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.
9. Zorn, B et al., (2002) Decline in sex ratio after 10-day war in Slovenia. Human Reproduction.17(12):3173-3177.
10. Fukuda, M, et al. (1996) Kobe earthquake and reduced sperm motility. Human reproduction. 11(6):1244-1246.
11. Clarke R.N., et al., (1999) Relationship between psychological stress and semen quality among in vitro fertilization patients. Human Reproduction. 14(3):753-758.
12. Lenzi, et al. (2003) Stress, sexual dysfunctions, and male infertility. J Endocrin Invest. 26(3 Suppl):72-6.
13. Sheiner, et al., (2002) Potential association between male infertility and occupational psychological stress. J Occup Environ Med. 44(12):1093-1099.
14. Pook, M, et al. (1999). Coping with infertility: distress and changes in sperm quality. Human Reproduction. 14(6):1487-1492.
15. Tuschen-Caffier B, Florin I, Krause W, Pook M. (1999) Cognitive-behavioural therapy for idiopathic infertile couples. Psychother Psychosom 68:15–21.
16. Campagne, D.M., (2006) Should fertilization treatment start with reducing stress? Human Reproduction. 21(7):1651-1658.
17. Wheeler, G. D., et al. (1991) Endurance training decreases serum testosterone levels in men without change in luteinizing hormone pulsatile release. J. Clin. Endocrinol. Metab. 72: 422–425.
18. Arce, J. C., et al. (1993) Subclinical alterations in hormone and semen profile in athletes. Fertil. Steril. 59: 398–404.
19. De Souza, M. J., et al. (1991) Gonadal hormones and semen quality in male runners. A volume threshold effect of endurance training. Int. J. Sports Med. 15: 383–391.
20. Lucia, A, et al. (1996) Reproductive function in male endurance athletes: sperm analysis and hormonal profile. J Applied Physiology. 81:2627-2636.
21. Swan SH et al (2007) Semen quality of fertile US males in relation to their mothers’ beef consumption during pregnancy. Human Reproduction. 22(6):1497-1502.
22. Cho E, Chen WY, Hunter DJ, et al. (2006) Red meat intake and risk of breast cancer among premenopausal women. Arch Intern Med 166:2253–9.
23. Emanuele, MA et al. (1998) Alcohol’s effects on male reproduction. Alcohol Health and Research World. 22:195-201.
24. Muthusami, KR et a;, (2005) Effect of chronic alcoholism on male fertility hormones and semen quality. Fertility and Sterility. 84(4):919-924.
25. Robbins, WA, et al. (2005) Effect of lifestyle exposures on sperm aneuploidy. Cytogenetic & Genome Research. 111(3-4):371-7.
26. Curtis KM, et al. (1997) Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecundability. Am J Epidemiol. 146(1):32-41.
27. Martini, AC, et al. (2004) Effects of alcohol and cigarette consumption on human seminal quality. Fertility Sterility. 82(2):374-377.
28. Vine MF. (1996) Smoking and male reproduction: a review. Int J Androl.19:323–337.
29. Klonoff-Cohen, H, et al. (2002) A prospective study of the effects of female and male caffeine consumption on the reproductive endpoints of IVF and gamete intra-Fallopian transfer. Human Reproduction. 17(7):1746-1754.
30. Tanrikut C, Schlegel PN (2006) Antidepressant-associated changes in semen parameters. Fertil Steril. 86(3):S14.
31. Robinson, N, et al. (2005). Regular Use of Ibuprofen Does Not Affect Semen Analysis Parameters, Need for ICSI, or ART Clinical Pregnancy Rate. Fertility and Sterility (84): S14.
32. Agarwal A, et al., (2007) Effect of vaginal lubricants on sperm motility and chromatin integrity: a prospective comparative study. Fertil Steril. In press.
33. Hershlag A, et al. (1995) Pregnancy following discontinuation of a calcium channel blocker in the male partner. Human Reproduction. 10(3):599-606.
34. Kolodny RC, et al. (1974) Depression of plasma testosterone with acute administration. In: Braude MC, Szara S editor. The pharmacology of marijuana. New York: Raven Press; p. 217–225.
35. Mendelson JH, et al. (1974). Plasma testosterone levels before, during and after chronic marihuana smoking. N Engl J Med. 291:1051–1055.
36. Whan, LB, et al., (2006) Effects of delta-9-tetrahydrocannabinol, the primary psychoactive cannabinoid in marijuana, on human sperm function in vitro. Fertil. Steril. 85(3):653-660.

