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Lifestyle and infertility

Lifestyle and infertility. Laura dracea, MD, PhD Gynera Fertility Center Bucharest, Romania.

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Lifestyle and infertility

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  1. Lifestyle and infertility • Laura dracea, MD, PhD • Gynera Fertility Center Bucharest, Romania

  2. We hope you enjoyed your coffee.Don’t worry! Up to 5 cups of coffee/day have No demonstrable adverse effects on your health.Higdon J, Frei B. Coffee and Health: a review of recent human research. Crit Rev Food SciNutr 2006; 46

  3. Lifestyle and infertility • Laura dracea, MD, PhD • Gynera Fertility Center Bucharest, Romania

  4. "Destiny is not a matter of chance, it is a matter of choice."Winston Churchill What if our choices or our patients’ choices could make a difference?

  5. What we do know? • One out of six couples have fertility challenges • Lifestyle choices may contribute to their infertility • Social trends lead to deferring childbearing and care • Most patients are not aware on potential consequences • No evidence-based guidelines available • Reduced counseling focused on lifestyle modification

  6. What we do not know? Infertility factors identified What about the other 20% ? in 80 % of the cases Different results of the treatment Why ? in patients with same causes Adjuvant medication Why not adjuvant lifestyle ? Patients underestimate the What about professionals ? influence of certain factors Aren’t we missing something?

  7. Why is it relevant?Modifiable factors! Inexpensive modification! • With appropriate counseling we may be able to: • Improve natural fertility • Improve reproductive treatment outcome • Reduce obstetric and neonatal complications

  8. What to do? • Review current knowledge and recent meta-analysis • Provide updated evidence • Provide results of our recent awareness study • Make recommendations for appropriate counseling

  9. main factors • Deferring childbearing and aging • Deferring treatment • Smoking • Obesity • Alcohol and caffeine • Environmental toxins • Psychological stress

  10. Aging Infertility Increases With Age Percent chance Age Group (years) Percent Infertile of remaining childless 20 - 24 7 6 25 - 29 9 9 30 - 34 15 15 35 - 39 22 30 40 - 44 29 64 • Adapted from Menken J,TrussellJ,Larsen U. Age and infertility. Science. 1986;23:1389.

  11. Aging • Risk of Spontaneous Abortion with Advancing Age • Maternal Age (years) Spontaneous Abortion (%) 15-19 10 20-24 10 25-29 10 30-34 12 35-39 18 40-44 34 ≥45 53 • Adapted from P.R. Gindoff and R. Jewelewicz. Reproductive potential in the older woman. FertilSteril 1986; 46:989

  12. Risk of Spontaneous Abortion with Advancing Age • Heffner L., Advanced, maternal age – how old is too old? New England Journal of Medicine 2004; 351(19):1927–29

  13. Aging • Risk of Chromosomal Abnormality in Newborns • by Maternal Age • Adapted from Maternal Fetal Medicine:Practice and Principles. Creasy and Resnick,eds. W.B. Saunders,Philadelphia,PA. 1994:71.

  14. Aging Success rates of ART treatment by maternal age The most recent United States IVF-monitoring U.S. 2007 (CDC online publication) Average pregnancy rate per cycle: Woman age < 3535-3738-4041-4243-44 Fresh cycles 40 % 31 % 21 % 12 % 5 % (nondonor) U.S. Department of Health and Human Services, Centers for Disease Control (CDC) at /www.cdc.gov/ART/ART2007

  15. Success rates of ART treatment by maternal age Review of data from the various IVF centers in the USA 2007 CDC Report

  16. main factors • Deferring childbearing and aging • Deferring treatment • Smoking • Obesity • Alcohol and caffeine • Environmental toxins • Psychological stress

  17. smoking Smoking vs Nonsmoking women Relative risk of infertility increased 60% Clark et al., 1998 Increased miscarriage risk Natural conception Augood et al., 1998 Assisted conception Winter et al., 2002 Increased risk for ectopic pregnancy Saraiya et al., 1998 Conception delay over 1 year Augood et al., 1998 Hull et al., 2000 Require nearly twice the number of IVF cycles to conceive Feithinger et al., 1997 Each year of smoking - 9% increased risk of unsuccessful ART Klonoff-Cohen et al.,2001 Decreased IVF pregnancy rate for passive smokers as well Neal et al., 2005 Menopause occurs one to four years earlier Mattison et al., 1989 Baron et al., 1990 Higher gonadotropin dose requirements MacMahon et al., 1982 More diploid oocytes in the ovary Zenzes et al., 1995 Lower sperm count in male progeny Storgaard et al., 2003 Increased risk of trisomy 21 offspring Yang et al., 1999 Increased transmission of modified DNA to embryo Zenzes et al., 1999 Much of the risk may be reversed within a year of cessation Hughes et al., 2000

  18. smoking Smoking as a risk factor for men Most recent systematic review and meta-analysis Li et al., FertilSteril 2011 57 cross-sectional studies 29,914 participants from 26 countries/regions Sperm parameter Pooled mean difference Test for overall effect IV 95 % CI p value Sperm volume -0.25 (-0.32,-0.18) < .00001 Sperm density -7.07 (-10.03,-4.10) < .00001 Total sperm count -32.20 (-43.28,-21.11) < .00001 Sperm motility -1.85 (-3.27,-0.43) .01 Sperm normal morphology -4.92 (-6.90,-2.94) < .00001 Sperm abnormal morphology 0.72 (0.15,1.29) .01

