Associations Of Healthy Lifestyle Factors With Infertility Risk

The global burden of infertility affects millions of people and affects a wide range of clinicians and individuals and their families planning or struggling to have a family. Infertility, less common and more complex than most health conditions, is influenced by a multitude of exposures that do not occur in isolation. Rather, the cumulative effect of lifestyle and other exposures over time best predicts the outcome of fertility. Modifiable daily habits that affect reproductive health are clearly outlined in this book. For health practitioners, “lifestyle work” is fundamental to good preconception health whether the couple is hoping to conceive naturally or require assisted reproductive technologies.

Why It Matters

Infertility affects more than just your health it affects almost every aspect of your life, including your emotional and psychological wellbeing, your relationship with your partner, your financial situation and your long-term health. Stress about your infertility and its treatment can also have a direct effect on your mental health and wellbeing. The process of dealing with infertility can be long drawn out causing stressful emotions to be carried into and out of work affecting other family members. Even mild stress can impact lives and treatment for infertility can intensify the stress load. Not only is the stress and pressure intense and often unbearable but it is also transferred to and from the treatment itself, often with very costly results in terms of money and missed days of work searching for that elusive pregnancy and successful birth.

There is a surge of demand for evaluation and treatment of infertility placing a considerable burden on the health system and payers, in terms of referrals, imaging, tests, and visits to reproductive health specialist physicians. From a broader public health perspective, challenges of infertility and delayed childbearing also impact programs aimed at promoting healthy pregnancies, preventing maternal morbidity and optimizing the health of newborns and mothers. Improving the preconception health of women and men with infertility can address significant challenges in these domains with substantial returns.

Lifestyle factors are actionable prevention targets

Lifestyle habits that are modifiable, such as tobacco use, alcohol and caffeine intake, body weight, sleep, reproductive behaviors, use of medications/supplements that can affect fertility and/or reproductive health, and diet quality, are commonly discussed with patients in primary care and other settings. Counseling patients on healthy lifestyle habits can not only improve fertility but also reduce risk for multiple cardiometabolic diseases, enhance mental health, and reduce risk for certain pregnancy complications. From the patient’s perspective, even small gains in several of these areas can improve reproductive health. Therefore, clinicians must frame messages about healthy lifestyle habits within the context of fertility.

The reproductive cells are maturing over weeks to months, not days or weeks, and the male’s recent smoking habits, recent frequency of sexual intercourse, recent nutritional intake and recent beverage intake may take months to detect changes in. Women’s ovulation and early embryo metabolism are even more sensitive to maternal metabolic and hormonal stability, and can change more slowly than the typical weight change rate (0.5 to 1 kg/week). Patients who are trying to conceive are at their best emotionally and can be extremely disappointed by what they perceive as “poor” nutrition, sleep and/or sedentary behaviour or slow weight loss. Clinicians need to be able to educate their patients regarding the long timeframe that is necessary to see changes in reproductive outcomes secondary to making lifestyle modifications.

Behavior change is not one-size-fits-all

Describing to patients how to translate lifestyle associations into practical action is one of the hardest things I do. People have fixed budgets, finite time, and an unrelenting to-do list that often seems to consume every waking moment. That’s why they walk out of my office fully aware that a healthy diet includes produce and seed oils, armed with the latest scientific evidence on the benefits of exercise, yet unable to afford these healthy options. It costs too much, or it takes too much time to make, and they’re out the door. Or, the challenge is that patients are already pushing up against their limits in ways that negatively affect their circadian rhythm, ovulation, insulin sensitivity, and stress hormones because they are sleep deficient through consistent night shift work. Then there are the couples in their late 30s and early 40s who know the clock is ticking for age-related decline in fertility, and must weigh maximizing lifestyle interventions with the need for swift evaluation and treatment.

During the counseling of patients with risk factors for infertility, it is important for the healthcare provider to assess how to best integrate messages about lifestyle modification into the patients and their partners’ reproductive planning and personal goals. Some individuals will benefit from defining a “lifestyle optimization window” (8 to 12 weeks) during which they can attempt to improve aspects of their medical or recreational behaviors before proceeding to more costly and invasive diagnostic and therapeutic treatments. Others may be counselled to simultaneously attempt to modify unhealthy behaviors while beginning their timely diagnosis and treatment. Establishing a framework by which to organize these efforts is crucial in order to avoid either delaying or overly promoting potential for successful treatment.

