The impact of lifestyle and diet on ART outcomes

There are factors that we call non-modifiable and modifiable. All modifiable factors concern lifestyle. Diet is one of the main factors that can have an impact. Then we have your weight or BMI that is related to obesity or being underweight. Another thing is exercise or physical activity, smoking, alcohol, but also caffeine. About caffeine, there is a lot of very contradictory information everywhere, on what should we do if we want to get pregnant—should we drink coffee or should we completely avoid it. So caffeine, alcohol, obviously drugs, and then stress. Another factor that I would like to specifically address is supplements or vitamins, it is another question that is often asked. I think it is important to discuss a bit on what’s the evidence that we have on using fertility supplements and try to boost our chances of having a successful outcome.

When it comes to smoking-the evidence is very clear for men and women. In the case of women, it is clear that smoking can reduce the ovarian reserve, it can have what we call a mutagenic effect on oocytes and it can increase the risk of having an ectopic pregnancy. It’s also linked to a higher risk of miscarriage. We’ve seen that patients who smoke can even have menopause up to four years earlier than patients who don’t. It is also related to having a less successful outcome on the pregnancy that goes well. It also can cause a higher risk of miscarriages and lower response when we are doing an IVF treatment. Usually, there are fewer oocytes collected in total and fewer mature oocytes and the likelihood of having a successful outcome out of the IVF cycle is lower. In patients who are doing the egg donation treatment, we’ve also seen that the likelihood of implementation is lower. Smoking also has a negative effect on sperm quality because it increases what we call the oxidative stress in the body which can increase the sperm DNA fragmentation also, alter some parameters of the quality of the sperm related to motility and morphology and sometimes concentration but especially the morphology.

About alcohol, the evidence is not that clear when we are looking for pregnancy. It is clear, and I am very sure with my advice on that -once you are expecting — you should avoid alcohol. There is zero tolerance when it comes to drinking alcohol once you are pregnant because we have clear information about the negative effect it can have on the baby once you’re pregnant. When we are speaking about seeking pregnancy, the evidence is not that conclusive both for male and female. In general, women have less tolerance to alcohol. Most of the guidelines f.e., NICE (The National Institute for Health and Care Excellence), used in the UK, or the American Society of Reproductive Medicine — all recommend not to drink more than one unit of alcohol a day for women. Men should not drink more than two units a day. To clarify what a unit is because sometimes there are patients who are a bit confused about it. F. e., one glass of wine could be two units of alcohol, but also one beer could be two units. My advice and I’m not saying that you should avoid alcohol completely while you’re doing a fertility treatment or while you’re seeking the pregnancy naturally, but I would not promote getting drunk or anything like that. I wouldn’t recommend drinking daily, but if on a Saturday night you go out for dinner, and you fancy a glass of wine, it’s not a problem. There is not enough evidence that both men and women should completely stop drinking alcohol. About coffee, there have been lots of data and old articles and papers, saying that women who drink coffee have a high risk of miscarriage, or it’s going to be more difficult to achieve pregnancy, or you completely should stop drinking coffee. Very recently, late last year there were a couple of studies published in the Fertility and Sterility which has lots of reviews or papers that we use., They studied the Scandinavian population — who are probably drinking the most coffee in the world. Those studies were done on the patients undergoing IVF, and they were drinking up to 4 cups of coffee a day. They did not show any difference in terms of success rates or miscarriage rates in patients who were drinking coffee or not. So far this is one of the best evidence that we have in terms of study that it went on with a lot of patients etc. So in that sense as well my advice would be: If you love coffee and you fancy coffee it is not necessary that you completely abstain from coffee while you’re looking for pregnancy. I would not encourage anyone to drink more than one or two coffees today, but it’s not necessary to completely avoid it.

