Preparing for pregnancy: Pre-Conception Counseling - Carmelo S. Sgarlata, MD Reproductive Endocrinologist and Director of Integrative Medicine
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Preparing for pregnancy:
Pre-Conception Counseling
Carmelo S. Sgarlata, MD
Reproductive Endocrinologist and Director of Integrative Medicine
www.rscbayarea.com
@ Dr_Sgarlata
I have no disclosures or industry affiliations
Learning Objectives
At the conclusion of this presentation, participants
should be able to:
1) Identify risk factors and list techniques and strategies to
plan for a successful pregnancy.
2) Understand the role of preconceptional screening,
lifestyle, nutrition and supplements in pregnancy
preparation.
3) Apply interventions to educate and promote healthy
pregnancy.
The Periconceptional Period
In Women:
~ 26 weeks before conception, primordial follicles leave the resting
state.
The active phase of follicular development starts around 14 weeks
before ovulation
In Men:
The spermatogenic cycle is 65 - 74 days
Final sperm maturation occurs in the epididymis over ~ 10-15 days
Once conception occurs, organogenesis occurs between week 4 and 10
of pregnancy.
http://cnx.org/resources/7aaae1b0e6fc814c0f038aa695ed3d5f/Figure_28_02_03. . Licensed under Creative
Commons Attribution 3.0
"Figure 28 01 04" by OpenStax College - Anatomy & Physiology, Connexions Web site.
http://cnx.org/content/col11496/1.6/, Jun 19, 2013.. Licensed under Creative Commons Attribution 3.0
Steegers-Theunissen R P et al. Hum. Reprod. Update 2013;humupd.dmt041 © The Author 2013. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com
CDC Definition of Preconception Health
and Healthcare*
“A set of interventions that aim to identify and modify
biomedical, behavioral, and social risks to a woman’s
health or pregnancy outcome through prevention and
management, emphasizing those factors which must
be acted on before conception or early in pregnancy to
have maximal impact. “
*CDC’s Select Panel on Preconception Care, June 2005
WHO Definition of Preconception Care
“Preconception care is the provision ofbiomedical,
behavioural and social health interventions to women and
couples before conception occurs, aimed at improving their
health status, and reducing behaviours and individual and
environmental factors that could contribute to poor
maternal and child health outcomes.”
“Its ultimate aim is improved maternal and child health
outcomes, in both the short and long term.”
http://www.who.int/maternal_child_adolescent/documents/concensus_preconception_care/enWhy Preconception Care?
Placental development begins within 7 days post
conception
The fetus is most vulnerable in the first 17-56 days after
conception
The neural tube closes by 28 days post conception (6
weeks)
Often the first prenatal visit does not occur until 11-12
weeks
Up to 30% of American women begin prenatal care after
13 weeksWhy Preconception Care?
Allows for:
Risk Assessment
Health promotion
Interventions to reduce risks/improve outcomes
Counseling and implementation
Remember: Men should also prepare for a healthy
pregnancyPREPARATION for PREGNANCY: GENERAL
Review
Reproductive life plan
Past medical history
Past Ob history including inter-pregnancy care
Family and genetic history, Potential carrier status
Lifestyle and Environment
Manage medical conditions: Make sure any existing
medical conditions are under fully evaluated and
under proper control before attempting pregnancy.PREPARATION for PREGNANCY: GENERAL Medications: Review all prescriptions, OTC’s, supplements and herbal preparations. Remember ask the patient specifics- they often fail to disclosure what they are actually are using. Preventive Care: Folic Acid Immunizations Screening labs, Pap and Mammogram Dental care Counseling
PREPARATION for PREGNANCY: GENERAL
CBC, Hg Electrophoresis as indicated
STD’s
GC/Chlamydia/Syphilis
Hepatitis B & C
HIV
Immunity
Rubella
Varicella
Blood type/ Antibody Screen
FBS/HgA1c
Vitamin D?PREPARATION for PREGNANCY: GENETIC
PREPARATION for PREGNANCY: GENETIC
ETHNICITY DISEASE CARRIER FREQUENCY
Ashkenazi Jewish: Tay-Sachs 1/30
Canavan 1/40
Cystic fibrosis 1/29
Familial Dysautonomia 1/30
Mediterranean: Thalassemia 1/20-1/50
Sickle cell anemia 1/30-1/50
European Caucasian: Cystic fibrosis 1/29
African American: Sickle cell anemia 1/10
Thalassemia 1/30-1/75
Cystic fibrosis 1/65
Asian: Thalassemia 1/20-1/50
Cystic fibrosis 1/90
Hispanic: Cystic fibrosis 1/46
French Canadian/Cajun: Tay-Sachs 1/30-50
Cystic fibrosis 1/29
Women Fragile X Syndrome 1/100-250Genetic Carrier Screening Guidelines
★ = ACOG ✪ = ACMG
Disease Caucasian Ashkenazi Cajon/ African Hispanic Mediterr. Asian
Jewish Fr Can
Cystic Fibrosis ★ ✪ ★ ✪ ★ ✪ ★ ✪ ★ ✪ ★ ✪ ★ ✪
SMA ✪ ✪ ✪ ✪ ✪ ✪ ✪
Tay-Saks Disease ★ ✪ ★
Canavan Disease ★ ✪
Familial ★ ✪
Dysautonomia
Bloom ✪
Syndrome
Fanconi Anemia ✪
Type C
Mucolipidosis IV ✪
Niemann Pick ✪
Disease Type A
Sickle Cell ★
Thalassemia ★ ★ ★PREPARATION for PREGNANCY: DIET
Vegetables Fruits Protein Whole Grains “Let food be thy medicine and let medicine be thy food.” Hippocrates Healthy Fats Dairy Fluids Spices
PREPARATION for PREGNANCY: DIET
During follow-up in NHS-II, 438 women reported
ovulatory infertility. Total carbohydrate intake and dietary
glycemic load were positively related to ovulatory
infertility.