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

While many factors leading to female factor infertility are out of a patient’s control (genetics, for example), there are several measures patients can take that will help optimize their chances of conception.

At the forefront is receiving routine gynecological care. During the preconception phase, it is important that the patient have an up-to-date Pap smear and mammogram. Furthermore, the patient should undergo testing for infectious diseases (Hepatitis C, Hepatitis B, syphilis) and immunization status for varicella and rubella and hormones which can affect ovulation (prolactin and TSH). Any fibroids or polyps the patient has should be evaluated to make sure they wouldn’t adversely affect the chances of conception. Also, the patient should be taking essential prenatal vitamins as prescribed by her OB/GYN.

Certain behavioral factors should also be assessed and, in some instances, eliminated prior to trying to conceive. Smoking and drinking should be eliminated and exercise should be moderated. Incorporating a regular exercise program along with a balanced diet is recommended. The diet should include lean proteins, a colorful variety of fresh fruits and vegetables, combined with a limited intake of processed and fatty foods.

Women who are extremely thin or very heavy should seek the help of a nutritional counselor to attain a healthy weight without fad or crash diets. Embarking on a new, strenuous exercise regimen or crash diet just before attempting to become pregnant is not recommended. Medications being taken for preexisting medical conditions should also be evaluated to ensure they won’t compromise a pregnancy.

If the patient requires a fertility specialist, it is recommended the following tests be performed prior to seeing a specialist. This will streamline the diagnosis process and expedite them on their path to proper treatment. This includes testing of the ovarian hormones, follicle stimulating hormone (FSH), Estradiol; a semen analysis (for the male partner) and an HSG (dye study) to assess tubal patency. See more about fertility testing…

Age is a critical factor in the outcome of infertility treatment and it is important for patients to be more proactive the older the patient gets. At Pacific Fertility Center (PFC), our guideline for patients is to seek help from a fertility specialist after: 1 year of trying for women less than 35 years of age; 6 months of adequately timed intercourse or inseminations for women ages 35-39; 3-6 months of trying for women over 39. See more about age and fertility…

Again, time is of the essence when it comes to getting treatment from a reproductive expert, and, keeping that in mind, there are several tests that we do not encourage patients to take prior to seeing an infertility specialist based on their limited usefulness.

They include:

• Post coital test
• Sperm penetration assays
• Endometrial biopsy
• Serum antisperm antibodies
• Cervical cultures
• Laparoscopy
• Autoimmune factors

Ultimately, conceiving through assisted reproductive technology (ART) is a team effort involving the patient, OB/GYN, and fertility specialist, with the process beginning several months before the patient steps foot in an IVF clinic.

Click here for more information on pregnancy preparation.

– Eldon Schriock, MD

Male factor infertility is quite common, contributing to 40% of infertility diagnoses. Treatment is designed around the particular type of problem and can be remarkably effective. For those with male factor infertility, the initial course of action is to review personal health habits. Stress, poor diet, and alcohol use have all been correlated with male factor infertility. Alcohol use, in particular, has been shown to have a dose-related effect on sperm; the more one drinks, the poorer the reproductive outcome. High temperature exposure from hot tubs or hot baths (immersion in hot water), or heavy exercise, particularly bicycle riding, have been correlated with male factor infertility as well. Resting a laptop computer on one’s lap has also been implicated in raising testicular temperature.

Diagnosis of male factor infertility starts with a semen analysis. The semen analysis should be performed on an ejaculated sample collected on at least two occasions 2-7 days following abstention from sexual activity. Measurement of the sperm count, motility, and volume can reveal production problems as insufficient or poor quality sperm are released from the testes. Table 1 lists the standards for assessing a semen analysis (Source: The World Health Organization, 1992).

