Knocked Up Podcast - LIFESTYLE FACTORS PART 1: HOW TO IMPROVE YOUR FERTILITY OUTCOMES
Dr. Alexandra Harvey, Senior Research Scientist at Melbourne IVF joins us to explain the real impact of lifestyle modifications on your fertility.
Part 1 of our 2-part series on lifestyle factors and fertility features Dr. Alexandra Harvey, Senior Research Scientist at Melbourne IVF. With 25 years of experience in embryology and fertility research, Dr. Harvey breaks down the science behind modifiable factors that can impact your fertility journey.
Age as the biggest factor in IVF success - why maternal age matters and how paternal age also plays a role
Temperature effects on sperm quality - from underwear choices to sauna use
Diet and nutrition myths vs. evidence - why extreme diets aren't helpful and what the Mediterranean diet research actually shows
The supplement dilemma - when more isn't necessarily better and the importance of balance
Environmental toxins hiding in everyday items - from Teflon pans to thermal receipts
Coming up in Part 2: We'll dive deeper into smoking, alcohol, stress, and other lifestyle factors that can impact your fertility journey.
TRANSCRIPT
Host: Women's Health Melbourne is an innovative, holistic fertility and women's health practice. We are world leaders in IVF and egg freezing and provide our patients with every opportunity to achieve their goals.
Our hand-picked expert team provides the ultimate care experience for our patients. Reach us at womenshealthmelbourne.com.au and follow us at Women's Health Melbourne and @drraelialew.
Jordi Morrison: Okay, hello and welcome to Knocked Up, the podcast about fertility and women's health. You are joined, as always, by me, Jordi Morrison, and Dr. Raelia Lew, CREI Fertility Specialist. Today we're joined by Dr. Alexandra Harvey, Senior Research Scientist at Melbourne IVF. Welcome, Alex.
Dr. Alexandra Harvey: Thanks for having me.
Jordi Morrison: Alex, what is a senior research scientist?
Dr. Alexandra Harvey: So a senior research scientist at Melbourne IVF is a scientist that is interested in improving the quality and success rates of IVF through a process of evaluating new technologies and designing novel technologies, in the hope that we can make an impact and bring more people into having a family.
Jordi Morrison: Yeah, beautiful. I think it's so lovely, this series we're doing with other experts at Melbourne IVF, because we can really see what it takes to make a baby.
Dr. Raelia Lew: Absolutely. It takes a lot — and it takes a... what's that saying? A village.
Jordi Morrison: A village. It takes a village. I think, Raelia, you've said before it takes around 25 people. Is that about right?
Dr. Raelia Lew: Yeah, definitely. I think people don't really appreciate sometimes what's involved in IVF. We think of the words "in vitro fertilisation" and we think, oh, that's just what doctors and scientists do to help people have babies. But behind the scenes, in getting ready for IVF, we have a whole lot of support — a cast of many very specialised people. And that includes people like our administration team, who help coordinate all of the various events behind the scenes. We have our nursing team, who help patients navigate what can be quite a complex series of treatment plans that a doctor designs for them. We have, obviously, fertility specialists who work together with the nursing team to help patients get egg and sperm ultimately to the lab. And then, once the egg and sperm is in the lab, we have our amazing scientist team who really make the magic happen from a technology and science perspective. And then we throw back to the clinical team again, translating that science to creating pregnancies in the body, and a support team helping patients navigate that journey — whether they conceive, or whether they have to regroup and reconsider and try a different strategy to have another attempt, until we're ultimately successful. And of course, we have a myriad of other teams along the way, like our hospital teams who help us for egg retrieval, our counselling teams who help prepare and support our patients for treatment before getting started. And we also have regulatory systems that need oversight from our management teams to make sure that nothing goes wrong at any phase along the journey, and that we're always optimising our processes and procedures for patient safety and to improve patient experience. So really, there are lots of people involved in making an IVF baby — not just the patient, the doctor, and the lab.
Jordi Morrison: Yeah, it's fascinating, isn't it? And it really is a village. Alex, can you tell us about your background, your professional experience, and what has brought you to your current role at Melbourne IVF?
