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.
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.

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.