Meet with a Registered Dietitian and:

Nutrition consultations consist of:

 Not sure if you are a candidate for nutritional counseling?

Set up a time for a free 20 minute phone chat with the dietitian to find out!

Ask a member of the front desk or call 415-834-3000 for more information or to set up an appointment.

Alison Boden, MPH, Registered Dietitian

Alison received her undergraduate degree from UC Davis, followed by graduate training in nutrition and public health from the University of North Carolina at Chapel Hill.  As a practitioner of integrative nutrition she takes a holistic approach to wellness, recognizing that the foundation for optimal health and healing begins with a health promoting diet. Her emphasis is on using medical nutrition interventions to create a basis for health promotion and healing.

A lover of good food, Alison believes that a healthful diet should be thoughtful, enjoyable and satisfying.  Each meal does not only provide calories, but is an opportunity to supply our organs with the nutrients and building blocks needed for health. When the body is out of balance, as in the case of infertility, proper food choices can correct deficiencies and bring balance back to the system. What you eliminate from your diet is often as important as what you include. Consultations with Alison will help you address the key components of your diet that may be affecting your fertility and wellbeing, as well as help prepare your body for pregnancy.

Alison has experience assessing and counseling clients related to pregnancy and fertility, weight management, lipid control, food allergies, digestive health, sports nutrition, and chronic diseases such as cardiovascular, kidney disease and cancer. She views each person as a unique individual, and is dedicated to educating patients on natural ways to achieve optimal health and allowing them to take an active role in their health care decisions.

Alison is a member of the American Dietetic Association and the Women’s Health and Integrative and Functional Medicine practice groups.

Meet with a Registered Dietitian and:

Nutrition consultations consist of:

Not sure if you are a candidate for nutritional counseling?

Set up a time for a free 20 minute phone chat with the dietitian to find out!

Ask a member of the front desk or call 415-834-3000 for more information or to set up an appointment.

Alison Boden, MPH, Registered Dietitian

Alison received her undergraduate degree from UC Davis, followed by graduate training in nutrition and public health from the University of North Carolina at Chapel Hill. As a practitioner of integrative nutrition she takes a holistic approach to wellness, recognizing that the foundation for optimal health and healing begins with a health promoting diet. Her emphasis is on using medical nutrition interventions to create a basis for health promotion and healing.

A lover of good food, Alison believes that a healthful diet should be thoughtful, enjoyable and satisfying. Each meal does not only provide calories, but is an opportunity to supply our organs with the nutrients and building blocks needed for health. When the body is out of balance, as in the case of infertility, proper food choices can correct deficiencies and bring balance back to the system. What you eliminate from your diet is often as important as what you include. Consultations with Alison will help you address the key components of your diet that may be affecting your fertility and wellbeing, as well as help prepare your body for pregnancy.

Alison has experience assessing and counseling clients related to pregnancy and fertility, weight management, lipid control, food allergies, digestive health, sports nutrition, and chronic diseases such as cardiovascular, kidney disease and cancer. She views each person as a unique individual, and is dedicated to educating patients on natural ways to achieve optimal health and allowing them to take an active role in their health care decisions.

Alison is a member of the American Dietetic Association and the Women’s Health and Integrative and Functional Medicine practice groups.

Successful conception does not just involve eggs and sperm and the reproductive tract. The reproductive system, just as all other areas of human physiology, works best when the entire organism is healthy and balanced. This includes not just physical health, but mental health and sexual health.

With respect to physical health, most of what we should be doing is just common sense. For women, mild to moderate regular exercise is best. Although data on the level of exercise that is optimal for conception is scarce, probably no more than 4 hours per week of aerobic exercise may be best¹. Much higher levels can lead to too low a level of body fat for women (optimal body fat for women should be about 20% of total body weight). Excessively lean women (less than 10%) have more problems with proper reproductive hormonal functioning when it comes to ovulation. And while speculative, it is likely humans evolved mechanisms to limit female reproduction in times of starvation (low body fat may mimic a starvation mode) and when we are too much on the run as well. A study published in 2002 looked for associations between exercise levels and pregnancy and birth outcomes in exercising pregnant women². The study reported that women who exercised heavily during pregnancy had smaller babies, more labor inductions and longer labor and well as more colds and flu than more sedentary pregnant women. These are surprising results! Despite these studies it is likely that some moderate amount of exercise helps to promote a sense of well-being and the mental composure to deal with the stresses of every day life and the stress of dealing with fertility issues. Cardiovascular fitness can only be a good thing for pregnancy and beyond.