We have growing evidence about stress and its impact on the likelihood of having a successful outcome with fertility treatments. In general, both IVF and egg donation. The thing is that the data that we have is very heterogeneous because it’s hard to quantify the stress or have a single way to measure it. We have several studies, but in most of them, the stress is measured in this one piece. We’ve seen the patients were more stressed when we are collecting the eggs, and we’re going to see a bit less fertilization rate, we can see in general that the effects of stress are negative. How big that impact is — it’s not clear. What we can say at the moment is that we should try to do our best to have our stress under control as much as possible. How can we manage it better? From my experience: things that are working well for a lot of my patients is meditation, there are some apps that you can find like calm or headspace, or even other ones that are short meditations, and should be easy to use. Now in these times that we found ourselves in (COVID-19), most of us have a little more time, and that would probably be a good moment to try to start it. This is going to have lots of benefits for you, not only for fertility but for managing stress in general, in your life. There are some sports like yoga that help a lot of my patients as well to manage stress, but for each person, it might be something different. Someone wants to play soccer, and that’s the way that they get rid of stress, some others prefer doing physical activity or some exercise that is something that can help for sure as well. A lot of my patients also found acupuncture very helpful to manage stress. I would always try to make room for more natural things to handle it. Try to avoid taking any medication. It would be okay if you were drinking herbal teas or induced more natural ways, but I would probably recommend trying to avoid any medication for that if possible.

Generally, when we speak about physical activity there are some specific aspects of the physical activity that you have to consider. When we say physical activity, that doesn’t necessarily mean working out or doing exercises at the gym. We also speak about how active you are in your life because there are people who, f. e. are super active, and they don’t go to the gym. They walk a lot throughout the day, or they have jobs that are physically very demanding, etc. When we’re speaking about exercising we should take into consideration not only the intensity of the exercise which is very important but also the frequency and the length of time in which we’re doing that exercise. Being physically active will have a positive effect on your overall health and, also on your chances of success. The idea is that if we have a sedentary work like most of us have, and work for eight hours or ten at the office, we should do at least 30 minutes of physical activity a day of moderate-intensity, which will be like a short walk or doing a gym class, things that are not super demanding. Also swimming or going for a jog. And if not, we should do a physical exercise that is of more intense activity that lasts at least an hour or so three times a week. That way it’s going to help us to maintain our weight, also that way we can avoid becoming insulin-resistant. When we are obese, we are more prone to have diabetes or to have high blood pressure and so, it’s going to have a beneficial effect on our likelihood of having a successful outcome with our fertility treatment. The idea is to try to be physically active. On the other hand, some people work out a lot, and I’m speaking about people who are doing more like high-intensity training most of the days of their lives, or they are super fit. This also can have a negative effect, especially for example for women who have a low percentage of fat in their body the percentage of fat. They can even lose their periods because of that, and that also have a negative effect on the likelihood of success and, so the moderation, in that case, is the key and the intensity of the exercise is something to reconsider. If you’re not working out at all, I think it is important that at least you’ll try to be active, as I was saying — go for a walk if you have a dog that is the perfect opportunity to go out. And if not, try to look for something that you will enjoy and so that it will help you to cope with stress. If you’re doing something that you like and it involves a bit of movement that will be fantastic. If, that becomes a habit in your daily life — even better.

We have some data that the patients who are overweight or obese are more likely to have a more erratic response to the stimulation when we’re doing a cycle of IVF with their own eggs. This means that many times they need more medications, and we may collect fewer eggs the egg collection is going to be more difficult. It has also been linked to a higher risk of having a miscarriage and to have some more difficulties or a likelihood of complications along with the pregnancy. Being overweight or obese is also related to lower levels of testosterone a lot of times and with poorer sperm quality.

