Six Steps to Increased Fertility: An Integrated Medical and Mind/Body Program to Promote Conception

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YES, YOU PROBABLY CAN GET PREGNANT

...and the really good news is that most of you can conceive naturally, without expensive high-tech intervention. The six-step mind/body fertility enhancement program from Harvard Medical School could give you the answer.

  • How can I relax when I'm worried sick about getting pregnant?
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Overview


YES, YOU PROBABLY CAN GET PREGNANT

...and the really good news is that most of you can conceive naturally, without expensive high-tech intervention. The six-step mind/body fertility enhancement program from Harvard Medical School could give you the answer.

  • How can I relax when I'm worried sick about getting pregnant?
  • Can antidepressants affect my fertility?
  • Is there some medicine I can take to increase my sperm production?
  • Does being a vegetarian increase or decrease my chances of conception?

Start to help yourself by learning the newest information on how simple lifestyle changes affect fertility.

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Editorial Reviews

Library Journal
Recently, infertility books have either followed the medical or the natural approach. Bridging this gap, this book provides incremental guidelines to maximizing chances of conceiving naturally, then progresses to more advanced medical alternatives. Alice Domar, a guru of women's mind/body health, has collaborated with two colleagues at the Harvard Medical School to present this well-balanced introduction to reproductive health. Believing that couples should begin with the safest, simplest approach, the authors recommend lifestyle changes (diet, exercise, and even the type of underwear) as well as techniques for handling emotional stress. Basic reproductive physiology is reviewed with a brief description of male and female reproductive problems, common diagnostic tests, and medications. All this is carefully wrapped up in an overview of the most advanced approach, that is, assisted reproductive therapies. This is a helpful tool for younger couples on the verge of seeking medical assistance; those desiring a more alternative approach to infertility should try Shana Albo's Infertility Solutions: Natural Approaches (Avery: Penguin Putnam, 2000). Highly recommended for all health collections. (Index not seen.)--Lisa A. Errico-Cox, Nassau Community Coll. Lib., Garden City, NY Copyright 2000 Cahners Business Information.\
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Product Details

  • ISBN-13: 9780684855226
  • Publisher: Free Press
  • Publication date: 1/28/2000
  • Pages: 256
  • Product dimensions: 5.56 (w) x 8.22 (h) x 1.14 (d)

Meet the Author


Robert L. Barbieri, M.D., is the chairman of the Department of Obstetrics and Gynecology at Brigham and Women's Hospital in Boston and a professor of obstetrics, gynecology and reproductive biology at Harvard Medical School.
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Read an Excerpt


Introduction

As doctors dealing with fertility problems, we see, listen to, and ultimately help hundreds of people to get pregnant each year. We know how concerned you become when another month passes and conception has not occurred. We know a great deal about your dreams and aspirations -- and your frustrations and sense of failure. And we wanted to write this book to answer many of the questions and concerns we hear daily from you in our offices. Most of all, though, we wanted to write this book to reassure you that most of you will be able to conceive. Research has shown that although 20 percent of couples will be unable to achieve a pregnancy after a year of unprotected intercourse -- the current definition of infertility -- most of them will eventually achieve a successful pregnancy. Very few people have physical conditions that make it impossible to have a child, and in many cases, simple lifestyle changes and low-tech strategies can make a decisive difference. Besides, one year is far from a magic number -- age and health differences and many other factors will influence your own chances of becoming pregnant.

If you do have difficulty getting pregnant, there is a great deal more you can do about it today than ever before. While assisted reproductive technology can help a large number of couples previously infertile, many couples can be helped by our greater knowledge of how lifestyle factors like stress, exercise, and nutrition affect conception, of better ways to regulate and target ovulation cycles, and of common medicines to avoid that can inhibit sperm and egg production. So much attention in the media is focused on the latest high-tech intervention that many people forget to give nature enough of a chance.

Each of us is an expert in a particular area affecting fertility. Dr. Barbieri, chairman of obstetrics and gynecology at Brigham and Women's Hospital, specializes in physical problems women have in getting pregnant. Dr. Loughlin, professor of surgery at Brigham and Women's Hospital, specializes in physical problems men have in conception. And Dr. Domar, the director of The Mind/Body Center for Women's Health at The Mind/Body Medical Institute, specializes in how the mind and emotions affect conception. We are delighted to be able to bring our separate viewpoints and expertise to this book. Like three pieces of a puzzle, we provide information that separately shows only part of the picture, but taken together creates a clear blueprint for success.

In this book we take a step approach to dealing with infertility. Just because we have sophisticated technology doesn't mean that everyone needs to make use of it. We believe that couples should always try the simplest, safest approach first before advancing to a more complicated and often more stressful and expensive intervention. In fact, for some of the steps in this book, you don't need a doctor at all.

Along the way you will meet a number of patients who have experiences similar to your own, and a host of tips and suggestions for maximizing your natural fertility.

But we will also tell you when it is time for the next step -- the kind of tests and doctors that would be most helpful -- and give you enough information to be sure you are getting the best available care. And because many couples are so anxious to get pregnant that they are tempted to skip important steps and jump to procedures that may not be necessary, we remind readers to always get a second opinion after a diagnosis and before starting a course of treatment.

One of the pleasures of this book is that you can start right now -- today -- without making a doctor's appointment, to improve your chances of conception. We hope this book can help bring you knowledge, peace of mind, and ultimately, a successful pregnancy.

Copyright © 2000 by the President and Fellows of Harvard College

STEP 1

Begin Making Healthy Lifestyle Changes Today

If you are thinking about getting pregnant, you can do many simple, effective things right now to improve your chances of conception, because lifestyle can have profound effects on the reproductive functions of women and men. This means that increasing your fertility potential is something that you both can do without outside help: you can adopt healthy ways of eating, you can eliminate habits that may diminish fertility, and you can make sure your weight is within the range that's conducive to starting a pregnancy.