For men, there really are no restrictions on physical activity. The one exception would be too much bicycling for men hoping to conceive with their partner. The current bicycle saddles do affect testicular function in men who are frequent riders. In general, maintaining good physical shape enhances sexual functioning and of course, sex is important for conception! Speaking of sex, for men to have optimal sexual health, it is important to avoid excessive alcohol. While alcohol does lower mental inhibitions, it also inhibits erectile function, so excess alcohol, contrary to popular belief, does not enhance the sexual experience. Long term excessive alcohol also causes liver damage and raises estrogen levels in men. Higher estrogen levels can lead to smaller testicular volume and lowered sperm production. There is no problem with an occasional drink – just be aware of how much. Avoid intoxication, dehydration, hangovers, and the other consequences of excessive alcohol intake.

As many of our patients are aware, the experience of trying to conceive, especially if it’s taking a long time, can take a toll on sex and intimacy in a relationship. It is so important for partners to be patient with each other and make the effort to maintain the romance and intimacy which keep the relationship healthy. Yes, plan to have sex on the most fertile days of the month, but don’t stop having it before and after the fertile times as well! There is no medical evidence that sex is harmful during the post-ovulation or early pregnancy period. Try to keep the sex-as-fun-and-special attitude alive throughout the month, including baby-making sex days. If there are stresses associated with this issue, we can provide referrals to psychologists that specialize in counseling about sexual health and are professionals in this area. Remember that our sex lives will outlive the infertility, the new baby and the growing children experiences. So it is crucial to nurture this aspect of the relationship.

There is no question that having a good sexual relationship promotes intimacy and better communication. This is so important when it comes to supporting each other. Fertility problems can be a crisis time in the lives of young adults. Sometimes the crisis situation can bring a couple closer together and sometimes it can cause them to feel isolated, even from each other. Communication is essential. For most women, communication is usually inherently verbal; she wants to talk about it and about her feelings. For most men, dealing with painful feelings, such as that recent negative pregnancy test or that recent miscarriage can be difficult for him to verbalize. Add to this frustration, the obvious sorrow of his female partner and men can feel helpless. It doesn’t necessarily help to try to force people to talk about these feelings, at least until they are ready. Letting him go the gym or shoot some hoops with some friends might be a better way for him to initially deal with bad news. But when the time comes, talking and acknowledging each other’s feelings and understanding how each person deals with difficult situations can make a relationship much stronger.

References:

1. Effects of Lifetime Exercise on the Outcome of In Vitro Fertilization  Morris, Stephanie N.; Missmer, Stacey A.; Cramer, Daniel W.; Powers, R Douglas; McShane, Patricia M.; Hornstein, Mark D.Obstetrics & Gynecology. 108(4):938-945, October 2006.

2  Antpartum, Intrapartum, and Neonatal Significance of Exercise on Healthy, Low-Risk Pregnant Working Women. Maqgtann, Everett F., Evans, Sharon F., Weitz, Beth, Newnham, John. Obstetrics & Gynecology. 99(3):466-472. March 2002.

We all know that people that are not particularly health-conscious can conceive, many times easily or even unintentionally. However, conception is a much more common event when the involved parties are young, and eggs and sperm are much more likely to be genetically normal. It may also be that the reproductive system has not been subjected to years of accumulated age-related, environmental damage. Successful conception does not just involve eggs and sperm and the reproductive tract. Just as in all other areas of human physiology, the reproductive system works best when the entire organism is healthy and balanced. This includes not just physical health, but mental health and sexual health. 

It makes sense that healthy people are more likely to have healthier babies, and this may be especially true in the later reproductive years. For example, a woman in her forties with mild high blood pressure is going to have a safer pregnancy when she keeps her weight down and consistently takes her medications for blood pressure. Similarly, the liver function may be negatively affected by the cumulative effects of drinking alcohol over many years and the liver is crucial to clearing toxins from the body.

The feeling of lack of control is one of the main issues for women and men facing the challenge of infertility. No one can know exactly when they are going to conceive, but for infertility patients undergoing fertility treatments, even the how of conception is being determined by medical factors that again are out of their control. One way to gain back some control is to take charge of our health and nutrition. Eating healthy and living healthy can only help one’s chances for successful conception. Furthermore, when a pregnancy is achieved, the habits set prior to conception and continued during gestation will provide for the best physical environment to nurture the developing fetus. In this issue, we present information about nutritional needs during pre-conception and early pregnancy. The goal of pre-conception nutrition is to promote the health of the gametes (eggs and sperm) and to set the nutritional habits that will carry on into pregnancy and breast feeding.

