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ROLE OF LIFE STYLE AND ENVIORNMENT IN INFERTILITY

by Dr. Keshav Malhotra

Introduction:

Lifestyle factors are behaviours and circumstances that are, or were once, modifiable and can be a contributing factor to subfertility. Fertility is the capacity to produce offspring, whereas fecundity is a woman's biological ability to reproduce based on the monthly probability of conception . The causes of infertility are wide ranging including ovulatory disorders, tubal disease, endometriosis, chromosomal abnormalities, sperm factors and unexplained infertility.

The impact of lifestyle on reproductive performance may vary depending on individual aetiology and circumstances. Here we focuses on the impact of potentially modifiable, non-communicable lifestyle factors on reproductive performance in the general population and the infertile population undergoing assisted reproductive technology (ART) treatment. The impact of several lifestyle factors including; age, weight, smoking, diet, exercise, psychological stress, caffeine consumption, alcohol consumption and exposure to environmental pollutants.The potential for environmental and occupational exposures to chemicals and pollutants to adversely affect fertility is not surprising, as environmental and lifestyle factors are said to be key factors in human disease. Certain environmental exposures have been implicated in adverse effects on reproduction.

Some lifestyle choices that may affect your fertility

Alcohol- Having a glass or two of alcohol won’t have a big impact on your fertility, but you should limit the amount of alcohol you consume. Heavy drinking has been linked to an increased risk of ovulation disorders in women and poor sperm quality in men.( 2)

Smoking- As most people already know, smoking is harmful to overall health but many don’t realise it also affects fertility. Smoking has major adverse effects on both egg and sperm quality, but that’s not all. It also lowers sperm count, pregnancy rate and increases sperm DNA fragmentation, which can lead to miscarriage.( 3).Passive smoking is also important in increasing complications in pregnancy as well as in ivf cycles.

Weight- Being either overweight or underweight can decrease the fertility of both men and women. Men with a high body mass index (BMI) tend to have a lower sperm count and reduced sperm quality. Women with a high BMI are at greater risk of miscarriage, stillbirth and caesarean delivery.

During under-nutrition, when leptin secretion from fat cells plummets, the reproductive system essentially shuts down because of reduced production of GnRH and consequent reduction of LH and FSH. In turn, the absence of these hormones results in a lack of follicular development, a lack of sex steroids and an absence of ovulation.

By contrast, in overweight women and/or those with polycystic ovary syndrome (PCOS), an increase in the number of fat cells results in a cascade of changes, involving increased leptin and insulin levels and a preferential increase in LH, but not FSH, levels. The net effect of these changes is to stimulate the partial development of follicles that secrete supranormal levels of Testosteron, but which rarely ovulate (hence low progesterone). These changes are exacerbated by insulin-induced reduction in SHBG, which amplifies ovarian androgen production/action.(4)

Diet- What you eat – or don’t eat – can also play a role in fertility. For example, women trying to conceive shouldn’t have a high protein diet because excessive protein has been linked to decreased fertility.They should avoid vitamin A. It has also been found that 25% of women in their childbearing years have a vitamin D deficiency, which has also been linked to lowered fertility.

Exercise- Staying fit through regular exercise is an importance aspect of a healthy lifestyle; however, when it comes to fertility it can be too much of a good thing. Extremely vigorous and frequent physical activity can lead to a lower sperm count and reduced ovulation, or lack thereof.

Caffeine. Though the evidence is not completely convincing, some research suggests that too much caffeine can reduce fertility, especially in women. A cup of coffee or two a day won’t do much harm, but it is advisable to avoid excessive caffeine consumption.it seems reasonable to keep this below 200-300 mg/day. (5)

Stress- stress may reduce female reproductive performance in various ways. The autonomic nervous system, the endocrine and immune systems have all been implicated There is, however, a lack of clear consensus as to the definition and measurement of ‘psychological stress, bringing into question the nature and strength of any putative association. Given that infertility and ART treatment are associated with stress determination of whether stress contributes to or is a consequence of infertility and ART treatment is problematic.

Environmental Factors:

Adverse effects of radiation on male and female reproduction have been demonstrated in various animal species as well as human beings ( Kumar, 2004 ). The reproductive system in males and females are sensitive to radiation causing temporary or permanent sterility dependent on dose, duration and dose rate ( Schieve et al. , 1997 ; Parker et al. , 1999 ; Kumar, 2004 ). However, there is a lack of evidence to support an association between exposure to electrical and magnetic fields and fetal loss or adverse pregnancy outcomes ( Shaw, 2001 ).

Exposure to pesticides and solvents has been associated with sperm threshold values below normal ( Oliva et al. , 2001 ; Kumar, 2004 ). Sperm counts were reported to be 40% lower in fertile men in an agricultural area than for men in three urban areas and they also had higher urine concentrations of commonly used pesticides ( Oliva et al. , 2001 ; Swan et al. , 2003 ). Supporting these findings is a study of 726 couples undergoing IVF in the Netherlands ( Tielemans et al. , 2000 ). A reduced implantation rate was found in women whose partners worked in occupations with high levels of organic solvent exposure. Men exposed to pesticides and welding have been shown to be at risk for oligozoospermia( Wong et al. , 2003 ) and other chemicals such as phthalates have also been linked to infertility. Certain phthalate metabolites are related to reduction in semen quality ( Duty et al. , 2003 ) and endometriosis in women ( Cobellis et al. , 2003 ). In females, cosmetics have been associated with an increased risk of spontaneous abortion and exposures to various factors in the home, such as glues, have been associated with infertility ( Ford et al. , 1994 ).