Think of this as a wellness program: Like an athlete, you'll be training for optimal performance. Not only can you enhance your prospects for a pregnancy, but as healthy parents you will be better prepared for the physical work of raising a child. Here are some simple strategies to pursue right now.

Keep Your Exercise Moderate

Women and Exercise

Getting enough exercise is an important part of helping your body to function well. But some women do so much exercise that it can be counterproductive, especially as far as fertility is concerned. A Harvard study by Dr. Rose E. Frisch examined the health of over 5300 women who had been athletes in college and found that strenuous or elite-level exercise appeared to impair fertility, which was often demonstrated by a lack of menstruation and ovulation. The most obvious indication that you are exercising too much if you want to become pregnant is having light or irregular periods or none at all. Professional or dedicated women athletes who want to have a baby need to cut back to much less strenuous levels of exercise or stop their workout programs altogether.

For the woman who already is experiencing infertility, Dr. Alice Domar and her colleagues at the Harvard Mind/Body Program for Infertility recommend that although giving up all exercise can be difficult for a woman who is concerned about weight gain or is used to exercising vigorously, she stop all exercise for three months to make sure exercise isn't a factor. Even when menstruation and ovulation appear normal, exercise can cause a decrease in progesterone levels that might prevent an embryo from implanting. Dr. Domar has seen a number of pregnancies result when women stopped exercising. Stretching routines, yoga, and relaxed strolls (under two miles) are good tension reducers and can be useful substitutes for vigorous exercise. A yoga program should be supervised by someone familiar with the effects of infertility treatments on the body.

Drs. Kevin Loughlin and Robert Barbieri, however, feel that a simple reduction in the number of miles women (and men) run or bicycle or in the hours they spend working out is sufficient to overcome most exercise-related fertility problems. Since exercise can affect body fat and a person's body mass index (BMI), its effect on fertility is difficult to sort out.

LILLIAN'S STORY

In her job as a supervising chef at a well-known restaurant, Lillian was on her feet for eight to ten hours a day, with little opportunity to relax. "Our food had to be amazing, day after day, because we had a reputation to maintain. Something often goes wrong. It was exciting but demanding." In addition, Lillian ran for recreation and to keep fit. At five feet eight inches, she liked to keep her weight at 120 pounds. When she started attending the Mind/Body Program for Infertility, she had been trying to get pregnant for two years and the cause of her infertility couldn't be explained. She was thirty-three years old.

When she learned about the possible connection between too much exercise and infertility, Lillian slowed down. She gave up running and walked more slowly at work. As part of her effort to take life more easily, she also practiced the relaxation routines and meditation exercises taught in the program. "Overall, I became much calmer. For a month I gave up trying to get pregnant. I relaxed about everything, I didn't worry about when to have intercourse -- and I got pregnant in six weeks. It was entirely unplanned." She now has a less demanding job and takes care of her baby.

Men and Exercise

Men can work out more than women without adversely affecting their fertility, but many research studies have found that high levels of exercise and endurance training can lead to a decrease in testosterone levels, negatively affecting libido and sperm health. Furthermore, men who are extremely lean can also experience marked drops in their testosterone levels, and may lose their interest in sex and their ability to have erections. Long-distance runners and scullers trying to keep to a lighter weight are examples of men who may experience infertility because of a combination of high-level exercise and lean bodies with little fat. These effects can be reversed with a modest weight gain.

We also should mention that over fifty miles a week of bicycling on a hard, narrow seat may lead to impotence. Studies have shown that sitting for long periods on such a seat can flatten the artery that controls blood flow to the penis. This type of bicycle seat may also cause nerve damage. Impotence specialists recommend switching from a solid seat to a type that has an oval opening built into the saddle. Various seats are available at bike stores.

Eat Well

An important influence on fertility is attaining a level of good nourishment that permits your body to function as it should. Bad eating habits can reduce the reserves of nutrients necessary for reproductive hormone systems to work properly. Inadequate nutrition also may weaken your immune system to the point where any sickness might diminish your fertility. This isn't just a woman's issue; men who don't get enough of certain vitamins and minerals may have low sperm counts and low testosterone levels.

It's important to eat regular, adequate meals -- at least three a day -- and to choose foods that are rich in nutrients and low in fat. And we recommend that you have one or two nourishing snacks every day as well. Good snacks help you avoid the temptation to reach for empty-calorie foods high in fat and sugar.

Eat More Fruits and Vegetables

This is the time to heed nutritionists' advice about stepping up the number and variety of fruits and vegetables you eat every day -- currently the recommendation is five to eight servings per day. That may sound like a lot, but one serving can be as little as a couple tablespoons of raisins or a handful of fresh peas or grapes.

If you're not an enthusiastic vegetable/fruit eater and want to make each serving count the most, every week eat at least several dark green and orange/yellow vegetables such as Swiss chard, kale, sweet potatoes, and carrots, as well as red, orange, and yellow fruits. Deep-colored foods tend to have more nutrients. For instance, pink grapefruit has more nutritional value than white grapefruit, and watery-but-red watermelon is surprisingly nutritious.

GOOD HEALTH TIP

To make salads more nourishing, use lettuces such as romaine, Boston, or greenleaf (iceberg lettuce is not rich in vitamins) and include fresh spinach. Real time-savers are the lettuce mixes sold by most supermarkets. Because they contain a variety of greens, both flavor and vitamin content are better. For a change of pace that's quick, toss a leafy salad with a minimum of low-calorie dressing, and add several slices of ripe pear or mango to each serving. This looks elegant and tastes delicious.

A word about salad dressings: If you can wean your family from their favorite bottled dressings, it's cheaper and usually lower in fat and calories to mix a jar of your own. Do as Europeans do and toss the entire salad with just 1 or 2 tablespoons (or less) of dressing to barely coat the leaves so that the taste of the greens comes through.