Dr. Alexandra Harvey: So I've been in the industry for around 25 years now, and I fell in love with the whole concept of how a single cell — the egg — develops into such a complex system of who we are. And so I've come from a background where I started as an embryologist, looking at how we grow an embryo in the IVF lab and how that can impact on the quality and the success of IVF. I then moved a little bit of focus into stem cells, because the embryo is the ultimate stem cell — well, the structure of the embryo itself contains the stem cells that create all of what we are. And so with a similar focus on how growing those cells in a laboratory environment can impact on their quality. And then I took a step back and returned to my first passion — embryology — and have since spent a number of years looking into the effects of nutrients and diet, particularly from both an embryo exposure perspective, but also from just a consumption perspective. And so it's really about understanding the significance of nutrients. The field is changing because we're now understanding that they're more than just nutrients. So it's really exciting to be in this space now. And we're also looking at applying a lot of what we're learning in terms of how we manage patients, which is really exciting.
Jordi Morrison: What are some of the recent — and also just career-long — research highlights of how you have applied that interest to improving outcomes for patients?
Dr. Alexandra Harvey: One of the biggest successes that I've had is looking at the gas environment that we grow our embryos in. And so when we breathe normally, we're sitting in an atmosphere that contains 21% oxygen — there's a little bit of nitrogen and a little bit of carbon dioxide in there as well. But when we actually think about what our cells see in our bodies, they don't see 21% oxygen. They actually see something much lower. That low-oxygen replication is now the norm, whereas 25 years ago, when I started doing research in this space, it was really about trying to replicate the physiology of the body and improving the way in which we grow embryos so that we can improve outcomes. And my work has really found that replicating that low-oxygen environment in particular — but also replicating the levels of nutrients within the reproductive tract at the most appropriate time as that embryo develops — are really important for embryo quality, embryo health, and success rates.
Jordi Morrison: It's fascinating, isn't it, that just these small adjustments can really make a big difference.
Dr. Raelia Lew: Absolutely. Alex, we hear a lot about how Melbourne IVF just has the most incredible lab. What does that mean to those of us that are not scientists?
Dr. Alexandra Harvey: So that means that we — or Melbourne IVF — provide an environment which is considered and that focuses on the health of every stage of that embryo, from the minute it's retrieved from the body through to when that embryo is then transferred back. And I think understanding the science and the importance of all of these contributing factors to the health of the embryo is really important, and that puts us in a unique position to really do the best we can for our patients. And so from a research perspective, Melbourne IVF is focused on improving success rates for our patients and making the journey to having a baby shorter, less complicated — hopefully — and less stressful if we can, but also improving those outcomes for your family and doing the best things that we can to improve the process.
Jordi Morrison: One of the things I find most exciting — we're now in the eighth year of this podcast — is... you said you've been doing this for 25 years. In 25 years, what's the most exciting change you've seen?
Dr. Alexandra Harvey: There's been many, but I think as we see novel technologies improve the process — for example, time-lapse imaging, where we can actually take pictures every 15 minutes of the embryo and see how it develops — that has really revolutionised our understanding of what happens during those first few days of life. And from that, we can use that information to understand how making those small changes can actually then have quite a large impact, even though it might be something as subtle as a few hours' difference in the timing of a particular event. We can still use that information. And as that is now being encompassed by AI — having technology that can assess things in an image that even we as humans can't see, and relate that to success — that's really the new frontier. And Melbourne IVF is at the forefront of that, which is great. So it's really exciting to see those developments, because they have had a big impact on how we understand embryo quality and success rates.
Dr. Raelia Lew: And for patients who freeze eggs, we hope in the future to be able to better assess egg quality — and therefore the chance of an egg making a baby — through similar means.
Dr. Alexandra Harvey: Absolutely. That's really an exciting space, because we've got all of that technology for the embryo, but an egg is only an egg for a short window of time. And having AI layered on top of that — to understand how those minute details that we can't visually see could impact the whole process — it starts with the egg at the end of the day. The quality of your egg and the quality of your sperm — it starts there. And so how we relate that to the rest of the journey is going to be exciting to see.
Jordi Morrison: We've got you on today to talk to us about lifestyle factors. Lifestyle factors are important when you're trying to conceive, either naturally or with some assistance.
Dr. Alexandra Harvey: Absolutely.
Jordi Morrison: Why are lifestyle factors so important?
