Title: The Fertile Kitchen Cookbook

Can diet influence fertility? Can altering your diet help you conceive? Is it true that you are what you eat (and so is your baby)?

At age 40 and after trying to conceive for over a year, Cindy Bailey and her husband Pierre Giauque were told that they were unlikely to conceive. With disconcerting medical test results and failure in conven tional treatment, alternative therapies seemed the best option. After trying a fertility-friendly diet, to their surprise, their son was conceived four months later.

The Fertile Kitchen is one couple’s story of overcoming the odds against conception while using common sense and easily executed measures to optimize health. Using fresh, high quality, organic ingredients, and reducing wheat and dairy; the couple developed a nutritional plan that they feel contributed to their success. These authors found that optimizing the basic ingredients for life, adjusting calories, carbohydrates, fats, and proteins into a regimen that has the potential to optimize pregnancy rates, should be considered in a given fertility plan.

Science is still catching up to medical concerns about fertility and diet. As an example of this emerging science, it is known that women with abnormal body fat levels, either high or low, suffer from lower pregnancy rates, and that improvement in body weight and body fat levels improves fertility rates…Certain types of animal protein are potentially problematic for fertility, whereas vegetable protein sources seem to carry less risk. Calorie source, simple sugar versus protein, makes a difference in treating anovulatory women. Irregular menstrual cycles can be optimized by changing diet. Omega-3 fatty acids are related to uterine artery perfusion pressures, and supplementation seems to provide some clinical improvement in these parameters. Studies are showing a role for B-complex vitamins, folic acid, and dietary fat in regulating ovulation.

It is unfortunate that some people have serious challenges to fertility that cannot be addressed with a change in diet. Diminished ovarian reserve, male factor, and tubal occlusion are problems that go beyond what can be remedied with diet alone. With that said, fertility treatment programs, regardless of the health issues, should include a healthy diet, as a good preventative measure for already healthy women wishing to conceive. The recipes in this book are easy to follow and the ingredients are amply available at most grocery stores.

Fertile Kitchen Media Kit (pdf)

— Philip Chenette, M.D.

This year’s flu season is certainly not your standard flu season. 2010 brings not only the current seasonal flu variety, but also the pandemic H1N1 virus, commonly known as Swine Flu. These are two separate viruses. H1N1 is not only of great concern for all members of the population, but also of particularly serious concern for pregnant women.

The single most important action, strongly recommended by the Centers for Disease Control (CDC), is for pregnant women to be vaccinated against both the seasonal flu and, most importantly, H1N1. Both the seasonal flu vaccine and the H1N1 vaccine can be administered at the same time, at separate injection sites. There are two methods of dispensing the flu vaccine; either by injection or by a nasal spray (Flu Mist).

For immunization of pregnant women, only the injectable vaccine should be administered. Ob/Gyn practices will be the first to receive the vaccine. Patients should plan to be vaccinated at their Ob office.

Above: Tis the season to be conscious about germs

In addition to the flu vaccines, there is medication available to treat those with symptoms of the flu or those who have been exposed to someone with the flu. Symptoms of the flu can include: cough, sore throat, runny or stuffy nose, body aches, headache, chills, fatigue, and sometimes diarrhea and vomiting. Fever is common, but it is important to note that not everyone with flu will have a fever. If you have symptoms or if you have been exposed to someone who has the flu, call your doctor right away.

Pregnant women with suspected influenza, or experiencing more severe symptoms such as evidence of lower respiratory tract infection or clinical deterioration should receive prompt empiric antiviral therapy, regardless of previous health or age. Most healthy persons who develop an illness consistent with uncomplicated influenza, or persons who appear to be recovering from influenza, do not need antiviral medications for treatment or prophylaxis.

Pregnant women exposed to someone with influenza should consider antiviral chemoprophylaxis. Chemoprophylaxis should generally be reserved for persons at higher risk for influenza-related complications who have had contact with someone likely to have been infected with influenza. However, early treatment is an emphasized alternative to chemoprophylaxis after a suspected exposure. Household or close contacts (with risk factors for influenza complications) of confirmed or suspected cases can be counseled about the early signs and symptoms of influenza, and advised to immediately contact their healthcare provider for evaluation and possible early treatment if clinical signs or symptoms develop. Early recognition of illness and treatment when indicated is preferred to chemoprophylaxis for vaccinated persons after a suspected exposure.

Go to the emergency room immediately if you have difficulty breathing, or shortness of breath, pain or pressure in your chest or abdomen, sudden dizziness or severe or persistent vomiting. Prevention is certainly the best defense–and there are a number of things we can all do to minimize the spread of flu this season.

Wash your hands! Frequent hand washing or use of alcohol-based hand sanitizers is a major preventative measure. Carry a hand sanitizer in your purse, in the car, even a small bottle in your pocket. You can use them just about anywhere at any time.

Cough into your elbow! This helps to keep your germs to yourself.

Keep your hands away from your face! You will not be infected with the flu by touching a contaminated surface — unless you then touch your eyes, nose, or mouth.

Stay away from sick people if you are healthy and from healthy people if you are sick! You do not want to knowingly expose yourself, but remember, if it does happen, call your doctor straight away.

You do not want to spread the flu if you have it. Stay home and stay away from other family members as much as possible and make sure to call your doctor as soon as you have symptoms.

