WHAT IS THE ‘IMPLANTATION WINDOW’ IN FERTILITY TREATMENT AND HOW TO IMPROVE IT?
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Lifestyle and fertility

Andreia Trigo, RN BSc MSc
Founder of Enhanced Fertility Programme, Enhanced Fertility Programme

Category:
Emotions and Support

Lifestyle and fertility - ivfwebinars
From this video you will find out:
  • modifiable risk factors: health, lifestyle, habits and environment
  • folic acid as a crucial nutrient when trying to conceive
  • the role of physical activity on your fertility
  • radiation – risks
  • scrotal/testicular heat
  • cadmium (toxic heavy metal) – how to avoid it?

 

 

How does your lifestyle affect your fertility?

In this webinar, Andreia Trigo, RN, the Founder of the Enhanced Fertility Programme, explains the relationship between data-based lifestyle habits and fertility.

As regards the quality of the evidence pyramid shown on the first slide, Andreia explains that all studies that will be developed throughout the session are based on meta-analysis and systematic review classification. That is to say, the conclusions formed based on these studies’ reviews are of a high quality and reliable nature, whereas articles and pieces of information from unreliable sources are discouraged to take seriously according to the lower classifications of the pyramid.

Modifiable risk factors

According to Andreia, there is good-quality evidence that the following factors including health, lifestyle, environment, and habits are important to consider. According to Andreia, there are at least 22 modifiable factors, however, during her presentation, she focused on 5 most important ones which include:

Folic Acid

It can also be found as folate or B9. It is known to be an essential nutrient that is required for the DNA to replicate itself, as the necessity of women and the baby of folate increases a lot during pregnancy due to fetal development and growth. Furthermore, it is also known that the increase occurs during early pregnancy stages, which can cause abnormalities or anaemia if a shortage of folate is not enough in the system. It is one of the 13 essential vitamins. It cannot be synthesized by the body and is obtained from a diet that includes green vegetables, spinach, legumes, citrus fruits, and supplements.

It is recommended that women of reproductive age who could become pregnant consume at least 400 micrograms of folate every day.

Physical activity

As regards physical activity, a differentiation is needed for the terms of physical activity, exercise, and sedentary behaviour.

Physical activity is defined as any body movement produced by skeletal muscles that requires energy expenditure. However, exercise is a type of physical activity that is planned, repetitive, and structured to maintain or improve one component of physical fitness. In addition, sedentary behaviour tendencies should be reconsidered as they comprise time spent in periods of little or no movement while awake. A minimum of one hour of exercise three times a week improved rates of implantation and pregnancy and reduced the risk of miscarriage in 436 women undergoing ICSI.

Depending on the intensity of physical activity, a series of benefits were associated with the duration of it. For instance, vigorous and moderate exercise is associated with a reduced risk of miscarriage and an increase in the chance of having a baby in women who undergo ART. In the same way, even low to moderate exercise is also associated with increased implantation rates in women undergoing assisted reproduction techniques.

Things to try:

  • Yoga
  • Dancing
  • Leisure bike riding
  • Aerobics
  • Jogging
  • Swimming
  • 30 minutes walks

Things to avoid:

  • Hot Yoga
  • Boot-camp training
  • Extreme running
  • Any type of vigorous or strenuous training

Radiation

Radiation is said to be all around, and it can be of numerous types and sources. It can be present in our daily lives through exposure to devices such as mobile phones, televisions, and computers and can also be found in medical interventions such as diagnostic imaging, radiology procedures, and anticancer therapy. Therefore, it is important to make a distinction between the different types of radiation as these will have different impacts by the time of conception.

Ionizing: It is commonly the one most associated with affecting fertility and is defined as high-energy radiation that knocks electrons off the electron shell, leaving the atoms with a net positive charge. Biologically, it is known that the consequence of this electron strip is either direct or indirect damage to the cell’s DNA, as there might be some damage. This is the reason why the preservation of eggs is suggested in patients undergoing cancer treatment.

Non-ionizing radiation: In contrast to the former type, this type is not so widely known. It is acknowledged as an electromagnetic field that does not have enough energy to release electrons, although the ability to excite the movement of an electron to a higher state. It is divided into two categories:

  • Extremely low frequency
  • Radiofrequency (RF)

It is also known to induce oxidative stress with an increased level of reactive oxygen species, besides increasing the risk of miscarriage and reducing progressive motile sperm count. The impact depends on the exposure and distance of the source.

What can you do?

