David R. Meldrum, MD

Lifestyle / Fertility / ED
Recent studies are uncovering many effects of lifestyle and nutrition on fertility in both partners. Also, sexual dysfunction is common in infertile couples and male fertility is influenced by most of these same factors. You will have the maximum chance of success if you pay attention to these issues right from the beginning, but they become more important as the treatments become more complex, and particularly with IVF. I have provided more detailed information at www.lifechoicesandfertility.com and www.erectile-function.com regarding these important ways to maximize both your fertility and your sexual relationship. References with a short description of the key findings are also provided.

Weight
Obesity (BMI over 30) decreases a woman’s fertility, increases the chance of miscarriage, and most importantly, increases the chance of premature birth with all of its attendant risks for the offspring. The higher the BMI the more pronounced these problems are and ideally you should lose weight before attempting conception if your BMI is over 35. However, you may not have time (gradual weight loss due to increased activity and improved food choices and amounts should be followed for 3 to 6 months before IVF and drastic dieting may be counterproductive for IVF success). Unfortunately these effects of obesity, particularly prematurity, are even more pronounced in African American women. Exercise at any level has very positive effects on obese women trying to conceive. With a brisk walk for 30 minutes and only 300 fewer calories each day you will lose 40 pounds per year. If you start at the beginning of your attempts to conceive, by the time IVF would be considered you will have lost up to 50 pounds or more, which will have major benefits in reducing all of the above problems. Excess body weight also contributes to sexual dysfunction in both sexes, but particularly for the male partner. At erectile-function website you can download “Survival of the Firmest”, that has many helpful hints for losing weight and for healthy eating.
Obesity in the male partner reduces sperm quality. The effects are not great, but even one fewer embryo getting fertilized could be the one that would have implanted.
Low body weight can also cause infertility by stopping ovulation and menstrual periods, and low body weight increases the chance of poor fetal growth (small for dates). BMI should be normal before attempting pregnancy.

Exercise
Moderate exercise increases both male and female fertility. Moderate exercise (e.g. a brisk walk) for 30 minutes most days of the week is the current recommendation for all adults and this level is fine for fertility. Two studies have suggested more than 3-5 hours of moderate exercise per week for the female partner may reduce the chance of success with IVF, hence the above guidelines. Any level of exercise markedly increases IVF success in obese women, probably by reducing their elevated level of oxidative stress. Moderate or even high exercise for the male will enhance erectile function and will help prevent any decline of that function with aging. Only intensive exercise like marathon running has negative effects on sperm, although biking for more than 5 hours per week reduces semen quality, possibly through accumulation of heat around the testicles

Nutrition
Recent studies have suggested that a “prudent” diet improves fertility for both partners, i.e less red meat and saturated fat, more seafood, and more fruits and vegetables, often referred to as the “Mediterranean diet”. Trans fats should be avoided entirely, for example, doughnuts, Danish pastries, French fries and fried foods in general. In a recent study, the birth rate with IVF was significantly lower for women who consumed more sugary drinks. Sugar causes oxidative stress, which can be counteracted by ingestion of a strong antioxidant. Studies point to antioxidants and omega-3’s as the factors involved in these benefits and these are therefore discussed in detail below.

Antioxidants
Antioxidants improve sperm motility and oxidative stress has been shown to be increased in the semen of men with reduced sperm motility. Sperm are very sensitive to oxidation because they have to shed their cytoplasm in order to be able to move rapidly. The cytoplasm (all of the cell’s bulk except the nucleus carrying the chromosomes) contains the cell’s natural antioxidant defenses.  In men with increased fragmentation of their sperm DNA, 1,000 mg of vitamin C and vitamin E decreased the proportion of sperm with fragmented DNA (from 22 to 9 %). I don't recommend vitamin E because doses of 400 IU or more have been associated with increased all-cause mortality, and a recent study associated vitamin E with increased prostate cancer. Most likely any strong level of antioxidant will have a similar impact, such as a small bowl of berries each day, or 1,000 mg of vitamin C, 200 IU of vitamin E and 2 cups of green tea daily. A commercial antioxidant, pycnogenol, two 40-60 mg capsules daily, would also provide a good antioxidant dose. All fruits and vegetables contain antioxidants but berries have the most with blackberries having almost twice as much as blueberries. Dark chocolate is also an excellent source of antioxidants.
As women get older, the amount of antioxidant in the fluid around the egg decreases. Without antioxidant protection, the cells surrounding the egg are less able to provide nutrition for the egg as it matures. The resulting poor function of those cells correlates with reduced embryo quality and the chance of pregnancy. The same suggestions for increasing antioxidant intake given above for the male also apply for the female. Women should not take vitamin E during the IVF cycle as it could increase the chance of bleeding with the egg retrieval, and although recent studies are conflicting, we recommend no caffeine except one cup of decaf tea or coffee (therefore no chocolate, which has caffeine).