The CDC will continue to update their website as there is new information:

For general information on 2009 H1N1 flu go to:
cdc.gov/h1n1flu/qa.htm

For more information on flu shots go to:
cdc.gov/h1n1flu/vaccination

Mind/body therapies are frequently initiated for groups with serious medical conditions, from lupus to multiple sclerosis to major heart disease. It is only natural that the more critical an illness, the more anxiety it can induce, thus potentially inducing accelerated and aggravated symptoms. Breaking this vicious stress/body cycle through the use of stress reduction techniques can provide an overall improvement in health. For those experiencing infertility, the hope is that breaking this cycle would lead to an improved ability to conceive.

Skeptics point out that millions of people, under extremely stressful circumstances, regularly get pregnant. But some facts are clear: ongoing chronic stress can affect menstrual function; change hormone levels; alter blood sugar; increase heart rate and change a person’s immune response.

Pacific Fertility Center’s team has examined the scientific, medical and anecdotal information surrounding the topic of stress and infertility. We have found that various stress reducing techniques are likely to have an overall positive impact on a patients’ general health. For this reason, PFC continues to offer classes modeled around Dr. Alice Domar’s mind/body practice (see PacificFertilityCenter.com for more information on Dr. Domar and Mind/Body@PFC Workshops).

Alice Domar, PhD has extensively probed the mind/body infertility correlation. She initiated one of the few controlled studies funded by the National Institute of Mental Health on this topic. Results of the research showed an improvement in pregnancy rates through the use of either relaxation techniques or the psychological support of joining a group. Based on the results of her research, Dr. Domar’s mind/body programs include instruction on relaxation techniques, controlled breathing and posture awareness; yoga, meditation, journaling, neuro-linguistic programming, and the joining of a support network. These techniques are designed to help women adjust their stress responses so their bodies might have a higher chance of conceiving.

It is our hope that the growing attention to the mind/body stress reduction methodologies will lead to the development of more critical scientific knowledge on the topic. Meanwhile, take a deep breath and review Peggy Orlin’s tips on relieving stress during this holiday season.  Carolyn Givens, MD and Isabelle Ryan, MD

Coping is developing the ability to manage in a difficult situation.
Excited children, crowded stores, decorations, and holiday parties are descending upon us. Yet because the winter holidays tend to celebrate families and children, these usually joyous occasions can bring up painful feelings when you are struggling to create and celebrate with a family of your own. In order to feel as good as possible during the holidays, you will need to develop some good holiday coping skills. Use whichever of these suggestions seem helpful to you. Do what feels right for you.

DO: Give up any and all guilt for how you are feeling. There is no right or wrong way to experience infertility. Your feelings may run the gamut from indifference to intense anger and despair and everywhere in between.

DO: Reach out to childfree friends. Their parties will be adult-focused.

DO: Choose the gatherings you attend carefully. If being around children upsets you, gracefully decline invitations to events where they are likely to be present. Know your limits and stick with them.

DO: Think of non-child centered holiday rituals. Take a vacation. Eat at a fancy restaurant.

DO: Continue to exercise moderately, eat healthy foods and get plenty of rest. You will feel better if you treat your body with care.

DO: Shop for the holidays online or from catalogs. You will avoid mall madness.

DO: Attend religious services at the time when there will be the least number of children. Attend a service on a university campus, which is more adult focused.

DO: Volunteer at a nursing home or homeless shelter. It may help others having difficulty coping and in turn may help you.

DO: Plan for how you will answer uninvited questions about when you’re going to have children. Remember, you are not required to tell them your entire “story!”

DO: Meet and talk with others who are experiencing similar feelings. Finding that you are not alone helps.

DO: Communicate with your partner to let him/her know of your feelings. If you are single, call a friend with whom you feel safe sharing your feelings.

Peggy Orlin, MFT

Introduction

Sara (a hypothetical patient) found a breast lump. 36 years of age, she was a single active professional, otherwise healthy, careful about her diet, and carefully evaluating her options after a diagnosis of breast cancer. Along with the discussion on surgery, chemotherapy, and radiation therapy came the question “Were you planning to have children?”

A diagnosis of cancer presents many decisions that must be made quickly. Confirming the diagnosis and planning therapy will be the primary concerns, but the implications of therapy on long-term quality of life must be assessed. One of the primary issues facing women with a diagnosis of cancer is future fertility.

Candidates

Cancer treatment can interfere with future fertility. Toxicity varies by treatment. Cyclophosphamide, an alkylating agent used in many chemotherapy regimens, is highly toxic to sperm and eggs; methotrexate and 5-flouro-uracil (5FU) are not. Medications used for longer time intervals create a higher risk of fertility problems than shorter time intervals; effects on women in older age groups are more severe than younger. Radiation therapy, in high doses, can have effects on eggs and sperm. Surgery and anesthesia are not known to have direct effects.

It is difficult to give specific fertility risks for chemotherapeutic regimens, since studies are not yet definitive. Among the more toxic treatments are stem cell transplantation for leukemia in which total body irradiation and cyclophosphamide are used, beam radiation to a field that includes the ovaries, and extended chemotherapy of up to 6 cycles using cyclophosphamide in combination with other agents. After conventional chemotherapy for breast cancer for women under 40, the chance of infertility is roughly 50%, in older women the risk is over 80%.

Treatment options

What are the options for fertility in patients diagnosed with cancer? The best choices are available to those that have not yet initiated treatment and involve cryopreservation. During treatment, the risk of problems rises, and after treatment, there may not be adequate recovery of fertility to achieve pregnancy.