Additional tests to evaluate sperm quality include the detailed or Krueger morphology. This entails viewing individual sperm cells under a high-powered microscope. This is a strict test that reveals abnormalities in the shape and size of the sperm heads, mid-pieces, and tails. A normal morphology is present when over 14% of sperm are normal.

Survival of the sperm on extended testing is also a useful diagnostic test. The sperm survival test, or SST, is a method for testing the lifespan of the sperm. At 24 hours, sperm survival should be over 40% (i.e. 40% of the sperm sample should survive); conversely, lower survival rates correspond to lower pregnancy rates.

Additional testing for male factor infertility includes a physical exam, blood tests for FSH, prolactin, and testosterone, and an ultrasonography of the collecting tubes of the male reproductive system. In some cases, an assessment of DNA fragmentation can give an index of sperm quality as well.

One condition we encounter at our clinic is azoospermia, which is the absence of sperm in the ejaculate. This can occur from birth defects, injury or infection, or rare endocrine abnormalities. In azoospermia, a high FSH level indicates testicular failure. Insufficient levels of testicular hormones lead to an increase in the release of pituitary gland FSH to compensate. High levels of testicular hormones are often accompanied by testicular atrophy (small testicles). Testicular biopsy may confirm the clinical findings.

Men with testicular failure (and very low sperm counts) should be tested for Y-chromosome microdeletions and abnormal karyotypes, or chromosomal count. Microdeletions may be transmitted to offspring, resulting in fertility problems for boys born after treatment.

The most common abnormal karyotype is Klinefelter Syndrome, where the male has three or more sex chromosomes, instead of the normal two. Such chromosomal defects can have effects on children born after treatment, and men should receive genetic counseling and risk assessment prior to treatment. Men with testicular failure may still have partial sperm production. Detailed assessment with microscopic surgery may detect a sufficient amount of sperm to use with in vitro fertilization (IVF).

Obstruction is another type of male factor infertility, as potentially normal sperm cannot move from the testes to the ejaculate. Men with a normal FSH may have an obstruction in the vas deferens or any of the other collecting tubes that gather sperm from the testes. Men with congenital absence of the vas deferens (CBAVD) may be carriers of cystic fibrosis, and should be tested. Surgical obstruction, or vasectomy, is readily repaired. Microsurgical techniques, and an experienced surgeon, will increase success rates. The procedure may be attempted for many years after an initial vasectomy. More unusual obstructions can result after infection of the epididymis. Ejaculatory duct obstruction can be treated with a cystoscopic procedure. Obstructions can sometimes be repaired, but often a simple needle aspiration procedure (percutaneous epididymal sperm aspiration, PESA) will yield enough sperm to achieve fertilization with IVF.

The key treatment when working with low sperm numbers, whether in the ejaculate or obtained by needle aspiration or biopsy, is to perform in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). ICSI is when a highly trained embryologist uses micromanipulators to inject an individual sperm into an egg, optimizing for fertilization.

ICSI has become a common procedure, resulting in many pregnancies worldwide for men that otherwise could not have children. Sperm with a variety of abnormalities, ranging from low counts, to extremely low motilities, can be suitable for use. The DNA of the sperm is tightly compacted in ways that protect it from injury, even when the other components of the sperm do not function well. Injecting the sperm into the egg can bypass the barriers separating sperm and egg.

Another condition we encounter which can lead to abnormal sperm parameters is the presence of a varicocele. A varicocele is an enlarged vein along the upper part of the scrotum. The blood carried in these veins may elevate the scrotal temperature, and possibly carry toxic materials into the testicle, affecting sperm production. Only varicoceles that are palpable are thought to contribute to infertility. Ultrasound is sometimes used to confirm an uncertain diagnosis, but there is doubt whether subclinical varicoceles are associated with infertility. Varicoceles can be repaired, or various fertility treatments attempted, including sperm wash and insemination, and in vitro fertilization. The decision of treatment depends on both male and female factors, such as age, tubal disease, and ovulation disorders.