Omega-3’s
Omega-3’s, as well as antioxidants, increase blood flow by increasing a chemical called nitric oxide. Blood flow is very important for ovarian response to stimulation, and blood flow around the mature egg has been correlated with improved egg quality. Blood flow presumably is also very important for function of the testicles. In one study two agents known to increase nitric oxide increased sperm count and motility as well as the circulating level of testosterone. Omega-3’s are also important in the make-up of sperm membranes. In various recent studies, omega-3’s have been associated with improved sperm and egg quality.
An easy and inexpensive way to get omega-3’s is from fish oil. A reasonable dose is 500 to 1,000 mg, but make sure that is the amount of EPA and DHA (the two principle omega-3’s) and not just the amount of oil. They are listed on the nutrition label on the back of the bottle. If you take this amount you will not need a more expensive prenatal vitamin containing DHA. There are some early indications that omega-3’s may decrease premature birth. DHA has been added to some prenatal vitamins as it may aid fetal brain development, although a study at age 4 did not confirm any benefit.
Omega-3’s themselves are very sensitive to oxidation so always take a good level of antioxidants along with boosting your omega-3 intake. Also, they work together to increase blood flow for fertility or male sexual function. In a recent study a larger dose of 1800 mg per day increased all aspects of semen quality when tested over a 7 month period.

Co-enzyme Q-10
A Canadian researcher has done some intriguing studies on egg quality in the aging rat (the older female rat’s eggs show very similar changes compared to eggs from older women). This is discussed in detail at www.lifechoicesandfertility.com . As yet there is only a very small experience in humans that did suggest benefits. The dose suggested based on the amount given in the animal model is 600-800 mg per day. We can’t recommend it because it has not yet been sufficiently studied in humans for this purpose. Individual patients over age 37 may elect to take it, accepting any unknown risk. It has been taken for other reasons without apparent problems observed, but usually at lower doses. If it is taken, I would recommend stopping it with a positive pregnancy test, as effects on pregnancy and the fetus have not been investigated.

 
Smoking
Smoking by the female decreases the chance of success by 50% and increases miscarriage. It is absurd for a woman to not stop smoking before fertility treatments, particularly IVF. Even second-hand smoke reduces the chance of pregnancy and decreases ovarian reserve. Fortunately the adverse effects of inhaling tobacco smoke appear to go away 3-6 months after stopping. Smoking by the male partner reduces semen quality, increases DNA fragmentation, and decreases the success rate with IVF. Of course the serious health risks of smoking are more important reasons to quit. However, if the male partner is unable to quit, he should take high amounts of antioxidants (above), which may counteract some of the adverse effects on sperm and on the cardiovascular system.

Caffeine
The female partner should not have more caffeine than one cup of decaf coffee or tea (5 mg or less) before and during an IVF cycle (although two more recent studies showed no negative impact). Chocolate contains about 20 mg per serving and sodas about 80 mg. The sperm are not as sensitive to caffeine, but the male should not drink more than the equivalent to 3 cups of coffee (one cup contains about 150 mg). Larger amounts have been reported to increase sperm DNA fragmentation.

Alcohol
Neither partner should drink alcohol during an IVF cycle (studies have shown a decreased pregnancy rate and an increased rate of miscarriage). However, when first attempting to conceive, in one study drinking 5-6 glasses of wine per week by the female partner reduced the time to become pregnant. With most adverse lifestyle factors a greater reduction of pregnancy outcome is observed with more advanced treatments.

The environment
Men should avoid significant heat exposure to the testicles (hot tubs, Jacuzzi’s, steam baths) and they should not use a lap top directly on the lap (hot showers are OK). The testicles are outside of the body because sperm production requires a lower temperature. It is probably better to wear boxer rather than jockey shorts, although one study did not show any change in sperm function. Recent studies have also suggested that extensive use of a cell phone transmitting from a front pocket should be avoided. Trans fats also adversely affect sperm, so avoid doughnuts, French fries and Danish pastries and anything without a nutrition label that says no trans fats. Plastic recycle number 7 (polycarbonate and “other”) should be avoided. Polycarbonate is also in food can linings and heat-activated receipts such as the credit card receipts we all handle (wash your hands before handling food). Polycarbonate releases the hormone disruptor Bisphenol A. BPA levels have been associated with reduced sperm count and motility, lower testosterone levels, poor ovarian response to stimulation, and increased miscarriage.

Stress
Finally, any discussion of life choices and fertility would be incomplete without discussing the effects of anxiety, stress, and depression. Various studies have shown a reduced success rate in achieving pregnancy in women experiencing these symptoms, and an intensive stress reduction program (Mind/Body) has been shown in controlled studies to reduce the time to achieve a pregnancy in couples just beginning to attempt conception and to increase the pregnancy rate with IVF. One study showed that certain individuals are more vulnerable to stress. When exposed to stressful visual and auditory stimuli, those exhibiting greater increases of their pulse and blood pressure had a reduced chance of pregnancy with IVF. This study also indicated that reduced blood flow may be the mechanism through which such an effect is manifested. Stress can also be reduced by taking on fewer tasks, by relaxation techniques such as yoga, or even by taking off time from work during the ovarian stimulation through until well after embryo transfer, as full-time employment has been correlated with a lower pregnancy rate with IVF.

Good luck
Actually, luck has relatively little to do with it. One of my favorite sayings is “it doesn’t matter so much what happens to you as much as how you handle it”. If you pay attention to the factors outlined above, if you are in a good fertility center such as ours, and if you are persistent, you will very likey be successful. Even more important is to not let the infertility wear away at your relationship, including your sexual enjoyment. Challenges can strengthen the bond between you and your partner if you support each other and handle them together, and if you pay attention to all of our recommendations at www.erectile-function.com, you might well find your sexual relationship better than at any time in the past.