UNLOCKING FERTILITY: An overview of the evidence behind lifestyle choices
By Sònia Gayete Lafuente, MD, PhD, who is a Foundation for Reproductive Medicine Research Fellow at the CHR. She can be reached through the editorial office of the Reproductive Times.
BRIEFING: Fertility can be influenced by a myriad of lifestyle factors, yet misconceptions and pseudoscience often overshadow the evidence. This article explores critical components of lifestyle contributions, providing a better understanding of how these elements impact fertility. Additionally, the article addresses the role of alternative therapies, evaluating their scientific grounding in fertility enhancement.
Dietary habits, physical activity, emotional well-being, and exposure to toxins play pivotal roles in general and reproductive health. Despite a wealth of information, many myths persist regarding optimal practices for those trying to conceive.
Diet and fertility
Recent studies confirmed that a balanced diet rich in fruits, vegetables, whole grains, and healthy fats can enhance fertility. Despite all reported attempts to design specific “fertility diets,” currently there exists no one specific diet menu that has proven to increase IVF treatment outcomes, for example. Certain patterns of the Mediterranean diet have, however, been associated with improved reproductive health in both males and females, being rich in antioxidants, vegetable protein, fiber, monounsaturated fatty acids (MUFAs), omega-3, vitamins, and minerals. Importantly, this diet has been shown to protect against chronic diseases associated with oxidative stress, which also translates into pregnancy success. Conversely, increased consumption of hypercaloric and high-glycemic-index foods with high content of refined sugars and trans fats, and reduced consumption of dietary fiber, may detrimentally affect ovulation and sperm quality, therefore impairing fertility.
Nutritional supplements
While such supplements as folic acid are recommended to all women for preconception health, others lack robust evidence. Efficacy of supplements such as coenzyme Q10 (CoQ10), vitamin D, and omega-3 fatty acids are widely accepted but really require further investigation. An enormous variety of over the counter “fertility supplements” on the market are usually blends of many substances at negligible doses and/or without any evidence of efficacy. Moreover, they can at times interfere with activities of prescription medications. Consequently, we recommend against the self-prescribing of “fertility supplements” and strongly suggest prior consultation with a knowledgeable physician before spending a lot of money on supplements that may not improv, and may at times even harm, pregnancy chances. One frequently encountered example is inositols, often prescribed to women with polycystic ovary syndrome (PCOS). They, indeed, are appropriate prescriptions for certain cases of PCOS; in others the inositols may, however, be harmful because they may counteract androgen supplementation with dehydroepiandrosterone (DHEA) or testosterone. Therefore, women and men should consult healthcare providers to tailor supplement regimens to their individual clinical needs.
Physical Activity
Likely at least in part due to fat reduction and cardiovascular benefits, regular physical activity is also closely linked to improved fertility in females and males. Excessive exercise can, however, have adverse effects, particularly for women, by disrupting menstrual cycles. For instance, prolonged high-intensity physical stress can lead to significant caloric deficits and/or increased cortisol and prolactin levels with subsequent negative feedback to the hypothalamic-pituitary-ovarian axis, consequently interrupting women’s normal menstrual cycles.
Lacking robust data supporting specific training programs during the pre-conceptional period, a balanced approach that promotes moderate exercise (considered to be 30-60 minutes of cardiovascular activity 5 times weekly) is generally recommended to optimize overall reproductive health. Additionally, resting and metabolic recovery time could also play a role, with limited data pointing to the possibility that decreased sleep time (less than 7 hours daily) could negatively affect female fertility. These data, however, still require confirmation.
Alcohol
Alcohol consumption is often considered socially acceptable, but its negative effects on gonadal function in both females and males have been consistently reported in over 30 years. In women, excessive alcohol consumption can disrupt hormonal balances, leading to irregular menstrual cycles and impaired ovarian function, which may result in, or contribute to, infertility.
Alcohol use during pregnancy in addition is associated with the so-called fetal alcohol syndrome, characterized by abnormalities in facial features and mental status.
In men, alcohol can affect sperm numbers and quality, reduce motility, and increase the likelihood of abnormal sperm morphology. Moreover, alcohol is associated with cellular oxidative stress and inflammation, further compromising reproductive health. Although complete alcohol abstinence is ideal during the periconceptional period, occasional and mild social intake prior to pregnancy is generally considered acceptable by most health professionals.
Cigarettes and vapes
Tobacco consumption is remarkably common. Despite progressive declines in the U.S., recent reports still suggest a prevalence of over 20% in individuals of reproductive age, a rather disturbing percentage, given the well-known negative effects on reproductive and sexual function as well as general health. Smoking—both traditional and electronic cigarettes and vapes—is linked to reduced fertility due to its detrimental effects at many levels of reproductive function, including reproductive hormones, ovarian function, and sperm quality.
In women, smoking is associated with decreased fertility, increased risk of spontaneous abortions, and ectopic pregnancies. Smoking may also accelerate the decline in reproductive function and lead to 1 to 4 years earlier menopause. Using assisted reproductive technologies (ART) including in vitro fertilization (IVF), heavy smokers can require almost twice as many IVF attempts to conceive compared to nonsmokers. This negative effect is much less pronounced in occasional or light smokers.