In closing, it is important to remember that infertility is not just a “female” issue and that men should engage in lifestyle habits that will not compromise their fertility. Furthermore, advancements in assisted reproductive technology (ART) have given men with infertility diagnoses newfound hope in their quest to build a healthy family.

– Philip Chenette, MD

Question: I’m a heavy coffee drinker, consuming five cups per day. I’m concerned that my addiction to caffeine will hurt my chances of getting pregnant. How much caffeine is acceptable?

Answer: Moderate caffeine intake for women trying to conceive is acceptable. As a general guideline, women trying to conceive should limit intake to 3 cups of coffee (or 300 mg of caffeine) per day (Organization of Teratology Information Services (OTIS) 2001). Results from large published studies have not demonstrated that moderate caffeine intake adversely affects fertility (International Food Information Council (IFIC) August 2002). Furthermore, caffeine consumption has not shown to have an impact on fertility or birth defects for the male partner or sperm donor (OTIS 2001).

For women who are pregnant, there have been several studies analyzing the affect of caffeine and pregnancy with the conclusions of those individual studies being mixed (IFIC August 2002). Keep in mind that if you are pregnant or breastfeeding, the caffeine you consume may transfer to the infant. As such, guidelines for caffeine intake of pregnant or breastfeeding women are a little more rigid. The recommendation by OTIS and Motherisk is that consuming less than 1½ cups of coffee (or 150 mg of caffeine) per day is not likely to increase the chances of miscarriage or a low birth weight baby. The American Academy of Pediatrics states that: “no harm is likely to occur in a nursing child whose mother drinks one cup of coffee a day.”

For more information on the affect of caffeine on fertility, visit the National Toxicology Program-Department of Health and Human Services website. The website provides a more detailed look at some of the clinical studies referenced above. Additionally it provides a chart showing the levels of caffeine in certain food and drinks. This information is available at: http://cerhr.niehs.nih.gov/common/caffeine.html.

– Eldon Schriock, MD

PFC patients often inquire about the use of acupuncture as a part of their infertility treatment, and, as such, PFC brings you insight from Bethany Richardson M.S., L.Ac and Leslie Oldershaw, L. Ac., two Bay Area acupuncturists who integrate fertility treatment into their practices. As background, Bethany Richardson was originally a massage therapist who took a Chinese diagnosis course while working on her Shiatsu certification. That course sparked her interest in pursuing a degree in acupuncture and led her to discover her love for science and the integration of eastern and western medicine. Leslie Oldershaw entered the field of acupuncture after spending her college years dedicated to pre-med courses. She became aware of Chinese medicine as a system of treatment while in college, and it fit perfectly with her passion for eastern philosophy and culture. She had always been interested in women’s health and found that fertility treatment in Chinese medicine truly encompasses all aspects of a woman’s health. Recently, PFC interviewed Leslie and Bethany about their approach to infertility, integrative medicine, and the strengths and weaknesses of acupuncture as a fertility treatment.

PFC: When a patient first comes to you and cites infertility as the reason for their visit, what sort of initial work-up do you do?

Leslie Oldershaw: I do a very comprehensive intake that involves an interview that takes a full medical history. Depending on their history, they may have had labwork done, or I may be ordering tests. From a fertility standpoint I like to see the basic hormone panels, including a cycle day 3 FSH, TSH, Estradiol, and also a mid-luteal progesterone test. If they have done a Clomid Challenge test, I love to see those results. If they have had a HSG or an ultrasound, I like to see that as well. From a general wellness perspective, I need to see a CBC and lipid panel and a comprehensive metabolic panel. When it comes to age, if a patient is younger we can be less aggressive. If a patient is older, we will be more aggressive. If they are 30, I will do this basic work-up, but I will be more inclined to just look at how they do over the next 6 months. If someone who is 40 comes to me, I will recommend that they consult a reproductive endocrinologist. They may want to have more of an accelerated timeline in terms of their treatment options. One of the challenges that I have is that I get patients who don’t want to do the western tests. They don’t want a workup, or the partner doesn’t want to do a semen analysis. I spend a lot of time educating patients to make an informed decision rather than shooting in the dark. I will be more persuasive with my arguments as the patient gets older!