Cryopreservation allows cells to be stored with great stability for long periods of time. The record time from sperm cryopreservation to pregnancy is 28 years; there probably is no real limit to the time that cells can be stored. To store cells requires technology that reduces the formation of ice crystals, which disrupt cells, and prevents the rapid rise in salt concentration that occurs as water freezes. Cryopreservatives and management of temperature changes (slow freeze or vitrification) are used to reduce the risk of these problems.

Male

The option for fertility preservation in men is straightforward, cryopreservation of sperm. Sperm is obtained by masturbation and frozen in multiple vials in liquid nitrogen. 2-3 sperm samples can be obtained per week, with 2-4 vials stored per ejaculate; two weeks worth of donations could yield 8-24 vials of sperm. Costs vary widely, but would range from $1500-$3000 for processing and 3 years of storage.

Testicular sperm extraction is an option for individuals with azoospermia. Testicular tissue cryopreservation remains a theory that has not yet produced a human pregnancy. It has been proposed as an option for preservation of fertility in children, but has yet to be proven in clinical practice.

Female

Women have the option of cryopreservation of oocytes or embryos. For women without a partner, oocyte cryopreservation holds promise as a means to preserve fertility potential without committing to a specific sperm source or partner. For women with a partner or sperm donor, embryo cryopreservation is a proven technology.

To create cryopreserved oocytes, Follicle Stimulating Hormone (FSH) is administered over a ten day time period to stimulate ovarian follicles. The oocytes are retrieved under sedation with a needle guided by ultrasound and then stored in liquid nitrogen.

Newer techniques of oocyte vitrification secure good pregnancy rates for those with good oocyte quality. Traditional oocyte cryopreservation is performed using a slow freeze technique, but more rapid vitrification procedures optimize results. The trick with cryopreservation is to lower the temperature while avoiding ice crystals that disrupt cell membranes and proteins. Vitrification, an ultrarapid freezing process utilizing a minimal fluid volume, reduces the risk of these problems and optimizes cell quality.

For those women with a partner, or that are willing to commit to a specific sperm donor, embryo cryopreservation is an excellent option. After stimulation and retrieval, oocytes are inseminated and cultured in an incubator for 1-5 days, followed by cryopreservation. The embryos can be thawed and transferred at a later date, after clearance from the oncologist. Embryo cryopreservation is the best established of the fertility preservation techniques, with years of experience in its applications. Good pregnancy rates can be anticipated.

Ovarian tissue cryopreservation, the cryopreservation of whole pieces of the ovary, as opposed to cells, remains experimental. Complex tissues are more difficult to cryopreserve than cells, though rare success has been reported.

Cancer recurrence

Is there risk to the use of fertility drugs in patients with cancer? It does not appear in studies to date that breast or ovarian cancer risk is affected by use of fertility drugs. Studies indicating an increased risk are balanced by other studies indicating a reduction in risk. Studies to date have been limited, and treatment decisions still must be individualized.

Does pregnancy increase the risk of cancer recurrence? In theory, certain types of cancer could be aggravated by the hormones of pregnancy, but studies have not confirmed an overall risk. Certain types of cancer are less common in women that have delivered a pregnancy. Treatment decisions must be individualized, as future studies gather more information.

Pregnancy

Certain cancer treatments create organ toxicity that must be evaluated in considering patients for pregnancy. Heart output is limited in patients that have received doxorubicin. Uterine irradiation is associated with miscarriage and pre-term labor.

Children

Children born after fertility preservation procedures do not carry any increased risk for birth defects. There are hereditary syndromes that can be associated with cancer that could be transmitted to children, but there does not appear to be any other increased risk for cancer or genetic disease in children of cancer survivors.

Patients contemplating conception must consider life span expectations as part of their decision on whether to conceive. Such considerations are not, however, a reason to withhold treatment, and are ultimately the individual and family should decide.

Philip E. Chenette, MD

Resources:

www.fertilehope.org Fertile Hope

www.livestrong.org Lance Armstrong Foundation

www.cryobank.com California Cryobank

www.PacificFertilityCenter.com Pacific Fertility Center

The Trans fat, found in processed foods, may play a role in infertility. Implicated in prostate cancer, heart disease, and diabetes, and long thought to be a significant hindrance to good health, trans fat has been associated with ovulation disorders, according to a new publication¹.

Trans fats are created in food processing. To avoid rancidity in foods, manufacturers heat oils under pressure to convert natural unsaturated fat to partially saturated fat, adding hydrogen molecules to change the bonds between carbon atoms in the long fatty molecule. Saturated and partially saturated fats are sometimes called partially hydrogenated fats. Saturated fats melt at a higher temperature, and are more stable on the grocer’s shelf. Partially saturated fat is resistant to oxidation and damage, melts at a higher temperature, and does not take on rancid odors and taste. Crisco, partially saturated cottonseed oil, was the first commercial product to be produced with the technique in the early 1900s.

Foods prepared with partially saturated fats can contain up to 45% trans fats. French fries, cheeseburgers, fried chicken, cookies, and chips are common offenders. An order of large French fries can contain 15g of trans fat. Oreo cookies contained trans fat until a lawsuit in 2003 induced Kraft Foods to alter its recipe.