  • Reduction of exposure to no ionized radiation from sources of computers, and mobile phones, as well as exposure to ionized radiation by all means.
  • Considering antioxidants to minimize the impact of non-ionized radiation.
  • It is also suggested to consider fertility preservation in case of ionized radiotherapy in high doses is required.

Exposure to scrotal/testicular heat

The process of spermatogenesis implies the creation and growth of sperm, and it is also known for being temperature-dependent because a slightly lower temperature of the testicles is required compared to that of the body. A detrimental effect is evident when the raised testicle temperature increases, thus affecting spermatogenesis and the resulting spermatozoa. However, the modification of lifestyle, behaviour, and occupation habits is achievable and can be both altered or avoided with conscious effort.

Causes of scrotal/testicular heat:

  • Clothing and posture
  • Hot baths and Sauna
  • Laptop use
  • Radiant heat
  • Cycling
  • Cryptorchidism
  • Varicocele

What can you do to prevent it?

As formerly explained, there is indeed an association between elevated scrotal temperature and semen quality. Therefore, minimizing scrotal heat exposure as much as possible will be effective because the effects of heat are reversible after one spermatic cycle (74 days) in ejaculated sperm.

Exposure to Cadmium

Firstly, Cadmium (Cd) is a non-essential toxic heavy metal that has no beneficial role concerning the human body. In terms of environmental aspects, it is mainly used in industrial activities such as the manufacture of nickel-cadmium batteries and electroplating and so forth. It is known that it pollutes the water and air in the environment.

As regards absorption, it was proved that it can be absorbed through the gastrointestinal, respiratory, and dermal systems. Furthermore, smoking is regarded as the major source of inhaled cadmium intoxication. Thus, a daily dose of cadmium is absorbed, while non-smokers are said to have an intake through the consumption of contaminated water and food. Speaking of the consequences, on the one hand, women’s fertility is said to be affected as well as fecundity via the alteration of reproductive hormones and inflammatory pathways whereas sperm mobility and deterioration of spermatogenesis are afflicted in the case of men.

The preference for organic food and avoidance of smoking are suggested to reduce exposure to cadmium.

- Questions and Answers

I have asked my donor to take prenatal vitamins, organic cold-pressed flaxseed oil, folic acid 800 mg, vitamin D 1,000 mg and probiotics over 50 billion and over 30 multi strains. What is the quantity of each she should take? Iodine, apparently, is very important. What should that quantity be?

That’s a very interesting question because one of the modifiable factors that we talked about today. We can probably do another webinar just on supplements because there are so many and the conditions that each woman or men has that affect their fertility. Some supplements might be better than others and some might be more recommended than others but I can tell you that when it comes to folic acid, the recommended dose is 400. It’s 400 micrograms; not sure if you are confusing milligrams with micrograms but 400 micrograms is the recommended dose. Some people will need a higher dose than that. These are cases, for example, when the baby’s biological father has a neural tube defect and this has to do with a deformity in the spine, if the woman has already had a pregnancy with a neural tube defect or if there is a history in the family of neural tube defects, if the woman has diabetes or if the woman is taking medicines for epilepsy, if any of these conditions are met, she needs to take a higher dose of folic acid which is five milligrams which is so much higher than the recommended dose to the general population. But, again, if she doesn’t have any of this history then she needs to take just the recommend 400 micrograms. It’s really important that she doesn’t take more than what she needs because like I said a lot of people are not able to break down the folic acid into the form that your body can use. If you’re taking too much, it can be accumulated in your system and you don’t want to do that. Vitamin D I can tell you that it’s really important as well. Most people take 1,000 milligrams and that is the correct dose so you can take that. Some countries recommend higher doses than others so there isn’t quite a consensus but I would say that is an average dose for vitamin D and that’s correct. In terms of probiotics, I haven’t found a lot of evidence in terms of trying to conceive. I was just reading about it today but I haven’t found much evidence. I found some evidence for women who are already pregnant, in terms of improving the vaginal bacteria but not in terms of trying to conceive. If you look, for example, at a multivitamin which is a tablet that has already all of these, for example, prenatal vitamins, will already have all of this so you don’t need to buy separate tablets – that’s a possible solution to find the right doses.

What should my surrogate take in terms of vitamins, folic acid, vitamin D, probiotics, etc.? I think flaxseed oil is not good at a certain point in pregnancy. When is that point?