Bethany Richardson: Normally, by the time a patient sees me they have already been to a fertility expert. I ask them to bring in their most current blood work. If they have had an antral follicle count, I want to know what that is. The basal temperature chart gives me a wealth of information. I look at it more in terms of a Chinese diagnosis, not necessarily are they ovulating or when they are ovulating, which is important, but are they running too hot or too cold. It gives me a lot of subtle information from a Traditional Chinese Medicine (TCM) standpoint. If I am looking at a woman who is younger, maybe 31 or 32 years old, then I look at her history of antibiotic use and if they have a history of digestive problems. I look at her menstrual cycle, her PMS, and if she is able to detoxify her hormones correctly. If I am looking at an older woman, I look and see if she is too hot or too cold. Does she have an excess of hormones? I see people mainly when they are desperate. They come to me after two cycles of IVF and want to do everything they possibly can for the next cycle. And unfortunately, I would be more effective if I saw them earlier on, but I do what I can when patients come to me.

PFC: If a patient comes to you and she already knows she must do IVF or IUI to get pregnant, what type of protocols do you offer in conjunction with her fertility treatment?

Leslie Oldershaw: When I work with a patient leading up to the treatment cycle, there are a couple of different protocols we can utilize. The more comprehensive protocol requires 2-4 months and allows you to incorporate nutrition, acupuncture and herbal modalities. We can do a tremendous amount to build a patient up, particularly if they are coming out of a miscarriage. We also work with patients on a shorter timeline, where they might be coming in to work with us a few weeks before an IVF cycle, and then we are primarily relying mostly on acupuncture to promote good blood flow and circulation. We will talk to the patient about nutritional support, including a pre-natal vitamin and omega-3 essential fatty acids. There is not enough research at this point to use fertility medications in conjunction with herbs. If things don’t go as expected the doctor needs to be able to troubleshoot what went wrong. My feeling is that acupuncture is of benefit to everyone. The people for whom acupuncture does not work are the patients who are very needle phobic. And I have to say, my IVF patients are champs. They look at my very small needles and they scoff!

Bethany Richardson: The type of treatment depends where on the continuum they are. I look at whether or not they have done IVF before, and what the results were. Were they a poor responder? How old are they? Sometimes they come to me and they tell me their IVF cycle is in three weeks. I can’t do anything with herbs in three weeks, but I can do some acupuncture. If it is six weeks or eight weeks, then we will have a real protocol. From my perspective the hormones you inject are a very warm tonic, which can burn out your cooling system. Depending on how they react to the injectables, I might try to work with them to take some time off from IVF and load them up with cooling tonics. What I see then is that cervical mucus increases, sleeping patterns regulate and stress levels go down. It’s hard for me to prove that it works, but I honestly believe that it does. Stress management, diet, acupuncture and IVF combined can add up to a much greater level of success.

PFC: What are the strengths and weaknesses of using acupuncture to treat infertility?

Bethany Richardson: It regulates the hormones, helps detoxify the body so you don’t have systemic inflammation, reduces PMS and pain. I think its only downfall is that it takes time. And a lot of the time—women aren’t willing to wait. And that’s where I come in again and say, it’s not a sprint, it’s a marathon. Acupuncture isn’t a golden pill. If you continue to eat poorly and not give your body good nutrients and antioxidants, then I can’t do as much.

PFC: Is there anything you want to add about treating infertility with acupuncture?

Leslie Oldershaw: I have always been keen on integrative approaches. There is a tremendous amount that western medicine can do to help people achieve a pregnancy. But what makes a critical difference for me is the integrative approach. What I am doing with my patients is different than what a Reproductive Endocrinologist does, but together we can work synergistically to create the best outcome.

Bethany Richardson: I am very excited about the future. I am hoping that eventually there will be research money that is earmarked for this arena. Often times acupuncture is seen as competitive with western medicine, and I don’t think it has to be. If we join forces we can be more effective together.

In last month’s issue we introduced our readers to Peggy Orlin, MFT, Pacific Fertility Center’s in-house therapist. This month we interviewed her about the key psychological issues affecting individuals and couples experiencing infertility.