Ideal for a manufacturer interested in long-term storage, saturated fats are not so well tolerated by the human body. Raising levels of LDL and lowering levels of HDL cholesterol, saturated fats have been implicated as a prime cause of the rising risk of coronary heart disease through the 20th century. According to the Nurses’ Health Study², each 2% increase in trans fat calories doubles the risk of coronary artery disease. Since trans fats carry no health benefits and are potentially risky, experts have recommended reducing trans fats to trace amounts in the diet.

Infertility has been associated with trans fat intake. A study published in the January issue of American Journal of Clinical Nutrition from a group of researchers at Harvard University found that women with ovulation-related fertility problems tended to eat more trans fats than fertile women. Obtaining just 2 percent of total calories from trans fats was associated with a doubled risk for this type of infertility. The study showed that each 2% increase in dietary trans fat calories was associated with a 73% increased risk of ovulatory infertility³.

It has been difficult to separate out the effects of total fat and trans fat, since a diet high in trans fat diet is often high in total fats. In contrast to trans, higher total fat is known to decrease the risk of ovulation problems, improving ovulation, whereas women with a diet high in trans fat have an increased risk of ovulation disorders.

Dietary fats have been linked to markers of inflammation, a possible mechanism of trans fat effects⁴. In a randomized crossover study, 50 men consumed diets for five weeks that varied in trans fat content. Inflammatory protein markers were higher in men after the trans fat diet, showing that dietary fatty acids can modulate markers of inflammation.

The data is preliminary, but concerning. Since trans fats have no benefit and carry potential risks, they are best limited in the diet. Labeling requirements now include listing of trans fat content for foods. Lawmakers in several major US locales have passed regulations banning trans fats. Tiburon, California, on a voluntary basis was the first city to have trans fat free restaurants. Restaurants in New York City and Philadelphia are barred from using trans fat containing frying oils and spreads. The ban will be expanded to all restaurant foods next year. California is considering a statewide ban on trans fats.

Reducing processed foods and avoiding trans fats in your diet is an excellent goal for all, but patients with infertility may have special concerns. While more research is required regarding infertility and diet, there is no question a healthy diet is important. A diet of diverse and balanced carbohydrates, proteins, and fats, including omega-3 fats, will provide personal and possibly reproductive benefits for years to come.

Philip Chenette, MD

References:

1. Chavarro JE et al., May 2007, A prospective study of dairy foods intake and anovulatory infertility, Human Reproduction, 22 (5): 1340-1347.

2. Hu, FB et al. 1997 “Dietary fat intake and the risk of coronary heart disease in women”. New England Journal of Medicine, 337 (21): 1491-1499.

3. Chavarro JE et al., January 2007, Dietary fatty acid intakes and the risk of ovulatory infertility. American Journal of Clinical Nutrition, 85 (1), 231-237.

4. Baer DJ et al., June 2004, Dietary fatty acids affect plasma markers of inflammation in healthy men fed controlled diets: a randomized crossover study. American Journal of Clinical Nutrition, Vol. 79, No. 6, 969-973.

The American Society for Reproductive Medicine (ASRM) is the largest organization in the United States for medical professionals in the field of Reproductive Endocrinology and Infertility. In 2002, ASRM published medical and psychological guidelines for ovum donation. The psychological recommendations for donors are general guidelines for addressing moral, ethical and psychosocial issues that may confront ovum donors. Included are standards for what should be included in a psychosocial screening of donors and reasons to exclude donors. A few of the objective reasons for donor exclusion include known substance abuse, positive family history of heritable psychiatric disorders such as schizophrenia or bipolar disorder, or instability in donors’ lives. To determine “inclusion” I take a psychosocial history and administer a psychological test that informs me about the donor’s personality profile, including just how much they are trying to impress me – the “fake good” factor. I am also assessing motivation to donate and the donor’s “need” versus “desire for” the compensation. Stability, stress levels, and reproductive history are also part of an ASRM assessment of donors.

Although I would like to base my entire decision on objective information, much of my decision on donor acceptance must, in fact, be based on intuition. Throughout my 25 years as a therapist, I have found that my intuition is quite accurate, but it is not fool proof.

There is one major controversy in the field that may hinder a psychotherapist’s ability to screen donors. That is the hotly debated topic on compensation of donors. In August 2000, the Ethics Committee of The American Society for Reproductive Medicine concluded that there is no consensus on the precise payment that oocyte donors should receive. It was suggested, “sums of $5,000 or more require justification and sums above $10,000 go beyond what is appropriate.” Due to costs of living and the scarcity of available donors, there are significant regional variations that affect these rates.

The Society for Assisted Reproductive Technology (SART) has attempted to assist clinics and patients by creating a list of Egg Donor Agencies that have signed an agreement stating that they will abide by the Ethics Committee Guidelines governing the compensation of egg donors.

The debate centers on the fact that donors could feel undue inducement and exploitation in the process if the fee is so high as to be coercive. Part of the job of the mental health professional is to provide donors with informed consent. Might donors conceal pertinent medical information that could be important for themselves or offspring if the monetary incentive is so high? Will donors discount risks to themselves? How can the donor actually give informed consent about the medical procedure and pay attention to the risks if $$ signs are floating before their eyes?

Ethicists and some in the field of women’s health advocacy express concern “that lucrative payments are enticing young women with credit-card debt and steep tuition bills to sell eggs without seriously evaluating the risks.” Can the payment cloud someone’s judgment and can we assess that? How much is too much? Where is that line?

When I began working with PFC in 1998, we were paying first time egg donors $2,500. Nine years later, the compensation is $6,500 for a first time donor and $7,000 for any subsequent donations. Even adjusted for inflation, the payment is rising at a phenomenal rate. Competition, supply and demand govern these rises.