Equity must be part of the conversation

Lifestyle counseling has the potential to either decrease or increase health disparities depending on how it is delivered. Suggesting patients have time, money, access to a variety of healthy foods, and safe neighborhoods to increase healthy lifestyle behaviors can be unrealistic or dissuading for many patients. Discussing fertility with patients can add unwanted social pressure to become a parent for patients who do not desire children or who are already experiencing feelings of guilt and failure for not becoming parents when they had desired to do so. Lifestyle counseling can be most effective by combining health advice with strategies to support patients in making changes, using a culturally relevant approach to address barriers to health behavior change, and making appropriate referrals for mental health treatment.

Who It Affects

The primary target audience for this poster is people or couples trying to conceive. This could be a woman, a man, or couple of any age and background. While fertility is not the property of one individual it is usually a couple who share the lifestyle and environment that contributes to their reproductive health. Even though one partner may have a diagnosed factor affecting their fertility, both partners could be optimising their sleep, nutrition and substance use in order to conceive, have a healthy pregnancy, and optimal long-term health for themselves and their new family.

Women and people with ovaries

For women, lifestyle factors can impact reproduction at different stages in the menstrual cycle, including ovulation, egg quality, implantation and hormonal regulation. Cigarette smoking is recognized as a reproductive health danger to both women and men, reducing chances of conception. Similarly, moderate alcohol consumption has been linked to decreased fertility in women, while heavy or binge drinking appears to have a negative impact on women’s cycles and hormonal balance. When it comes to weight, both under- and over-nutrition have been shown to have a negative impact on ovulation in women. Surprisingly, even normal weight women can become “obese” from a reproductive standpoint, putting them at risk for ovulatory dysfunction, insulin resistance, and increased inflammation that impairs fertility.

In terms of overall diet quality, studies suggest that consumption of a healthy diet that is rich in vegetables, fruits, legumes, whole grains, fish and unsaturated fats is associated with favorable reproductive health markers. This is in contrast to a highly processed diet rich in added sugar that impairs fertility.

The topic of sleep and stress could also be explored. As individuals or couples face busy schedules, mental health issues such as depression and/or anxiety, sleep and stress can become major concerns. As we discussed with poor sleep inducing insulin resistance stresses, stress can have a profound effect on sexual function, relationship satisfaction, and attempts to live a healthy lifestyle. While stress may not cause infertility, it is not irrelevant to those experiencing infertility. Stress can interfere with adherence to medical treatment, can interfere with behaviors that are healthy for those trying to conceive, and can color the experience of family building.

Men and people with testes

For men, the sperm quality factors can include overall health, substances that he is exposed to (such as toxins, cigarettes and recreational drugs), temperature, current or past medications and supplements. Smoking and excessive drinking of alcohol can decrease quality of both semen and increase oxidative stress. Anabolic steroids and many of the current products touting to increase testosterone can have a very negative impact on sperm production and also cause long term infertility. Similarly, men who use hot tubs or saunas frequently may have poor quality of sperm. Research on cannabis is still emerging, but studies are indicating decreased sperm parameters and negative effects on testosterone.

Men’s fertility receives little attention compared to that afforded to women’s. Early assessment of the male can avoid unnecessary investigation and delay diagnosis of decreased male fertility. An accurate semen analysis, understanding of a man’s medical and recreational drug history and consideration of sleep, weight and medical status all provide critical insight into potentially modifiable factors affecting his fertility. Improving these factors not only benefits the man’s health but also is associated with optimal health for the mother and the developing baby, such as proper embryo development and some pregnancy outcomes.

Whether traveling for business or leisure, such as individuals with unique dietary requirements, couples in wedding parties, people recovering from illness or injury, convention-goers, groups visiting on special occasions or families with infants.

Many of our clients are seeking to start a family, and may be impacted by a chronic health condition such as obesity, PCOS, diabetes, thyroid disease, endometriosis or a mood disorder. Often their health condition affects their fertility and will need to be considered when developing a lifestyle plan. PCOS is the most common endocrine related fertility problem in women, and is frequently associated with insulin resistance and ovulatory dysfunction. Therefore nutrition, physical activity and sleep can be major considerations for PCOS women wishing to become pregnant. Women with thyroid disorders are at risk of ovulation problems and poor early pregnancy if they have untreated or poorly treated hypothyroidism or hyperthyroidism. Similarly women with diabetes or metabolic syndrome are at risk of hormone imbalances or serious pregnancy complications if they have poor control of their blood sugar levels. In many cases it would be helpful to work with the client to achieve the best possible control of their condition before they attempt to become pregnant.