Smoking during pregnancy, of course, also remains a major cause of maternal, fetal, and infant morbidity and mortality, and should strongly be discouraged.
In men, smoking can lead to lower testosterone levels and impaired sperm function due to defective spermatogenesis, sperm maturation, and sperm function. Underlying these effects is elevated oxidative stress, DNA damage, and cell death, with all these factors playing important synergistic roles. While evidence suggests that semen quality and sperm competence are in smokers lower dose-dependently, it has not been definitively proven that smoking reduces male fertility.
Harmful effects, moreover, carry over to passive smoking, with nonsmokers exposed to significant tobacco smoke experiencing similar reproductive issues to smokers.
On a positive note, smoking is likely the main reversible cause of diminished ovarian reserve and reduced sperm quality. Parameters can be expected to significantly improve after a few months of smoking cessation. Therefore, all smokers should be advised of this and strongly encouraged to quit smoking as soon as possible in their fertility journey. For smoking cessation, medications such as varenicline, bupropion, and combination nicotine therapy should be prioritized under medical supervision; in randomized trials, they have been shown to be approximately twice as effective as placebo.
Therapy, meditation and mindfulness
Stress, quality of life, and reproductive function, especially in women, strongly interphase and, hence, affect fertility. Consequences, therefore, are more often found in infertile than fertile females. Moreover, infertility itself often can lead to feelings of grief, anxiety, and depression, affecting relationships and overall well-being.
Despite the often profound psychological ramifications of infertility, they are frequently overlooked. Understanding these emotional challenges is critical for healthcare providers to be able to offer appropriate support. Patient groups, professional therapy, and mindfulness practices have all shown efficacy in helping individuals cope with the infertility-related emotional burden. Creating a supportive network and fostering open conversations about emotional experiences can alleviate feelings of isolation, frustration, and hopelessness. For these reasons, recognizing and addressing the psycho-emotional impact of infertility on patients but also healthcare providers is essential from the initial consultation on at an IVF center. Appropriate tailored support strategies can then empower individuals on this complex journey.
Treating the psychological needs of infertility patients has increasingly been recognized as an area of subspecialty, with increasing numbers of licensed fertility psychologists and therapists and even coaches available to serve infertile individuals and couples. Emerging evidence also appears to support the positive effects of mindfulness and of other stress-reduction techniques on fertility outcomes and by improving emotional well-being, indirectly influencing reproductive health.
Alternative therapies
While the treatments described above represent the mainstay of currently available treatments, so-called alternative therapies are making quick inroads. They include a broad variety of technical procedures, pharmaceutical interventions, and what we like to call pseudo-treatments, the latter often marketed as fertility enhancers without really having offered sufficient scientific data in support of their claimed utility.
The most common examples are herbal medications where even content is often undefined; or consider homeopathy and mind-body practices such as yoga, also to this group of intervention especially in association with IVF. They also include the very popular use of acupuncture because the literature in support of specific outcome benefits is really lacking.
The CHR, nevertheless, does not object to peri-implantation stage use of acupuncture because it may have beneficial psychological effects on the patient, even though outcome benefits in terms of pregnancy and live birth rates do not appear likely. Most common form of acupuncture in this setting usually involves two sessions on the day of embryo transfer, before and after the procedure, respectively, but can also take different formats and timing.
Much more concerningly are increasing numbers of other “add-ons” to fertility treatments –mostly to IVF– that have appeared in recent years on the market, often with too little or no established evidence at all in support of some claimed efficacy. Among those we would include so-called “fertility massage,” which has been alleged to enhance circulation and relieve tension in the reproductive organs. In our opinion there is no evidence that these effects can really be expected, and we are somewhat concerned about potential adverse effects on a pregnancy, especially in the third trimester. But, as massages obviously have beneficial stress-relieving effects if well-performed, we, of course, do not oppose them.
Another in our opinion unsupported benefit is the so-called cupping therapy, also alleged to improve circulation and relieve muscle tension, and potentially supporting reproductive health, as are alignments of spine and pelvis by chiropractic practitioners, and the so-called energy therapies, like Reiki or healing touch, alleged to promote relaxation and “balanced energy.”
Use of herbs, like chaste tree (Vitex), red clover, and maca root are common and widely claimed to support reproductive health, yet usually lack even minimal scientific validation. Academic research is limited, and many studies have small sample sizes or lack standardization, resulting in mixed findings. Most importantly, potential risks associated with unregulated herbal use must be considered. The CHR in general opposes the use of herbal products for two specific reasons which especially apply to Chinese herbs: First, their exact content is only rarely known, and many contain estrogenic compounds which can interfere with testing of patients during IVF cycles. Moreover, at least one well-performed study in the literature in Europe reported lower pregnancy rates in IVF cycles with use of Chinese herbs.
Conclusions
The interplay between lifestyle factors and fertility is complex, necessitating a nuanced understanding of diet, exercise, emotional health, and toxicities, among other factors. By favoring evidence-supported practices, patients can enhance their fertility journeys while navigating around common myths and misconceptions. Through ongoing research, the CHR is committed to exploring all these here-discussed dimensions of good health because the better the overall health of our patents is at time of their treatment for infertility, the quicker and the more successful CHR will be in helping them to achieve pregnancy.
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