Fertility


Definition/Description

The World Health Organization calculated that over 10% of women are affected by infertility and subfertility.[1] Infertility is the inability to conceive despite frequent coitus. Infertility refers to a state in which the capacity for fertility is diminished, but not necessarily absent. Fertility issues can be a burden in almost every aspect of life for individuals and/or couples; socially, physically, mentally, and financially. Relationships can suffer with the spouse or partner, but also those with friends and family members. This could be due to feelings of frustration from well-intentioned, unsolicited advise that may be painful, or social isolation from family and friends who may be pregnant or have children, and feelings of stigmatized. Dealing with various outcomes while dealing with fertility issues can be very emotional. Individuals and couples can deal grief and distress after a/multiple miscarriages, or a failed IVF cycle, and overjoyed with successful attempt, regardless, the process can be long and arduous. If an individual is using medication to improve fertility outcomes, this often comes with side-effects which can affect the individual physically and mentally. Lastly, seeking medical assistance for fertility issues can be very costly and is often not covered by insurance or medical services. This is also a huge barrier to seeking assistance with fertility.[2][3]

Etiology

Pathology affecting fertility[4]

  • Ovulatory dysfunction: 21%
  • Tubal damage: 14%
  • Endometriosis: 6%
  • Coital problems: 6%
  • Cervical factor: 3%
  • Unexplained: 28%
  • Male factor (hypogonadism, post-testicular defects, seminiferous tubule dysfunction): 26%

Modifiable lifestyle factors affecting fertility

Factors affecting fertility Information
Tobacco use
  • has been associated with infertility, particularly if the female partner is using tobacco[5]
Weight
  • increasing obesity is associated with decreasing spontaneous pregnancy rates and increased time to pregnancy[6][7]
  • increased weight in both males and females has a negative impact on fertility[8][9]
  • a prospective cohort study found that every 5 kg body weight increase is associated with a current duration of pregnancy attempt increased by 5%[10]
  • weight loss is advised for females with an elevated BMI because weight reduction aids in spontaneous conception in some studies and reduces the need for fertility treatment[11][12]
  • the risk of unsuccessful in vitro fertilization (IVF) increases with increasing BMI and may be related to poor oocyte quality, ovarian function, endometrial quality, or a combination of these factors[13]
Exercise
  • vigorous exercises may have an adverse effect on fertility on females with a BMI <25 kg/m2, however, exercise has a positive effect fertility on females who are overweight[14]
Alcohol intake
  • moderate alcohol intake in females and males does not appear to affect fertility[15][16]
Diet
  • see below under "Diet and Fertility" resources
Caffiene
  • caffiene intake less than 200mg/day in both females and males does not seem to affect fertility[15]
Stress
  • in a meta-analysis a small but significant negative associations were found between stress, distress and reduced pregnancy chances with assisted reproductive technology[17]

Management

Physiotherapy

Although there are no specific physical therapy protocols for fertility, physiotherapists may be well positioned to assist patients with aspects of their fertility journey. The first step for physiotherapists is to become educated on the topic and aid in educating the public on the importance of exercise and weight management in fertility. As stated above weight and exercise have an effect on fertility, and physiotherapists can have a more direct role through creating and implementing an exercise program to suit the needs of their clients. Exercise is a relatively inexpensive addition to “usual care” in improving the outcomes of assisted fertilization. Additionally, exercise may aid in the mental health of clients during this challenging time. The ultimate goal is to aid individuals in reaching their fertility goals and it is important that as healthcare providers we are informative and proactive regarding the breadth of issues that could be affecting their assisted fertility outcomes. As discussed this can be a very stressful time, techniques such as mindfulness meditation, deep breathing, guided imagery, and yoga can be promoted for stress management.

A study conducted by Kiel et al. (2018), examined the effect of high-intensity interval training (HIT) on women undergoing assisted fertilization through a pilot randomized control trial. Eighteen woman with a body mass index of over 25.0 kg/m​2​ were split into two groups: the control group “usual care” (n=10) and the intervention group “HIT” (n=8). The first outcome measure was “ongoing pregnancy” and the second was “insulin sensitivity, reproductive hormones, oxygen uptake, and body composition.” The study concluded that HIT significantly improved insulin sensitivity, VO​2 ​peak, and abdominal fat. Furthermore, fertility outcomes may increase by improving insulin sensitivity and the regulating the hypothalamic-pituitary-adrenal axis, central obesity, as well as, cardiovascular fitness.[18][19]

Exercise therapy may be beneficial, however, this must be prescribed with caution in some cases as there may be an increased risk of ovarian torsion.[20] The risk of ovarian torsion increases with the presence of an ovarian mass and increased ovarian size, and individuals actively going through assisted fertility therapy (ie. in vitro fertilization), which stimulates the ovaries, increasing their size.[21][22]

Common conditions that physiotherapists may encounter that could affect fertility include: endometriosis, polycystic ovarian syndrome (PCOS), cancer and/or cancer treatments.

Medical Interventions

The following tests are useful in most couples with fertility issues:[23]

  • Semen analysis to assess male factors.
  • Menstrual history, assessment of luteinizing hormone surge in urine prior to ovulation, and/or luteal phase progesterone level to assess ovulatory function.
  • Hysterosalpingogram or sonohysterogram with a test of tubal patency such as hysterosalpingo-contrast-sonography to assess tubal patency and the uterine cavity.
  • Assessment of ovarian reserve with day 3 serum follicle-stimulating hormone and estradiol levels, anti-Müllerian hormone, and/or antral follicle count.
  • Thyroid-stimulating hormone.

