General lifestyle modifications:
Delay of Fertility
Couples are delaying their efforts to have a family because of careers and because contraception allows them to wait until their circumstances are more ideal. Unfortunately, fertility decreases with ages of the male (De la Rochebrochard, 2006, Fratterelli, 2008, Girsh, 2008) as well as the female. The antioxidant status of tissues of the body is lower as age increases. scaleThe older age at marriage often means contact with more sexual partners and sexually transmitted diseases like chlamydia which can damage the fallopian tubes. Endometriosis increases as more menstrual periods occur. Finally, more time allows more body weight to accumulate. Even an extra 100 calories per day causes a weight gain of 10 pounds per year and 100 pounds in 10 years. Obesity decreases fertility, increases miscarriage, and causes pregnancies to be more complicated (see weight and fertility).
Personal habits such as smoking and alcohol can have effects on fertility. Surprisingly, even second hand smoke damages the sperm and eggs, apparently as much as smoking.
Exercise and Fertility
Modern society has devised so many tools to avoid physical activity that we all have to make a conscious effort to set aside time for exercise. Recent studies show that fertility increases with moderate exercise in both the male and female partner. It makes sense, because exercise improves blood flow and the body’s natural antioxidant status. On the other hand, high levels of exercise appear to reduce fertility. Two studies have suggested more than 3-5 hours of vigorous exercise per week for the female partner may reduce fertility (Morris, 2006, Wise, 2012), hence the above guidelines. Moderate or even high exercise for the male will enhance erectile function and will help prevent any decline of that function with aging. However, in a very thorough and well controlled study, normal young men assigned to regular high intensity exercise had significant reductions of most semen parameters and gonadotropin and testosterone levels (Safarinejad, 2009, Hayden RP, 2018). As it is likely that men with decreased semen quality would have similar or greater adverse effects, we do not recomment regular, high intensity exercise for the male partner. Biking for > or = 5 hours per week (Wise, 2011) has been reported to have negative effects on sperm. Overheating of the testicles may explain the effect of biking.
Nutrition and Fertility
Recent studies have suggested that a “prudent” diet improves fertility for both partners, i.e less red meat and saturated fat, more seafood, and more fruits and vegetables, often referred to as the “Mediterranean diet” (Vujkovic, 2010, Twigt, 2012, Gaskins, 2012). Trans fats should be avoided entirely (Chavarro, 2011), for example, doughnuts, Danish pastries, French fries and fried foods in general. Studies point to antioxidants, monounsaturated oils, and omega-3’s as the factors involved in these benefits and these are therefore discussed in detail below.
Men having reduced semen quality have a significantly lower intake of dietary antioxidants (Mediola, 2010). Antioxidants improve sperm motility and oxidative stress has been shown to be increased in the semen of men whose sperm don't move well and have increased fragmentation of their DNA (Shamsi, 2009). Sperm are very sensitive to oxidation because they have to shed their cytoplasm in order to be able to move rapidly. The cytoplasm (all of the cell’s bulk except the nucleus carrying the chromosomes) contains the cell’s natural antioxidant defenses. In men with increased fragmentation of their sperm DNA, 1,000 mg of vitamin C and vitamin E decreased the proportion of sperm with fragmented DNA (from 22 to 9 %) (Greco, 2005). We do not currently recommend vitamin E because it has been linked to all-cause mortality and a recent study associated it with increased prostate cancer. Most likely any strong level of antioxidant will have a similar impact, such as a small bowl of berries each day, or 1,000 mg of vitamin C and 2 cups of green tea daily. A commercial antioxidant, pycnogenol, has been shown to improve semen quality (Stanislavov, 2009); two 40-60 mg capsules daily would also provide a good antioxidant dose. All fruits and vegetables contain antioxidants but berries have the most with blackberries having almost twice as much as blueberries (Halvorsen, 2006). Dark chocolate is also an excellent source of antioxidants. Carotenoids, particularly lycopene (which is particularly high in tomatoes) has been positively correlated to sperm motility (Zareba, 2013).
As women get older, the amount of antioxidant in the fluid around the egg decreases. egg and granulosa cellsWithout antioxidant protection, the cells surrounding the egg are less able to provide nutrition for the egg as it matures. The resulting poor function of those cells correlates with reduced embryo quality and the chance of pregnancy (Suh, 2002, Elgindy, 2008). The same suggestions for increasing antioxidant intake given above for the male also apply for the female, except women should not take vitamin E during the IVF cycle if they are also taking low dose aspirin, as it could increase the chance of bleeding with the egg retrieval, and, although recent studies are conflicting, we recommend no caffeine except one cup of decaf tea or coffee (therefore no chocolate, which has caffeine). Soy may be a particularly good source of antioxidants. A recent study found soy intake was significantly related to live birth in women having IVF (Vanegas, 2015).