Generally, when we speak about physical activity there are some specific aspects of the physical activity that you have to consider. When we say physical activity that doesn’t necessarily mean working out and that doesn’t necessarily mean doing exercises at the gym. We also speak about how active you are in your life because there are people who for example are super active, and they don’t go to the gym. They walk a lot throughout the day, or they have jobs that are physically very demanding, etc. When we’re speaking about exercising we should take into consideration not only the intensity of the exercise which is very important but also the frequency and the length of time in which we’re doing that exercise. Being physically active will have a positive effect on your overall health and also on your chances of success, the idea is that if we have a sedentary work like most of us have, and we work for eight hours or ten, and we are at the office, we should do at least 30 minutes of physical activity a day of moderate-intensity, which will be like a short walk or doing a gym class, things that are not super demanding. Also swimming or going for a jog. And if not, we should do a physical exercise that is of more intense activity that lasts at least an hour or so three times a week. That way it’s going to help us to maintain our weight. That’s going to also help us to avoid becoming insulin-resistant, we are more prone to have diabetes or to have high blood pressure and also it’s going to have a beneficial effect on our likelihood of having a successful outcome with our fertility treatment. The idea is to try to be physically active. On the other hand, some people work out a lot and I’m speaking about people who are doing more like high-intensity training most of the days of their lives, or they are super fit. This also can have a negative effect, especially for example for women who have a low percentage of fat in their body the percentage of fat. They can even lose their periods because of that and that also have a negative effect on the likelihood of success and so the moderation, in that case, is the key and the intensity of the exercise is something to reconsider. If you’re not working out at all, I think it is important that at least you’d try to be active, as I was saying — go for a walk if you have a dog that is the perfect opportunity to go out. And if not, try to look for something that you will enjoy and so that it will help you to cope with stress. If you’re doing something that you like and it involves a bit of movement that will be fantastic. If that becomes a habit in your daily life — even better.

Should I take supplements? And my partner? In that case, what supplements would you recommend? You have to know, there are millions of supplements out in the market, and it can be very confusing and very tricky to know which ones you should be taking. All of them claim to be like a fantastic solution for your fertility problems. In general terms, most of the data that we have both for men and women say that there is no clear evidence about supplements being something that we should be taking to improve our chances of having a positive outcome, besides the folic acid. We have to make sure that you take it to avoid an increased risk of having neural tube defects. I think that it’s also important to check that you don’t have any deficiency in any specific vitamin. If that’s the case, I think that it should be covered f.e. vitamin D deficiency is something very prevalent because, even though I’m Spanish, and it’s usually very sunny here, I spend most of my days working, so I’m deficient in vitamin D as well, so we won’t get that vitamin from the sun which is the main way to transform the vitamin actively. We should look if we have any specific deficiency, besides the folic acid or any other vitamin deficiency you might have, there is no evidence about the rest of the supplements. About antioxidants for male — Cochrane review indeed said that in patients who have alterations in the sperm in motility and the morphology or the concentration taking antioxidants might be helpful and in some cases might even help to increase the likelihood of having a baby. The problem is that if you ask me, which supplement increases that likelihood of having a baby — we don’t know because most of the studies have been done with combinations of different antioxidants. So we don’t know what is the exact formula. What I can tell you is that most of them have very similar products in it. So the main ones which for example for a male would be using zinc, selenium, vitamin E, vitamin C, and all those are going to be in most of the preparations. Patients, who already done one or two IVF cycles that did not go well and their age is a problem as well, and they found themselves in that situation of maybe doing their last IVF IVF, or possibly they’re moving towards egg donation, when they come for the consultation, they ask what supplements I should be taking. Should I take CoQ10 or melatonin, what is the evidence on taking those? CoQ10 is an antioxidant that was mainly used for cardiac disease, and it showed very good results for cardiac disease and all things related. Coq10 is an antioxidant, so I don’t think that is going to do any harm at all if you take it, but the evidence that we have about the impact it can have on egg quality is very small. There are not so many studies on this that have been published. Only a small number of patients were included in them, and the results are not that conclusive. So what I would say is, it could be helpful, but we don’t have enough evidence to support giving that supplement to all patients. If you can afford it and you want to take it when you’re about to do the last cycle of IVF, or when you are concerned about the egg quality, you can take it. And always, if you take it, it’s better to take it in the form of ubiquinol as you can absorb it better. With melatonin, the situation is pretty much the same, in terms of evidence. Melatonin is one of the hormones that we produce naturally, and it helps us sleep well. There have been some studies issued as well on it and that it can be something which can help with egg quality, but it’s not that clear. I can say the same, if you can afford it and want to take it — you can do it. But keep in mind, the evidence doesn’t say, it should be recommended generally.