Dietary glycemic index was positively related to ovulatory
infertility only among nulliparous women.
Specific foods: only cold breakfast cereal and soda were
statistically significant.
Women with a high glycemic index diet also consumed less
saturated fat, animal protein, alcohol and coffee, had a
higher intake of trans fat, lower intakes of fiber and
multivitamins and were less physically active.
Chavarro et al Eur J Clin Nutr. 2009; 63(1): 78–86PREPARATION for PREGNANCY: DIET Key recommendations from The Fertility Diet (a 8-year study of more than 18,000 women that is part of the landmark Nurses' Health Study) include: Avoiding trans-fats. Eating more vegetable protein and less animal. Drink a glass of whole milk or having a small dish of ice cream or full-fat yogurt every day. Get into the "fertility zones" for weight and physical activity.
PREPARATION for PREGNANCY: DIET
Mediterranean-type diet and IVF
2010 Prospective cohort study from the Netherlands
Preconception Mediterranean-type diet associated with a 40% increased
probability of pregnancy among couples undergoing IVF
Mediterranean diet had higher red blood cell folate, B6, and levels of follicular
fluid
Preconception questionnaire/ counseling at a Dutch Clinic
Adherence to recommendations of the Netherlands Nutrition Centre was
associated with an increased chance of ongoing pregnancy after the first
IVF/ICSI treatment.
Thus, a one-point increase in the PDR score associates with a 65% increased
chance of ongoing pregnancy.
Vujkovic et al. Fert Steril 2010;94(6) :2096–101
Twigt et al Hum Reprod 2012; 27 (8): 2526–2531PREPARATION for PREGNANCY: DIET
Mediterranean diet and IVF
Spanish case–control study of 485 women, age 20–45 who
reported difficulty getting pregnant
1,669 age-matched controls who had at least one child
Results: greater adherence to a Mediterranean-type dietary
pattern was associated with a lower risk of consulting a physician
because of difficulty getting pregnant.
44% less difficulty conceiving in the highest quartile Mediterranean
pattern compared with the lowest quartile (odds ratio 0.56, 95% CI
0.35–0.95)
Toledo et al. Fert Steril 2011;96(5):1149-53.PREPARATION for PREGNANCY: DIET
“Pre Pregnancy Dietary Patterns and the Risk of Pregnancy Loss”
Prospective cohort study of 15,950 reported by 11,072 nurses in the NHS II
between 1992-2009
Pre pregnancy dietary habits were self-reported using a validated questionnaire
Looked at 3 healthy diets: alternative Healthy Eating Index (aHEI-2010),
alternative Mediterranean diet (AMED) and the Fertility Diet (FD).
Results:.
Spontaneous abortions in 17.3% (2756)
Stillbirths in 0.8% (120)
None of the 3 diets were found to be associated with the risk of pregnancy loss
Gaskins et al. Am J Clin Nutr 2014: ajcn.083634PREPARATION for PREGNANCY: DIET
The Food and Drug Administration (FDA) and the
Environmental Protection Agency (EPA) say pregnant
women can safely eat up to 12 ounces (340 grams) of
seafood a week.
Similarly, the 2010 Dietary Guidelines for Americans
recommend 8 to 12 ounces of seafood a week for
pregnant women.
Avoid 4 types of fish: tilefish from the Gulf of Mexico,
shark, swordfish, and king mackerel. These 4 types of
fish are highest in mercury.
http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm393070.htmPREPARATION for PREGNANCY: DIET
Methyl mercury and Fish
Methyl mercury is a known teratogen
Pregnant women are advised to consume 8-12 ounces
of fish weekly (2-3 meals)
Women in the preconception period and those who
are pregnant should avoid:
Shark
Swordfish
King Mackerel
Tilefish from Gulf of Mexico
http://www.epa.gov/mercury/exposure.htm
http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm393070.htmPREPARATION for PREGNANCY: DIET
Eat a variety of seafood that's Other safe choices include
low in mercury and high in Shrimp:
omega-3 fatty acids: Pollock
Salmon Catfish
Anchovies Tilapia
Herring
Sardines Canned light tuna - Limit
Trout – Atlantic albacore tuna and tuna
Pacific Mackerel steak to no more than 6
ounces
Pay attention to local
advisories
http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm393070.htmPREPARATION for PREGNANCY: DIET
Dietary Fat and IVF
With higher intakes of total and saturated fat, a
reduced number of mature oocytes (Mii’s) were
obtained
Polyunsaturated fat consumption was inversely related
to embryo quality.