Salad dressings taste better if they're made a day or two (or more) beforehand, well mixed, and stored in the refrigerator. Or mix your dressing right in the salad bowl as you start dinner preparations. Try crushing a garlic clove, then adding two parts olive oil, 1/4 teaspoon of Dijon mustard, one part wine or cider vinegar or lemon juice, a drizzle of honey, and pepper to taste. Letting the dressing warm up to room temperature 30 to 60 minutes before tossing it with the greens enhances its flavor.

Although vegetables provide much of the vitamins, minerals, and fiber you need, if you are a vegetarian and are trying to improve your fertility, be sure that you're getting enough protein. Women who are vegetarians may have fertility problems because they have skewed levels of reproductive hormones: they metabolize estrogen into inactive products more quickly, and have longer menstrual cycles than women who include meat in their diets. Moreover, you are much more likely not to menstruate if you are both a runner and a vegetarian.

GOOD HEALTH TIP

One of the easiest ways to get enough fruit and vegetables is to use them as between-meal snacks. Supermarkets sell packages of baby carrots, cherry tomatoes, and assortments of bite-size pieces of melon that are easy to pack along to the office or to nibble on while watching TV. You can spend a few minutes cutting up broccoli and cauliflower or else buy a small vegetable party platter from your supermarket and use it for salads and snacks all week. (To wash away insecticides and other possible contaminants, thoroughly wash all precut vegetables and salad greens in water, add a few drops of dish detergent, then rinse well, before eating.)

To make a good accompaniment for fresh and cooked vegetables, add fresh dill, other herbs, or garlic powder to plain yogurt. And simply adding fresh spinach or slices of fruit to salads dramatically increases their nutritive value.

Snacks Can Be Good for You

Don't be afraid to eat snacks between meals. Choose snacks that are low in fat and salt, taste good, and make you feel satisfied, so that you can override any yearnings for high-sugar, high-fat foods. Keep several on hand for those times when your energy is flagging or you have the greatest cravings for junk food. See the box that follows for ideas for between-meals foods.

To make a snack more satisfying, combine carbohydrate foods with protein foods. If you don't want to gain weight, check the portion size and calorie amount listed on the food label to help you determine how big a snack to eat.

Snacks are also more satisfying if you eat them slowly and mindfully. Be aware of how much you're eating, how full you feel, and how it tastes. Avoid eating while you're doing something else to lessen the risk of thoughtless munching. Serve yourself one portion and put the rest of the food away. When you're very hungry and preparing a meal, nibble on chunks of raw vegetables such as sweet red or green peppers, cucumbers, or celery instead of reaching for potato chips. A more nutritious substitute for chips are whole-grain crackers such as Wasa Crispbreads, Kavli, Finn Crisp, whole wheat matzos, and Whole Foods Baked Woven Wheats.

Food Supplements Help

In addition to eating a fruit- and vegetable-rich diet, both men and women should take a multivitamin/mineral supplement. Taking a single multivitamin/mineral tablet avoids the danger of taking too much of one vitamin or mineral. Megadoses of vitamins should be avoided, especially if they're fat soluble. Fat-soluble vitamins, such as vitamin A or vitamin D, are not readily excreted and can build up to toxic levels in your body, a particular concern if you're trying to get pregnant. This doesn't mean you should avoid these important vitamins, but just be sure not to take doses that are over the federal recommended daily allowance (RDA) without the advice of a nutritionist or doctor. RDAs are listed on the labels of vitamin bottles.

WARNING: LIMIT YOUR VITAMIN A

At any time it's wise not to take too much vitamin A, but this is especially important when you are expecting to have a child. A study of 22,000 women showed an apparent increase in the number of birth defects when pregnant women took over 10,000 international units (IU) of this vitamin. To be on the safe side, nutritionists recommend you choose a multivitamin that contains only 5000 IU of this vitamin. This allows you to also eat a lot of foods every day that are rich in this vitamin and in beta carotene, its precursor.

Folic Acid. A woman hoping to get pregnant should take a daily supplement that includes at least 400 micrograms (mcg) of folic acid. Folic acid is a synthetic form of folate (one of the B vitamins), and is now available in most multivitamin/mineral tablets and as a supplement in a few food products. Folic acid helps prevent anencephaly and spina bifida, birth defects of the brain and spinal cord, respectively. It's vital to have enough of this vitamin in your body before you conceive as well as afterward because such defects can occur within the first thirty days after the egg is fertilized. (It's also important, however, not to take more than 1000 mcg of folic acid unless your doctor or other health care provider clearly advises it.) Although you can get folate from foods, it is only half as available to the body as folic acid. The simplest approach may be to get the recommended minimum of 400 mcg every day in a multivitamin and think of the folate in foods as a bonus.

Calcium. During their reproductive years (and afterward) women also should consume about 1200 milligrams (mg) of calcium every day. To get that much, you will need to eat or drink at least three 8-ounce servings of dairy products, such as low-fat or nonfat yogurt and milk, or healthy fortified foods such as calcium-fortified orange juice. Read the product labels -- they list serving size and the amount of calcium per serving.

If you can't eat enough calcium-rich food every day, a good way to make sure you're getting enough of this important bone preserver is to take a supplement. Calcium carbonate, calcium lactate, calcium citrate, or calcium citrate malate all are good, readily digested supplements. They are best absorbed when taken with a meal in doses of 500 mg or less. If you can't take your supplement with meals, calcium citrate is the form most easily digested on its own. Check the labels to make sure the form you buy is low in lead. Calcium derived from bonemeal or oyster shells can contain higher levels of lead. At all ages, everyone, male and female, should consume at least 1000 mg of calcium every day.