I think I’ve answered the question in terms of the doses of folic acid, vitamin B, probiotics. I haven’t found evidence to say that it’s useful. Flaxseed oil, again, I haven’t found any high-quality evidence but again it’s something that I can look into and I haven’t found anything so far.

How soon should both the egg donor and the surrogate start taking those supplements?

The person who is donating the egg needs to start taking it before they have the egg collection. We know that eggs and sperm take around three months to mature and become good quality so just if you take it around three months before the retrieval that would be good. In terms of surrogates, the surrogate needs to start taking the folic acid and the vitamin D as well ahead of time, I would say at least a month because she needs to have that good level of folic acid in her system so that when the embryo is transferred and starts developing and the placenta starts developing, she has enough resources of folic acid for herself and for the embryo. It needs to be ahead of time.

I’m a little confused on vitamin D. Do you mean 1,000 iu which is actually 25 micrograms. This is what we take daily or should I be taking higher doses?

That’s a good question. In the UK if you buy supplements, you will have 10 micrograms, if you buy them in Europe, you will have 25 micrograms. If you are living in the UK, you will only be able to find 10 micrograms, if you are buying them online, you will have 25 micrograms. But there is no consistency in terms of universal recommendations on how much vitamin D is required. But again this is a separate modifiable factor that I can talk about. I didn’t talk about it today but it will depend as well on how much sun you are getting. We produce a lot of vitamin D if we are spending some time outside, for example, 10-15 minutes at lunch time going outside with your arms showing just to make sure you are getting the sunlight. Countries that have less sun should take more but again in the UK the recommended dose is 10 micrograms, 10 mcg, and in Europe, there’s a lot of countries recommended 25.

I have darker skin. Should I take a higher dose of vitamin D? I live in the UK so not so much exposure to sun.

That’s a good question. Vitamin D – it’s something that we haven’t talked about today. In the UK, the recommended thing for everyone even for people who are not trying to conceive is to take vitamin D in the winter months. If we start thinking from September to March, start taking vitamin D and here the dose we have available is 10 micrograms. If you notice, for example, now that we are in lockdown, if we’re not going outside much, then you can still continue taking it even though we are almost in the summer – so that that is currently the recommendation in the UK.

It is recommended that I take 5 mg of folic acid due to a pre-existing autoimmune condition. But isn’t methyl folate better? If so, what would be the equivalent dose? I am currently taking 1,200 micrograms. Should I avoid taking both folic acid and methyl folate at the same time?

As I said both, folate and folic acid are available in supplement form. If you are eating foods that have been enriched, you are most likely eating folic in enriched rice or cereals. If you are taking it as a supplement tablet, you will find supplements that have folic acid and supplements that have folate. Now some people are not able to metabolize folic acid as easily as other people. Some nutritionists often recommend folate but if we look at all the medical recommendations, if you go on the NHS website, the World Health Organization where other organizations worldwide that are medical, they will not talk about methyl folate, they will not talk about folate and their recommendations are always around folic acid. If you have been recommended a higher dose, the five milligrams of folic acid by your doctor, then I think that’s the dose that you should follow instead of trying to switch or definitely not try and take two supplements because you could be overdosing yourself. If you have that higher dose, stick to the brand and the dose that your doctor has recommended to you and just make sure that you are eating those dark leafy vegetables and get the natural source of folate from there, instead of trying to have a different sort of tablets and which could mean that you could be overdosing yourself.

If you have to use a computer for work, how would you limit your exposure and be a safe distance away? What would your limit be? How many hours per day?

Here we’re talking about the radiation RF-EMF so we’re talking about having the computer close to you but, for example, if you can limit your work time on the computer to, for example, 8 today but not having your phone next to your computer or the radio next to you, at the same time, or the TV in the same room, so it’s about the devices that you’re using and how close you are to them but as well how many you have around you. So many times we have all these devices around us and necessarily mostly because we are not aware that they can be harmful to us. If you have to use the computer, use it for the minimum time that you need to actually perform the job. We haven’t found any type of time limit that has been identified in these research studies but it’s all about limiting the use of the devices and having them close to you when you need them but further away or turn off the switch when you’re not using them.

Is there any evidence for Coenzyme Q10? Is Ubiquinol better? What dose is recommended if not other medical conditions?