Dr. Alexandra Harvey: Lifestyle factors are really important because they have the potential to impact on our health and our wellbeing. And when that is affected, then of course there's a natural progression from there — it can affect the way in which we respond to treatments, or even just in the natural sense. If we are not at our optimum, then we can have issues with conception. And I guess that's why Melbourne IVF and fertility clinics exist — because there are so many interacting factors that can contribute to either fertility or infertility. And that's really about understanding the small impacts that some of these things can actually have.
Dr. Raelia Lew: I tell my patients this all the time — it's very rare that bad lifestyle is the only issue that causes infertility. And it's also so complicated, because on one hand, it's something within our control. It's modifiable. We can change it. It's empowering. On the other hand, it can be quite frustrating for patients whose fertility burden and its causation is actually not associated with anything negative in their diet and lifestyle. They can say, "Look, I eat healthily. I'm conscious of what I put into my body. I exercise. I'm not overweight. I don't smoke. I don't take drugs. And I'm infertile — what the...?" And it's: what can I do differently? So I think this is probably a topic that can be a bit emotional for people. I've had patients who look within and say, "What else can I do? I'm doing X, Y, Z — what else can I do?" — not in frustration, but in a sense of inquiry, because they're really motivated. And then there are other people who smoke cigarettes and eat junk food and are overweight and get pregnant naturally. So can you tell us your perspective on these factors? Maybe let's break it down a little bit into what the different factors are, and also what ignited this as a passionate area of interest for you.
Dr. Alexandra Harvey: Sure. That's a really important point that you've made — it's not just one thing, and potentially people can be doing everything right. But it's one of those things — we just really don't understand all of the complexities that go into making a baby in real life. And there are subtleties and interactions between all of the factors that exist in our environment, our lifestyle, and our genetics that interplay — and for some reason, whatever that reason is, people end up on an infertility journey rather than having an easy journey to a family. But I think it's really important to at least acknowledge the potential of lifestyle factors. And because they're things that, as you say, we can potentially control a little bit more, they still can have an impact — and slight changes to the way in which you do things may or may not have a benefit on your treatment journey. And so the biggest factor that we have to consider in the success of IVF is age — particularly maternal age. And we know that women are born with all the eggs they're ever going to have. And as we age, the quality and the quantity of those eggs declines. And so with those degenerative changes, there are lower success rates for IVF. We're talking around that mid-30s age range, where women below the age of 35 have a roughly 30% chance of conceiving by IVF, but for women above 40, it's only around about 6%. So it's one of those things to acknowledge and be conscious of. But it's not just a female thing — and I think that's really important to note as well. We're now recognising that even though men can produce sperm throughout their lifetime, things like semen volume and sperm morphology also decline, and so does the effect on fertilisation and embryo development. So they have a role in IVF success as well.
Dr. Raelia Lew: I just want to unpack a stat that Alex just mentioned — approximating a 6% probability of success in IVF for those over 40. That's a stat that's quoted from all patients who start a cycle of IVF at that age, whether that cycle goes ahead, whether it's cancelled, whether it's completed, whether that patient has an embryo transfer or whether they don't. Actually, when we look at our lab at Melbourne IVF for patients at 40, their chance of having a baby from an embryo transfer is actually much closer to one in five for someone at age 40. And if we test an embryo and only transfer an embryo whose DNA is actually in order and correct, then it's actually more like one in two. So the issue there is that a lot of people who are trying to have a baby in their 40s have very poor-quality eggs — not that they can't get pregnant with the right embryo. And that's important, because when we quote stats like that, it can be really scary. But I just want to point out that in our practice, we help a lot of patients in their early 40s have babies. But quite often, it's not a one-treatment exercise. We also have other factors at that age which are really complicating. One is egg count — so we've talked about egg quality going down, but egg count goes down as well. And so the number of eggs you can get in one go is actually a limiting factor and contributing to that success rate. If we have someone who's 40 who can still make a lot of eggs, she's going to have a better success rate per cycle initiated than someone who can only make a few. Because if all things are equal, she's just got a better chance of finding a good embryo in that batch of eggs. So everyone's different, everyone's an individual. And we find that our cumulative pregnancy rates — which means how likely are we to help someone get pregnant eventually — even in the early 40s, are still quite reasonable. And so it's one of those things. But Alex is right — it is a lifestyle factor in that having babies later in life is a change in our behaviour rather than a change in our biology. And that is a major issue.