Zinc. Men, too, may benefit from taking a daily multivitamin supplement, particularly one that contains the RDA of zinc, which some researchers found is associated with the production of healthy sperm. An adequate level of zinc in the body is needed for the testicles to function normally. A deficiency in this important mineral also may decrease libido and contribute to impotence, probably by reducing testosterone levels. Other studies have found that a lack of zinc can reduce sperm count; however, the benefit of oral zinc on male infertility is still uncertain.

Increase Your Body Fat

For a change, this is not a suggestion to lose weight, unless you are very overweight. Like too much exercise, being too thin can delay puberty or slow down or stop menstrual periods entirely. To be able to reproduce, you must store a minimum amount of body fat. Teenagers need to have a certain amount of body fat in order to start having periods. A decrease in body fat can cause menstruation to stop. Women whose body mass index is below 17 are more likely to find that their periods have become further apart, are light, or have stopped, compared to women of normal weight for their height.

Body mass index describes body weight relative to height and is strongly correlated with total body fat content in adults. Its numbers apply to both men and women. The normal body mass index for adults is between 20 and 27. A six-foot-tall person who weighs 221 pounds or a person who is five feet six inches and weighs 186 pounds will each have a BMI of 30 -- and both would be considered excessively heavy. The new BMI guidelines, as developed by an expert panel, define overweight as a BMI of 27 to 29.9 and obesity as a BMI of 30 or more.

You can calculate your own BMI by multiplying your weight in pounds by 703 and dividing that amount by your height in inches squared. (For example, the square of 68 inches tall is 68 x 68, or 4624 inches.) If your weight is 150 pounds, and you multiply that by 703 you'll get 105,450. Dividing 4624 into 105,450 reveals a body mass index of 22.8 -- well within the normal adult range.

The hypothalamus, which governs reproduction in both women and men, receives information from other sensors located in the brain. External factors such as stress, temperature, nutrition, and physical effort influence the hypothalamus. A combination of intense exercise and little body fat affects women and men much the same way: the hypothalamus secretes too little gonadotropin-releasing hormone (GnRH) or releases it in an abnormal pattern, which in turn affects the timely secretion of other reproductive hormones that are important to normal fertility in either sex. Produced in the hypothalamus, GnRH controls the production and secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which in turn stimulate the ovaries and testicles.

In our female ancestors, this action of the hypothalamus probably evolved to ensure that conception would occur only when the woman's body had enough fat calories stored to nourish a fetus and then allow ample breast-feeding. Women who became pregnant when they were thin probably lost their babies or didn't survive themselves. This may have been the process of natural selection that led to the fact that women today carry more fat than men -- about one-fourth of female weight normally is in fat.

Excessively thin women have difficulty reproducing. We can see the effect of too little body fat today in women athletes who don't ovulate or who ovulate but can't get pregnant, even though their body mass index may be in the normal range. That's because most of their body is made up of muscle and, despite having a normal BMI, they don't have enough fat. Men's bodies, too, need some fat for them to maintain normal testosterone levels and healthy sperm. Body weight doesn't always reflect the amount of fat a body contains.

In addition, having a lower than normal BMI, even without strenuous exercise, may cause ovulation to stop "silently" -- menstruation may continue and may seem normal, but ovulation doesn't occur. According to Harvard scientist Rose E. Frisch, the infertility that could result from this can be reversed by weight gain or less exercise, or both. Furthermore, a very restrictive diet can lead to low levels of progesterone, slow the growth of egg follicles (the fluid-filled pockets in which eggs grow), and inhibit the surge of luteinizing hormone (LH) that facilitates ovulation.

More recently, researchers have found that very thin women who gain weight and increase their body fat in order to conceive need to wait until their BMI is in the normal range before they try to get pregnant. Women who are on the low end of the BMI normal range may have difficulty in maintaining a pregnancy. Women need sufficient fat reserves to nurture a fetus.

Men whose BMI is 18 or less also may have reduced fertility. They are likely to experience a loss of libido and have decreased amounts of the prostate fluids that carry the sperm out of the penis and protect them after ejaculation. In addition, their sperm will be less active and shorter-lived. As in women, weight gain restores these losses.

Reduce Your Body Fat

The other extreme -- having too much body fat -- in women, at least, is also associated with long periods between menstruation (thirty-five days or more), a lack of menstruation, and infertility. An overweight body produces higher than normal levels of certain hormones that then inhibit ovulation. The pregnancy rate for overweight women -- women who have a body mass index that's higher than 27 -- often is reduced.

Exactly what hormonal changes take place when women have too much body fat is not entirely known, but researchers have seen that hormone levels return to normal and menstrual cycles become more normal when overweight women lose even as few as fifteen pounds. It appears that many women must be within a certain BMI range to have normal ovulatory cycles. Just as gaining weight can restore ovulation if you're too thin, losing weight can be very effective if the cause of your ovulation problem is overweight.

Drinking: Women Should Stop; Men Should Be Moderate

The effects of drinking beer, wine, or liquor on pregnancy have been studied for many years, but until recently there was little information available on the specific effects of moderate or no alcohol intake on reproductive capability. Studying more than 1000 infertility patients and 3800 women who recently gave birth, Harvard researchers in 1994 found that women who were "moderate" drinkers -- who usually had one drink a day -- experienced a slightly greater rate of ovulatory infertility. This risk was greater in women who had more than one drink a day. Endometriosis, however, in which fragments of the lining of the uterus are found in other parts of the pelvic cavity, was more common in women who drank, regardless of the amount. Both of these problems are linked to hormone function, which appears to be affected by alcohol intake.