As part of my objective/intuitive approach to interviewing donors, I discuss money with them. What would she use the compensation for? How does she support herself? What kind and how much debt does she have? While $25,000 in student loans points to a person’s drive toward positive goals, the same amount in credit card debt speaks to me of impulsive behavior. How much have they educated themselves on ovum donation? Whom have they talked with about their desires? Do they have their own children? Are they science majors who may be more likely to view gametes as DNA and not their own children? Are their answers well thought out?

My goal is to provide the recipients of donated eggs with intelligent, healthy, and thoughtful young women who understand the implications of ovum donation both for themselves and for the recipients. Donors who are motivated by the “need” for money are more likely to provide inaccurate information on their applications, or leave out information that could be pertinent to the recipients or their offspring. It is my job and the job of the Egg Donor Agency to determine motivation.

Although impossible to attain, we would all like donors to be motivated altruistically. We may diminish altruism by making the donation about eggs for money. However, I believe we can increase altruism by helping the donors to have a greater understanding of who the recipients are and what their struggles have been.

Peggy Orlin, MFT

Ms. Orlin served as 2006-7 chair of ASRM’s Executive Committee of the Mental Health Professional Group, is a member of Resolve’s National Mental Health Advisory Board. She co-teaches PFC’s Mind/Body workshops.

To register for the September 8th Mind/Body@PFC Workshop, please phone 415-834-3095.

Sperm are clearly sensitive to environmental conditions. It is possible, through changes in lifestyle and activity, to improve sperm health. The studies available to evaluate environmental effects are unfortunately limited, but they offer insight into sperm sensitivity and ways to optimize their performance.

Temperature The scrotum where sperm are produced is 2 degrees lower than core body temperature. Raising the temperature by a few degrees results in a decline in sperm count and motility. Men suffering from cryoptorchidism, where the testicles are located above the scrotum, closer to central body temperatures, frequently suffer from low sperm counts. Infertile men tend to have a higher scrotal temperature⁽¹⁾, a characteristic that seems to be genetically determined⁽²⁾.

Common illnesses and every day activities can be sources of an increase in scrotal temperature. Acute fever associated with illness causes a significant decline in sperm quality⁽³⁾. In one study, total sperm count decreased within two weeks after a fever and required 79 days to return to normal. The DNA component of these sperm showed high levels of DNA fragmentation. Researchers in France installed temperature sensors to nine volunteers, and recorded scrotal temperatures while driving⁽⁴⁾. Scrotal temperature increased gradually over several hours, peaking 2.5 degrees higher at three hours. Another study showed that scrotal temperature was lowest while standing naked, and highest while clothed, seated, with legs crossed⁽⁵⁾. Higher scrotal temperatures have been associated with use of a laptop computer⁽⁶⁾. A group in Germany looked at scrotal temperatures with a variety of underwear⁽⁷⁾. As expected, tight underwear increased the temperature more than loose or no underwear. The effect was most pronounced while walking and less noticeable while sitting, since sitting temperature was somewhat elevated regardless of type of underwear worn.

The common sense approach is to avoid activities which can increase scrotal and testicular temperature, use loose-fitting underwear, and provide adequate ventilation to the scrotum. Exposure to hot tubs or saunas should be avoided. Take showers rather than baths, because heat conductance is lower when the testicles are not immersed in hot water. Sitting or driving for extended periods should be minimized.

Stress The effects of stress on sperm are complex. Under conditions of extreme stress, sperm counts decline. Analyses of prisoners awaiting sentencing have shown complete suppression of spermatogenesis on testicular biopsies⁽⁸⁾. A study of semen characteristics after the Slovenian war in 1991 showed a reduction in sperm count and motility, and a reduction in the proportion of male children born⁽⁹⁾. In 1995 a strong earthquake of magnitude 7.2 on the Richter scale occurred in Kobe, Japan killing 5,502 people. Sperm motility declined immediately, with low motility lasting for months⁽¹⁰⁾. The sperm of a man who lost his home and his father had still not recovered 10 months after the earthquake.

Stress associated with fertility therapy affects sperm and sexual function. Sperm parameters may decline in patients undergoing in vitro fertilization⁽¹¹⁾. Male fertility patients have a higher incidence of erectile dysfunction, ejaculatory disorders, loss of libido and a decrease in the frequency of intercourse⁽¹²⁾. One study of infertility patients showed an increase in burnout in male patients⁽¹³⁾.

Unfortunately, studies of the effect of stress reduction on sperm are rare,^(14)(15) so the treatment of stress has not been conclusively shown to improve sperm parameters⁽¹⁶⁾. In spite of the lack of clear data, stress reduction therapy is recommended for fertility patients and may reduce problems with sexual dysfunction.

Exercise The risk of developing male fertility problems appears to increase with the intensity of exercise. Intense exercise, such as endurance running, will lower levels of luteinizing hormone (LH) and testosterone.^(17)(18) Studies of semen characteristics have shown variable results. DeSouza⁽¹⁹⁾ developed the concept of a training volume threshold, in which running more than 100 km or 62.14 miles per week was associated with decreased levels of testosterone and sperm motility.

A detailed prospective study comparing competitive cyclists and triathletes with sedentary controls⁽²⁰⁾ was unable to show any suppressive effect of competitive exercise on FSH, LH, or testosterone levels. Although those with the highest levels of training had higher levels of circulating testosterone at baseline, these levels did not change with training. Competitive cyclists developed lower sperm motility during competition, however, motility values returned to normal following competition.