Jordi Morrison: Alex, when you as a scientist see eggs in the lab, you really see it's a tangible, real thing — it's not just like a headline in a newsletter or a newspaper or an article that "at 35, egg quality declines." It's a real fact that you see in the lab.
Dr. Raelia Lew: One more factor for women in their 40s is that they're more likely to have a partner who's the same age or older. So that is definitely a factor. And we know that paternal age is a negative predictive factor for IVF success rates. Even though we know men can make babies later in life compared to women, their age does have an impact. And one interesting thing we also see is that when we're treating women in their 40s and they have a younger partner, they have better success rates with a younger partner than if they had a same-age or older partner — with more DNA integrity and I guess the elixir of youth — they do a little bit better, even at the same age.
Jordi Morrison: So, Alex, when we speak about lifestyle factors that can impact fertility, what are we talking about?
Dr. Alexandra Harvey: So when we're thinking about lifestyle factors, we're talking about those modifiable things. And we've obviously spoken about age, which is considered a lifestyle factor — it's obviously not something we can necessarily change. But in terms of those modifiable factors, we're looking at things like diet, which we've already spoken about a little bit. We are thinking about smoking and alcohol consumption, recreational drug use. But we're also talking about things that might be a little bit more inconspicuous — they're more like an environmental exposure, an environmental toxin, that we may or may not be aware of lurking in our environment that can have a potential impact on fertility. And an interesting one for men is actually heat. We find that sperm quality is really a reflection of, potentially, their use of saunas and the way in which the scrotal temperature can increase. And there is actually a really interesting study from a few years ago where men presenting to an IVF clinic were asked about what underwear they wear. And it was found that those that were wearing boxers had better sperm quality than those that were wearing tighter-fitting underwear, simply from a temperature perspective. So the little considerations — there could potentially be a little bit of a difference. And that's where biology is what it is. There's a reason the scrotum is on the external body rather than internal — it's at a little bit lower temperature.
Jordi Morrison: So when we're talking about these lifestyle modifications that we can make, are we looking at a substantial difference in improving fertility, or is it quite small? Do we know?
Dr. Alexandra Harvey: That's really dependent on the lifestyle modification, and I'm going to say the general theme for this will be that we don't really know the true impact, because the way in which studies are performed is generally quite inconsistent in terms of the way in which they're designed and the endpoints that they assess. But if we just take a step back and think about smoking, for example — for those that smoke, we can actually detect approximately a 20% reduction in sperm quality. So there is a potential measurable gain there by quitting. And similarly, with alcohol consumption, the chance of conceiving or achieving a live birth can be reduced by 5 to 10% with alcohol consumption. And you've got twice the odds of becoming pregnant if you abstain around the time that you're trying to conceive. There are some factors where you can see an improvement, and other factors are less clear-cut — there might only be marginal to moderate differences. But again, we're also talking to that variability in the population, and understanding how small changes can affect an individual when there are so many other interacting factors that may or may not be contributing to their infertility.
Jordi Morrison: And is there a recommendation around when to start making these modifications? Is it as soon as you start thinking of conceiving? Is it a few months in and you haven't? Is it when you start speaking to a doctor? Is there a recommendation around this?
Dr. Alexandra Harvey: The earlier, the better. If you're thinking of conceiving, then obviously assessing whether you feel you want to make some lifestyle changes is an important consideration. But usually the recommendation for starting to make those changes is at least three months before you're trying to conceive — so that it's really about achieving stable change and being able to know that you are comfortable in whatever the change is that you're trying to make, that you're able to achieve what you want to achieve. Of course, if you don't achieve where you want to be, it doesn't mean you can't start trying. Again, small improvements are always good. But for things like smoking and alcohol, where there are clear impacts on health — not only yours, but your pregnancy and your child — the sooner you can reduce consumption, with the goal of eliminating them, the better.
Dr. Raelia Lew: Going into diet and nutrition — a lot of patients are taking a lot of different supplements by the time they see a doctor. Sometimes they've researched online, and I find that patients are often taking a whole concoction. One thing that I worry a bit about is whether excessive supplementation of various things that are not normally at high concentration in a diet may have detrimental or negative effects, as well as potential positive effects — and they might even have toxicity effects. Can you tell us your take on that? And are there specific nutrients or supplements that you feel show real clinical benefits for egg and sperm quality?
