An Integrative Approach to Enhancing Fertility

July 12 2013

by alex

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Dr. Connie Deline wrote this commentary as an invited guest on the blog of Tian Shi Acupuncture. Please take a moment to visit their website: 

As a physician who included obstetrics in my practice in Canada, I cared for women pre-conception, during pregnancy, delivery and post-partum. Of course, I also cared for the newborns along with the whole family. I’ve seen the impact of lifestyle on conception rates, the course of pregnancies and the health of the newborns. There is an abundance of research about optimizing fertility and the health of new babies, yet sadly, much of it is not shared with prospective parents. For this discussion, I will focus on the lower tech aspects to consider pre-conception, not just for those struggling with infertility; but for anyone hoping to conceive. The balance of viewing a pregnancy in terms of creating an optimal environment for the fetus, but without obsessing excessively about every little detail, is an approach that makes the most sense to me.

For those couples planning a pregnancy, employing an integrative approach in optimizing health can optimize not only fertility, but the pregnancy outcomes and health of the baby.
An integrative approach can:
Make it easier to get pregnant
Reduce the risk of miscarriage
Reduce the risk of pre-term birth
Reduce the risk of birth defects
Enhance the health of the baby.
What is an integrative approach to fertility? In simple terms, it includes the high-tech diagnostics, medications and procedures that modern medicine offers but also includes the low-tech approaches such as nutrition, exercise, stress reduction, traditional Chinese Medicine and acupuncture to achieve the best outcomes for women and their babies.

There is no question that we have seen declines in human fertility in recent decades. Average sperm counts have decreased. Infertility rates even in young women have increased.

There are many known contributors to reduced fertility. These include age, genetics, general health, anatomical problems, nutrition, hormonal status, stress and environmental toxins. There may be male factors. Occasionally, undiagnosed celiac disease is the cause. There may be no identifiable factors. It makes sense to modify what we can. And even when we need to include the high-tech interventions, like IVF (in vitro fertilization), we shouldn’t ignore the low-tech, because it all matters.

Anatomical Problems
Anatomical problems, such as uterine fibroids, blocked fallopian tubes and endometriosis need to be addressed from a surgical perspective in many cases.

Problems with Ovulation
Ovulatory dysfunction arises from hormonal problems, including PCOS (polycystic ovarian syndrome), or from abnormalities of thyroid or pituitary hormone function. Stress can cause or contribute to this. While a reproductive endocrinologist or gynecologist may need to offer some help with hormonal manipulation, medications and/or procedures, there are situations where nutritional support, mind-body medicine and other interventions such as acupuncture, can have an impact on ovulation to improve success rates.

If we look at the body weight of a woman, we know from the research that the ideal BMI (body mass index) is between 20 and 24. Too thin or too heavy makes it harder to conceive. Higher BMI lowers pregnancy and live birth rates with IVF as well and increases risk of pre-term birth. Obese women who do become pregnant have more complications including more miscarriages, more pregnancy-induced hypertension, more gestational diabetes and more congenital anomalies in their children. Children of obese women have an increased risk of obesity, diabetes and heart disease.
In men, higher BMI is associated with lower sperm counts, lower sperm concentrations, poor sperm morphology, lowers sperm motility and lower testosterone levels, which reduce fertility. We also know that if the father is overweight at the time of conception, the future weight of his daughter will be affected.
When both partners are overweight the miscarriage rates are higher with both spontaneous conceptions and in assisted reproduction.

Male factors
This focuses mainly on sperm counts, motility and morphology. These are impacted by body weight, hormonal factors and nutrition.

While quitting smoking before trying to conceive seems to be obvious, it is worthwhile to understand exactly why. Smoking makes conception more difficult, it speeds up the process of ovarian egg depletion and shortens total number of fertile years. IVF failure is more common. Smoking while pregnant increases the risk for a long list of pregnancy complications and low birth weight. Children have higher rates of brain and behavioral problems such as anxiety, depression, ADHD and lower IQ.

Low levels of alcohol intake of than 1 drink per daily in women appear to have no effect on conception rates. One or more drinks per day does decrease fertility. Alcohol use during pregnancy is well known to cause fetal alcohol syndrome with a variety of congenital defects and lowered IQ.
In men, alcohol use can lower fertility by reducing sperm concentration, volume and motility.

Environmental chemicals
This is a huge concern. Many chemicals are endocrine disrupting, meaning that they have hormone-like actions in the body, disrupting normal hormone function and therefore fertility. But the concern of chemicals goes well beyond the issue of fertility. The developing fetus is exquisitely sensitive to toxic chemicals, much more so than the adult. The evidence is growing that prenatal exposures to a whole range of chemicals cause and contribute to disease later in life. We cannot control all of these exposures but we can minimize exposures to some extent.
> Seafood
Fish and other seafood can contain mercury, PCBs, other organophosphates.
Limiting exposure is facilitated by using online resources that list less contaminated types of fish.
> Pesticides
Pesticide exposure at home and from food can be minimized.
Choose not to use pesticides in and around your home.
Organically grown produce minimizes pesticide exposure but due to availability and expense, it isn’t that easy to consume 100% organic. The Environmental Working Group annually updates a list of the most and least pesticide-contaminated produce items. These are called “The Dirty Dozen” and “The Clean 15″. These lists are available on their website ewg.org. Smart-phone apps are also available. Look for “Dirty Dozen”.
When choosing animal-based foods, such as eggs, dairy and meats, organic is very important since environmental toxins can be concentrated. Pastured and conventionally-raised animals have very different nutritional profiles.
> GMO foods
This is a complex topic, too complex to address here, other than to say, the associations with infertility are strong. These foods are best to be avoided. The easiest way to avoid genetically modified foods is to buy organic. These foods are also, for the most part, heavily sprayed with pesticides.
> Plastics and phthalates
Plastics and phthalates are endocrine-disrupting. These negatively impact fertility and the developing fetus. These are everywhere: food packaging, cans, bottles, plastic storage containers. Phthalates are in plastics but also in personal care products, cosmetics and cleaning supplies.