The best advice regarding exercise and sperm is moderation. While attempting conception, it is not advisable to undergo high intensity sports training. Good nutritional standards should be always be maintained when following an exercise program. An existing maintenance exercise program may be continued without concern for its effects on sperm.

Diet is a difficult topic to study in isolation, so fertility data is limited. A recent study of beef consumption showed that maternal consumption⁽²¹⁾ of beef resulted in lower sperm concentrations in sons. The proportion of men with low sperm counts was three times higher in the sons of women that consumed high levels of beef. Lifestyle, pesticide exposure, and xenobiotics (chemicals found in organisms that are foreign to them) were all considered potential factors. Heterocyclic amines (carcinogenic chemicals formed from the cooking of muscle meats), which are estrogenic, may also play a role⁽²²⁾.

Alcohol has long been associated with male reproductive dysfunction. Impotence, infertility, and male secondary sex characteristics are all affected by chronic alcohol use. Testosterone levels are lower, sperm production is reduced, and FSH and LH levels are affected⁽²³⁾. A study of chronic alcoholics demonstrated low levels of pituitary and testicular hormones, and significantly decreased sperm concentration and morphology⁽²⁴⁾. Sperm chromosomes are altered in men that consume alcohol⁽²⁵⁾.

Little data exists on the moderate consumption of alcohol. Data from the Ontario Farm Family Health Study did not show an adverse effect of alcohol consumption⁽²⁶⁾. In another study, alcohol or cigarette consumption did not alter sperm parameters, but when patients both smoked and drank alcohol a significant reduction in seminal volume, sperm concentration, percentage of motile spermatozoa, and a significant increase of the nonmotile viable gametes were detected⁽²⁷⁾.

Smoking tobacco affects sperm parameters, with reduced sperm counts, motility, and morphology reported in several studies⁽²⁸⁾. Whether these changes affect the male fertility remains uncertain. According to ASRM, “The effect of smoking on male fertility is … difficult to discern. The available data do not conclusively demonstrate that smoking decreases male fertility… Few studies have or can address the question, because of the confounding effects of partner smoking habits and fecundity. Although sperm concentrations, motility, and/or morphology are often reduced compared to results observed in non-smokers, they often remain within the normal range. Nevertheless, to the extent that the zona-free hamster egg penetration test reflects the ability of sperm to successfully fertilize a human oocyte, the available evidence suggests that smoking may have adverse effects on sperm function.”

Caffeine studies have revealed inconsistent effects on sperm, with at least one study showing no effect⁽²⁹⁾. Caffeine has been used as a sperm stimulant, increasing the motility prior to insemination. There does not appear to be any substantial adverse effect of caffeine on sperm.

Common Medications The list of medications with effects on sperm is long, and worthy of review. Noteworthy medications are the SSRI anti-depressants (Cipramil, Lustral, and Effexor were the reported medications), which were associated with near-azospermia in a case report⁽³⁰⁾. Ibuprofen (Advil, Nuprin) does not seem to cause adverse effects on sperm⁽³¹⁾.

Vaginal lubricants can interfere with sperm. FemGlide, Replens, and Astroglide lubricants demonstrated a significant decrease in motility, whereas Pre-Seed did not affect motility or DNA integrity⁽³²⁾.

Treatments for erectile dysfunction may have an effect on sperm motility. A significant increase in sperm progressive motility was observed after sildenafil (Viagra) administration as compared with baseline; in contrast, a significant decreased motility was observed after tadalafil (Cialis).

Antihypertensive drugs have numerous effects on sperm. Beta-blockers and diuretics have been associated with impotence. Calcium channel blockers (nifedipine, Procardia) have been associated with infertility⁽³³⁾. If you are on heart medications, review them with your physician.

Reports on the effects of marijuana use on sperm are conflicting. Early studies had poor controls, later studies showed reductions in testosterone and sperm quality⁽³⁴⁾ while other studies showed no effect on testosterone levels in chronic heavy smokers⁽³⁵⁾. A recent study revealed a direct effect of THC, the active ingredient in marijuana, on sperm motility and fertilization capacity⁽³⁶⁾. The conclusion of the study was that “the use of THC as a recreational drug may impair crucial sperm functions and adversely affect male fertility, especially in those who are already on the borderline of infertility.”

Conclusion Sperm are a biological substance, produced in a complex interplay of genetic predisposition, specific temperature and pH, and in association with specific cells and secretions. If the system is insulted, problems will often arise. The sheer numbers of sperm in an ejaculate provide a wide margin for maintaining fertility even after such insults occur, but repeated attacks on the reproductive system can ultimately result in male fertility problems.