Furthermore, in 1998, two studies emphasized the negative effects of alcohol on fertility: In a Danish study of 430 couples, women who drank moderately (fewer than five drinks a week) reduced their chances of conception, compared to women who didn't drink alcohol at all. In fact, the ability to become pregnant decreased steadily in a direct relationship to the amount of alcohol intake. Among women who had more than ten drinks a week, the odds of getting pregnant were about half those of the women who had fewer than five per week. The couples studied were between the ages of twenty and thirty-five and were trying to conceive for the first time. Among the male partners no association was found between alcohol intake and the couple's rate of conception. Most of the women in this study drank wine.

Research at Johns Hopkins University reinforced the Danish findings: Women who avoided both alcohol and caffeine were more than two and a half times as likely to conceive as women who consumed any alcohol and drank more than one cup of coffee a day. The highest conception rate was among women who didn't drink, didn't smoke, and had less than a cup of coffee or its equivalent per day.

Alcohol and Miscarriage

Alcohol also can endanger a pregnancy. According to some studies, the risk of spontaneous abortion (miscarriage) appears to increase with moderate drinking during the early weeks of pregnancy, particularly the first ten weeks. If a woman has one drink a day during the first trimester of pregnancy, her risk of a spontaneous abortion is about double that of the woman who doesn't drink at all. Other research, however, particularly in Europe, has not confirmed this association, so more studies are needed to resolve the issue.

In addition to the possibility that moderate alcohol intake may lead to ovulatory infertility or to a miscarriage, two or three bottles of beer or glasses of wine or two mixed drinks per day can have a detrimental effect on fetal development. Babies may be born with fetal alcohol syndrome, a combination of birth defects that result from this level of alcohol consumption by the mother during pregnancy. An embryo can be affected by any toxins in its mother's system, especially during the first two to six weeks of its development, a time when many women don't realize they are pregnant. And a chronic high blood-alcohol level during the third trimester may cause a growth deficiency and contribute to mental retardation in the infant. Practically speaking, there is no safe level of alcohol intake during pregnancy.

In men, some studies have found a link between heavy drinking and a reduction in testicle size, infertility, and/or decreased libido and impotence. Although the Danish study we mentioned shows no relationship between drinking alcohol and male fertility, other researchers have found that alcohol consumption produces significant changes in the shape of sperm and their ability to move. Furthermore, in men who are chronically heavy drinkers, the sperm production structure of the testicles becomes damaged so fewer mature sperm develop. Research shows that having more than one drink a day can interfere with testosterone secretion, reducing a man's sex drive and ability to produce mature sperm.

If you want to enhance your chances of conceiving, the bottom line seems to be that women should give up alcohol, coffee, and cigarettes and men should moderate their use of these stimulants.

Decrease Your Caffeine Consumption

Since 1988 there have been numerous studies regarding the effects of caffeine on a woman's fertility. Although the results are not totally definitive, there is enough information to recommend that you be cautious in your caffeine intake. A 1997 report on more than 3000 women in five European countries said that women who drank more than five cups (500 mg) of brewed coffee a day experienced delays in conceiving. This delay was increased if the woman was a smoker. The Johns Hopkins research on alcohol and caffeine consumption shows that more than a single cup of coffee a day can have a negative effect on fertility. And an earlier U.S. study found that a woman's chances of becoming pregnant were reduced if she drank more than three cups (300 mg) of brewed coffee daily. Furthermore, the combination of smoking and coffee drinking was associated with a significantly increased risk of delayed conception. We should point out that most coffee today is sold in 8-ounce cups that, on the average, hold 135 mg of caffeine, which is more than the 100 mg cups the studies describe. Three cups of takeout coffee will equal 405 mg of caffeine.

Caffeine also may be linked to a higher-than-normal risk of miscarriage, but the jury still seems to be out on this issue. A recent large study in Connecticut found a strong link between caffeine consumption and spontaneous abortion, while an even larger study in California found no such association.

Figure Out Your Caffeine Intake

If you want to estimate your caffeine intake, measure what your mug or cup holds. A full 8-ounce cup of most brewed coffees has approximately 135 mg of caffeine, a cup of instant coffee has 65 mg, a cup of tea 50 mg, 12 ounces of a soft drink contain 60 mg, and 12 ounces of a diet soft drink provide 78 mg of caffeine. Decaffeinated coffee has only 2 mg per 8 ounces. Cups of coffee offered at some coffeehouses may supply more than 135 mg of caffeine, however. The amount can vary from one establishment to another and from one type of coffee to another.

Some over-the-counter drug products also contain significant amounts of caffeine. These include NoDoz, a product designed to help people stay awake, and the headache painkillers Excedrin and Anacin. One tablet of Maximum Strength NoDoz provides 200 mg and one tablet of Regular Strength has 100 mg of caffeine. Two tablets of Excedrin add up to 130 mg of caffeine and two tablets of Anacin together have 65 mg.

Even though the question of the effect of caffeine on the length of time it takes to conceive is not entirely settled, you may want to enhance your chances by switching to decaffeinated coffee or tea. If you're a serious coffee drinker, reduce your consumption very slowly -- by a half cup per week -- to avoid withdrawal problems such as headaches or fatigue.

Give Up Nicotine, Marijuana, Cocaine, and Steroids

Tobacco smoking has been linked to reduced fertility in both women and men. In addition, a recent British study has found an association between smoking and stillbirths, low birthweight babies, and sudden infant death syndrome (SIDS). A woman who smokes is likely to have less chance of becoming pregnant and giving birth when treated with in vitro fertilization (IVF) than a woman who doesn't smoke. This is especially true if she smokes twenty or more cigarettes a day. A mechanism that may link cigarette smoking and reduced pregnancy rates following IVF is the observation that smoking appears to accelerate the rate of egg loss. Women who smoke have the elevated hormone levels that indicate a depleted supply of eggs and prematurely aged follicles.

For men, anything that may lead to atherosclerosis, such as untreated diabetes or hypertension or even health habits such as smoking and a high-fat diet, may damage blood vessels and impair blood flow, leading to impotence. A good blood supply to the penis is necessary to achieve an erection.