What is the most common reason why someone comes to see you at PFC? At Pacific Fertility Center everyone who uses a known or unknown egg or sperm donor or a gestational carrier is required to meet with me. This is mainly an educational session designed to help people think through and discuss the issues involved with using a third party to assist them in building a family. Each meeting is custom tailored to meet the patient’(s) particular needs.

	Use of a third party for reproduction and its impact on a relationship.
	Attachment to a non-genetically related child.
	Disclosure of third party reproduction to family, friends and the child.
	Choice of meeting or not meeting with the donor.
	Use of a family member or friend as the donor.
	Multiple pregnancy (twins or triplets) and its impact on your lives.
	Support services during and after treatment.

What are some of the other reasons people seek your help?
Some patients have had a failed cycle and are having trouble coping with the losses. Other patients have experienced a miscarriage. Both of these scenarios can leave patients feeling bereft and not sure how to move forward. During a session, I can help them understand the grieving process and we can discuss ways that they might ritualize their loss in order to move forward.

The stress of infertility diagnosis and treatment often brings them to me either at the center or in my private practice. It is important to understand that no two people will have exactly the same experience and that infertility can strongly impact those within a committed relationship. A recent diagnosis of infertility, as well as the stress and/or disappointments of treatment, can lead to feelings of isolation and depression. Additionally, people may experience grief over the loss of fertility choices. It is not uncommon that I am the first person, other than their partner, with whom they discuss their feelings about their infertility challenges.

There are those who are at a critical decision point and are seeking help thinking through their reproductive alternatives. This may include deciding whether or not to do one last IVF, move on to egg donation, select an egg donor or complete their family through adoption or childfree living. In the therapy sessions, we discuss and explore the pros and cons of a decision from the unique perspective of their life beliefs and situation.

Others may need help with developing positive coping mechanisms and stress reduction techniques such as setting aside time each day to discuss infertility with their partner, rather than allowing it to be a constant topic of conversation. We may also discuss how they can reduce their isolation possibly by talking with others who are having similar experiences. We may even explore how to include moderate exercise in their schedule to reduce symptoms of depression.

What is your advice to those who are uncertain whether or not they should see a therapist?
For patients at the clinic, one exploratory visit can be helpful. Their doctor can refer them to me for one free session during which we can discuss any concerns they may have and talk together about whether or not seeing a private therapist might be useful for them. They are not signing on for long-term therapy by talking with me. As with stress reduction techniques-it can’t hurt and it might help.

Could you discuss the Mind/Body@PFC Workshop and who might benefit from attending?
The jury is still out on the connection between stress and infertility. Recent studies indicate that there may be a stronger connection between depression and infertility than between anxiety and infertility. The Mind/Body classes not only teach people simple ways to relax, but the small group class gives them the experience of being in a safe environment with others who are all experiencing infertility and know just what it’s like to be going through infertility treatment. This group experience helps to reduce stress and may be helpful to ease mild depression. (Call 888-834-3095 to register or Click here for more information)

How does your private practice differ from your practice at Pacific Fertility Center?
Clients in my private practice tend to be those who are interested in more than one session. Some stay for a few sessions and some want longer-term therapy. Many are couples who are struggling with how differently they are approaching and/or moving toward resolution of their infertility journey. Sometimes clients are self-referred for infertility issues and then as we meet, they chose to move on to other issues in their relationship or their lives. Although I have a specialty with infertility patients, my private practice is with adults experiencing all types of distress.

Depression frequently accompanies infertility. When should someone seek a therapist?
The experience of symptoms of depression which last more than a couple of weeks is an important reason to set up an appointment with me or a therapist of your choosing. Remember, everyone will feel some of these symptoms, some of the time. They become a problem when the number and intensity of symptoms increase and/or don’t abate.