  19. obesity 30%–47% of overweight women have irregular menses Castillo-Martinez et al., 2003 Obesity decreases fecundity, even in ovulatory women Gesink Law et al., 2007 Ovulation and pregnancy rates improve after weight loss Clark et al., 1995 Obesity decreases IVF pregnancy rate Nichols et al., 2003 Obesity increases requirement for gonadotropins Fedorcsac et al., 2004 The risk for spontaneous abortion increases in overweight Wang et al., 2002 The risks for preeclampsia, gestational diabetes increase Dokras et al., 2006 The effect of BMI on sperm parameters is uncertain Li et al., 2011

  20. alcohol Moderate alcohol consumption Detrimental effects on fetal development American Academy of Pediatrics, 2001 N o evidence to indicate that adversely affects fertility Parrazini et al., 1999 Higher alcohol consumption (> 2 drinks/day) Decreases fecundity Williams et al., 2009 Can reduce semen volume Li et al., 2011

  21. caffeine High levels of caffeine consumption (> 5 cups/day) Decrease fertility Bolumar et al., 1997 Increase the risk for miscarriage Signorello et al., 2004 Mild consumption of up to 200 mg caffeine per day ( 2 cups) Not associated with any apparent adverse effect on reproduction

  22. environmental toxins Have been shown to have a negative effect on fertility: Toxins and solvents used in the dry cleaning and printing industries Heavy metals Pesticide exposure for agricultural workers Lead Industrial microwaves Radiations

  23. Psychological stress The most common reason for discontinuation of fertility treatment Inversely related to pregnancy and life birth rate in IVF No convincing evidence demonstrates a direct adverse effect on fertility More often an effect than a cause for infertility: Prolonged infertility Too many treatment cycles High psychological impact

  24. other possible threats Sexual behavior Multiple partners Unprotected intercourse via Sexual transmitted diseases Recreational drugs Cannabinoids Cause hormonal dysregulation in women Reduce testosterone level, sperm motility and capacitation Medication Anabolic androgenic steroids Suppression of hypotalamo-gonadal axis Methadone Depress spermatogenesis NSAI Impairment of follicle rupture and tubal function Calcium channel blockers Fertilization failure Anderson K et al. Lifestyle factors in people seeking infertility treatment - A review. Aust N Z J ObstetGynecol 2010

  25. Further clinical trials needed To Investigate: • Environmental pollutants • Oxidative stress and role of antioxidants • Diet • Excessive physical activity • Medication

  26. Awareness among professionals Roth et al., 2001

  27. Awareness among patients • Gynera Fertility Center, Bucharest, 2010 - 2011

  28. What to do? • Review current knowledge and recent meta-analysis • Provide up-dated evidence • Provide results of our recent awareness study • Make recommendations for appropriate counseling Tool: Provide convincing evidence !

  29. practical recommendationsAging For patients: Do not defer childbearing! For professionals: Do not defer fertility treatment! Do not defer IVF treatment for women over 38!

  30. practical recommendationsAging How relevant is this choice? 35 42 Percent of infertile women < 15 % 29 % Risk of spontaneous abortion 15 % 30 % Risk of genetic defects in newborn 1/192 1/42 Average success rate of IVF 30-40 % < 12 %

  31. practical recommendationsSmoking • Quit smoking! • Avoid passive smoking! How relevant is this choice? You will: • Reduce the conception delay by 1 year • Reduce the risk for miscarriage and ectopic pregnancy • Reduce to half the number of IVF attempts required to conceive • Delay menopause (by one to four years) • Be healthier

  32. practical recommendationsObesity Loose weight to: • Improve ovulation • Reduce requirement for fertility drugs • Reduce the risk for miscarriage and other complications during pregnancy • Look and feel better Dilemma: Delaying treatment to allow loss of weight

  33. practical recommendationsAlcohol Stop drinking alcohol during pregnancy! No safe level of consumption to avoid detrimental effect on fetal development Avoid high consumption (>2 drinks/day) when attempting pregnancy! No evidence to indicate that moderate consumption adversely affects fertility

  34. practical recommendationsCoffee Quit drinking coffee? Not necessarily. Just do not exaggerate!

  35. practical recommendationsPsychological stress Do not blame the psychological stress for everything. This is not supported by evidence. • Add some psychologic therapy during fertility visits • Refer to professional counseling where appropriate • Avoid persisting too long with low chance treatments • Move quicker to IVF if woman is over 38 years old

  36. What is the trend of modern lifestyle? Older, fatter, stressed, tobacco intoxicated and infertile but having a career and affording assisted reproduction?

  37. conclusion Apparently, the lifestyle factor that has the most detrimental effect on fertility potential seems to be the social trend of having a career before a family We need to make people aware of the consequences ! They could deal with both goals in a much more efficient way.

  38. We should be able to slow down this trend. • We could do better.

  39. Thank you

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