Marijuana has been linked to an inability to perform sexually and to diminished fertility. It also has been associated with increased levels of female hormones in men and to the development of abnormally shaped sperm. This has the effect of reducing the production of LH and therefore decreasing the levels of the male hormone testosterone.

Cocaine may have a negative impact on sperm development. Recent animal experiments have shown that it damages the cells that produce sperm.

Steroids commonly used by men to build more muscular bodies can also inhibit the ability to have a baby. Thought by some to improve sexual performance, they actually act as a male contraceptive by depressing hormone secretion and interfering with normal sperm production.

Men should avoid using a testosterone patch, pills, or shots unless they are under a physician's supervision. In addition, men should be aware that their use of testosterone may have the effect of depressing or shutting off the secretion of follicle-stimulating hormone and luteinizing hormone, which govern the production of sperm.

In most cases, if you stop using these substances, sperm production eventually returns to normal, although it can take at least one full cycle of sperm production -- seventy-four days -- before most sperm are healthy and show up in normal amounts in your semen.

Check Out Your Medicines

A number of prescription drugs have been reported to have a negative effect on the male reproductive systems, including the ulcer drug Tagamet (cimetidine), some antibiotics, and antihypertensive medications. For example, the use of a class of high blood pressure medicines known as calcium channel blockers can interfere with the ability of a sperm to penetrate the outer membrane of an egg.

In women, thyroid replacement therapy may affect ovulation, depending on how carefully thyroid hormones are maintained at normal levels. Ovulation may be impaired in women who have low thyroid hormone levels, so when they are on thyroid replacement therapy, the levels of pituitary hormone (which controls the thyroid) in their blood should be monitored regularly and carefully kept in the normal range.

As a couple, tell your physicians early on the you're trying to get pregnant and that you're concerned about the effects of medicines on your fertility. It's a good idea to remind your doctors about this every time they start to write a prescription for either of you.

MEDICATIONS LINKED TO MALE INFERTILITY

Chemical or Generic Name

Spironolactone is a component of several antihypertensive drugs; it may impair production of testosterone and sperm.

Sulfasalazine is found in a few medicines used for irritable bowel disease, colitis, or Crohn's disease. It adversely affects normal sperm development. Drugs with mesalamine can be substituted, instead.

Colchicine and allopurinol are used to control gout and can affect the ability of sperm to fertilize.

Antibiotics including tetracyclines, gentamicin, neomycin, erythromycin, and nitrofurantoin (in extremely high doses) can negatively affect sperm generation, movement, and density.

Cimetidine, the active ingredient in Tagamet, can sometimes cause impotence and semen abnormalities. Drugs with ranitidine and famotidine, however, do not seem to have the same effect.

Cyclosporine is used to improve graft survival in organ transplants but may have a detrimental effect on male fertility.

Be Careful with Herbal Remedies

Several popular herbal preparations probably should be added to the list of substances to avoid if you want to protect your fertility. Although many people believe that because herbs are "natural" they're safe, those that have druglike effects on the body do contain potent chemicals. Like some over-the-counter or prescription medicines, some herbal remedies may interfere with normal reproduction.

Three herbs that were tested in laboratory studies on human sperm and on hamster eggs produced adverse effects in either the sperm or the eggs, or both. Researchers at Loma Linda University School of Medicine in California have found that tiny amounts of St. John's wort, echinacea purpurea, and ginkgo biloba made the eggs impossible or difficult to fertilize, changed the genetic material in sperm, and reduced a sperm's viability.

The researchers pointed out that their laboratory work indicated only a potential risk. They said it was possible that people who did not exceed the recommended doses would not experience negative effects, and in the human body such doses might not actually reach eggs and sperm. However, it should be noted that, in the lab, the eggs and sperm were exposed to only minute fractions of the herbal preparations.

Blue cohosh, an herbal dietary supplement long used by some midwives and American Indians to induce labor, is also sold as a menstrual remedy and could be dangerous for women of childbearing age.

In the laboratories of the U.S. Food and Drug Administration, blue cohosh produced significant birth defects in rat embryos, such as nerve damage, twisted tails, and poor or absent eye development. The research was done in 1996-98 by Dr. Edward J. Kennelly, now at the City University of New York. The herb is also known as blueberry root, squawroot, or papooseroot.

Have Infections Treated Right Away

Women should have any vaginal or cervical infection, such as bacterial vaginosis, trichomoniasis, chlamydia, or yeast, treated immediately because the discharge may stop sperm from entering the uterus.

Men should have urinary tract infections treated promptly because some urinary tract infections, especially those involving the epididymis, may diminish long-term fertility.

Avoid Exposure to Toxins Such as Solvents and Pesticides

Studies have linked specific pesticides, chemical solvents, dusts, and other substances in the environment to instances of infertility in women and abnormal sperm or low sperm production in men.

Pesticides. Frequent exposure to lawn and farm chemicals can be harmful, especially those applied as a spray, because the sprays can drift some distance and be inhaled unknowingly. When using any sort of weedkillers, fungicides, or pesticides, wear a mask, long pants, long shirtsleeves, and vinyl (not latex) gloves. If you work on a farm, or in any environment where toxins may be present, you may want to invest in a mask with replaceable charcoal filters (available at hardware stores) and to wear protective clothing consistently.

Dust and Solvents. Protect yourself not only around chemicals but in situations where there's a lot of dust in the air, including dust from grains and from woodworking, particularly when the wood has been pressure-treated with preservatives. You should also wear similar protection when using volatile solvents such as paint thinners and turpentine and make certain that your work area has extremely good ventilation. To be on the safe side, this concern should apply to home projects as well.