Higher intakes of monosaturated fat increased the
odds of a live birth
Chavarro et al Hum Reprod 2012; 27(supp2): O-200PREPARATION for PREGNANCY: DIET
Sugar-Sweetened Beverage (SSB) Intake and Sperm
189 men between ages 18-22 in Rochester, NY
Self-reported questionnaire on health habits and diet as
well as a single semen analysis
In those who consumed an average of 2.7 SSB daily (1
serving is 12 ounces), sperm motility was 6.3% lower
The association with lower sperm motility was only seen
in healthy, lean men.
There was the suggestion of an inverse relationship
between SSB intake and FSH levels, but not with other
reproductive hormones.
Chiu et al Hum Reprod 2014; 29(7): 1575-84PREPARATION for PREGNANCY: DIET
Dietary Fat and Sperm
In 33 infertile men
Sperm trans fat levels were negatively correlated with sperm
density
Polyunsaturated fat consumption was inversely related to
embryo quality
Higher intakes of monosaturated fat increased the odds of a
live birth
155 men with a total of 338 semen samples
Low-fat dairy intake was positively related to sperm density
and progressive motility.
Cheese intake was associated with lower sperm
concentrations among past or current smokers.
Chavarro et al Fert Steril 2011; 95: 1794-7
Afeiche et al Fert Steril 2014; 101(5): 1280-87Can Nuts Up Sperm Count?
A 12-week randomized trial of 117 men ages 21-35. At the end
of the 12-week study period, men in the walnut group showed
improvements in:
Sperm motility
Vitality
Morphology
Fewer chromosomal abnormalities
Researchers in Turin are looking to show that just 7 nuts
could have a significant positive impact on male fertility.
Robbins et al Bio Reprod 2012,112. 101634 – Online access
http://www.telegraph.co.uk/men/active/mens-health/11027770/The-secret-to-better-sperm-A-handful-of-nuts.htmlPREPARATION for PREGNANCY: DIET
Emphasize the Mediterranean or anti-inflammatory
diet
Whole grains
Avoid sugar/refined grains/trans fats
Reduce animal sources of protein
Eat fresh fruit/vegetables
EWG – “Dirty” dozen and “Clean” 15
Foods rich in monounsaturated fats
“Whole” dairy products
Reduce saturated fats- organic whole dairy is OK
Filtered waterPREPARATION for PREGNANCY: DIET
A Few Good Resources:
www.dietaryguidelines.gov
www.americanheart.org
www.drweil.com
www.eatingwell.comPREPARATION for PREGNANCY: VITAMINS Folic acid - at least 400 mcg daily Vitamin D DHA Which vitamin/prenatal?
PREPARATION for PREGNANCY: VITAMINS
Pre Pregnancy Vitamin
Vitamin A Max of 2500 IU retinol
Vitamin D 1000 IU
Vitamin E 200-440 IU (mixed tocopherols)
Folic Acid 400 mcg or greater
Vitamin B12 2.4 mcg
Iron 18 mg
Iodine 150 mcg
DHA 300-400 mg (Molecular
distilled)PREPARATION for PREGNANCY: VITAMINS
Folic acid supplementation and Pregnancy Loss
Nurses’ Health Study II between 1992-2009
Self-reported folate intake and pregnancies
In the cohort of 15,950 pregnancies:
The risk of spontaneous abortion was 20% lower among
women in the highest category of supplemental folate
intake (> 730 micro- grams/d) than in the lowest (0
micrograms/d) category.
A similar inverse trend was observed with the risk of
stillbirth, which fell short of conventional significance
(P trend=.06).
Gaskins et al Am J Obstet Gynecol 2014, 124(1): 23-31PREPARATION for PREGNANCY: VITAMINS
Folic acid supplementation and IVF
180 women with unexplained infertility compared to 188 fertile women
in the control group
Women with unexplained infertility had higher folic acid intake,
median plasma folate levels and lower median plasma homocysteine
levels than controls.
Neither folic acid supplementation nor folate status had a positive
impact on pregnancy or live birth rates.
Dietary Folate and Reproductive Success Among Women
Undergoing Assisted Reproduction
Folate intake in 232 women undergoing IVF
Supplemental folate of more than 800 mcg/day was associated with a
higher fertilization rates and probability of a live birth.