Medication review is an important component of preconception care as some medications can effect fertility and/or maternal and fetal health. Certain medications for acne, anti-epileptic medications, mood medications, or hormonal therapies may require a taper down prior to conception rather than a simple discontinuation. We can work with our patients to find optimal medical therapy that will not compromise their health at conception or in pregnancy.

Clinicians, health systems, payers, and policymakers

Dietitians, pharmacists and therapists can play an important role in translating advice to patients and families in order to promote healthy lifestyle in order to maximize fertility. Many healthcare professionals are involved in the care and counseling of individuals and couples with infertility, including primary care physicians, obstetrician/gynecologists, reproductive endocrinologists/androgologists, urologists, family medicine physicians, and a variety of behavioral health professionals. Health systems and payers are also key stakeholders as their coverage decisions can support or deny patients and families access to evidence-based reproductive health messages and programs that will help them maximize their fertility as well as overall health.

What Changes

1) Counselling should include a structured preconception lifestyle assessment as standard practice for all women of childbearing age.

All patients with reproductive potential who wish to become pregnant or are taking medications/supplements that could potentially hinder conception should be offered a brief preconception evaluation. Screening patients for preconception health factors using a standard preconception checklist is helpful. These factors include tobacco/vaping and caffeine use; alcohol and cannabis use; sleep duration and sleep quality; diet pattern; physical activity; history of obesity/underweight; workplace exposures and recreational activities that may put men at risk of heat illness; current medications/supplements and contraindicated medications/supplements that the patient is currently taking that may not be safe in pregnancy; and mental health status. Patients may not volunteer this information unless specifically asked about it, and patients need to understand that preconception counseling is supportive and nonjudgmental. All patients should also be screened for basic reproductive health knowledge, and simple, standardized messages should be provided for patient education regarding preconception health.

In the documentation of risk factors, guidance for counseling should be translated into specific actions that health care providers can take, such as a brief intervention, referral, and follow-up date, or a shared decision with the patient to start the evaluation. Risk information should not be presented in a form that cannot be applied.

2) Provide realistic and timely family building options that respect the couple’s specific fertility window.

Patients will thrive on a roadmap for success. A first period of improvement of 8 to 12 weeks with clearly defined goals is recommended during which patients should stop smoking, limit their alcohol intake to minimal amounts, establish a consistent sleep pattern, and a high fiber, low processed food diet. This time frame is ideal for sperm production in men and cycle regularization and metabolic parameter stabilization in women.

Consider how you are going to set up a plan for when to refer for evaluation in order to avoid delay. Leaving it to couples to refer for evaluation “when they are ready” is completely inappropriate and insensitive. Some couples will need to refer for evaluation earlier than others. Couples with irregular ovulation, absent ovulation, known PCOS, endometriosis, pelvic infection, male factor risk for infertility, recurrent pregnancy loss, or advanced maternal age should be advised that they need to refer for evaluation earlier than those couples without risk factors. It is reasonable and appropriate to have couples start healthy behaviours at the same time that you are starting the process of evaluation for and treatment of infertility.

3) Make the nutrition, activity and sleep advice you give to your patients realistic and achievable. If the advice you give isn’t sensible, sustainable or realistic nothing will change. There is little point in recommending a 30 minute walk at lunchtime to a busy working mother, or suggesting that a patient should be in bed by 10.30pm to a shift worker

While general advice is most useful when it becomes part of daily routine, a fertility-supportive eating pattern can be communicated in a more practical and palatable way. For example, emphasize a diet rich in vegetables and fruits, and legumes and whole grains, with adequate protein from fish, poultry, beans and dairy (if indicated). Emphasize the need to increase unsaturated fats (olive oil, nuts, seeds, avocado) and decrease ultra-processed foods, sugary drinks and frequent high-glycemic snacks. Recommending patients switch to water from one sugary drink per day or eat one more serving of vegetables per day may be a realistic place to start.

To have a good metabolism women need to hear that intensity is NOT everything. That it is best to do daily activity. That swimming, brisk walking, yoga, and dancing can add up to meet her daily activity goals. Running long distance and high impact activities can be contraindicated for women because of the changes that occur with hormones, but moderate activity can help counteract these changes. Planning activities around these hormonal fluctuations can be helpful.