That is a great question but again one that I’m not going to answer today because this is part of the other modifiable factors that I have not brought here today. I can tell you that there is good evidence on Coenzyme Q10. The evidence is noted high up in the hierarchy so if we were using a traffic light system, I would say it’s orange, so it’s not green saying go ahead there’s 100% certainty that you need it like folic acid or vitamin D, but it’s yellow, it’s useful in certain circumstances. But, again, I’m not going to talk about it today but I’m more than happy to hold another webinar where we talk about other modifiable factors. There’s so much information and people are so curious about it and it was really hard for me to choose which five modifiable factors I would bring here today but I thought it would be interesting to bring a variety of all of these factors but I’m more than happy to be more thorough in the next webinar.

Regarding antioxidants, do you recommend anything else on top of vitamin C? We take 1,000 milligrams per day?

Vitamin C is one of the most researched antioxidants and it’s good. You can also get antioxidants from dark fruits, for example, blueberries. So getting a mixture of antioxidants from fruits and vitamin C that’s I would say a good amount. Let me just clarify one thing. Antioxidants are good if you are undergoing oxidative stress. Oxidative stress comes not only from food but it comes from your environment, lifestyle, smoking, so the more oxidative stress you have, the more antioxidants you’ll need. The key thing is to minimize our exposure to oxidative stress so that we don’t need a lot of antioxidants. We can take them to minimize the impact and the DNA damage from oxidative stress but if we can minimize exposure then it’s best. If you are pre-diabetic and you choose to take a tablet to deal with that without making any changes to your diet when maybe changing your diet would mean that you wouldn’t need a tablet. Minimizing exposure is as important or even more important than taking antioxidants.

Is it bad to have a mobile phone near you when you sleep? For example, to be used as an alarm clock. Should the phone be turned off at night or just simply far away from you?

I would say that if you can have your phone turned off at night that would resolve the issue. If you use it as an alarm, I would say having it far away from you and that could actually be quite a good strategy but you because you wouldn’t snooze the alarm, you’d have to wake up, stand up to turn it off so that might be a good strategy to have it far away from you. But turning it off would also be good. In terms of the techie stuff, it’s the more you have, the more exposure you will have. It might be okay for most people but, for example, if you notice that his sperm has DNA problems, if it has a lot of oxidative stress, then maybe those are some of the things that you can reduce. If we’re thinking about the heat exposure that we talked about today, for example, using very tight underwear or tight trousers or having the computer on his lap, that is more important to address that than addressing the radiofrequency stuff. Instead of thinking of all the things that you could do, think in terms of the priority. Are you addressing all the other things and everything is okay and is this the only thing left to change and adjust? Think of ways that you can minimize instead of removing it altogether. I understand it can be very difficult for us to remove all these things that are part of our lives. Change is really really hard. Think of ways of minimizing it, avoiding exposure where you can but not removing it or completely moving to an island in the middle of nowhere – that might not be necessary, just minimizing, doing most of the stuff 80% of the time, not 100%. Otherwise, we’ll go mad.

Would it be better to have an actual alarm clock or is that also bad?

No, that’s fine. If you think about one of those basic alarm clocks, then that’s absolutely fine that there’s no Wi-Fi, there’s no radiation coming from it so you can have an actual alarm clock.

If one has been having a phone and a computer exposure for months, is there anything to do to reverse the situation since I guess that damage is done?

That’s a good question. If we’re talking about sperm, we know that sperm changes take 74 days so it’s reversible. If you start reducing the exposure to the computer and the phone, it takes 74 days for sperm to be born again all beautiful without changes affected by those factors. If we’re talking about eggs, eggs take about three months since they are very little and then they start growing into follicles so it’s reversible. We have an opportunity with these lifestyle interventions to make a change to our lifestyle, to our habits, to our environmental factors and then see an actual difference in just a few months’ time.

Do we know if melatonin supplement, two milligrams, has a positive effect on eggs?

Melatonin – it’s not one of the supplements that we have found of high-quality. The most important thing in egg quality is age. We know that quality starts reducing from the age of 37 and we know that some of the other factors we’ve been talking about can make a difference in egg quality but melatonin is not one of the supplements that we found much evidence for.
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Authors
Andreia Trigo, RN BSc MSc

Andreia Trigo, RN BSc MSc

Andreia Trigo is a multi-awarded nurse consultant, author and TEDx speaker. Combining her medical experience and her own infertility journey, she developed unique strategies to help people undergoing similar challenges to achieve their reproductive goals. Her mission is to improve accessibility to fertility care and support worldwide at minimal cost to populations. She is also The Founder & Director of Enhanced Fertility Programme, the evidence-based programme that improved help for fertility, currently in use by several clinics and patients worldwide.
Event Moderator
Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.