Philip Chenette, MD

References:

1. Zorgniotti, A.W. and Sealfon, A.I. (1988) Measurement of intrascrotal temperature in normal and subfertile men. J. Reprod. Fertil., 82, 563–566.
2. Hjollund, N., Storgaard, L., et al. (2002) Correlation of scrotal temperature in twins: Brief Communication. Human Reproduction, 17(7):1837-1838.
3. Sergerue, D.E.S.S., et al., (2007) High risk of temporary alteration of semen parameters after recent acute febrile illness. Fertil Steril, In press.
4. Bujan L, et al. (2000) Increase in scrotal temperature in car drivers. Human Reprod 15, 1355–1357.
5. Mieusset, R. et al., (2007). Effect of posture and clothing on scrotal temperature in fertile men. J Androl. 28(1):170-175.
6. Sheynkin, Y., et al., (2006) Increase in scrotal temperature in laptop computer users. Human Reproduction. 20(2):452-455.
7. Jung, A., et al. (2005) Influence of the type of undertrousers and physical activity on scrotal temperature. Human Reproduction. 20(4):1022-1027.
8. Steve, H. (1952) Der ein Fluss de nerven System auf ban und Fatigkeit des Geschlechtorgane des Menschen. Theim, Stuttgart.
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As a patient undergoing fertility treatment, the many months of testing, uncertainty and waiting had begun to take its toll. Dividing my life into two week increments no longer had the same hope and anticipation that defined my first few months of trying to conceive. Seemingly harmless questions from friends and relatives, like “So…any good news to report?” had become annoying questions that received a snappy response.

Attending the Mind/Body workshop was a valuable experience on many levels. We began the day with a tasty breakfast and coffee while we introduced ourselves and spoke briefly about our own experiences trying to conceive. PFC instructors Peggy and Allison presented the research on the stress/infertility connection, and spoke about the isolating nature of infertility. Because the topic of infertility is not openly discussed in social situations, the person or couple going through treatment often lacks social support.

Next, we were introduced to relaxation techniques, which Allison and Peggy call “Minis” because they are short and easy to incorporate into daily life. We lay on yoga mats in a darkened room and slowly counted our breaths, letting go of the tension in our arms and legs. We were led through some basic tai chi moves, and then ended with a guided relaxation that put me immediately to sleep.

After a delicious lunch the discussion moved to the cognitive distortions that frequently emerge during stressful periods and cause people to magnify their problems. Peggy and Allison led us through some cognitive restructuring steps, which can help identify a true thought versus a magnified and distorted fear.

Questioning negative thought patterns is a difficult but extremely helpful way to take some of the blame off of myself and ease the level of stress I was feeling. Hearing that others had the exact same thought patterns as I did was also extremely reassuring and made me feel as though I was not alone in my challenging journey.

The next part of the day was my favorite. We learned a variety of yoga postures that can easily be done in a desk chair or in front of a computer. My co-workers may think I look funny, but I have been contorting myself at my desk ever since, and found that it truly does relieve the physical stress of staring at a computer all day, and provides me with a nice mental break before I start a new task.

After another guided relaxation session, which again left me in a deep sleep, we convened as a group to review the day. Peggy asked us to think about what brings us joy, and how we incorporate those things into our lives. As I looked around the room, most people were smiling as they wrote down the things that bring them joy – everything from pets, partners and family to bubble baths, traveling, and good food.

As we finished the day with questions, answers and good-byes I left feeling refreshed from my mini-naps and excited to have some tangible skills to utilize whenever I find myself too stressed to relax. From our very first discussions over breakfast to our final activity, I felt the isolation of my own stressed out perspective melting away. I’m grateful that I attended the Mind/Body workshop, both for the feeling of community and the concrete relaxation skills I came away with.

The Mind/Body Workshop was an invaluable experience. I came away feeling like I had:

• Gained tangible relaxation and yoga skills that I can use in my daily life.
• Decreased feelings of isolation and anxiety.
• Finished the day feeling calm, centered and ready for my journey to parenthood!

Erika Linden

Infertility can cause extreme feelings of stress and isolation. From diagnosis to treatment, the stress of infertility can affect every area of life including marriage, job, and family relationships. Pacific Fertility Center’s Mind/Body Workshop is designed to address the emotional and physical strain caused by infertility treatment and the far-reaching effects it has on one’s life. These workshops are run by Pacific Fertility Center’s Peggy Orlin, MFT and Allison Chamberlain, RN, who were both trained by Alice Domar, PhD, a Harvard Medical School expert and pioneer in the subject of the mind/body connection to fertility. The next Mind/Body Workshop will be held on September 8th. Please call 888-834-3095 for class information, fees and your registration form. This one-day workshop is a loving and supportive environment in which you can gain self-awareness and practice techniques that will give you strength as you travel on your journey.

- Allison Chamberlaine, Mind/Body Instructor and Clinical Coordinator The workshop provides people with a safe space to learn relaxation techniques and to connect with others that know how difficult the infertility experience can be.

- Peggy Orlin, Mind/Body Instructor and Marriage and Family Therapist

Many women are aware that very low body weight and low percentages of body fat can compromise ovulation and chances for successful conception. What many don’t realize is that excess body fat can also affect one’s chances.

A review of the literature shows that the majority of studies published report decreased chances of conceiving with in vitro fertilization (IVF) if a woman in significantly overweight. IVF data is useful to study this issue because all the women undergo similar treatments and because follow-up data on pregnancies is usually readily accessible to researchers. It may also be true that excess body weight is a negative factor in spontaneous conception and non-IVF treatment as well.

How much of a factor is weight in decreasing conception? One study from the Netherlands reported a higher cycle cancellation rate due to poor response to stimulation and lower fertilization rates¹ than normal weight women. Another study from Norway reported higher requirements for stimulation medications and a higher miscarriage rate in the first 6 weeks of pregnancy². One of the largest studies was from Cornell and reported on 960 women undergoing IVF. Although they did not find a statistically significant decrease in clinical pregnancy rates, rates of cycle cancellation were higher and gonadotropin dose requirements were greater in the obese patients³. Another large study from Iowa (1,293 patients) looked at outcomes in women who were obese and morbidly obese. Again, this study found that clinical pregnancy rates per egg retrieval were similar to normal-weight women but cancellation rates and gonadotropin dose requirements were much higher in the obese women. Furthermore, rates of pregnancy complications such as preeclampsia, gestational diabetes and cesarean section were higher in the obese women⁴.