Lead and X rays. Severe lead intoxication -- seen most often among lead battery workers -- can have a negative effect on both male and female reproductive systems. In addition, the reproductive organs of you and your partner should be protected against radiation when medical X rays are taken.

Men -- Avoid Hot Water and Tight Pants!

The germ cells in the testicles that produce sperm work best in temperatures slightly below normal body temperatures. If the temperature within the testicles is elevated by only two, three, or four degrees Fahrenheit, both sperm and testosterone production are negatively affected. To keep the testicles cool, the scrotum (the skin sac that holds them) loosens up so that the testes are held away from the body. But if you wear tight jeans, bicycle shorts, or leather pants that hold the testicles close against your body, their temperature may rise. This also may happen if you wear undershorts made of nylon or other artificial fibers, even if they're not tight. Such fabrics hold in more heat than cotton and wool, materials that "breathe." Keeping your genital area cool also helps avoid infections that thrive in warm, moist places.

Spending time in hot tubs, Jacuzzis, and saunas, and taking long, hot showers or baths also overheat the sperm cells and may significantly impair sperm function.

One of the many scientists in Cambridge, Massachusetts, was fond of doing much of his thinking while having a long soak in a hot bath every day. After he and his wife had tried to conceive unsuccessfully for many months, she did a little research of her own and then firmly requested that he switch to taking short, tepid showers and do his thinking elsewhere. This tactic has proved successful -- they're now the parents of four children.

Maximize Your Lovemaking

Small changes in how you conduct your lovemaking can help sperm reach the uterus more easily:

• If you use a lubricant, choose it carefully. Better still, avoid them. Even though they're not designed to kill sperm, some nonspermicidal gels are gooey enough to reduce the number of sperm that get into the cervix. Even the presence of hand lotion or saliva in or near the vagina can slow down or kill sperm.

• Don't douche because it may wash out sperm you need.

• The best position for intercourse when you are trying to get pregnant is the traditional one, in which the man is positioned on top of the woman, because this allows his penis to penetrate deeply and puts the sperm close to the cervical entry to the uterus.

• After lovemaking, it's thought to be helpful if the woman lies still for twenty to thirty minutes, giving the sperm more time and opportunity to find their way into the uterus. A pillow under your hips can help the ejaculate slip toward your cervix.

• Once you know that you're ovulating, the conventional wisdom is to have intercourse every other day. There doesn't seem to be any reason, however, for not making love as often as you want during the two or three days just before and one day immediately after ovulation, when cervical mucus is receptive and your temperature chart or ovulation kit indicates that this is your fertile period. (Methods for detecting ovulation are discussed in Step 3.) However, don't feel that you need to "schedule sex" -- this idea easily could have an inhibiting effect.

Learn to Reduce Stress

If possible, try to cut back at work and/or reduce the amount of traveling in your schedules for a number of months. If you can't reduce your responsibilities at work, do make a point of not taking on any extra projects at home. Tip the scales in your favor -- make this a special time for the two of you to kick back and relax. Several relaxation techniques are discussed in Step 4, along with other ideas for reducing stress and being good to yourselves.

Copyright © 2000 by the President and Fellows of Harvard College

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Table of Contents


Contents

Introduction

Step 1: Begin Making Healthy Lifestyle Changes Today

Step 2: Maximize the Response of Your Reproductive System

Step 3: Target Possible Problems

Step 4: Ease Emotional Stress: The Harvard Behavioral Medicine Program for Infertility

Step 5: Take Advantage of Nature -- Tests and Medications That Help

Step 6A: Find and Treat Anatomical Problems in the Woman

Step 6B: Diagnose and Treat Male Problems

Extra Steps: Choose Assisted Reproductive Technologies

Glossary

Appendix

Sources

Index

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First Chapter

STEP 1

Begin Making Healthy Lifestyle Changes Today

If you are thinking about getting pregnant, you can do many simple, effective things right now to improve your chances of conception, because lifestyle can have profound effects on the reproductive functions of women and men. This means that increasing your fertility potential is something that you both can do without outside help: you can adopt healthy ways of eating, you can eliminate habits that may diminish fertility, and you can make sure your weight is within the range that's conducive to starting a pregnancy.

Think of this as a wellness program: Like an athlete, you'll be training for optimal performance. Not only can you enhance your prospects for a pregnancy, but as healthy parents you will be better prepared for the physical work of raising a child. Here are some simple strategies to pursue right now.

Keep Your Exercise Moderate

Women and Exercise

Getting enough exercise is an important part of helping your body to function well. But some women do so much exercise that it can be counterproductive, especially as far as fertility is concerned. A Harvard study by Dr. Rose E. Frisch examined the health of over 5300 women who had been athletes in college and found that strenuous or elite-level exercise appeared to impair fertility, which was often demonstrated by a lack of menstruation and ovulation. The most obvious indication that you are exercising too much if you want to become pregnant is having light or irregular periods or none at all. Professional or dedicated women athletes who want to have a baby need to cut back to much lessstrenuous levels of exercise or stop their workout programs altogether.

For the woman who already is experiencing infertility, Dr. Alice Domar and her colleagues at the Harvard Mind/Body Program for Infertility recommend that although giving up all exercise can be difficult for a woman who is concerned about weight gain or is used to exercising vigorously, she stop all exercise for three months to make sure exercise isn't a factor. Even when menstruation and ovulation appear normal, exercise can cause a decrease in progesterone levels that might prevent an embryo from implanting. Dr. Domar has seen a number of pregnancies result when women stopped exercising. Stretching routines, yoga, and relaxed strolls (under two miles) are good tension reducers and can be useful substitutes for vigorous exercise. A yoga program should be supervised by someone familiar with the effects of infertility treatments on the body.

Drs. Kevin Loughlin and Robert Barbieri, however, feel that a simple reduction in the number of miles women (and men) run or bicycle or in the hours they spend working out is sufficient to overcome most exercise-related fertility problems. Since exercise can affect body fat and a person's body mass index (BMI), its effect on fertility is difficult to sort out.