First, I think that if you’re smoking, you should quit not only for fertility but for your general health. In terms of alcohol and coffee, once you are not yet pregnant, you can drink both in moderation, so maybe one glass of wine when you go out for dinner during a weekend or something like this, and with the coffee, you can drink 1 or 2 cups a day without a problem. In terms of BMI, you should try to keep your BMI within the normal range, so not too low nor too high. It should be between 20 and 25. Being physically active and doing some exercise that is something that is going to be beneficial for your fertility as well. We would recommend that you do at least 30 minutes of moderate physical activity daily and if not, more intense activities at least three times a week. Try to look for mechanisms that help you cope with stress. Not only stress-related to fertility but also the stress related to your daily life, that is something important as well. Meditation, yoga, acupuncture, all the things that can help you with that. As I was saying before, everyone has their hobbies or their ways to cope with stress, and whatever works for you, it’s going to be fine. And then in terms of diet, you should avoid eating anything that is processed, anything that has a high percentage of sugars, refined sugars or carbohydrates, all those fizzy drinks, fatty foods, trans fats as well. Try to have a diet that is mainly based on fresh products. If possible, make sure the vegetables and fruits are organic. Make sure that you have a well-balanced diet of high-quality protein, free of any antibiotics or growth hormone. A good source of healthy fats and lots of fruits and veggies, as I explained it will help you better than taking multivitamins. Check that your protein intake is sufficient. As for supplements: folic acid for sure for everyone that is seeking for pregnancy. Check your vitamin D levels. If you’re vegan or vegetarian, look for your B12, which is probably going to be lower.

The confusion comes from the fact that nowadays a lot of the fish that we have is very contaminated, and we are mostly concerned about the very high concentrations of mercury that we can find especially in the big oily fish like tuna, shark, swordfish, etc. In terms of white fish — I think that white fish that it’s of high quality and it’s wild if possible, they will have a very good source of protein and usually they are very low in fats. I would also try to look for something that is not very salty. For example, cod as it’s preserved in salt so it can be very salty and I would try to avoid that. But if it’s a fresh one, you can have it. I would also avoid all these kinds of fish that are considered low quality, the ones that we know are in the lowest part of the food chain, and they might be eating things that might be contaminating both the sea and the water for example — tilapia. And in terms of oily fish, what I would say is that for sure I would avoid eating any of the fishes that we know have a very high concentration of mercury or at least control the consumption of such fish like tuna. It’s not that you can’t get it if you love tuna or sushi, you can have it for example once a month but I would probably avoid it. It’s better to try to eat oily fish that are small because the smaller ones will not have that much mercury, like sardines or mackerel. And I’d say that you can eat oily fish around twice a week and white fish — one to three times a week. Also, salmon is a good source of oily fish. I would probably look for wild salmon because most of the salmon that we can now find in the supermarkets are from farms. Such salmon is not the same as the wild one. It has more fat, nutritionally speaking it is not as good as the wild ones.

I know that ubiquinol (coQ10) is expensive. We don’t have that much evidence to support that its general use is to improve egg quality. Some studies have reported that egg quality can be a bit better. Four hundred (400) milligrams per day would be a good dose that is more easily absorbed. But is it worth it? I wish I had the certainty to give you a clear response on that, but I don’t have the evidence to support this. So what I would say is that, if you’re going for one of your last attempts of IVF with own eggs and you can afford it, and you have already taken it — I would continue. The last thing that I want or that you need is, that if for whatever reason the cycle does not work — you’ll keep on asking yourself if you didn’t stop taking it, if that had made the difference, which I don’t think so, honestly.

The evidence is limited when it comes to confirming the benefits of supplements like CoQ10. It is an antioxidant, so I don’t think that it’s going to do any harm. But in terms of that, I always think that having a super healthy lifestyle and diet and trying to follow all those recommendations that I gave you in general for your lifestyle, this is going to be much more beneficial than if you take the CoQ10 for example, and you keep on smoking one box of cigarettes a day.

