The prevention
of disease is certainly more efficient and cost effective than its treatment.
Nevertheless, human reproduction faces continued obstacles through lifestyles
selected by patients often unwittingly. As healthcare professionals, we are responsible
for educating our patients on reducing their risk of illness. In women, rarely
a problem exceeds the importance during their reproductive years as fertility.
To demonstrate the significance of this issue, the American Society for Reproductive
Medicine (ASRM) established a public service announcement campaign, “Protect
Your Fertility.” Since 10-15% of the reproductive-aged population (approximately
6 million people) experience infertility, this article is essential and will
summarize the ASRM recommendations. Specifically, smoking, sexually transmitted
infections (STIs), age, and an unhealthy body weight can all increase the risk
of infertility in both men and women.
Smoking
Currently, one-third of all men and women in this country smoke cigarettes
and this behavior results in a 40 - 60% increase in infertility. Smoking accelerates
follicular atresia and estradiol metabolism resulting in higher rates of miscarriages,
ectopic pregnancies, and a several year earlier onset of menopause. Considering
Assisted Reproductive Technology (e.g. in vitro fertilization therapy), ovarian
reserve, ovarian response to fertility medication, the number of oocytes retrieved
and fertilized, and the pregnancy rates are reduced in smokers compared to non-smokers.
The pregnancy rate in in vitro fertilization treatment cycles is decreased in
smokers by 34%. The problem is not limited to women since sperm counts are reduced
an average of 22%, and show a dose response with increased cigarette smoking
correlating to a greater reduction in sperm count. Despite counts remaining in
the normal range, sperm fertilization potential is reduced from smoking.
Smoking cessation prevents further damage and one study suggested that ex-smokers
have fecundity similar to that of women who have never smoked, following one
year of cessation. Unfortunately, the amount and duration of smoking has a significant
effect on subsequent fertility, and it is not enough for just the patient to
stop since passive smoke appears to be just as harmful.
STIs
If hypertension is considered the silent killer then STIs, particularly Chlamydia,
is considered the silent killer of fertility by damaging the fallopian tubes.
Although not practicing safe sex (specifically barrier contraception) may risk
pregnancy, paradoxically it also risks subsequent infertility and ectopic pregnancy.
The latter complication increases from a baseline of 2% to 8%. The incidence
of tubal factor infertility increases 7-fold, 16-fold, and 28-fold, following
one, two, and three infections to the fallopian tubes (salpingitis), respectively.
Aggressive screening and prompt treatment may reduce the damage to reproductive
potential.
Age
As more women are delaying childbirth and more "baby boomers" are reaching
midlife, the problem of diminished ovarian reserve is increasing. Ovarian aging
has several major medical consequences including decreased bone mass with risk
of fracture, abnormal uterine bleeding from anovulation, infertility, and vasomotor
symptoms. The main impact on pregnancy rate is oocyte quality and quantity. As
a result, fertilization is impaired, implantation is reduced, and miscarriage
is increased along with the increased potential for chromosomal abnormalities
of the fetus. Initiation of the first pregnancy should be encouraged to begin
before the female turns 30 years of age.
More recently, male age greater than 40 has been implicated in increased risk
of infertility and miscarriage as well as offspring with congenital anomalies
and autism. While this data is preliminary, certainly further studies are vital
due to the delaying of parenting in the population.
Body Weight
Twelve percent of all infertility cases are a result of a woman being either
over- or under-weight; the proportion is 6% from each. Weight is a critical factor
in the hypothalamic pituitary axis and will influence the onset of puberty. The
most common endocrinopathy from an elevated body mass index is Polycystic Ovarian
Syndrome resulting in chronic ovulatory dysfunction and an increased risk of
the metabolic syndrome. An extremely low body mass index can also affect ovulation
dysfunction and is often associated with the female athlete triad (amenorrhea,
bone loss, and eating disorder). In men, obesity results in a hormonal disturbance
that decreases testosterone and sperm counts.
According to ASRM guidelines, “if a woman’s body weight is less
than 95% of predicted ideal body weight or greater than 120% of predicted ideal
body weight, then weight management should be the primary therapeutic recommendation.
More than 70% of women who are infertile as the result of body weight disorders
will conceive spontaneously if their weight disorder is corrected through a weight-gaining
or weight-reduction diet as appropriate.”
As mentioned, men are not immune from lifestyle risks affecting fertility
and should follow the following recommendations: avoid drug use, smoking and
excessive alcohol (women should discontinue alcohol use when pregnancy is desire);
avoid excessive scrotal temperature to prevent impaired spermatogenesis; and
avoid STIs.
For more information on educating your patients to reduce their risk of infertility,
please visit the ASRM sponsored website, http://www.protectyourfertility.com as well as their home page on human reproduction, http://www.asrm.org.
Dr. Mark P. Trolice is the Director of Fertility C.A.R.E and is Board-certified
in Reproductive Endocrinology and Infertility (REI). He is also the Division
Director of REI at Winnie Palmer Hospital for Women & Babies in Orlando.
Please direct any inquiries by calling 407-672-1106. 866-9FERTILITY.
© Mark P. Trolice Copyright 2010
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