maximized. Your pregnancy will be less complicated and your health will be better for many years to come.
Do not try to lose weight while you are pregnant. That could result in poor growth of your baby and even a loss of I.Q. points. However, women who are overweight can gain less weight during pregnancy than women who have a normal weight, without adversely affecting the offspring. Ask your OB how much weight you should gain based on your pre-pregnancy weight.
You must not be on a high protein diet when attempting to conceive. A high protein diet has been correlated with decreased fertility in animal studies. The higher concentration of ammonia found in reproductive tissue may inhibit embryo development and cause abnormal gene function.
Exercise has only positive effects for the male, but in one study from Harvard, more than three hours of aerobic exercise per week for the female was associated with a reduced pregnancy rate with IVF. Until this is clarified by further studies we suggest only the standard 30 minutes of moderate exercise (such as a brisk walk) most days a week that is advised for good general health. It is possible that the stress on the body of greater degrees of exercise may add together with the stress of infertility and produce an adverse effect. This may only pertain to the most advanced fertility treatment involving IVF.
There has been relatively little study of the effects of the environment on fertility. It has long been known that lead, cadmium and some pesticides adversely affect sperm quality, and a recent study suggested that having a cell phone in a front pants pocket transmitting to an earpiece may influence sperm quality through cell phone radiation. A recent study correlated the levels of bisphenol-A, which is an endocrine disruptor that leaches out of some plastic water bottles (avoid plastic recycle number 7), with reduced ovarian response to stimulation.
Smoking has major adverse effects on both sperm and egg quality. With female smoking, natural fertility is decreased and the chance of successful pregnancy with IVF is decreased by 50%. Although one would assume that the effects would be lesser in degree, second-hand smoke was found to have a similar effect on the outcome of VF compared with smoking. The effect is not only on egg quality. Recipients of egg donation who smoke also have a significantly lower pregnancy rate. In the male, smoking increases sperm DNA fragmentation, which can increase miscarriage and may help to explain why male smoking decreases IVF success by a third, even when a sperm is directly inserted into each egg. Female smoking also increases miscarriage. Exposure of infants and young children to second-hand smoke increases asthma, bronchitis, pneumonia, ear infections, and sudden infant death syndrome.
Alcohol also reduces fertility in both partners and alcohol intake by the male may increase miscarriage. In one study small amounts of caffeine and alcohol appeared to have additive or even synergistic effects in the female. As with most adverse life choices, the effects appear to be greater with the more advanced procedure of IVF. With the exception of couples just beginning to attempt conception, avoiding alcohol will give them the greatest chance of being successful.
Caffeine intake does not appear to affect male fertility unless it is excessive (over 3 cups of caffeinated coffee per day). However, female fertility is influenced to a greater degree, with moderate amounts reducing fertility and any significant intake reducing the success with IVF. Caffeine should not be used by pregnant women as it has been associated with miscarriage.
Frequency of intercourse certainly is very important in attempting to conceive. The recommended frequency is every one to two days around the expected time of ovulation. Frequent ejaculation may also be helpful before IVF or ICSI by decreasing sperm DNA fragmentation. More frequent erections may also decrease the later development of erectile dysfunction (ED). In a study of men aged 55 to 75, a two-fold incidence of ED was noted with less frequent intercourse. The stress and performance anxiety involved in timing intercourse to the time of ovulation may worsen erectile performance. The web site www.erectile-function.com gives many recommendations that are highly successful in improving erectile function. There is some overlap between decreased fertility and decreased erectile function because increased blood flow, better lifestyle choices, and improved nutrition benefit both functions.
Although there have been many empirical suggestions to try to improve the contact of sperm with cervical mucus before and following intercourse such as placing a pillow under the buttocks, there have been no studies to substantiate such effects, and sperm have been found in pelvic fluid within five minutes of being placed on the cervix. Nevertheless, it is usually recommended for the female to remain lying down on her back for 15-20 minutes to maximize sperm migration. Likewise although vaginal lubricants theoretically may interfere with sperm viability there have been no actual studies to show such an effect with intercourse. There is a product that has no adverse effects on sperm (PreSeed) that is commonly recommended when a sexual lubricant is needed and is available at some local pharmacies.
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, 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. One study showed that certain individuals are more vulnerable to stress. 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.
Perhaps the most effective to reduce stress is a mind-body class which helps to not only reduce stress, but also to teach relaxation techniques and cognitive realignment, giving the couple the belief they can succeed rather than feeling they are doomed to failure. Traditionally a mind-body program consists of a series of classes which, in today's busy world, can be very difficult for couples with demanding jobs and busy lifetyles. Now there is an exciting online alternative: In 7 weeks, the Fertility Within Home Study Course can transform your relationship with stress in ways that are clinically proven to improve pregnancy rates.
It should be apparent from the above discussion that there are many lifestyle choices a couple can modify to increase their chances of being successful. Ideally these should be altered when beginning to try to conceive, but all of these factors become progressively more important as the fertility treatments become more involved. Also keep in mind the changes you are able to achieve will improve your general health for many years to come.
You can see a more thorough discussion of these issues with references at www.lifechoicesandfertility.com. We have added a discussion for each study so you can appreciate the evidence behind my recommendations.
David R. Meldrum, MD,
Scientific Director, Reproductive Partners Medical Group,
Redondo Beach, CA,
Clinical Professor, UCLA and UCSD
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