Certainly the most important component in eggs and sperm is the DNA, which carries the genetic material from the parents to the embryo. DNA molecules are long linear chains of nucleic acids, sugars and proteins. Damage to and degradation of DNA is a consequence of living.  The energy packets in all our body’s cells, including sperm and eggs, are called mitochondria. Mitochondria contain DNA and produce important enzymes for metabolism and energy production. Molecular by-products of metabolism, oxygen free radicals and nitric oxide species, are constantly forming in our bodies .These free radicals can damage both nuclear and mitochondrial DNA. All living organisms have developed many mechanisms to protect their DNA from the environmental damage of excessive nitric oxide and oxygen free radicals. Anti-oxidant nutrients and vitamins are essential to support these protective mechanisms. Truth be told, we all should be ingesting anti-oxidants throughout our lives to protect our DNA and all our tissues from assaults from the outer (and inner) world, but no time is more crucial for the next generation than at conception and fetal development. There are known substances and chemicals in the modern world that can overwhelm our highly evolved physiologic protective processes. Just one well-known example is phthalate ester, a chemical used to soften plastics such as in disposable water bottles, which leaches into the water it contains. These phthalates have been shown to have toxic effects in animal studies on the reproductive system¹ and have been found in urine and breast milk of pregnant and lactating women². Unfortunately, phthalates are only one of many, many chemicals we are exposed to on a regular basis. So, there are substances to avoid, when possible, but can we really avoid every harmful chemical? Not likely. What we can do, beyond avoiding these chemicals,  is make sure we are getting the nutrients, vitamins and minerals that help our own enzymes and proteins to protect our DNA.

There are numerous books on nutrition for pre-pregnancy and pregnancy. It is not possible to cover this topic exhaustively in this series of two articles. Suffice it to say that there is no one diet that has been conclusively shown to promote fertility. It is common sense that nutritionally empty diets, especially those that promote obesity, are clearly harmful to conception. Diets lacking in essential vitamins and minerals can have consequences beyond infertility, such as very poor pregnancy outcomes and malnourished babies. One recent article from the Netherlands² looked at the diets of women undergoing IVF. They measured blood levels and follicular fluid levels of some essential vitamins and minerals in these women. To paraphrase their findings: In women, two dietary patterns were identified. The “health conscious–low processed” dietary pattern was characterized by high intakes of fruits, vegetables, fish, and whole grains and low intakes of snacks, meats, and mayonnaise, and positively correlated with red blood cell folate (β = 0.07). The “Mediterranean” dietary pattern that is, high intakes of vegetable oils, vegetables, fish, and legumes and low intakes of snacks, was positively correlated with red blood cell folate (β = 0.13), and vitamin B6 in blood (β = 0.09) and follicular fluid (β = 0.18). High adherence to the “Mediterranean” diet increased the probability of pregnancy by 40%. Their conclusion was “A preconception “Mediterranean” diet by couples undergoing IVF/ICSI treatment contributes to the success of achieving pregnancy.”

So avoiding environmental toxins and eating a healthy (possibly “Mediterranean”) diet may be helpful for general health, fertility and pregnancy, but what are the specifics? What to avoid? What to include? For some very general guidelines, see the side bar to this article. For more comprehensive help, I recommend the book “Fertility and Conception” but Dr. Karen Trewinnard³, listed in the References. Please also look for PART 2 to this article next month for more nutrition and health advice and information.

References:

SIDEBAR: 

What to Avoid (a much-abbreviated list):

1. Drinking from plastic water bottles.
2. Microwaving food in plastic (and especially stryofoam!) containers
3. Pesticides and herbicides – whenever possible, buy organic, when not possible, wash fruits and vegetables well.
4. Heavy metals such as lead (soldering, stripping old paint from walls), mercury (in high-food chain fish) and cadmium (cigarettes, solder materials, pesticides)
5. White foods: too much white bread, refined sugar, white rice, potatoes 
6. Too much salt and butter, fried foods
7. Caffeine – it’s a blood vessel constrictor
8. Alcohol – more on this next issue.

What to Include (somewhat abbreviated):

1. Olive oil rather than butter
2. Fish that do not contain mercury (e.g. salmon, most shellfish, halibut, flounder)
3. Organically-grown fresh fruit and vegetables
4. Whole grains
5. Omega-3 Fish oils
6. Anti-oxidants such as blueberries, cranberries, tomatoes (lycopene)
7. Pre-natal vitamins containing at least 800 mcg folic acid and 2000 IU of Vitamin D3 (for a more thorough discussion of the essential vitamins and minerals, see the website www.essbeg.com)

This past July, I had the opportunity to attend the 23^rd Annual In Vitro Fertilization and Embryo Transfer meeting in Santa Barbara, CA. This is an IVF meeting sponsored by UCLA.  It’s hard to believe that a meeting devoted solely to IVF has been presented annually for 23 years now.  I used to think of IVF as a brand new field, but it really has matured as a specialized area of medicine. This meeting is not considered a scientific meeting because it has more of a lecture/didactic course format rather than one of   presentations of new research by physicians and scientists.  However, this meeting is devoted to bringing various experts together with clinicians providing IVF care to discuss the latest theories and clinical practices. I had not attended this meeting in several years as it had not appeared to present much new information.  However, this years’ meeting was surprisingly thoughtful and relevant.

