Knocked Up Podcast - LIFESTYLE FACTORS PART 2: 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 2 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.
In Part 2 we cover:
Weight and inflammation – why body composition and hidden inflammation can make a big difference to fertility outcomes
Smoking’s silent sabotage – how it damages egg and sperm quality and reduces IVF success rates
Alcohol and conception – what the evidence says about “moderate” drinking and fertility health
Stress and reproduction – the mind–body connection and why managing stress matters for conception
TRANSCRIPT
Jordi Morrison: 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 are also joined by Dr. Alexandra Harvey, Senior Research Scientist at Melbourne IVF.
This episode is part two in our exploration on lifestyle factors and how we can make a change to our own fertility. If you missed part one, we covered age, temperature, diet, nutrition, supplements and endocrine disruptors. We also had Alex explain to us what a research scientist would do. In this episode, we start off by discussing the impact of weight and inflammation, and then dive deeper into the impact smoking, alcohol and stress can have on fertility.
We've mentioned before, Raelia, I think you've said that being overweight is actually an inflammatory state. How does that impact fertility?
Dr. Raelia Lew: Oh, there's so many ways. Unfortunately, and really, this is more pronounced the more extreme things are. But for example, someone's in the obese weight zone, they're more likely to have a miscarriage with a normal embryo. They're more likely to have trouble getting pregnant. They're more likely to have complications during a pregnancy, like, for example, complications like gestational diabetes and other downstream consequences of that, which can affect placental function and can put their baby at increased risk of different conditions like polyhydramnios, which is basically too much fluid around the baby, which can lead to, in some cases, preterm rupture of membranes, premature birth. Babies can be more vulnerable. There's unfortunately an increased risk with stillbirth in gestational diabetes. There's an increased risk of caesarean birth. There's an increased risk of obstructed labour. There's an increased risk of things like shoulder dystocia, which is when a baby gets stuck on its way out the birth canal, which can lead to trauma to the baby. So there's all kinds of things that can be affecting both fertility, but also downstream pregnancy health and outcomes for mothers and children.
But the most important thing to say is that these are modifiable states and we do have really good interventions now. And without putting the onus just on the female, we know that when the male partner is overweight and obese, there is poorer sperm quality. There can be a higher production of oestrogens in the male because oestrone is made in the adipose tissue. We can therefore see reduction in sperm count. We can see reduction in sperm quality, possibly to do with what Alex was talking about before, the overheating, because our body temperature is hardest to maintain in the scrotum at the ideal temperature in obese men because there's more adiposity or fat deposition in that area which can impede cooling. So there's so many ways, but we do have really good solutions these days and we do have a few past episodes of Knocked Up we can point to in the show notes talking about medical and surgical manoeuvres to improve weight. And we've got some really good medications now to help patients really effectively, but they're not compatible with trying to conceive. So it really does mean that we have to take some time out in order to optimise weight before trying to conceive. That can be really complex for patients who are older or who have a lower egg count and other infertility factors because it's not a quick fix and it does take a lot of time.
And I'd also say that many patients who are overweight and obese, it's not the first time they've considered that. And they have often made great efforts and had struggles in optimising those factors. Although I will say that trying to have a baby is a really motivational aspiration that can help patients to really do the needful when it has been a barrier, because it is so motivating. It is something that they want so badly for themselves, their partner and their family.
Jordi Morrison: And are there any physical limitations when trying assisted reproductive technologies and weight?
Dr. Raelia Lew: Definitely, and there will be in various IVF units around Australia and the world limitations on patients who are accepted for treatment above a certain weight due to anaesthetic risk, due to difficulty in visualising the ovaries through ultrasound, due to therefore increased complication rates around egg retrieval. And it is also very difficult to perform embryo transfer due to anatomical concerns above a certain BMI, as well as medical considerations about the responsibility that physicians take for patients getting pregnant when we know that they are at a weight zone that could be associated with a very high risk pregnancy. So a lot of clinics will have a cutoff for BMI for helping people to get pregnant just due to those concerns.
Jordi Morrison: One of our very first episodes was, does stress cause miscarriage? And the quick answer was no. But we know so much more about stress and mental health now. Does stress have an impact on fertility? That's another important lifestyle factor that many of us would be dealing with.