How much weight is significant for this effect? Most studies calculate weight as Body Mass Index, or BMI. This calculation takes in weight vs. height. To calculate your BMI, many websites such as the one at the Centers for Disease Control ( www.cdc.gov/nccdphp/dnpa/bmi/index.htm) can provide a calculator. There is also a chart at the federal government’s website www.consumer.gov/weightloss/bmi.htm. You just need to know your height in feet and inches and weight in pounds. A normal BMI is between 18.5 and 24 and overweight is a BMI of 25 to 30. A BMI of 30 or more is considered obese and 40 or more is considered morbidly obese.

In general, it appears that excessive body weight can negatively impact a woman’s chances for conception and for a healthy, uncomplicated pregnancy and birth. It makes sense that being a normal body weight and in good shape is a good idea and should be a goal for aiding successful conception.

Carolyn Givens, MD

References

1. Gynecol Obstet Invest. 2005;59(4):220-4. Epub 2005 Mar 7. Obesity and Clomiphene Challenge Test as predictors of outcome of in vitro fertilization and intracytoplasmic sperm injection.van Swieten EC, van der Leeuw-Harmsen L, Badings EA, van der Linden PJ.

2. Hum Reprod. 2004 Nov;19(11):2523-8. Epub 2004 Aug 19. Impact of overweight and underweight on assisted reproduction treatment. Fedorcsak P, Dale PO, Storeng R, Ertzeid G, Bjercke S, Oldereid N, Omland AK, Abyholm T, Tanbo T.

3. J Reprod Med. 2004 Dec;49(12):973-7 Obesity and in vitro fertilization: negative influences on outcome. Spandorfer SD, Kump L, Goldschlag D, Brodkin T, Davis OK, Rosenwaks Z.

4. Obstet Gynecol. 2006 Jul;108(1):61-9. Obstetric outcomes after in vitro fertilization in obese and morbidly obese women. Dokras A, Baredziak L, Blaine J, Syrop C, VanVoorhis BJ, Sparks A.

Many couples, in the midst of their struggle with infertility and who may have undergone several cycles of fertility treatment, have a hard time visualizing success. They often have an even harder time believing they could conceive a multiple gestation. On the other hand, many fertility patients may see a twin gestation as a positive thing in that they can increase their family size all at once – a bargain!

In this country, we have seen an increase in the percentage of twin births that has become phenomenal and is mostly due to an increase in the use of fertility medications and assisted reproductive treatments. Of the 35,025 babies born from IVF in the year 2000, 44% were twins and 9% were triplets or more. Nationwide, the number of twins has increased by 65% since 1980 and by 38% since 1990. These numbers have not gone unnoticed by public health officials, insurance companies and increasingly, lawmakers.

Thankfully, although in the early 1990′s we saw astounding increases in the number of triplet and higher-order multiple gestations, the good news is that these numbers are falling. This change is felt to be due to increased awareness on the part of reproductive specialists and consequently better education of their patients about the desirability of avoiding triplet+ gestations.

Although most twin and even most triplet babies survive without serious problems, these pregnancies do involve significant increases in the risk for poor outcomes. This is because the gestational age at delivery (averaging 40 weeks for a singleton pregnancy) is decreased on average by 3 weeks for each additional fetus. Neonatal Intensive Care Unit admissions are significantly higher as a consequence. Only 9% of singletons end up in the NICU but 48% of twins and 78% of higher order multiples are admitted to the NICU. Intrauterine death (stillbirth) is increased 5-fold in twins. Neonatal death (death within the first month of life) is increased 7-fold for a twin as compared to a singleton. (See Table below.)

Treatment of prematurity has allowed even some of the lowest birth weight babies to survive. But survival may not mean disability-free living. Cerebral palsy is a devastating permanent brain injury that occurs either in the uterus or at the time of birth. For twins, the incidence is 4 times higher than singletons and the incidence is 17 times higher for triplets. Ultimately, the main worry is having a child with a severe handicap. This risk is 1.7 times higher for twins and 2.9 times higher for triplets. While the risks of twin gestation are definitely measurable, most high-risk pregnancy specialists do not advocate selective reduction of twin gestations. Most do advocate selective reduction of triplet+ gestations, however.

The maternal risks increase with multiple gestations and the risks rise with each additional fetus. These risks include high blood pressure, postpartum hemorrhage, excessive nausea, miscarriage, gestational diabetes, preterm labor, Cesarean section and even maternal death. Although obstetrics has come a long, long way in this country in the last 100 years, pregnancy and childbirth still pose medical risks to mothers and these risks are definitely affected by multiple gestation.

The purpose of this article is not to frighten patients considering fertility treatments. It is meant to educate our patients about these risks and to help our patients to understand why Pacific Fertility Center is doing its best to adhere to ASRM guidelines. However, we wish to retain the rights to individualize our treatments and adapt to the specific circumstances for each of our patients. We do not want to see the government interfere with medical decisions that should be made between physicians and their patients. This is why our motto is “Conception Solutions: One Healthy Baby at a Time.”

Carolyn Givens, MD