Symptoms of depression:
Feelings of emptiness or extreme sadness
Loss of interest and motivation to do regular activities
Increased level of anxiety
Decreased level of energy
Difficulty sleeping or sleeping more than usual
Difficulty concentrating
Abnormal weight loss or gain
Obsessive thinking about your infertility
Feelings of isolation from friends and family
Extreme and persistent feelings of anger
Persistent thoughts of death or suicidal thoughts or attempts
Persistent feelings of inadequacy, or worthlessness

What is the best way to make an appointment with you?
PFC patients phone the front desk at (415) 834-3000 and ask to set up an appointment. Those who prefer to see me outside PFC can make an appointment for a visit at either my San Francisco or Berkeley office by calling (510) 528-2750.

– Peggy Orlin, M.S., M.F.T.

Exercise and diet improvements are excellent enhancements to fertility therapy. There is evidence of a reduced risk of diabetes, high blood pressure, and pre-eclampsia in women who exercise in pregnancy. Some reports have identified a greater sense of well-being, shorter labor and fewer obstetric interventions in physically well-conditioned women. The standard recommendation by the Centers for Disease Control and Prevention, as well as the American College of Sports Medicine suggests that a minimum 30 minutes or more of moderate exercise per day, every day of the week, is ideal for pregnant women. The American Academy of Family Physicians and the American College of Obstetricians and Gynecologists (ACOG) endorse this 30 minutes per day recommendation.

In addition to physical benefits, gentle to moderate exercise is a healthy way to control the stress related to dealing with infertility diagnosis and treatment, but not all exercise is beneficial.

Level of Exercise
Everyone has a different level of exercise at which point it interferes with fertility. There is risk that the biological stress associated with exercise may induce ovulation problems and can, at times, increase the risks associated with fertility treatment. Maintaining or initiating a well balanced diet is important. This includes diverse nutrients (complex carbohydrates, balanced protein, low fat), a vitamin supplement and adequate hydration, especially during periods of exercise. Weight should be monitored: if weight loss occurs, intake should be increased; if weight gain occurs, intake should be evaluated and revised accordingly. Rapid weight gain or loss is not recommended.

Extreme exercise may affect fertility in both men and women. Serious athletes may have to add more calories to ward off fertility problems. Individual evaluation by a physician is recommended for those who are in a rigorous exercise program and concerned about their fertility.

If a woman has an established exercise program prior to treatment, that level of activity may be maintained and continued with some minor modifications and reasonable precautions.

If a woman has not begun an exercise program prior to treatment, a gentle start is advised such as walking or swimming 15 to 30 minutes, three days a week. A slow and steady increase in duration and frequency can be accomplished over a period of several weeks. A good guideline to follow is if it is difficult to carry on a conversation, slow down. For those starting a new program and can afford the luxury of a professional trainer, working with one who has expertise in exercise during pregnancy is a great way to begin.

Heavy exercise spurts followed by long periods of no activity is not recommended. Gentle to moderate, regular exercise is best.

Modifications to Exercise During Infertility Care
Generally, it is safe to assume that if an activity is uncomfortable, don’t do it, especially when considering discomfort in the region of the ovaries. Near the end of an IVF cycle and for a month after, avoid jostling tender ovaries and activities where even slight injury to the abdomen may occur. Ovaries are enlarged and may be uncomfortable when being jostled. Aside from causing discomfort, there is an increased risk of ovarian torsion, particularly after 5-7 days of gonadotropins. Bouncing exercises to avoid include vigorous step aerobics and running. Less traumatic, low impact exercises, such as walking, yoga, Pilates, swimming, are preferred.

A general rule of thumb is to aim for a target heart rate of 120-130 from stimulation day 8 to one week post transfer.

Contact sports or other activities that may increase the chance of bumping or hitting the abdomen or increase the risk of a fall such as horseback riding, vigorous racquet sports and downhill skiing should be avoided.

Avoid overheating especially during exercise; this includes hot tubs, hot yoga and exercising during very hot days.

Avoid conditions that limit oxygen availability especially during aerobic exercise; hiking up to a 6000 feet altitude is an acceptable limit.

Scuba diving is absolutely not recommended.

These are general guidelines, however, everyone’s level of comfort and physical condition is unique. It is always recommended patients discuss their exercise regimen with their physician.

– Philip Chenette, MD