Women also need to hear that sleep is as important as exercise for weight regulation. This means not only sleeping long enough (7-9 hours per night) but also being consistant with this each night.

4) Strengthen substance use counseling without stigma

Counseling women and their partners about tobacco, alcohol, cannabis and other illicit substances should be a priority fertility health behavior issue using approaches to health behavior that recognize that aiding tobacco cessation depends upon more than just a woman’s willpower to stop smoking. Brief counseling, pharmacotherapy and referrals to quitting programs can help women and their partners stop tobacco use for life-long periods. Advice about alcohol use should be provided in an informed fashion that is non-moralistic, focusing on decreasing alcohol intake before conception and avoiding binge drinking rather than total abstinence. Information about cannabis and other illicit substances should be provided to women and their partners in a balanced fashion, acknowledging that plausible adverse effects on reproduction have not been established. Counselling women and their partners to decrease or cease illicit substance use before conception is a more appropriate approach than recommending absolute abstinence.

Counseling on caffeine intake should be positive and individualized. Most people can safely consume moderate amounts of caffeine whereas others (especially those predisposed to poor sleep or anxiety) may benefit from decreased intake as sleep and stress levels can dictate certain fertility behaviors and overall health.

5) Scale up multidisciplinary solutions with a particular focus on coverage and service delivery redesign to support integration and draw on multidisciplinary perspectives.

Health systems and insurers can maximize their return on investment by covering supportive components of healthy lifestyle behaviors within their medical benefits. For example, health plans can cover and bill for nutrition counseling, weight management programs, tobacco cessation treatments and mental health and addiction treatments as part of the benefits offered for preconception and fertility treatments. These services can be delivered through a variety of channels including telehealth, group visits, community health workers and/or digital health coaching to maximize reach, particularly for women who may only see their provider every few months.

Care pathways should make straight-forward referral to fertility counseling as quick and easy as possible. By embedding fertility counseling into the primary care pathways, straight-forward links can be created to dietitians, behavioral health professionals and reproductive endocrinologists so that patients are not left dangling between advice and support.

6) Prioritize equity by addressing real-world barriers

Offering equity-focused fertility counseling starts with identifying what is possible with your patient, and then working together to create a plan to make that possible. There are many easily modifiable elements of typical fertility counseling that providers can change to better support patients struggling with multiple barriers to fertility. Additionally, providers can address food or housing instability, lack of transportation, or demanding work schedules by connecting their patients with relevant community resources. Exercises and counseling can be chosen or adapted to be cost effective, to take only a few minutes in the patient’s busy schedule, to be scheduled at convenient times, or to include nutrition education that is culturally relevant and can even incorporate the patient’s traditional cuisine and methods of preparation.

This webinar will explore the language and stigma around infertility and why having a conversation about fertility in a stigma-filled culture that often blames individuals with infertility for their situation is so important. We will look at how taking a strengths-based approach when supporting individuals and couples who are struggling with infertility is key, and acknowledge that infertility is medical and multi-factorial. Finally, we will talk about how healthy lifestyle can be one of the many tools that can support optimal fertility, and how this message can be communicated in a way that does not place additional burden or guilt on individuals and couples who are already facing a complex, medical, and emotionally-weighty process and treatment.

7) Make doctors more knowledgeable about safe use of medications that can cause birth defects and the optimal timing of medication for women of childbearing age.

Incorporating a woman’s routine medications and supplements into the discussion of preconception health is essential for women with medical illnesses. Many medications and dietary supplements require dose modification or medical monitoring during pregnancy. The health care provider must be in close communication with other medical specialists to determine the best course of action for the woman. In addition, patients should be queried regarding the use of any products they are taking for fertility as well as products marketed for hormone boosters. Many of these products contain androgenic hormones that could increase the risk for congenital vaginal anomalies.

Quality improvement is a process that reinforces best practices. Health systems can track whether or not patients planning pregnancy receive documented lifestyle screening, counseling and referral for behavioral interventions as well as follow-up within the timeframe outlined in this practice.

*— American College of Obstetricians and Gynecologists*

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC12093646/ https://pmc.ncbi.nlm.nih.gov/articles/PMC8812443/ https://www.nichd.nih.gov/health/topics/infertility/conditioninfo/causes/lifestyle