Dr. Alexandra Harvey: Infertility is really a silent struggle and many people, particularly men, are not comfortable talking about it. So it's not surprising that infertility itself is associated with higher levels of anxiety and depression. And the level of anxiety and depression is obviously going to depend on your prognosis as well. However, the association between stress and IVF outcomes really isn't clear cut. And again, we're talking about studies where there's variability in how stress is measured. And particularly from a psychological stress point of view, it's not routinely been examined. But there are some studies that look to assess cortisol. And cortisol is a hormone that's really one of the key regulators of the stress response. It's the hormone that gives you that fight or flight response. And it's really important for regulating energy and alertness during stressful situations. It also impacts our mood and our motivation. And the studies that have looked at cortisol really haven't found an impact on the success of fertilisation or embryo quality or clinical pregnancy rate when it came to cortisol levels. But a more recent study has actually started to look into anxiety and depression during an IVF cycle. And this particular study that evaluated a range of studies that are out there actually found that anxiety is most elevated at the time of egg retrieval, which is quite interesting. It's quite obviously an invasive procedure and it's the first court of call almost in the journey with IVF, and so there's the all-important egg number that we need to reach to have a successful cycle. It's also possible that's the first time a person has ever had anaesthetic in their lives. If we're thinking that most patients that come for fertility treatment are generally very healthy and young, they won't have had much experience with seeking medical care before.
Jordi Morrison: That would be very stressful, I would think.
Dr. Raelia Lew: Absolutely. And I think that's one of those things where we underestimate the potential impact of going through this process. You don't have the insight into the impact it might have, because you do it every day. But if it's the first time you've been admitted to hospital, even though it's a day hospital, even though it's twilight anaesthesia, to someone who isn't familiar with all of this, it's really scary.
Dr. Alexandra Harvey: Yes, and I think that's also speaking to the way in which we respond to our environment differently too. We've always got to be conscious, I think, of the fact that the bright lights of an IVF clinic may not actually be conducive to a lot of people's psyche. And the way in which we process stress is also very different across individuals. And so, again, we have all of those interacting lifestyle factors of diet and smoking and drinking that interact with the way in which we deal with everyday problems, let alone a stressful journey like IVF.
Jordi Morrison: Yeah, absolutely. I think it'd be really interesting to have studies, I know we don't have them, just with a control of how the same patients would react to going into hospital for another procedure, because I think part of that is just coming into hospital for a procedure.
Dr. Raelia Lew: As Jordi was saying, it's a pretty scary thing. It's because we have to that we tell you every single possible risk known to man that could ever occur in a surgery. It's a medico-legal responsibility these days in the way we practice modern medicine. I can guarantee that it wasn't the case in generations past. And it's just a new principle, probably led by the litigious nature of society, that we have to tell you about risks that are less likely to happen than being run over on the way to the clinic or being struck by lightning on the way to the clinic. But we have to tell you that you might die from an anaesthetic, for example, when we talk about these things. So it is very anxiety-provoking, probably, and even in IVF, when most people will get an egg and will get an embryo from a cycle, we have to ask our patients to sign consent forms that say this may not work, you might have a complication from your procedure, you know, it's possible you won't get any eggs collected, it's possible you won't get any eggs fertilised, it's possible you won't get an embryo to transfer or to freeze from this cycle. And with taking into account the emotional loading and also the financial pressure of going through this treatment, I think we probably do induce some of that stress in our patients.
Jordi Morrison: Doing due diligence.
Dr. Raelia Lew: Correct. It's very loaded from that perspective. I think that also we should have some insight into how we counsel. I don't know the answer because I think it is important that patients have informed consent and it is our duty of care to provide that. But I do think that most of the time, nothing goes wrong with an egg collection. It's probably technically the simplest part of IVF. It's an ultrasound guided procedure with a very fine needle passing into the ovary. The doctors that are doing it have done thousands and thousands of these procedures before. It's very safe. Really come into hospital for half an hour and then you go home. Most of the time you don't have any complication afterwards. And it's one of those things that sometimes we create this pressure, maybe ourselves, in the way we practice medicine. It's very confronting if you think about it that way.
And I think it's really important that the relationship between your fertility specialist and yourself, and the communication that you establish, is really an important part of the process and trying to eliminate as much as possible the potential stress that is caused by going through this process.
Dr. Alexandra Harvey: And I think also when you... certainly in Melbourne, when you go through this, you are connected with a counsellor who you can draw on when you need to. And it doesn't have to necessarily be about the fertility process in a conventional sense. It could be about the procedure if that's what's causing the stress.