Murto et al Reprod BioMedicine Online 2014
Gaskins et al Obstet Gynecol 2014; 124(4):801-09PREPARATION for PREGNANCY: VITAMINS
Omega-3 fatty acids
Omega-3’s and IVF
98 women with prior complete fertilization failure
1 gram omega-3’s from day 3 of prior cycle
Higher fertilization rate and good quality embryos
Omega-3’s and Men
Men with the highest third of omega-3 fatty acids had higher % of
normal morphology
Fertile men have higher blood and spermatozoa omega-3 levels and
a lower omega-6/omega-3 ratio
238 infertile men randomized to 1.84 grams daily EPA/DHA or
placebo with total sperm density, motility and normal morphology
significantly increased at 32 weeks
Kim et al Fert Steril 2010; 94(supp) S242
Safarinejad et al Andrologia 2011; 43: 38-47
Attaman et al Hum Reprod 2012; 27: 1466-74PREPARATION for PREGNANCY: VITAMINS
Anti-oxidants in Women
A 2013 review of 28 RCT’s involving 3548 women
The quality of evidence for live birth, clinical pregnancy
rate and adverse effects was rated a “very low to low”
Key results:
Antioxidants were not effective in increasing either the
clinical pregnancy or live birth rate
Antioxidants did not appear to be associated with an
increased risk of miscarriage, multiple or ectopic pregnancy
Showell et al 2013 Cochrane Reviews; Antioxidants for female subfertilityPREPARATION for PREGNANCY: VITAMINS
Anti-oxidants in Men
Most commonly used supplements include Folic acid,
Vitamin D, CoQ10, Omega 3’s and L-Carnitine
2011 Cochrane review of anti-oxidant supplements
taken by the male partner 2876 couples (34 RCT’s)
In 3 trails, live birth rate was increased (OR 4.85)
In 15 trials, pregnancy rate was increased (OR 4.18)
Showell et al 2011 Cochrane Database of Systematic Reviews; Issue 1PREPARATION for PREGNANCY: SUPPLEMENTS DHA/Fish oil Patients with PCOS: Cinnamon Inositol Advanced Maternal Age/Diminished Ovarian Reserve ? Co-Q-10 ? DHEA Others
Supplements Nutritional supplements along with weight management, exercise and a nutritious diet may play an important role in the preparation for pregnancy, esp. those who are infertile or older. Most scientific studies looking at supplement use to enhance fertility are limited to use in patients undergoing IVF. Adequately powered RCT’s are difficult to perform.
PREPARATION for PREGNANCY: WEIGHT
PREPARATION for PREGNANCY: WEIGHT Maintain a healthy body weight. Optimal body mass index (BMI) of 18-25 is ideal. There is good medical evidence that as BMI rises above this range, (particularly over 35) fertility treatment is less successful and pregnancies have more complications. Women with a low BMI (< 15) are at increased risk for ovulation disorders. Men with a BMI greater than 35 may have reduced sperm count and motility.
The predicted probability of conception with changing body mass index (BMI kg/m2), after
adjusting for age, smoking, race, education, occupation and study centre.
Gesink Law D et al. Hum. Reprod. 2007;22:414-420PREPARATION for PREGNANCY: WEIGHT
Underweight BMI < 20
Higher association of anovulation and infertility
SGA infants
Overweight BMI >30
SAB
Poor obstetrical outcomes
Neural tube defects, CV anomalies, Hydrocephaly
PIH, GDM
Preterm delivery
C-section. Post partum hemorrhage
MacrosomiaPREPARATION for PREGNANCY: WEIGHT
“Maternal Obesity: Bad for a Baby’s Future”
Up to 2/3 of American women of reproductive age are either overweigh or obese (obesity
rates in the United States vary from 20-36%)
Maternal Obesity is associated with:
Gestational Diabetes
PIH
Large and small for gestational age babies
Prematurity
Increased C-Section rate and postpartum hemorrhage
Congenital birth defects
Children of obese mothers are at increased risk for:
Overweight/Obesity during childhood and as an adult
Elevated blood pressure as early as age 5-6 (activation of autonomic function)
Increased risk for developing diabetes
Kett and Denton Hypertension 2013; 62;457-8
Gademan et al Hypertension 2013; 62:641-47PREPARATION for PREGNANCY: WEIGHT
“Nutritional and Weight Management Behaviors in Low-
Income Women Trying to Conceive”
Cross-sectional survey of 1711 women ages 16-40.
8.9% (153) were attempting to become pregnant.
Results:
Women attempting pregnancy were more likely to participate in
unhealthy weight loss practices
Diet pills, supplements or herbs: 13.5% vs. 8.8%
Laxatives, induced emesis or diuretics: 7.7% vs. 3.0%
Fasting for 24 hours: 10.7% vs. 5.5%
“Obesigenic” lifestyle: low fruit and vegetable intake, frequent fast food
and infrequent physical activity
Berenson et al. Am J Obstet Gynecol 2014; 124:579-84PREPARATION for PREGNANCY: WEIGHT
A systematic review 21 studies on body weight and
male fertility of 13,077 men from the general
population and fertility clinics.
Compared with men of normal weight; the odds ratio
for oligospermia or azoospermia were:
1.15 for underweight
1.11 for overweight
1.28 for obese
2.04 for morbidly obese men
Sermondade et al Hum Reprod Update. 2013;19(3):221-231PREPARATION for PREGNANCY: WEIGHT
468 couples enrolled in a population-based prospective
Longitudinal Investigation of Fertility and the
Environment (LIFE) study. The male partners did not have
known infertility.
