Lifestyle Management Before Infertility Treatment
Peter Kovacs, MD, PhD
Peter Kovacs, MD
Clinical Reproductive Endocrinologist, Research and Scientific Coordinator, The Kaali Institute-IVF Center, Budapest, Hungary
It is well known that women who are under- or overweight have difficulty with reproduction. Obese women are at risk for miscarriage, gestational diabetes, gestational hypertension, preterm delivery, macrosomia, low birth weight, stillbirth, delivery via operative route, and postoperative complications. Underweight women are also at risk for miscarriage, low birth weight, preterm delivery, and stillbirth. Therefore, preconceptional counseling about weight and lifestyle management is very important.
During this counseling, one should evaluate the patient’s diet, frequency and intensity of exercise, toxic habits, and use of drugs that affect body weight. The best way to assess weight is to calculate the body mass index (BMI) using the following equation: weight (kg)/height2 (m2).
A BMI between 18.5 and 24.9 kg/m2 is considered normal. Women with a BMI < 18.5 kg/m2 are underweight, whereas women with a BMI > 25 kg/m2 are overweight, and those with a BMI > 30 kg/m2 are obese.
Underweight women should be screened for eating disorders and thyroid dysfunction. In some cases, it may be appropriate to work together with a nutritionist and a psychologist. Low body weight is associated with ovulatory dysfunction. Usually, minimal weight gain (3 to 5 kg) is sufficient to restore ovulation and to improve the outcome of a subsequent pregnancy.
Overweight women also need to undergo a throrough endocrinologic evaluation (thyroid function, Cushing’s syndrome, polycystic ovary syndrome [PCOS]). They should be screened for diabetes, lipid abnormalities, and hypertension and should be advised about a lower-calorie diet with approriate nutrients. Women with PCOS may benefit from a diet that is low in saturated fat and high in low-glycemic-index-carbohydrate. Besides adhering to a healthy diet, regular exercise is needed to burn excess calories and to help to maintain a lower weight. Daily moderate exercise for about 30 minutes is recommended. Very often ovarian activity is restored by losing 5% to 10% of weight, even without reaching the ideal range.
Drugs that improve insulin resistance also improve reproductive outcome among women with PCOS. They should not be used alone, however, but rather should be combined with a healthy diet and regular exercise.
Adequate folic acid intake is essential for reproductive-age women, as it can reduce the incidence of fetal neural tube defects and cardiac anomalies.
Weight control is very important for those women who enter an assisted reproductive technology (ART) program. Treatment outcome is clearly worse among obsese patients. Aside from the lower pregnancy rates and higher miscarriage rates and other obstetric complications, they are at higher risk during the entire process. Obesity can limit the accuracy of ultrasound monitoring. Obese patients are at higher risk during the procedures (eg, oocyte collection), especially when anesthesia is provided. Thin women are also at increased risk during ART; for example, ovarian hyperstimulation occurs more commonly among thin women.
Toxic habits not only adversely affect the developing fetus but also compromise gonad function. In men, smoking has been associated with lower sperm number and motility, and in women, smoking has toxic ovarian effects. Drug use may also affect gonadal activity by altering the stimulatory pathways of the central nervous system. Consumption of alcohol and caffeine adversely affects fertility, and their intake needs to be limited before attempting pregnancy.
Whether stress can cause infertility is a question commonly asked during pretreatment counseling. It is not easy to answer this question, as it is rather difficult to measure the degree of stress objectively. Although at least one small prospective longitudinal study has found no evidence that psychological stress influenced the outcome of in vitro fertilization (IVF) in women undergoing their first IVF treatment (the number of good-quality embryos transferred was the only variable that was independently associated with pregnancy), many experts believe stress can affect the outcome of infertility treatment. Infertility itself, with its family-related and social consequences, the evaluation and treatment (especially when repetitive), and the lack of success can have a major impact on a patient’s psychological well-being. Thoroughly explaining the steps and process of treatment and providing the patient with a plan if the first few attempts are not successful may reduce the psychological burden. It is also important to explain to the patient what she may reasonably expect. A patient with irrational expectations will have even greater difficulty accepting a treatment failure.
In summary, patients who lead a healthy lifestyle before initiating infertility treatment are optimizing the potential for a good outcome. Those who are not need to be encouraged and supported to alter their habits and counseled about the associated risks to which they and their fetus will be exposed. Finally, it is very important to have medical staff who are able to provide medical and psychological information and support during the course of infertility treatment.