Dr. Raelia Lew: Absolutely. And there's definitely a place for managing psychological care and reaching out, particularly if you feel that you are becoming more stressed by the process. And that's the benefit of having those counsellors available. Interestingly, this is just an observation from my own practice. I notice that when patients are having a frozen embryo transfer compared to a fresh embryo transfer, and when I say fresh embryo transfer, when they do an egg collection and we plan an embryo transfer directly to follow, it's a lot less stressful for the patient, and it is for multifactorial reasons. But one of the reasons is that we know that there's definitely an embryo that is available for transfer for that patient from the beginning of the cycle. When someone does a fresh embryo transfer, they don't know how many eggs they're going to get. They don't know how many are going to fertilise. They don't know how many are going to make an embryo. And they only find out if there's an embryo to transfer on the morning of the embryo transfer. So it's all very emotionally uncertain. Whereas when we do a frozen embryo transfer, it's often in a natural cycle. They often haven't had as many, certainly with my patients in a natural cycle, they don't have any injections in the lead up to the process of getting the body ready. We just rely on the natural process of the body preparing the uterus for embryo transfer. So they don't necessarily have that hormone excess and that heightened elevation of anxiety that comes with that hormone excess that happens in a stimulated cycle. But they also know that there's an embryo that is already created that has a reasonable chance of success from the beginning of the cycle. So again, I think some of the stress in IVF is inevitable, but some we can actually counter by how we treat our patients.
And sometimes a freeze-first philosophy, where we actually separate the egg collection part of a cycle and the creation of embryos to the embryo transfer, allowing that to be separated into two separate months so it's not overwhelming and all at once and directly, you know, so to speak, frying pan into fire. I feel that really can make a massive impact on how patients experience IVF and it can also improve success rates for certain patient groups, which is great.
Jordi Morrison: Thinking about lifestyle factors and people making changes, sometimes when you get into a new regime, you get a bit obsessed. That wouldn't be good for stress levels or mental health either. How are patients guided to manage recommended changes and integrating them into the everyday?
Dr. Raelia Lew: Look, we try and guide patients as best we can. You point out a really good fact that maybe there isn't enough support in that. And often we do see patients going down rabbit holes of self-research, in inverted commas, on the internet, where the research sources are completely unguided and sometimes providing misinformation which can generate a lot of anxiety. So that's a really good question. And I guess another question would be to consider, and I don't know if we could do this in a study, but how patients in the age of the internet feel doing medical therapies like IVF compared to prior generations who didn't have that kind of unguided, limitless source of information at our fingertips, because sometimes we open these Pandora's boxes of information. We may not fully understand them. They may or may not be completely relevant to our context at all. And then they generate different lines of inquiry and potentially open doors to further anxiety. And I feel that IVF is enough to get your head around just to understand what you need to do, what's involved, how treatment might affect you, how it might affect your body, how it might affect your state of mind, without adding in information that is not necessarily directly relevant to us and that can cause stress and pressure.
Dr. Alexandra Harvey: And I think that's a key point as well, is that there's never going to be a one-size-fits-all solution and what works for one person may not work for you. And so trying to find information online, which can be really overwhelming and easy to go down rabbit holes and exaggerate stress, it's really one of those things where you have to have a discussion with a medical professional to really identify the priorities that you should potentially focus on and what's worth stressing over, for lack of a better word, so that your journey is as supported as possible.
Jordi Morrison: We touched on both alcohol and smoking earlier. And I know, Raelia, we often talk about party drugs. What impact do these lifestyle factors have?
Dr. Alexandra Harvey: Smoking is consistently shown to increase the risk for infertility.
Jordi Morrison: For both men and women?