Studies have shown is that couples with the greatest adherence to a Mediterranean diet have a lower incidence of difficulty with conceiving; also that couples undergoing IVF have a higher conception rate. Since this diet also reduces the risk for cardiovascular disease, cancer, dementia, obesity, diabetes, hypertension, dyslipidemia and autoimmune diseases, it is unquestionably good dietary pattern to adopt for the long-term. This diet is nutrient-dense with healthy fats, some fish and more plant-based than animal-based protein.
For those women who are overweight or have PCOS, paying extra attention to the glycemic load of the diet becomes more important. Glycemic load of a meal refers to the measure of the rise in blood sugar after a meal; the sugar load, which causes a rise in insulin. Having chronically high insulin levels is associated with many adverse effects, including impacting fertility and making it more difficult to lose weight. Carbohydrates that metabolize into sugar quickly include grains processed into flour (both gluten-grains and non-gluten grains), so keeping flour products and sugars to a minimum is important. Fruit juices have a high glycemic index whereas whole fruits have a little lower glycemic index, so whole fruits are a better way to consume them.
Additional research findings on nutrition specific to better fertility:
Lower trans fat
Lower sugar
Higher plant-based protein than animal-based
Higher fiber
More high-fat dairy / less low-fat dairy [low fat dairy is higher in androgens, IGF-1 and prolactin]
> Vitamin D
Vitamin D deficiency is associated with reduced fertility as well as pregnancy complications. Supplementation is best guided by the results of lab testing pre-conception, during pregnancy and during lactation. The amount in most multivitamins may not be enough.
> Iron
Iron supplementation pre-conception also reduces ovulatory infertility. The amount in a prenatal multivitamin will usually be enough. Men should not supplement with iron.
> Multivitamin
Multivitamin users, both prospective mothers and fathers, have higher conception rates. Birth weight and pregnancy outcomes are also improved. Risk of pediatric cancer is reduced. One study showed that women who took a multivitamin for just 1-3 months before conception lowered their risk of having a child with autism or severe language delay.
> n-3 fats (omega-3 fats)
Higher intake of n-3 fats from fish oil or marine algae is known to improve the morphology of the embryo with IVF.
Fertile men have higher blood and sperm levels of n-3 fats; supplementation improves sperm counts and concentration in men with low sperm counts.
n-3 fats, especially DHA, are critical for brain and eye development of the fetus, so the woman should try to have her levels replete. Low levels are also associated with a higher risk of post-partum depression.
> Vitamin B12
Vitamin B12 deficiency is more common in vegans or in women who have been on metformin or proton pump inhibitors. Deficiency increases the risks of repeated miscarriage and birth defects. The amount in a multivitamin often won’t be enough to correct this deficiency.
> Vitamin C
There is some evidence that Vitamin C supplementation improves fertility in women with a luteal phase defect.
> Other supplements
There are a number of other supplements, including CoQ10, N-acetyl-cysteine, myo-inositol, acetyl-L-carnitine, DHEA, melatonin and botanicals (herbs) that are used in men or women in specific circumstances.

For women, exercise impacts fertility with an upside-down U-shaped curve. Moderate exercise improves fertility, while too little or too much exercise decreases it. More vigorous exercise also appears to reduce fertility. In men, fertility is less impacted by exercise.

The link between stress and female fertility exists even when there are no measurable changes in stress hormones. Stress activates the HPA (hypothalamic-pituitary-adrenal) axis which impacts the gonadal hormone axis and other hormones as well. Stress impacts sperm quality and motility as well.
Stress management (or mind-body techniques) have been shown to increase pregnancy rates with IVF (where it has been more intently studied). More time relaxing and de-stressing is never a bad thing.

Acupuncture and Chinese Medicine
Chinese medicine offers much to women struggling with infertility. A long anecdotal record among Chinese medicine practitioners is now being supported by research. In 2012, a meta-analysis of 24 studies of acupuncture in fertility, which included 5800 patients, revealed significantly higher pregnancy rates in the acupuncture groups. The evidence for improved pregnancy rates is significant enough for it to be routinely recommended in mainstream fertility clinics.
The Chinese approach to enhancing fertility is to normalize the menstrual cycle, and ensure the abundance of qi, blood and essence. Attention is paid to harmonizing and balancing yin and yang. The uterine environment becomes more hospitable to a fertilized egg. The female body is supported well beyond what standard fertility approaches do. Many acupuncturists find that women seek their help only during IVF surrounding embryo transfer, but find that earlier intervention is often better.

Final Comments
When prospective parents optimize their own health, they optimize their fertility as a couple as well as the health of their child. An integrative approach to fertility includes the high-tech diagnostics, medications and procedures that modern medicine offers but also includes the low-tech approaches such as nutrition, exercise, stress reduction, traditional Chinese Medicine and acupuncture to achieve the best outcomes for women and their babies.

Connie Deline, MD