Opportunities for Change

There is a large body of evidence relating to the impact of lifestyle on reproductive performance. However, motivating patients to modify their lifestyle can be difficult and challenging. Changing lifestyle behaviours requires time, considerable effort and motivation. A patient-centred approach to counselling and advice has been shown to produce the best outcomes.The provision of evidence-based information relating to the impact of lifestyle and reproductive performance can assist in motivating couples to modify their lifestyle. Motivational interviewing has also been used effectively to assist patients in lifestyle changes.

The concept of an individualized health-care plan in the form of a ‘reproductive health pathway’ may be an effective means of motivating patients to make positive changes to their lifestyle. A pathway designed around individual etiology and lifestyle would be planned for each couple. The aim being to provide the most effective and appropriate methods towards reaching the goal of improved reproductive performance, pregnancy and ultimately a healthy child. The pathway would aim to facilitate both immediate and long-term lifestyle changes. To maximize compliance and success, pathway should be planned in conjunction with the couple and be both appropriate to their individual needs and achievable. Illustrates the potential differences in pathways. Each couple has a common starting point of infertility and a clinical consult incorporating a medical assessment and identification of modifiable lifestyle factors. Pathways would then diverge, being tailored to individualized needs. The endpoint is a common goal of pregnancy and the delivery of a healthy baby.

Examples of two pathways are shown. Pathway 1: The female partner is diagnosed with anovulation. Identified lifestyle factors include obesity, poor diet and inadequate exercise and a high level of psychological stress. She is advised and assisted to increase her exercise and improve her diet, and strategies to decrease her stress levels are discussed. The pathway is aimed at assisting her to establish spontaneous ovulation, optimize the chance of pregnancy and delivering a healthy baby and to improve her general health and well-being. The male partner has no physiological problems on medical assessment, but his diet is inadequate and he does not exercise. He is advised to improve his diet and exercise to optimize the chance of conception and to improve his general health (the pathway of the female is shown). Pathway 2: The female partner has tubal damage, does not exercise and drinks four to five cups of coffee per day. The male partner has a sperm defect, smokes cigarettes and eats an unhealthy diet. She is advised to decrease her caffeine intake and to exercise, and he is advised to stop smoking and improve his diet.(Fig-1). The goal is to improve the quality of his sperm and to improve both partners' general health to optimize the chance of pregnancy and a healthy child through IVF.

Fig:1- Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology(2007).

Conclusion

The literature has clearly identified a series of modifiable lifestyle factors that potentially impact on fertility in the general population and the population undergoing ART. Moreover, the risk factors for fertility identified here often have other related serious health implications, such as the importance of smoking as a risk factor for cardiovascular disease and cancer. Efforts to improve reproductive health may, therefore, have other associated health benefits and vice versa. For the general population, there are opportunities for primary prevention to protect reproductive health, and for those undergoing ART, there are opportunities for secondary prevention to improve reproductive outcomes from treatment. Most lifestyle factors are theoretically modifiable, and couples attempting to conceive should be councelled and advised regarding their individual lifestyle factors. A structured programme of education, support and access to specialist health professionals should back counselling to encourage and facilitate appropriate lifestyle changes. This will facilitate the provision of optimum health care to couples attempting to become pregnant, improving their chances of success and minimizing the need for costly and invasive infertility treatment.

References:

Ref 1-Centre of reproductive and genetic health, UK

Ref 2. Astley SJ, Bailey D, Talbot C, Clarren SK. Fetal alcohol syndrome (FAS) primary prevention through fas diagnosis: II. A comprehensive profile of 80 birth mothers of children with FAS, Alcohol , 2000, vol. 35 (pg. 509-519)

Ref 3:AugoodC, Duckitt K, Templeton AA. Smoking and female infertility: a systematic review and meta-analysis, Hum Reprod , 1998, vol. 13 (pg. 1532-1539)

Ref-4: Richard m. Sharpe1 & Stephen franks2 Environment, lifestyle and infertility — an inter-generational issue,review in Nature cell Biology 4 (s1),S33(2002).

Ref-5:Leviton A,Cowan L.A review of the literature relating caffeine consumption by women to their risk of reproductive hazards.Food chem. Toxicol 2002;40:1271-310.

Ref 6: https://academic.oup.com/humupd/article/13/3/209/2457838/The-impact-of-lifestyle-factors-on-reproductive

Our team at Rainbow IVF has vast experience in Alternative Reproductive Techniques (ART) used in the field of Infertility.We provide everything under one roof. Apart from our dedicated team, the Agra center is situated in a 110 bed super-specialty hospital called RAINBOW Hospital with an unmatched critical care unit and a Neonatal Intensive Care Unit. Apart from the flagship infertility centers in Agra (the city of Taj) and Delhi, Rainbow IVF also provides technical collaboration and clinical expertise to 14 infertility clinics across India and 2 international infertility clinics abroad.
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