Analysis of semen quality parameters showed:
Increasing BMI and WC were linked to a linear decline in
semen volume (PObesity and IVF
Normal Overweight Class 1 Class 2 Class 3
18.5-24.9 25-25.9 30-34.9 35-39.9 >39.9
Pregnanc - 3% - 14% - 26% -41-53%
y
Live Birth - 10% - 25% - 34% - 39-229%
Preterm
< 32 wks - + 26% + 52% + 59%
Higher odds of cycle cancellation, cancellation due to poor response,
failure to achieve a clinical intrauterine pregnancy, and failure to
achieve a live birth all paralleled increasing BMI.
Luke et al Fertil Steril 2011; 96(4): 820-25PREPARATION for PREGNANCY: EXERCISE
PREPARATION for PREGNANCY: EXERCISE
Prospective cohort study of 3628 Danish women
planning a pregnancy in 2007-09
A dose-response relationship between vigorous
physical activity and delayed time to pregnancy
Moderate activity had a positive effect
An important part of a weight loss plan.
Enhances fertility in overweight and obese women.
Wise et al Fert Steril 2012; 97(5): 1136-42PREPARATION for PREGNANCY: EXERCISE
Population-based survey of 3887 women in Norway.
Survey initially 1984-86 with follow-up in 1995-97.
No association with fertility and low- level activity.
Exercising to exhaustion: 2.3 times odds of infertility.
Women who were active most days were 3.2 times
more likely to have fertility issues.
Gudmundsdottir et al Hum Reprod 2009; 24(12): 3196-3204PREPARATION for PREGNANCY: EXERCISE
Exercise and PCOS
A Systematic review of 8 published studies
Moderate intensity physical activity for 12-24 weeks
Findings during study period:
Improved rate of ovulation ( 3 of 5 studies)
Reduction in insulin resistance
Weight loss of 4.5-10%
Harrison et al Hum Reprod Update 2010; 17(2): 171-83PREPARATION for PREGNANCY: EXERCISE
Exercise and IVF:
Women who exercise >4 hours/ week for prior 1-9 years:
40% less likely to have a live birth
3 times more likely to have cycle cancellation
Twice as likely to have an implantation failure
An active lifestyle in the year before preceding an IVF
cycle was associated with a higher odds of
implantation and clinical intrauterine pregnancy.
Morris et al Obstet Gynecol 2006; 108 (4): 938-45
Everson et al Fert Steril 2014; 101(4): 1047-54PREPARATION for PREGNANCY: EXERCISE
There currently is no consensus on exercise and it’s
impact on male fertility.
The authors performed a systematic review of exercise
in men.
Regular, less demanding physical exercise does not
seem to alter male reproductive function.
High-load training may exert a negative impact.
Results are mixed in cyclists.
Plessis et al Open Reproductive Science Journal 2001; 3: 105-13PREPARATION for PREGNANCY: EXERCISE
With exercise, may see in men:
Development of OS
Increased scrotal temperature
Testicular micro trauma
ED
Hormonal imbalances:
Reduction in total and free T
Alterations in LH pulses
Plessis et al Open Reproductive Science Journal 2001; 3: 105-13PREPARATION for PREGNANCY: EXERCISE
Physically active (PA) vs sedentary men
TV watching inversely associated with total sperm
concentration
> 20 hr/week were 44% lower
15 or more hours of moderate to vigorous exercise every week
were 73% higher than those who exercise very little
With PA:
Higher sperm density
Increased total progressively motile sperm
Improved sperm morphology
Higher FSH, LH and testosterone levels
Gaskins et al Br J Sports Med 2013;Published Online
Vaamonde er al Eur J Appl Physiol 2012; 112(9):3267-73PREPARATION for PREGNANCY: LIFESTYLE Stress Alcohol Tobacco Caffeine Recreational drugs Sleep Shift work
Lifestyle and Fertility
Lifestyle habits that have been associated with reduced fertility:
Women
Cigarette smoking
Low or high BMI (weight)
Vigorous exercise
Caffeine
Alcohol
Herbs
Men
Heat
EMR- cell phones/WiFi
High BMI (weight)
Vigorous exercise?
Alcohol
Anabolic steroids/supplements
Recreational drugs: esp. marijuanaLifestyle and IVF
Survey of 118 women at Boston IVF
Behavior Before During IVF
Exercise 92% 100%
Alcohol 73% 49%
Caffeine 76% 75%
Smoked 3% 2%
Acupuncture 30% 47%
Herbs 14% 12%
5 servings of fruit/vegs 51% 50%
Domar et al Fert Steril 2012; 97(3): 697-701Alcohol and Fertility
Alcohol and Fertility
The Centers for Disease Control and Prevention (CDC) reports:
52 percent of non-pregnant women of childbearing age (18 to 44 years
of age) reported alcohol use and 15 percent reported binge drinking.
7.6 percent of pregnant women used alcohol and 1.4 percent admitted
to binge drinking.
The highest prevalence of prenatal alcohol use:
Ages 35-44: 14.3%
College graduate: 10.0%
Employed: 9.6%
White: 8.3 %
Employed and unmarried pregnant women were two- to three-fold
more likely to report binge drinking than unemployed and married
pregnant women.