Dr. Alexandra Harvey: For both men and women, yes. So the more you smoke, the more likely you are going to have problems with fertility. There's evidence that suggests that you can retrieve fewer oocytes and have lower clinical pregnancy rates in smoking women. But in men, it reduces sperm quality in terms of concentration and DNA damage. And so it's one of those things where it's quite a good motivator in the sense that sperm and egg health really are the thing that makes everything happen. So quitting before you actually try to conceive is really something worthwhile doing. From an alcohol perspective, we have similar changes in egg and sperm quality. So really it's, again, one of those things where stopping consumption, particularly when you're trying to conceive, is something that you should probably consider. And one thing that I just want to point out, because it's a common misconception amongst smoking men, is that if you've been to your doctor and your semen analysis has come back within normal parameters, in inverted commas, that doesn't mean that you have a green light to keep smoking in your fertility journey. The semen analysis test is not an assessment of the quality of the DNA in your sperm or the ability of your sperm to make a baby. What it is, it compares your sperm to a fertile population of men in terms of the number of sperm there, their swimming ability and how many are of normal shape and form. What we know is that relative to whatever your parameters were, you can improve them by stopping smoking. And every little bit counts in your relationship in terms of your ability to get pregnant with your partner. We know that men who smoke convey to their partner a higher risk of miscarriage. So even when they do get pregnant, they have a higher risk of losing their pregnancy. So it's not that the sperm can't fertilise the egg necessarily. It's that when they do, because of the damage in the sperm, they're less likely to succeed in making a pregnancy that's ongoing. So it is nuanced counselling. It's not if you smoke you can't ever get pregnant. There's lots of people who do smoke and who do get pregnant naturally with their partners and whose partners get pregnant naturally, but that does not mean that smoking is okay and it does not mean that smoking doesn't cause damage. And we know that children born to parents who smoke, where there is any smoking in the household no matter what the source, mother or father, are at higher risk of asthma in their life, of allergy, of cot death, amongst other things. So there are downstream risks to your child by smoking as well.
I think the important thing to point out, though, is that the effects of smoking and alcohol consumption are reversible, because there are studies that show that you can see an improvement in sperm quality, for example, three to six months out from quitting. So it's one of those things where it's better not to, for a number of reasons, but you can also see improvement not only just in overall health and wellbeing, but if you're trying to conceive, then you can actually improve the quality of your sperm and your eggs just by making, I won't say simple, but a small change.
Jordi Morrison: Do we know anything about vaping?
Dr. Alexandra Harvey: Yeah, we do. We know that it is not a get-out-of-jail-free card, that you're still introducing toxic chemicals to your body. And you may not be doing as much harm as if you are smoking, because some of that burning of tobacco releases further toxic chemicals that damage the body and the lungs and the sperm, but there are still toxic chemicals in vapes. Nicotine is your biggest toxin that is going to have an impact because it contributes to inflammation and oxidative stress, which are key mediators of DNA damage.
Jordi Morrison: In terms of other environmental toxins and everyday exposure, we've mentioned endocrine disruptors briefly and Teflon pans. We know a little bit about microplastics. What else should we be aware of? Or is it really the endocrine disruptors and microplastics?
Dr. Alexandra Harvey: I can speak to both of those. So yeah, those inconspicuous environmental toxins that we go about our everyday life and don't think much of could include things like endocrine disruptors, but also air pollution, for example. So particulate matter that is floating around in our environment, and air quality, that can considerably impact the way in which our bodies regulate our hormones and therefore also regulate the way in which our eggs and our sperm develop. And so there is some evidence that air quality can impact on clinical pregnancy rates. But when we're talking about endocrine-disrupting chemicals, we're talking about these pervasive chemicals that are in our everyday lives. And we have often no idea that we're consuming large amounts of these, either orally or we are actually absorbing them through our skin.
And so many people would be familiar with bisphenol A or BPA, which has been largely removed from a number of plastics. However, it's been replaced by structural equivalents called bisphenol F and bisphenol S. And so we actually know less about them scientifically, but they're likely to have the same activity. So it's one of those things where it seems like we're making improvements, but the toxic burden is actually still there. And another source for BPA is actually the thermal receipt paper that you get when you go shopping.
Jordi Morrison: I always say no to the thermal receipt just simply because you can absorb it through your fingertips. That's fascinating.
Dr. Alexandra Harvey: Yeah, there are consistent findings that show effects of bisphenols on sperm and egg quality. And so it's one of those things where if you want a small place to find where you can reduce your exposure, that's one way of avoiding plastic bottles and receipts. Another endocrine disruptor that's quite a hot topic out in the media at the moment, PFAS. So that's per- and polyfluoroalkyl substances, and they're the forever chemicals. And they're really chemicals that show resistance to heat and oil and water. And so they're the things that line our non-stick pans, but they're also used in cosmetics and food packaging. And we know that they can have an impact on our hormone system, but also then impact on oocyte quality and fertilisation. And so it's really important to consider that you may be exposing yourself through a number of different ways to a lot of these endocrine-disrupting chemicals.