Great natural anti-oxidants:
- Green tea
- Low sugar Dark chocolate
- Low cooked Vegetables
- Spices: e.g. ginger, oregano, turmeric, cumin.
Blood flow presumably is also very important for function of the testicles. In one study two agents known to increase nitric oxide increased sperm count and motility as well as the circulating level of testosterone. Omega-3’s are also important in the make-up of sperm membranes. In various recent studies, fish intake (Afeiche, 2014), and omega-3’s have been associated with improved sperm quality (Chavarro, 2009, Safarinejad, 2011, Attaman, 2012).
A recent study associated minor increases of circulating omega-3 levels with increased prostate cancer. Other studies have shown associations with reduced prostate cancer and suppressive effects on prostate cancer tissue. Associations do not show cause and effect relationships. The small increase of omega-3 levels could have been associated with other factors that increase prostate cancer. For example, overcooking of meat and fish has been associated with increased prostate cancer risk. People who don't eat fish regularly complain that it is bland and lacking in taste. If men in the above study who were accustomed to overcooking foods simply had a minor increase of fish intake because they found that fish had sufficient flavor when it was fried or grilled, a false association of omega-3 levels with increased prostate cancer could be created.
fish oilAn easy and inexpensive way to get omega-3’s is from fish oil. A reasonable dose is 500 to 1,000 mg, but make sure that is the amount of EPA and DHA (the two principal omega-3’s) and not just the amount of oil. They are listed on the nutrition label on the back of the bottle. If you take this amount you will not need a more expensive prenatal vitamin containing DHA. There are some early indications that omega-3’s may decrease premature birth. DHA has been added to some prenatal vitamins as it may aid fetal brain development, although a study at age 4 did not confirm any benefit. Because omega-3's may improve sperm morphology, 1,000 to 2,000 mg may be considered for men with low sperm strict morphology. In one study of 1,840 mg given for 8 months, strict morphology increased from 7.4 to 12.8%. Lesser doses or durations of treatment have not been examined, but there could be a need for loading to have maximal benefits. Also significant increases of sperm numbers (16 to 29 million per ml) and motility (19 to 27%) were seen in this study (Safarinejad, 2011).
Omega-3’s themselves are very sensitive to oxidation so always take a good level of antioxidants along with boosting your omega-3 intake. Also, they work together to increase blood flow for fertility or male sexual function.
Folic acid: This B vitamin also improves blood flow and helps to prevent elevated blood pressure. The recommended daily allowance (RDA) is 400 micrograms, which helps to prevent a small group of fetal abnormalities called neural tube defects. If you are already taking a prenatal vitamin containing folic acid (some contain 1000 micrograms or more), you do not need any further amounts.
Vitamin C, 500-1,000 mg: This antioxidant specifically acts to improve nitric oxide and therefore blood flow. Vitamin C can worsen heartburn, so don’t take it before bedtime.
Vitamin E: CAUTION vitamin E supplements are generally not recommended and should not be used by people who are taking aspirin. Vitamin E adds to the anti-clotting effect of aspirin. Women having IVF may be advised to take baby aspirin, and vitamin E could possibly increase bleeding with egg retrieval.
L-arginine: We recommend supplementing L-arginine if your protein intake is low because of being a vegetarian. A dose of 1000 to 2000 mg will help to bring your intake up to normal in such cases (the average intake in someone having an average amount of protein in their diet is 5000 mg). We do not recommend L-citrulline because it has not been studied in the female, and one study of a large dose of L-arginine seemed to have negative effects.
Pycnogenol: We recommend increasing your intake of natural antioxidants such as pomegranate, blackberries, blueberries, strawberries, raspberries, green tea and lots of fruits and vegetables. You could consider taking 50-120 mg of pycnogenol per day if your intake of natural antioxidants is low, particularly if you are age 40 or older. It contains proanthocyanidins similar to the antioxidants in blueberries and also found in cocoa, green tea and red wine. Pycnogenol should be stopped with a positive pregnancy test as its effects during pregnancy have not been examined.