MMWR. Alcohol Use and Binge Drinking Among Women of Childbearing Age — United States, 2006–2010
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6128a4.htm?s_cid=mm6128a4_e (Accessed on July 29, 2014).Alcohol and Fertility
ASRM recommendations “higher levels of alcohol
consumption (>2 drinks per day) should be discouraged for
couples trying to conceive.
The opinion also states “ of course, alcohol consumption
should cease altogether during pregnancy because alcohol
has well- documented detrimental effects on fetal
development, and no ‘‘safe’’ level of alcohol consumption
has been established.
In men alcohol consumption has no adverse effect on
semen parameters.”
Optimizing Natural Fertility: a Committee Opinion Fert Steril 2013; 100(3): 631-37Alcohol and Sperm
A number of adverse effects on sperm have been reported.
The data is inconsistent. Observations include:
Decreased
Seminal volume
Sperm count and motility
Morphology
IVF pregnancy rates
Increase in sexual dysfunction
Sharma et al Reprod Bio Endocrinol 2013, 11:66 – online accessAlcohol and IVF
Prospective cohort study of 2545 couples with adjustment
for confounders
Alcohol use was assessed at the start of the IVF cycle
A negative effect of alcohol was seen for both partners:
Women that consumption of as few as 4 alcoholic drinks per
week had a 16% less odds of a live birth rate.
If the male partner also drank at least 4 alcoholic drinks per
week, there was a 21 less odds of a live birth rate.
Rossi et al Obstet Gynecol 2011; 117: 136-42Alcohol and IVF
In couples who had failed prior > 2 IVF attempts, women
who abstained from all alcohol had a 90% chance of
achieving a successful pregnancy within 3 years.
Women who drank an average of just 3 small glasses of
wine a week had a 30% chance of conceiving over the same
period.
Even women who drank just 1 or 2 glasses of wine a week
showed a reduction in their 3-year success rate to 66 %
The researchers believe that the same patterns were likely
to hold true for couples trying to conceive naturally.
Godfrey et al Fert Steril 2013; 100(3): S423Alcohol and Fertility
My take on Alcohol and Fertility
Alcohol may negatively influence both egg and sperm
development and function.
The greatest negative effects of alcohol are likely to be seen
in those who consume several drinks daily or with binge
drinking.
Given that egg and sperm maturation takes up to 3 months,
it is ideal to stop/reduce alcohol consumption for at least
three months before attempting pregnancy.
Once pregnant, there is no safe level of alcohol intake for
women.Lifestyle
Tobacco and Fertility
Cigarette smoking clearly has a negative impact on fertility.
Smoking may accelerate the loss of a woman’s reproductive
function and may advance the time of menopause by 1 to 4 years.
Women smokers as well as those exposed to second-hand smoke
have a lower implantation and live birth rates. They may require
nearly twice the number of IVF attempts to conceive as
compared to nonsmokers.
Sperm parameters and sperm function tests are 22% lower in
smokers than in nonsmokers and appear dose-dependent.
Smoking has not yet been conclusively shown to reduce male
fertility.
ASRM Practice Committee Fert Steril 2012; 9(6): 1400-1406Lifestyle
Tobacco and Pregnancy
No current evidence that vaporizers are “safer”
Smoking is associated with increased risks of both
spontaneous miscarriage and ectopic pregnancy.
Obstetrical complications include:
Low birth weight
Preterm labor/delivery
Placental abnormalities
Children at greater risk for SIDS, asthma
colic and childhood obesity.Lifestyle - Caffeine
Wow- lots of studies and no real consensus
Moderate daily consumption of 200 mg/ day (12 ounces of
coffee) has not been shown to reduce fertility or increase
miscarriage rates.
A 2012 Danish study reported consumption of five or more
cups of coffee a day reduced the clinical pregnancy rate by
50% and the live birth rate by 40%. In this study, the effect
of consuming >5 cups of coffee per day was comparable to
the detrimental effect of smoking.
Weng et al Am J Obstet Gynecol 2008;; 198: 271-79
Charravo et al Epidemiology 2009; 20(3):374-8
Kesmodel et al Hum Reprod 2012; 27(S2): O-202Lifestyle - Caffeine © 2014 March of Dimes Foundation
PREPARATION for PREGNANCY:
LIFESTYLE
Shift Work
In men, there is no clear evidence between a reduction
of fertility and working night and/or long shifts.
In women, at least 2 studies have reported adverse
outcomes. The most recent observed:
Reproductive findings of female night shift workers:
Increased menstrual disruption (13.4 - 40%)
Increase in early spontaneous pregnancy loss (OR 1.41)
With confounder adjustment, no increase in risk for infertility
Stocker et al Obstet Gynecol 2014; 124(1): 99-110PREPARATION for PREGNANCY:
LIFESTYLE
Sleep
There is currently little research looking at sleep and fertility. In
a 1998 study, Nurminen observed that women who work at night
are more likely to have trouble conceiving or to miscarry.
In a cross-sectional study of 953 Danish men, the men with the
highest level of sleep disturbance had a 29% reduction in sperm
concentration.