In select couples, the following additional tests may be warranted:

  • Pelvic ultrasound to assess for uterine myomas and ovarian cysts
  • Laparoscopy to identify endometriosis or other pelvic pathology

Assisted Reproductive Technology (ART):

  • The use of ART is dependent on each individual's or couple's situation and reason for infertility, patient's should seek the advise of a physician with a specialty in fertility for more information on this option

Resources

Podcasts by Natalie Crawford, MD

Assisted Reproductive Technology: An informative video on the process post egg retrieval

Article: Can Physiotherapists Play a Role in Fertility

Diet and fertility:

References

  1. World Health Organization. Sexual and reproductive health. Available from https://www.who.int/reproductivehealth/topics/infertility/perspective/en/
  2. Harvard Health Publishing. The psychological impact of infertility and its treatment. Available from: https://www.health.harvard.edu/newsletter_article/The-psychological-impact-of-infertility-and-its-treatment
  3. Wu AK, Elliott P, Katz PP, Smith JF. Time costs of fertility care: the hidden hardship of building a family. Fertility and sterility. 2013 Jun 1;99(7):2025-30.
  4. Hull MG, Glazener CM, Kelly NJ, Conway DI, Foster PA, Hinton RA, Coulson C, Lambert PA, Watt EM, Desai KM. Population study of causes, treatment, and outcome of infertility. Br Med J (Clin Res Ed). 1985 Dec 14;291(6510):1693-7.
  5. Hughes EG, Lamont DA, Beecroft ML, Wilson DM, Brennan BG, Rice SC. Randomized trial of a “stage-of-change” oriented smoking cessation intervention in infertile and pregnant women. Fertility and sterility. 2000 Sep 1;74(3):498-503.
  6. van der Steeg JW, Steures P, Eijkemans MJ, Habbema JD, Hompes PG, Burggraaff JM, Oosterhuis GJ, Bossuyt PM, van der Veen F, Mol BW. Obesity affects spontaneous pregnancy chances in subfertile, ovulatory women. Human reproduction. 2007 Dec 11;23(2):324-8.
  7. Gesink Law DC, Maclehose RF, Longnecker MP. Obesity and time to pregnancy. Human Reproduction. 2006 Nov 9;22(2):414-20.
  8. Ramlau-Hansen CH, Thulstrup AM, Nohr EA, Bonde JP, Sørensen TI, Olsen J. Subfecundity in overweight and obese couples. Human reproduction. 2007 Mar 7;22(6):1634-7.
  9. Nguyen RH, Wilcox AJ, Skjærven R, Baird DD. Men's body mass index and infertility. Human Reproduction. 2007 Jul 17;22(9):2488-93.
  10. Gaskins AJ, Rich-Edwards JW, Missmer SA, Rosner B, Chavarro JE. Association of fecundity with changes in adult female weight. Obstetrics and gynecology. 2015 Oct;126(4):850.
  11. Kiel IA, Lundgren KM, Mørkved S, Kjøtrød SB, Salvesen Ø, Romundstad LB, Moholdt T. Women undergoing assisted fertilisation and high-intensity interval training: a pilot randomised controlled trial. BMJ open sport & exercise medicine. 2018 Jul 1;4(1):e000387.
  12. Özcan Dağ Z, Dilbaz B. Impact of obesity on infertility in women. Journal of the Turkish-German Gynecological Association. 2015 Jun 1;16(2).
  13. Rittenberg V, Seshadri S, Sunkara SK, Sobaleva S, Oteng-Ntim E, El-Toukhy T. Effect of body mass index on IVF treatment outcome: an updated systematic review and meta-analysis. Reproductive biomedicine online. 2011 Oct 1;23(4):421-39.
  14. Wise LA, Rothman KJ, Mikkelsen EM, Sørensen HT, Riis AH, Hatch EE. A prospective cohort study of physical activity and time to pregnancy. Fertility and sterility. 2012 May 1;97(5):1136-42.
  15. 15.0 15.1 Abadia L, Chiu YH, Williams PL, Toth TL, Souter I, Hauser R, Chavarro JE, Gaskins AJ, EARTH Study Team. The association between pre-treatment maternal alcohol and caffeine intake and outcomes of assisted reproduction in a prospectively followed cohort. Human Reproduction. 2017 Aug 8;32(9):1846-54.
  16. Eggert J, Theobald H, Engfeldt P. Effects of alcohol consumption on female fertility during an 18-year period. Fertility and sterility. 2004 Feb 1;81(2):379-83.
  17. Matthiesen SM, Frederiksen Y, Ingerslev HJ, Zachariae R. Stress, distress and outcome of assisted reproductive technology (ART): a meta-analysis. Human reproduction. 2011 Aug 1;26(10):2763-76.
  18. Kiel IA, Lundgren KM, Mørkved S, Kjøtrød SB, Salvesen Ø, Romundstad LB, Moholdt T. Women undergoing assisted fertilisation and high-intensity interval training: a pilot randomised controlled trial. BMJ open sport & exercise medicine. 2018 Jul 1;4(1):e000387.
  19. Hakimi O, Cameron LC. Effect of exercise on ovulation: a systematic review. Sports Medicine. 2017 Aug 1;47(8):1555-67.
  20. Littman ED, Rydfors J, Milki AA. Exercise‐induced ovarian torsion in the cycle following gonadotrophin therapy: Case report. Human Reproduction. 2003 Aug 1;18(8):1641-2.
  21. Varras M, Tsikini A, Polyzos D, Samara CH, Hadjopoulos G, Akrivis CH. Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings. Clinical and experimental obstetrics & gynecology. 2004;31(1):34-8.
  22. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Annals of emergency medicine. 2001 Aug 1;38(2):156-9.
  23. Practice Committee of the American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertility and sterility. 2012 Aug 1;98(2):302-7.