Green Tea: Green tea contains lots of antioxidants, but we do not recommend more than one cup of decaffeinated green tea for the female because caffeine may interfere with fertility (although not confirmed in two more recent studies). The decaffeination process does decrease the antioxidant content, but absorption can be markedly increased without increasing the absorption of caffeine by simply adding 50 mg of vitamin C to each cup (Green, 2007). A convenient product is Liquid Vitamin C. There are many good-tasting specialty green teas available. Decaf Coffee is also a good source of antioxidants.
CO Enzyme Q-10: is critical to energy production in the cell. In aging mice, this mitochondrial nutrient has been shown to reverse effects of aging on the egg (Ben-Meir, 2015). A dose of 600 mg per day is a comparable dose that an older female (over age 37) could choose to take, understanding that there is very limited information so far in the human showing that these same benefits would be seen. Supplements of Q-10 have been used in a number of other studies with no significant side effects or adverse events being reported. If you take Co Q-10, we advise stopping it with a positive pregnancy test.
These supplements are all quite reasonable in price. They will cost you less than other supplements marketed for fertility. Fertility is not the only reason to consider improving your nutrition. You will also improve your overall health.
Summary: Recommended for all women:
1. A healthy diet with fruits (especially berries) and vegetables, less red meat and no trans fats (doughnuts, French pastries, fried foods). Use olive oil for cooking and salads. Avocados and macademia nuts are also good sources of monounsaturated fat.
2.Omega-3’s (fish oil) 500-1,000 mg daily.
For women over age 37, add to the above:
1. Increase antioxidants- 500-1,000 mg vitamin C, decaf green tea or coffee (1cup per day); consider adding pycnogenol, 40-60 mg twice daily (this may replace or be added to the other antioxidants already mentioned.
2. Take 400 micrograms of folic acid; at least that amount usually is in all prenatal vitamins and multivitamins.
3. Consider adding 1-2 gm of L-arginine if your protein intake is low.
4. A small amount of vitamin C added to green tea aids absorption of antioxidants (see above under “green tea”).
5. Consider adding Co-enzyme Q-10, 600 mg daily (see caution above under “Co Enzyme Q-10”).
Folic acid: This B vitamin is a specific co-factor in the production of NO in the body. The recommended daily allowance (RDA) is 400 micrograms. We do not recommend taking more than 400 micrograms long-term, and if you are getting extra folic acid in wheat bread and cereal or if you eat a lot of veggies, we recommend cutting the tablets in two and taking only 200 micrograms per day. There has been some recent concern that excessive folic acid could increase colon cancer. Prenatal vitamins do often contain more than 400 micrograms. Folic acid for the female helps to prevent a small group of birth defects.
Vitamin C, 500 mg This antioxidant stimulates NO production. Vitamin C can worsen heartburn, so don’t take it before bedtime.
L-citrulline: L-citrulline and L-arginine are the raw materials for NO production, but L-arginine is largely broken down before being absorbed by the body. L-citrulline is an important intracellular source of L-arginine, and what is inside the cell is what counts for NO production. In a well-controlled study of 3 gm of L-arginine plus pycnogenol, a significant increase was noted in all semen parameters. Two grams of L-citrulline will increase L-arginine levels more than 3 grams of L-arginine (Schwedhelm, 2008). Natural sources of L-citrulline are melons, particularly watermelon, but you could not eat enough to influence your levels. These supplements are not clearly of benefit for somone with a normal intake of protein, but are logical for someone who's protein intake is low, as is often the case for vegetarians.
Pycnogenol: We recommend increasing your intake of natural antioxidants such as pomegranate, blackberries, blueberries, strawberries, chocolate, green tea and lots of fruits and vegetables. Also, pycnogenol is a potent antioxidant that helps decrease the breakdown of NO and has been shown to be quite effective for stimulating NO. It contains proanthocyanidins similar to the principle antioxidants in blueberries and also found in cocoa, green tea and red wine. The dose that was shown to increase sperm quality is 80 mg. You could take 60-120 mg of pycnogenol per day depending on your intake of natural antioxidants and vitamin C.
Green tea: Green tea contains lots of antioxidants. If you are bothered by the caffeine, you can take decaf green tea. The decaffeination process does decrease the content of antioxidants, but their absorption can be markedly increased without increasing the absorption of caffeine by simply adding 50 mg of vitamin C to each cup. (below). There are many good-tasting specialty green teas available. Green tea extract is another way to boost your level of antioxidants.