In 656 South Korean women prior to starting IVF treatment:
Pregnancy rates were highest (52.6%) among moderate-time
sleepers (7-8 hours).
Women who sleep 9-11 hours exhibited the lowest pregnancy rate at
42.9%.
Jensen et al Am J Epidemiol 2013; 177(10):1027–1037
Park et al Fert Steril 2013; 100(3): S466PREPARATION for PREGNANCY: Environment
It is important to identify potential toxins and
teratogens at home, school and work
Chemical Plastics
Solvents
Pesticides
Cleaning agents
Cosmetics
Biological Infectious disease
Hormones/Antibiotics
Toxoplasmosis
Radiation Occupational
Medical
Physical Heat
Secondary Smoke
PollutionPREPARATION for PREGNANCY: ENVIRONMENTAL
Avoid:
Potentially contaminated foods, esp. certain fish
Plastics, BPA, Phthalates
Toxins: pesticides, chemical exposure
Cat litter/feces
Heat esp. Men
EM energy: Wi-Fi, cell phones, computers, and electric
blanketsPREPARATION for PREGNANCY: ENVIRONMENTAL
RPL: Male Lifestyle and Sperm Quality
Patients with recurrent pregnancy loss (RPL)
Retrospective study of 68 couple vs. 63 in control group
Couples with RPL:
Significantly lower normal morphology and total progressive
motility
Increased chromatin damage
Lifestyle factors: Exposure to heavy metals, solvents and
pesticides ; unhealthy habits
Ruixue et al J Assist Reprod Genet 2013; 30(11): 1513-8
.PREPARATION for PREGNANCY: ENVIRONMENTAL
Pesticide Exposure and Human Sperm
Systematic review of 17 studies
15 studies showed significant associations between
pesticide exposure and and sperm quality
Strongest associations: reduced sperm count and motility
2 studies showed reduced morphology
.
Martenies & Perry Toxicology 2013; 307: 66-73BPA
Bisphenol A (BPA) is an endocrine disruptor with
estrogenic properties that can adversely affect meiotic
spindle assemblies.
The main sources of BPA are plastic containers (#7,
polycarbonate), epoxy resins (canned food linings) and
thermal receipts.
The major source of BPA is in our diet, including ingestion
of contaminated food and water.
.BPA and IVF
BPA was shown to have an inverse association to
total sperm count, sperm concentration. No affect
on embryo development was observed.
Bisphenol A has been associated with a reduced E2
response to stimulation during during IVF.
There has been observed a higher odds of
implantation failure in patients with the highest levels
of urinary BPA.
Reports have indicated an association between BPA
and reduced oocyte number, fertilization and embryo
development rates.
Fujgimoto et al Fert Steril 2011; 95 (5): 1816-19
Bloom et al Fert Steril 2011; 96 (3): 672-77
.
Erlich et al EnvirnHealth Prespect 2012; 120(7): 978-83
Erlich et al Hum Reprod 2102: 27(12): 3583-92BPA
BPA in men has been shown to:
Increase the risk of male sexual dysfunction.
Lower sperm count and motility by 2-4 fold.
The greater the amount of the BPA in the blood seems
to be inversely proportional to sperm quality.
Li et al J Androl 2010; 31: 500-6
Li et al Fert Steril 201; 95 (2): 625-30
.Conjugated bisphenol A in maternal serum in relation to
miscarriage risk
Retrospective cohort of prospectively collected serum samples.
115 women in the study, there were 47 live births and 68 clinical
miscarriages (46 aneuploid and 22 euploid). Median conjugated BPA
concentrations were higher in the women who had miscarriages than
in those who had live births (0.101 vs. 0.075 ng/mL).
Women with the highest quartile of conjugated BPA had an increased
relative risk of miscarriage (1.83; 95% CI, 1.14–2.96) compared with the
women in the lowest quartile. A similar increase risk for both euploid
and aneuploid miscarriages.
Maternal conjugated BPA was associated with a higher risk of
aneuploid and euploid miscarriage in this cohort. The impact of
reducing individual exposure on future pregnancy outcomes deserves
further study.
Lathi et al: Fert Steril 2014; 102 (1): 123-128Phthalates
Phthalates are a group of chemicals used to make plastics
more flexible and harder to break. They are used in
hundreds of products such as detergents, beauty products
and children's toys. Medical devices such as tubing, blood
bags and vinyl gloves contain phthalates.
They are often called plasticizers.
According to the CDC, people are also exposed to
phthalates by eating and drinking from containers
containing them.
.http://time.com/3393376/phthalates-linked-to-asthma/
Phthalates
Phthalates have been associated with:
A direct inhibitory effect on cells from the mature human
corpus
Phthalates are anti-androgens
Multiple phthalates associated with a significantly reduced T in
both sexes and differing age groups
Increased rates of sperm DNA damage
Lower sperm counts
Up to a 20% decline in fertility
Longer time to conception
Romani et al Fert Steril 2014; 103(3): 831-37
Duty et al Epidemiology 2003; 14: 269-77
Huang et al Fert Steril 2011; 96 (1): 90-4
Lewis et al Fert Steril 2014; 101(5): 1359-66
Meeker & Ferguson J Clin Endocrinol Metab 2014; doi: 10.1210/jc.2014-255Cell Phones and Sperm
There continues to be new information reported on the
potential impact of cell phones and male fertility. Here
is a brief update on what we now understand:
Cell phones emit non-ionizing radiation (electromagnetic
waves-EMW). This form of energy is different from ionizing
radiation such as X-rays and radioactive materials.
