Lifestyle Choices and Female Infertility
Frederick R. Jelovsek MD
About 14% of couples in industrialized countries report infertility problems. There is suspicion that the incidence of infertility is increasing. Since there are many things that can affect fertility that we have control over -- lifestyle choices of smoking, drinking alcohol or caffeine, food ingestion and weight, sexual practices and so forth -- it is important to examine how much effect these things can have on future fertility. Many women are unaware as to how important these lifestyle choices can be with regard to future attempts to conceive.
An article by Silva PD, Cool JL, Olson KL: Impact of lifestyle choices on female infertility. J Reprod Med 1999;44:288-296, helps us to put some of these lifestyle habits in perspective as to how they affect fertility. These authors did an extensive review of the literature to determine how much different life choices affect a woman's ability to later conceive.
How Weight Affects Fertility
Does being overweight affect fertility and if so, how?
Obesity has a strong association with infertility and menstrual irregularities. While some of the ovulation problems and menstrual changes are explainable by women with Polycystic Ovarian Syndrome (PCOS) who are also obese, women who do not have PCOS but are overweight also have the same problems. Group treatment programs that assist obese women with diet and exercise plans have shown return of fertility in many patients. Weight loss of 15 lbs (6.5 kg) has been shown to restore ovulation. It is thought that the improvement in insulin resistance has more to do with restoring ovulation than the actual amount of weight or weight loss itself. For most studies, 20% over ideal weight is considered obese. Officially, a BMI (body mass index) of 25-30 is considered overweight and a BMI of over 30 is considered obese.
Can weighing too little lower my chances of getting pregnant?
Low weight and weight loss is also associated with ovulatory dysfunction and thus infertility. Even a moderate weight loss of 10-15% under ideal body weight can result in menstrual irregularity. It does not need to be the weight alteration of 30% or more as seen in women with anorexia nervosa or bulimia. Weight gain programs in these underweight women have been shown to restore ovulation and pregnancy in up to 73% of women who were able to achieve 95% of their ideal body weight. For many studies affecting eating disorders, a BMI (body mass index) of 17.5 - 20 is underweight and under 17.5 (90 lbs at 5 feet 0 inches) is considered very underweight.
Age And Fertility
I want to put off having children until our careers provide more opportunity. Will delaying childbearing affect my ability to get pregnant?
It is quite common for women to pursue educational and career opportunities and put off childbearing into the late 30's and early 40's. Aging, however, brings with it many effects that will decrease fertility.
- Depletion over time of ovarian follicles affects menstrual regularity.
- Endometriosis has more time to produce scarring of the ovary and tubes so they cannot move freely or it can even replace ovarian follicular tissue if ovarian endometriosis persists and grows.
- Leiomyomata (fibroids) can slowly grow and start causing endometrial bleeding that disrupts implantation sites or distorts the endometrial cavity which affects carrying a pregnancy in the very early stages.
- Abdominal adhesions from other intraabdominal surgery, or ruptured ovarian cysts can also affect tubal motility needed to sweep the ovary and gather an ovulated follicle (egg).
Lifestyle And Fertility
Does smoking affect my ability to conceive?
Almost all studies show that smoking decreases fertility. Smoking causes decreased estrogens with breakthrough bleeding and shortened luteal phases. Smokers have an earlier than normal (by about 1.5-3 years) menopause which suggests that there is some toxic affect of smoking on the follicles directly. Chemically, nicotine has been shown to concentrate in cervical mucous and metabolites have been found in follicular fluid and been associated with delayed follicular growth and maturation. Finally, there is some affect on tubal motility because smoking is associated with an increased incidence of ectopic pregnancy as well as an increased spontaneous abortion rate.
I know alcohol is not good during pregnancy, but what about its use while trying to conceive?
The total effect of alcohol on fertility is not as well established as with cigarettes and other substance abuse. In one survey, women with high alcohol use reported more menstrual problems and gynecologic surgery. It has been shown to alter estrogen and progesterone levels as well as cause anovulation. Most chronic alcoholics become amenorrheic. While the effects of alcohol on fertility are real, it is not clear how much must be consumed to affect fertility, or conversely, how much consumption is safe. In pregnancy, we know that an average of 2 drinks per day or more, or binge drinking of 5 or more drinks at a time can produce fetal alcohol syndrome birth defects. As far as fertility, one study found that there was a 60% increase (risk ratio 1.6) in ovulation difficulties with the consumption of more than 100 grams of alcohol a week (about one drink a day). There was no increase with less than 100 grams consumption a week.
Some people say caffeine is bad for trying to conceive but I cannot believe two or three cups of coffee a day could really affect conception -- can it?
Not all reports, but many, show that increased caffeine consumption affects the ability to become pregnant and carry the pregnancy. Caffeine clearance from the body is decreased during the luteal phase. Animal and human data suggest an increased rate of spontaneous abortions with increased caffeine use and most human studies show a decreased fetal growth during pregnancy with increased caffeine intake. How much is too much? Consumption of 3 or more cups of coffee per day (greater than 300 mg caffeine) leads to fertility problems in 4 studies.
Does catching a sexually transmitted disease (STD) always cause infertility?
Tubal factor infertility accounts for about 15% of infertility and pelvic inflammatory disease from gonorrhea or chlamydia infections produce most of this. As many as 40% of untreated chlamydia cervical infections ascend into the tubes and pelvis causing PID (pelvic inflammatory disease). If a woman has PID, she has a 20% chance of being infertile. The biggest problem with the affect of PID on fertility is that it is most often contracted at a time when very little thought is being given to the future ability to become pregnant. Birth control pills and other hormonal methods of contraception do not protect against STDs. Only the barrier methods and especially the use of condoms and spermicidal foam decrease the chances of acquiring an STD.
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