Liquid Vitamin C: If you are not drinking three cups of regular green tea per day, you can add 50 mg to each cup. The absorption of antioxidants may increase three-fold according to one study. Green tea is also important in the prevention of prostate cancer.
Coffee: Of course many men will prefer coffee, and coffee actually contains more antioxidants than tea. In one study drinking 5 cups of coffee per day was associated with a lower rate of prostate cancer. In another study more than 3 cups daily was associated with increased sperm DNA fragmentation. Large amounts of coffee can have serious adverse effects on the heart in some individuals.
CO Enzyme Q-10: is critical to energy production in the cell. In men given 200 mg of Q-10 twice daily, the percentage of sperm with forward movement and the average sperm velocity were significantly increased (Balercia 2004) The Q-10 was given for 6 months, but an effect could occur in a very short time because Q-10 acts on the biochemical pathway producing energy. Because Q-10 is itself an antioxidant, it is difficult to separate a direct effect on the generation of energy by mitochondria from a non-specific effect due to its antioxidant properties. Supplements of Q-10 have been used in a number of other studies with no side effects or adverse events being reported. A man with low sperm motility could choose to take Q-10 if the other measures above do not normalize motility.
Dark Chocolate: Chocolate has potent effects on NO production, but it usually contains a lot of sugar, which reduces NO. You can get all of the advantages and avoid the sugar with a low sugar chocolate. You will get to enjoy it as much as regular chocolate. Don’t overdo it. This is our only recommendation that could make you gain weight. An ounce or so will give you lots of antioxidant and is enough to look forward to each day. Have some for a mid-afternoon break along with a cup of green tea.
These supplements are all quite reasonable in price. They will cost you less than other supplements marketed for fertility. Fertility is not the only reason to consider improving your nutrition. Infertility and erectile health are like most other things- an ounce of prevention is worth a pound of cure! And you will also improve your overall health.
Summary: Recommended for all:
1. A healthy diet with fruits (especially berries) and vegetables, less red meat and no trans fats (doughnuts, French pastries, fried foods)
2. Omega-3’s (fish oil) 500-1,000 mg daily.
For men over age 40 and/or with abnormal semen (low count, motility, and/or morphology) add to the above:
1. Increase antioxidants- 500-1,000 mg vitamin C, green tea (1-3 cups per day); consider adding pycnogenol, 40-60 mg twice daily (this may replace or be added to the other antioxidants already mentioned).
2. Consider increasing omega-3's to 1,000 to 2,000 mg. In one study of 1840 mg for 8 months all semen parameters improved, particularly strict morphology.
3. Consider adding folic acid, 400 micrograms and zinc, 15-30 mg per day as some studies have shown benefits for sperm. These are in many multivitamins.
4. Consider adding 2 gm of L-citrulline (see above explanation under “L-citrulline").
5. Dark chocolate is another strong antioxidant- use a low sugar brand.
6. A small amount of vitamin C added to green tea aids absorption of antioxidants (see above under “liquid vitamin C”)
7. Consider adding Co-enzyme CoQ-10, 200 mg twice daily. In one study it stimulated sperm motility.
Sexual Dysfunction and Fertility
Sexual difficulties are much more common with infertility. In one study almost a quarter of couples had sexual dysfunction. This is partly due to the same factors that can harm the eggs and sperm- excess body weight, a less than healthful diet, insufficient exercise, insufficient antioxidant intake, smoking, second hand smoke, and excessive alcohol all impair erectile function. Certainly the stress of infertility and fertility treatments and having to time relations to the time of ovulation are also factors, but sex doesn’t have to be regimented. Having relations every 1-2 days around ovulation is ideal. Just don’t let 3 days pass during that crucial time, and if your ovulation test turns positive, be sure to have relations that night or the next morning. Even before IUI, having regular ejaculation increases the success rate and that probably holds for IVF as well. The sperm’s DNA remains more intact when sperm spend less time in the collecting system where oxidative stress can damage them. And, as a bonus, having more frequent erections also improves erectile function and will help to prevent erectile dysfunction in the future.
Stress and Fertility
Stress is certainly a factor. The level of stress for a woman with infertility has been compared to having a diagnosis of cancer or HIV. Also, some individuals are naturally more reactive to stress. In one study, women scheduled for IVF were tested with stressful visual and auditory stimuli (Facchinetti, 1997). Those who failed to conceive had significantly greater rises of their blood pressure and pulse rate. That study suggested the adverse effect of stress is due to constriction of blood flow to the pelvic organs.