Dr. Alexandra Harvey: I would 100% agree with that thinking, Raelia — that when we are eating a balanced, healthy diet, we're really eating nutrients in balance. They're not only providing a specific nutrient that we might want to supplement, but it's also the co-factors that are really needed for the absorption and the metabolism of those nutrients that the body needs in combination. And so effectively, if you have an excess, it's potentially just as bad as having a deficiency. So it's one of those things where we have to be very careful — over-supplementation can be an issue. And there's obviously some discussion in the media around B6 in particular, where you can actually cause more problems by over-supplementing. And so it's really important, I think, that if you're coming into the journey of creating a family, that you be aware of what your levels and your deficiencies are. It's really about working in conjunction with your specialist team to understand if you actually need to supplement some of these things, and knowing whether you actually have a deficiency that warrants that. I think in terms of supplements that may or may not benefit egg and sperm quality, the supplement area of study is really quite limited in terms of what has been assessed. And so a lot of the time, some of the supplements that have been looked at have only been studied in limited populations of females, and often only in poor ovarian reserve patients. And so the applicability and generalisability of some of these studies may not actually be there for the regular population. So I think we're all aware of the importance of folate — for example, which is vitamin B9 — and that's really important, particularly in the early stages of pregnancy, for preventing neural tube defects, which is where there's incomplete closure of the spine during normal development. And so the interesting fact is that we actually don't really know as much about the importance of folate for the embryo and for the egg and the sperm. And so we're in a situation where, if you're over-supplementing those, we're not sure if there is any actual detriment to our IVF success rates. But there are a handful of supplements — like omega-3s, Coenzyme Q10, and vitamin D — that may have a beneficial effect. But I'm prefacing the word "may" because, again, there are some studies that support their use, but equally there are other studies that suggest there's no benefit. But if we just break each one of those down: omega-3s — they're essential fatty acids that can't be made by the body, and so they're really important to get through our diet. Good sources of those are things like oily fish — like salmon, sardines — and nuts. Omega-3s are really important for our cell membranes, and they help to maintain the health of our heart and our memory. And we tend to not get enough of those omega-3s. There are some studies that suggest that they may improve sperm count and morphology. Omega-3s are an important component of the sperm membrane. And there are also some studies that suggest they may be beneficial to embryo development and potentially increase clinical pregnancy rates and live birth rates. But again, other studies show that there's no consistent relationship. So supplementing may have a benefit, but it may not either. Another one that I mentioned was Coenzyme Q10, which is an antioxidant that the body makes naturally. It's important for heart and brain health. And there's some evidence to suggest that it may reduce the stimulation dose required during a stimulation cycle, while also increasing the number of eggs. But again, with all of these studies, it's really difficult to assess the benefit when these studies don't actually assess patient deficiency levels or sufficiency levels before they start supplementing. So again, the question really is — if we could design a study that looked at this appropriately, we would actually start from a point where we would understand our patients' levels of all of these different nutrients before we would even begin supplementing.
Dr. Raelia Lew: Yeah, it's so interesting. I often think to myself that when couples don't have any trouble getting pregnant, they're rarely on supplements for a long runway before they get pregnant. Whereas when couples have suffered infertility, they're often taking a prenatal supplement for a really long time. So that builds up in the body. Often, I would say, they're probably much less likely to be deficient in trace elements, given that they've been on — even if they're not taking other things — just a routine prenatal multivitamin for a long time.
Dr. Alexandra Harvey: Absolutely. And I think that really speaks to the complexity of nutrition and metabolism. We focus a lot on some of those key nutrients, but there are a lot of ways in which our body creates other nutrients, and it's that balance that we really need — that may or may not be swayed in a particular way by an oversupply, or even just from a sufficiency standpoint from taking a prenatal. It's really important that there are other factors probably interacting with that system that you only know about if you look for them. And so if you're only focusing on a very specific set of nutrients, then there might be a lot of other things that are changing in the background that we're not even measuring.
Jordi Morrison: We also find that people might be following specific diets — fertility diets — that may come and go. A lot of people talk about the Mediterranean diet, but that's not always culturally appropriate for our patients who might come from different backgrounds and eat different food types. What do you feel the evidence supports in terms of dietary recommendations for fertility?