While not the sole focus of the lectures, a definite theme running through the meeting addressed the current interest in the fundamental health of sperm and eggs. There were several talks covering the data (or lack thereof) of stress and our modern chemical-laden environment on reproduction. There was some discussion of the role anti-oxidants and other nutritional supplements play in reproduction. Dr. David Meldrum from Southern California and Dr. Peter Schlegel from Cornell Medical Center touched on whether or not anti-oxidants may be useful in improving eggs and sperm, respectively. The preliminary data is intriguing, but much further study will likely be needed. However, because anti-oxidant nutritional substance show so many benefits in other aspects of human bodily function, there is hope they will also be shown to be beneficial for reproduction.

Dr. Sarah Berga, Professor and Chairman of the Obstetrics and Gynecology Department at Emory University Medical Center in Atlanta, gave several excellent talks. Dr. Berga’s area of research interest is in the effect of stress and diet on reproduction. She is a thinker and applies scientific evidence to the theories of hormones and stress. She is an excellent speaker and has always been an open, accessible and friendly colleague of mine.

One of Dr. Berga’s talks focused on the topic of “What is Stress?” She defined two aspects of stress: metabolic stress and psychogenic stress. These two different aspects of stress result in the same pathologic process potentially leading to impaired reproduction. She discussed psychological stress that emanates from a sense of the “lack of control” that many of us, but especially individuals suffering from infertility, feel when faced with this challenge. In some individuals, there may be overly high personal expectation of oneself and of others, which contributes to a sense of failure. With regards to physiologic or metabolic stress, a harmful result of stress may be hypothyroidism. That is, decreased levels of thyroxine (thyroid hormone) may be a result of psychological stress, leading to metabolic stress, and in severe cases can contribute further to infertility and increased risks of miscarriage. In turn, it becomes the quintessential vicious cycle. With regards to diet, normal and healthy caloric intake can lower cortisol levels, which is good. Cortisol, an important adrenal hormone produced in response to stress, also shortens telomeres – the pieces of DNA on the ends of chromosomes that protect our chromosomes from damage and slows the aging process. Dietary caloric restriction and an over-energized metabolism can result in a person becoming significantly underweight.   Potentially, this could further raise cortisol levels and, in women, may contribute to lack of ovulation and infertility. Thyroid hormone levels drop, trying to slow down metabolism and hang on to calories. Furthermore, for the pregnant woman, the only source of thyroid hormone for the baby comes from the mother, and hypothyroidism in pregnancy is a serious challenge for the developing fetus. Thus far, other than thyroid hormone replacement (a band-aid for the problem), a potential solution is to attempt to break this cycle. Cognitive Behavioral Therapy (CBT) and techniques such as conscious relaxation (Mind-Body training) have shown promise in reversing these trends.

Another interesting speaker at the conference was Dr. Douglas Carrell, PhD, Associate Professor of Surgery (Urology), Obstetrics and Gynecology, and Physiology, University of Utah School of Medicine. One of his talks concerned how to locate the best sperm to inseminate eggs at the time of IVF, especially in men with male factor infertility, but potentially for all men. He spoke about various tests that some scientists currently advocate for determining whether a man’s sperm is capable of producing healthy embryos and healthy babies, such as DNA fragmentation assays. His bottom line take on this is that no one test on one sperm sample is likely to predict that all sperm are bad all the time. He also addressed an area that has interested us at Pacific Fertility Center: Hyaluronic Acid (HA) binding test and the Annexin separation sperm quality test. The HA binding test uses the phenomenon of good sperm binding to hyaluron prior to selecting that sperm for egg injection (ICSI). The Annexin separation test uses a similar substance to select out sperm that are apoptotic (DNA heavily damaged). While intriguing, neither test has yet been put to a definitive randomized controlled-trial, which would be needed to show improvement in pregnancy rates.

These are just a few of the many topics covered at this very interesting and thought-provoking meeting. I am fortunate to be a part of a fertility center that believes in the value of attending and participating in meetings that allow us to share ideas and concepts.  This sharing of ideas will no doubt lead to the further understanding and treatment of problems in human reproduction.

-Carolyn Givens, M.D.

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.

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.

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.
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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.
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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.
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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.