It is best to try to stay away from any endocrine disruptors that are those contaminants that we can find all over the place. It can have some endocrine function, and that can also jeopardize our likelihood of having a successful outcome with the fertility treatment. If you try to stay away from BP Plastics and toxins as much as possible, it’s going to have a positive effect on your general health and will not cause any diseases that are derived from this. There are already some studies on BPA related to endometriosis, not specifically on the impact on the IVF but I will need to have a look at this. But you should know there’s a lot of things that are contaminated and it’s almost impossible to stay away from them. If consciously whenever you go to the shop, and you are already buying things that are BPA-free, and you’re trying to avoid toxins as much as possible — it is going to be beneficial.

I haven’t mentioned that, so thank you for this question. Keeping hydrated is very important. It can be pretty hard for a lot of people. In general, one of the things that are helpful for a lot of patients or that I’ve seen is that whenever you go to work, or you work out — try to take a bottle of water with you. Try to have at least 1.5 -2 litres of water a day. If not only water then it can be f. e. herbal tea or other kinds of fluid that are not sugary. I don’t think, that is going to affect your fertility or implantation with egg donation. I think it has more to do with the fact that you are sufficiently hydrated.

There is no direct link that sugar can affect egg quality. When we speak about sugar, in general terms, it’s something that we can easily find in a lot of food that we eat. We are consuming between 5 and 10 times more sugar than it is recommended. I am talking about the diet we have here in Europe and the developed countries. So this can lead you to have obesity or weight problems or to have diabetes or insulin resistance. And those are directly linked with fertility problems. In the sense of insulin resistance f. e., and patients who have PCOS, they don’t have periods, and they have poor egg quality sometimes because of that. If, you have a very high intake of sugar every day that can also lead to obesity because the intake of calories is going to be much higher and that again can impact the likelihood of achieving a healthy pregnancy.

It’s not a problem at all. There’s very contradictory information about milk. I found studies supporting milk and stating that it improves fertility and other studies say we should avoid it. All the data, that we gathered from all those studies are not conclusive. So if you love milk, and you don’t feel well when you stop drinking milk, it’s completely okay to drink one cup of milk a day. Just make sure that you look for a good source of milk, that is organic and of good quality, and that’s it.

With DHEA, the evidence is not that clear. It can be considered, for patients who are low responders, or who don’t respond well to the medication. It is best to discuss it with your fertility doctor. The evidence is not that clear as it is f.e. with testosterone, both treatments have to be assessed by your doctor. Before taking DHEA, it is necessary to make sure that the liver function is perfectly okay because sometimes a DHEA can alter the liver function, so it needs to be monitored, before taking it.

I think that the most important thing is to try to get all those antioxidants from the right diet. If you have a rich diet, that includes lots of fruits and fresh vegetables etc., I don’t think that it is necessary to take all those antioxidants. Whether they’re going to help you— it’s not determined. So besides the folic acid, vitamin D, and in the cases that you have specific deficiencies, as some patients might have an iron deficiency — I always recommend them to take iron. And any vegan patients also have to take B12 because there are no good sources of it in the diet that they have.

When you say benefit, you’re asking me if I think that the response from the ovaries is going to be better, or if I think that it’s going to help you to be more relaxed and to have more likelihood of implementation. So far, what I can tell you, the evidence proved scientifically with having a lot of acupuncture for the treatment is not clear. I can tell you that most of the patients that have used it are very happy with acupuncture and most of them were more relaxed. They found it useful during the treatment, and it also helps them to cope with the stress. So maybe sometimes it might help a bit to have a better response, but I’m not sure about that.

You do need to eat healthy anyway because there is a lot of papers issued in the New England Journal of Medicine last year, on how important is, everything that what we do in our lifestyle before conception. All your habits in the previous six months, before you get pregnant are crucial and are going to determine a lot of things about the health of your future baby. So even if there is a month in between, I would very strongly recommend you to be as healthy as possible.

On the same day of the embryo transfer, of course not, and usually we recommend not to submerge in water in the next three-four days after the embryo transfer. It is to avoid any risk of infections. So if you wait for a few days or so, that should be fine.