Dr. Alexandra Harvey: Many people choose a diet potentially with a focus on weight loss. And I think that doesn't really necessarily mean that the diet is going to be appropriate for all life stages, particularly when we're talking about quite an energy-demanding process like conception. And so the Mediterranean diet is actually one of those few diets that has some scientific evidence suggesting it is beneficial and potentially improves outcomes of IVF success. But beyond the Mediterranean diet, there are very few diets that have that scientific evaluation behind them. And it's very easy for people to find information on the internet and hope that it might be relevant to them. But it's one of those things — the fertility diet, but also the ketogenic diet — both of those involve a large focus on an excess of certain nutrients over a more balanced nutrient profile. And so when we're talking about the ketogenic diet, we're talking about high-fat, low-carb. And some of the work that I've been involved with — studies in animals — is really around how the embryo itself, during those first few days of development, uses nutrients. And because the embryo is sitting in the reproductive tract, which is just a pool of fluid for that embryo, it is solely reliant on the nutrients within that fluid to develop. And so skewing development in an excess of a particular nutrient — like a ketone — what we're finding in these animal studies is some consistent changes, particularly in female offspring, that suggest there are changes that can impact the health of that offspring more long-term than just during pregnancy. And so it's really important to think about the ways in which we are eating, but at the same time, it's really important to think about the balance. The ketogenic diet was actually designed for epilepsy patients, and so there is a sound scientific basis for that. But again, whether that's relevant for conception is really something that we need as a field to assess. And that's really where a lot of the diet work needs to sit. It's very hard to control what people eat — so that's what makes animal models really useful. But it's also very difficult to then assess how the diet can actually impact IVF success rates when compliance is not always there, and tracking exactly how nutrients are used in a particular individual is challenging as well. And also, there's the question of cross-species relativity, because what might affect a mouse may not affect a human.
Dr. Raelia Lew: Absolutely. And I guess the other point about a lot of these studies on diet — particularly in animal models — is that they focus on a particular nutrient and its oversupply or undersupply. Whereas in a human situation, generally speaking, we have different sources of food, and we also have different ways in which we use and cook and create meals that will impact on the way in which that diet is experienced. So there are always other lifestyle factors on top of that. Animal studies are clean because we can control everything else, but for humans, we can't control all the other lifestyle factors that are interacting with that system.
Jordi Morrison: Yeah, and I think what you're saying about how we cook and those lifestyle factors — we could be sticking perfectly to the Mediterranean diet, but if we're deep-frying everything that we're eating, it doesn't matter that we're sticking to the diet so much. Or if we're using a Teflon pan and seeping chemicals into our food.
Dr. Alexandra Harvey: Absolutely. And that's one of those inconspicuous things that we don't think about — endocrine-disrupting chemicals. So an endocrine-disrupting chemical is something that impacts on the endocrine system. And the endocrine system is our hormone regulation pathway, really — which is of course so important for the way in which we regulate reproduction and wellbeing in general. But we're talking about these exogenous substances — or mixtures of these substances — that impact and interfere with hormone pathways, that then can have a downstream effect on other systems.
Jordi Morrison: When we talk about nutrition and weight, we're talking to a very heterogeneous — or varied — group of patients. And it's a different conversation, potentially, for somebody who's at an ideal weight compared to somebody who is seriously overweight or underweight.
Dr. Alexandra Harvey: Absolutely. So when we're talking about weight, we often think of those two extremes of obesity or underweight, which we know have an impact on fertility. But as we've spoken about, when we think we're doing everything right and we're sitting in that middle ground, perhaps it's other things that are having more of an impact.
Jordi Morrison: Incredible. Thank you so much, Alex, for your time this morning. Remember to subscribe to be notified when our next episode with Alex comes out in two weeks' time, where we continue discussing lifestyle factors — this time focusing on weight, stress, smoking, alcohol, and endocrine disruptors. Out in two weeks. To support Knocked Up, leave us a review or recommend us to a friend. Join us on Instagram at Knocked Up Podcast, and join Raelia at Dr Raelia Lew. And email us your questions to podcast@womenshealthmelbourne.com.au.
Thank you.
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
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