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Lifestyle and infertility. Laura dracea, MD, PhD Gynera Fertility Center Bucharest, Romania.

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lifestyle and infertility
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 SciNutr 2006; 46

lifestyle and infertility1
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
"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
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
What we do not know?

Infertility factors identified What about the other 20% ?

in 80 % of the cases

Different results of the treatment Why ?

in patients with same causes

Adjuvant medication Why not adjuvant lifestyle ?

Patients underestimate the What about professionals ?

influence of certain factors

Aren’t we missing something?

why is it relevant modifiable factors inexpensive modification
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
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
main factors
  • Deferring childbearing and aging
  • Deferring treatment
  • Smoking
  • Obesity
  • Alcohol and caffeine
  • Environmental toxins
  • Psychological stress

Infertility Increases With Age

Percent chance

Age Group (years) Percent Infertile of remaining childless

20 - 24 7 6

25 - 29 9 9

30 - 34 15 15

35 - 39 22 30

40 - 44 29 64

  • Adapted from Menken J,TrussellJ,Larsen U. Age and infertility. Science. 1986;23:1389.
  • Risk of Spontaneous Abortion with Advancing Age
  • 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

  • Adapted from P.R. Gindoff and R. Jewelewicz. Reproductive potential in the older woman. FertilSteril 1986; 46:989
risk of spontaneous abortion with advancing age
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
  • Risk of Chromosomal Abnormality in Newborns
  • by Maternal Age
  • Adapted from Maternal Fetal Medicine:Practice and Principles. Creasy and Resnick,eds. W.B. Saunders,Philadelphia,PA. 1994:71.

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 < 3535-3738-4041-4243-44

Fresh cycles 40 % 31 % 21 % 12 % 5 %


U.S. Department of Health and Human Services, Centers for Disease Control (CDC) at /

success rates of art treatment by maternal age
Success rates of ART treatment by maternal age

Review of data from the various IVF centers in the USA 2007 CDC Report

main factors1
main factors
  • Deferring childbearing and aging
  • Deferring treatment
  • Smoking
  • Obesity
  • Alcohol and caffeine
  • Environmental toxins
  • Psychological stress

Smoking vs Nonsmoking women

Relative risk of infertility increased 60% Clark et al., 1998

Increased miscarriage risk Natural conception Augood et al., 1998

Assisted conception Winter et al., 2002

Increased risk for ectopic pregnancy Saraiya et al., 1998 Conception delay over 1 year 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 as a risk factor for men

Most recent systematic review and meta-analysis

Li et al., FertilSteril 2011

57 cross-sectional studies

29,914 participants from 26 countries/regions

Sperm parameter Pooled mean difference Test for overall effect

IV 95 % CI p value

Sperm volume -0.25 (-0.32,-0.18) < .00001

Sperm density -7.07 (-10.03,-4.10) < .00001

Total sperm count -32.20 (-43.28,-21.11) < .00001

Sperm motility -1.85 (-3.27,-0.43) .01

Sperm normal morphology -4.92 (-6.90,-2.94) < .00001

Sperm abnormal morphology 0.72 (0.15,1.29) .01


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


Moderate alcohol consumption

Detrimental effects on fetal development American Academy of Pediatrics, 2001


o evidence to indicate that adversely affects fertility Parrazini et al., 1999

Higher alcohol consumption (> 2 drinks/day)

Decreases fecundity Williams et al., 2009

Can reduce semen volume Li et al., 2011


High levels of caffeine consumption (> 5 cups/day)

Decrease fertility Bolumar et al., 1997

Increase the risk for miscarriage 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
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


Industrial microwaves


psychological stress
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
other possible threats

Sexual behavior

Multiple partners

Unprotected intercourse via Sexual transmitted diseases

Recreational drugs


Cause hormonal dysregulation in women

Reduce testosterone level, sperm motility and capacitation


Anabolic androgenic steroids Suppression of hypotalamo-gonadal axis

Methadone Depress spermatogenesis

NSAI Impairment of follicle rupture and tubal function

Calcium channel blockers Fertilization failure

Anderson K et al. Lifestyle factors in people seeking infertility treatment - A review. Aust N Z J ObstetGynecol 2010

further clinical trials needed
Further clinical trials needed

To Investigate:

  • Environmental pollutants
  • Oxidative stress and role of antioxidants
  • Diet
  • Excessive physical activity
  • Medication
awareness among patients
Awareness among patients
  • Gynera Fertility Center, Bucharest, 2010 - 2011
what to do1
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
practical recommendationsAging

For patients:

Do not defer childbearing!

For professionals:

Do not defer fertility treatment!

Do not defer IVF treatment for women over 38!

practical recommendations aging1
practical recommendationsAging

How relevant is this choice?

35 42

Percent of infertile women < 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
practical recommendationsSmoking
  • 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
practical recommendationsObesity

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
practical recommendationsAlcohol

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
practical recommendationsCoffee

Quit drinking coffee?

Not necessarily.

Just do not exaggerate!

practical recommendations psychological stress
practical recommendationsPsychological 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?


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.