Usually, if hypothyroidism is well under control, that should not be a cause of miscarriage. Hypothyroidism is linked with a higher likelihood of miscarriage when it is not under control, and you’re not taking the medication. If you do — it should be fine.

Yes, BMI also impacts achieving a pregnancy with egg donation. It is a fact, and there is a risk not only of complications with the pregnancy but also the risk of miscarriage is higher if we have a very high BMI.

I wish I had a magic answer to that question. There’s very little or almost nothing that you can do when egg quality is poor. You can try to be as healthy as possible, do all those things that I’ve explained on a good lifestyle and diet but at the end of the day, there are some factors that unfortunately we cannot control, and we have to cope with them which are: age and egg quality. Even though I have super healthy patients, and they eat healthily, and they feel fantastic, but they are 46. So if you’re 46, and even if you are taking good care of yourself, your egg quality is not going to be good enough probably to give you pregnancy with your eggs. It comes to a point where we cannot change some things.

It depends on what kind of weight lifting, you mean. If you’re only lifting small weights, I don’t think that should be a problem. If you are talking about some heavy lifting, I would not recommend doing it now. In the first trimester, I wouldn’t do any high-intensity training as this time is very delicate.

If you were taking the drugs that we give you for IVF for years, that could lead in some specific case to a higher risk of cancer. But when we’re doing an IVF cycle, we give you that medication for stimulation for two weeks, in that sense there are no alternatives to stimulate the ovaries or to do the IVF preparation. We have the drugs that we use for each specific treatment. If we’re talking about embryo transfer, and we perform the egg donation treatment, there is a possibility of doing a natural cycle if you have regular cycles. But if you already had the menopause or you already stopped having periods— it is not possible. There are no alternatives to stimulate the ovaries for IVF. You need to keep in mind that if the risk of cancer has been high, we would not be doing these treatments.

I guess when you are saying colitis — you mean ulcerative colitis intestine disease. It is an autoimmune disease, so it can have an impact on the reproductive outcome, depending on the moment in which you had a flare of the colitis while you were doing the treatment or not. The fact that your uterus is retroverted, it is not related to infertility. A retroverted uterus is a way to describe the position of your uterus. There are two types of the uterus, an anteverted, so standard position, or retroverted one which is considered a variant of normality. But colitis as it is an autoimmune disease, it could have some impact, that is the fact.

Thanks for the question. It’s an interesting topic that you’re bringing here about folate rather than folic acid. Patients who have alterations on the metabolism of the folic acid, so patients with a genetic condition of alterations in the Methylenetetrahydrofolate reductas (MT HFR) will absorb the folate better rather than the folic acid. So, if you don’t have any problem like this, you can take a regular folic acid, but if you have any issues with the absorption, you should take folate. My opinion on organic cold-pressed flaxseed oil for both egg donors and surrogates, well, as far as I know, there is no specific evidence on it. If you have a very healthy diet and you’re making sure to take good quality fats etc. — it is not necessary.

We have to consider two things. The positive thing is that you are 33, so you are still quite young. That means that hopefully and most likely, the quality of your eggs is going to be good. AMH is one of the tools that we can use to calculate your ovarian reserve, but it is not the only information. We also use what we call the antral follicle count (AFC), and it is the information we get when we do a transvaginal scan. We count how many eggs we see in the ovaries. In this case, I don’t have such information, and we need to assess it all together. The fact that you have a low number of eggs doesn’t mean it’s going to be a problem, but it needs to be checked, and you need to reconsider if you were seeking for a pregnancy for a long time already and if so, if you considered a treatment, but also if you’d like to have one child or more. Whether you have a partner and if you know the quality of his sperm and then check all options available. The quality and quantity of your eggs will decline with time, and it is hard to say, how quickly that is going to happen. I think that it is good that you have the information, and that means that you have the tools to start moving things and do whatever it takes to start the treatment.

You should follow the general advice that I gave you on the diet, so fresh fruit and vegetables, and try to make sure that the number of calories is according to what you need and that your BMI is in control. And that you have a good source of good fats and protein as well.