Electromagnetic waves may have both thermal and non-
thermal effects.
Not all cell phones have the same electromagnetic radiation
output. Even when a phone is on and not in use, it send outs
an intermittent signal to connect with nearby cell phone
towers.
.Cell Phones and Sperm
TAKE HOME POINTS
A direct association between male infertility and cell
phone exposure has not been proven.
Cell phone use and the effect(s) on human sperm
remain uncertain.
As a precaution, consider keeping the cell phone away
from the body. Utilize the speaker function and
consider texting to reduce exposure to EMW radiation.
http://www.ewg.org/cell-phone-radiation-damages-sperm-studies-find
.Laptop Computers
Laptop computers represent a source of both electromagnetic
energy exposure (Wi-Fi) as well as thermal energy (heat). There
is limited information on the effects on human sperm.
In a laboratory experiment (in vitro), human donor sperm
samples were exposed to 4 hours of a laptop computer connected
to Wi-Fi. A significant decrease was seen in progressive motility
and an increase in sperm DNA fragmentation (breaks in the
chromosomes) was observed. Whether or not these changes are
also seen in men (in vivo) has yet to be demonstrated.
The heat generated by laptop computers while held in the lap
can cause significant elevation (> 1º C) in scrotal temperature
within 15 minutes. 29 healthy men participated in two 1-hour
exposure sessions.
Avendano et al Fert Steril 2012; 97(1): 39-4
Sheynkin et al Hum Reprod 2005; 20(2): 452-455PREPARATION for PREGNANCY: ENVIRONMENTAL
TAKE HOME POINTS
Drink filtered water. Avoid plastic containers. Use stainless
steel or glass water bottles.
Avoid using products that contain BPA or phthalates.
Minimize the use of food products or storage in cans or
plastic containers.
Minimize the use of personal care products such as
moisturizers, cosmetics, shower gels and fragrances.
Avoid the use of garden, household or pet
pesticides/fungicides.
Chemicals such as lead and pesticides can be tracked
indoors on shoes, so it is always recommended to remove
your shoes before coming indoors.PREPARATION for PREGNANCY: ENVIRONMENTAL
References to consider
http://www.ewg.org
http://www.ewg.org/skindeep
http://prhe.ucsf.edu/prhe/index.html
http://www.seafoodwatch.org/cr/seafoodwatch.aspx
http://www.goodguide.comPREPARATION for PREGNANCY: CAM Acupuncture/TCM Mind-Body Meditation Journaling Reiki Yoga
PREPARATION for PREGNANCY: CAM
Mind-Body and Infertility
Patients who participated in either a cognitive behavioral
or support group exhibited higher pregnancy (55% & 54%)
compared to a control group (20%).
MB participation was associated with increased in
pregnancy rates, esp. those who had attended at least half
of their sessions. Pregnancy rates for IVF cycle 2 were 52%
for MB and 20% for control.
Infertile women who attended a MBPI showed a significant
decrease in depressive symptoms, internal and external
shame, entrapment, and defeat.
Domar et al Fert Steril 2000; 73(4) : 805-12
Domar et al Fert Steril 2011; 95(7) : 2269-73
Galhardo et al Fert Steril 2013: 100(4): 1059-67PREPARATION for PREGNANCY: CAM
Mind-Body and Infertility
When and why Do Subfertile couples Discontinue
Their Fertility Care?
Drop rates have been reported from 17-70%
1391 consecutive couples referred for specialty care
1/2 dropped out before any treatment
1/3 stopped after 1 IVF
Main reasons: Emotional distress
Poor prognosis
Brandeis et al Hum Reprod 2009; 24(12): 3127-35Preparing for Pregnancy Conclusions Plan Ahead! At least 3 -6 months, if possible. Encourage each individual to have a reproductive life plan. Complete health assessment and screening before pregnancy Proper management of chronic conditions Take Folic Acid
Preparing for Pregnancy Conclusions Maintain/obtain a normal BMI Weight loss if overweight before pregnancy If you smoke- STOP! Limit alcohol consumption - < 4/week Increase the daily intake of fruit, vegetables and whole grains A good Multi-Vitamin will provide additional antioxidants to the diet
Preparing for Pregnancy Conclusions Avoid environmental factors (high temperatures, electromagnetic radiation, pesticides and pollution), Moderate, regular exercise is OK Healthy Sleep Stress management Acupuncture and Yoga appear to add benefit
Preparing for Pregnancy
Professional Resources
www.beforeandbeyond.com
www.cdc.gov/preconception
womanshealth.gov/pregnancy/before-you-
get-pregnant/preconception-health.html
www.acog.org
www.marchofdimes.com/professionalAny Questions?
www.rscbayarea.com
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