And you mentioned microplastics, and they're a really interesting space at the moment where we're producing millions of tonnes of plastic every year, most of which ends up as waste. And as that degrades, that's what forms microplastics. But it's also when you're cutting up your food on a plastic cutting board, you're creating plastic that you can then digest. And these microplastics are actually carriers for endocrine-disrupting chemicals like bisphenols and PFAS. And there are a couple of recent studies that have shown that there is quite a high level of prevalence of microplastics in the ovary and the testes. And so that's potentially concerning. And what impact they might have, that's for future science to address. But it's likely that they're going to have this concentrating effect where endocrine-disrupting chemicals are actually localised in this environment where the egg and the sperm are meant to be developing.
Dr. Raelia Lew: So that's interesting. And obviously there's some other things that we do that we might look at for that in terms of the lab. There's a lot of plastic in the lab. We use plastics all the time. We use dishes that are made of plastic. We use pipettes that might have some plastic elements. There's lots of plastic in the lab, that's for sure.
Dr. Alexandra Harvey: We're certainly not somewhere where we're unaware of the amount or the volumes that we're using. But I guess it's really important that from a lab perspective, we are always quality testing our plastics. There's a quality assurance level that comes with the products that we use. And we use particular types of plastic so that we are not exposing embryos to things like bisphenols. And that was actually how this whole field was first established, where someone was trying to grow embryos, mouse embryos, in a dish, and what was actually affecting those embryos and the number of embryos developing was the type of plastic. That was the only change to the system before they saw a drop off. And then they actually measured what was in the dish and found out that these bisphenols were the cause. And so that's where this whole quality assurance process has come into play and is really important as part of the day-to-day operation of the lab.
Jordi Morrison: That's a really interesting point for society moving forward, that if not all plastics are bad, maybe we have to really figure out which ones are and make some changes.
Dr. Alexandra Harvey: Yes, but it's the same with everything, though. You only see what you look for, so perhaps there are elements of all plastics that are detrimental in some way, shape or form. It's probably a concentration effect as well, and a time effect.
Jordi Morrison: I want to finish up with some misconceptions. We love a bit of myth busting on Knocked Up. In terms of misconceptions around lifestyle and fertility, what are perhaps some of the things you find patients doing or worrying about that really will make a minimal positive impact?
Dr. Raelia Lew: I would say that it's more about just recognising the benefits of what they're currently doing. A lot of patients do come to a fertility specialist a little bit later in their own journey. Most have tried to conceive by themselves. Most have sought advice from other health professionals, potentially allied health professionals as well. And most have made concerted efforts to do what they can already in terms of diet and lifestyle. So I would say that extreme diets of any kind are probably unnecessary and unhelpful. Unless you are a coeliac, cutting out gluten has no benefit to fertility. If you are a coeliac or if you are gluten intolerant, that may be something relevant for you to do in terms of your health and fertility benefits. But if you are not, cutting out things like dairy, cutting out things like gluten, actually are not helpful for fertility. If you are vegan, you probably do have some deficiencies and seeing a clinical nutritionist approaching a pregnancy and pregnancy planning for some personalised advice and testing is probably a very good idea. And I would encourage anybody who would like focused dietary advice and a focused dive into what they're doing now, how they could improve and potential benefits, to see a clinical nutritionist for a personalised assessment because, as Alex said, generalised advice can only get you so far and personalised advice is much more relevant for you.
Dr. Alexandra Harvey: I think an important point to make in terms of misconceptions, though, is that many people come on a fertility or infertility journey and it's not just about women in terms of their age or their weight or their lifestyle choices that are impacting fertility. It takes two and so the male is just as important.
Jordi Morrison: I think that's a nice way to end it. Yeah. Thank you so much, Alex.
Dr. Alexandra Harvey: Thank you. It's my pleasure.
Jordi Morrison: To support Knocked Up, leave us a review or recommend to a friend. Join us on Instagram @knockeduppodcast and join Raelia @drraelialew. And email us your questions to podcast@womenshealthmelbourne.com.au.
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.
Find us on Instagram - @knockeduppodcast
Have a question about women's health? Is there a specific topic you'd like us to cover? Email podcast@womenshealthmelbourne.com.au. We keep all requests anonymous.