LILLIAN'S STORY

In her job as a supervising chef at a well-known restaurant, Lillian was on her feet for eight to ten hours a day, with little opportunity to relax. "Our food had to be amazing, day after day, because we had a reputation to maintain. Something often goes wrong. It was exciting but demanding." In addition, Lillian ran for recreation and to keep fit. At five feet eight inches, she liked to keep her weight at 120 pounds. When she started attending the Mind/Body Program for Infertility, she had been trying to get pregnant for two years and the cause of her infertility couldn't be explained. She was thirty-three years old.

When she learned about the possible connection between too much exercise and infertility, Lillian slowed down. She gave up running and walked more slowly at work. As part of her effort to take life more easily, she also practiced the relaxation routines and meditation exercises taught in the program. "Overall, I became much calmer. For a month I gave up trying to get pregnant. I relaxed about everything, I didn't worry about when to have intercourse — and I got pregnant in six weeks. It was entirely unplanned." She now has a less demanding job and takes care of her baby.

Men and Exercise

Men can work out more than women without adversely affecting their fertility, but many research studies have found that high levels of exercise and endurance training can lead to a decrease in testosterone levels, negatively affecting libido and sperm health. Furthermore, men who are extremely lean can also experience marked drops in their testosterone levels, and may lose their interest in sex and their ability to have erections. Long-distance runners and scullers trying to keep to a lighter weight are examples of men who may experience infertility because of a combination of high-level exercise and lean bodies with little fat. These effects can be reversed with a modest weight gain.

We also should mention that over fifty miles a week of bicycling on a hard, narrow seat may lead to impotence. Studies have shown that sitting for long periods on such a seat can flatten the artery that controls blood flow to the penis. This type of bicycle seat may also cause nerve damage. Impotence specialists recommend switching from a solid seat to a type that has an oval opening built into the saddle. Various seats are available at bike stores.

Eat Well

An important influence on fertility is attaining a level of good nourishment that permits your body to function as it should. Bad eating habits can reduce the reserves of nutrients necessary for reproductive hormone systems to work properly. Inadequate nutrition also may weaken your immune system to the point where any sickness might diminish your fertility. This isn't just a woman's issue; men who don't get enough of certain vitamins and minerals may have low sperm counts and low testosterone levels.

It's important to eat regular, adequate meals — at least three a day — and to choose foods that are rich in nutrients and low in fat. And we recommend that you have one or two nourishing snacks every day as well. Good snacks help you avoid the temptation to reach for empty-calorie foods high in fat and sugar.

Eat More Fruits and Vegetables

This is the time to heed nutritionists' advice about stepping up the number and variety of fruits and vegetables you eat every day — currently the recommendation is five to eight servings per day. That may sound like a lot, but one serving can be as little as a couple tablespoons of raisins or a handful of fresh peas or grapes.

If you're not an enthusiastic vegetable/fruit eater and want to make each serving count the most, every week eat at least several dark green and orange/yellow vegetables such as Swiss chard, kale, sweet potatoes, and carrots, as well as red, orange, and yellow fruits. Deep-colored foods tend to have more nutrients. For instance, pink grapefruit has more nutritional value than white grapefruit, and watery-but-red watermelon is surprisingly nutritious.

GOOD HEALTH TIP

To make salads more nourishing, use lettuces such as romaine, Boston, or greenleaf (iceberg lettuce is not rich in vitamins) and include fresh spinach. Real time-savers are the lettuce mixes sold by most supermarkets. Because they contain a variety of greens, both flavor and vitamin content are better. For a change of pace that's quick, toss a leafy salad with a minimum of low-calorie dressing, and add several slices of ripe pear or mango to each serving. This looks elegant and tastes delicious.

A word about salad dressings: If you can wean your family from their favorite bottled dressings, it's cheaper and usually lower in fat and calories to mix a jar of your own. Do as Europeans do and toss the entire salad with just 1 or 2 tablespoons (or less) of dressing to barely coat the leaves so that the taste of the greens comes through.

Salad dressings taste better if they're made a day or two (or more) beforehand, well mixed, and stored in the refrigerator. Or mix your dressing right in the salad bowl as you start dinner preparations. Try crushing a garlic clove, then adding two parts olive oil, 1/4 teaspoon of Dijon mustard, one part wine or cider vinegar or lemon juice, a drizzle of honey, and pepper to taste. Letting the dressing warm up to room temperature 30 to 60 minutes before tossing it with the greens enhances its flavor.

Although vegetables provide much of the vitamins, minerals, and fiber you need, if you are a vegetarian and are trying to improve your fertility, be sure that you're getting enough protein. Women who are vegetarians may have fertility problems because they have skewed levels of reproductive hormones: they metabolize estrogen into inactive products more quickly, and have longer menstrual cycles than women who include meat in their diets. Moreover, you are much more likely not to menstruate if you are both a runner and a vegetarian.

GOOD HEALTH TIP

One of the easiest ways to get enough fruit and vegetables is to use them as between-meal snacks. Supermarkets sell packages of baby carrots, cherry tomatoes, and assortments of bite-size pieces of melon that are easy to pack along to the office or to nibble on while watching TV. You can spend a few minutes cutting up broccoli and cauliflower or else buy a small vegetable party platter from your supermarket and use it for salads and snacks all week. (To wash away insecticides and other possible contaminants, thoroughly wash all precut vegetables and salad greens in water, add a few drops of dish detergent, then rinse well, before eating.)

To make a good accompaniment for fresh and cooked vegetables, add fresh dill, other herbs, or garlic powder to plain yogurt. And simply adding fresh spinach or slices of fruit to salads dramatically increases their nutritive value.

Snacks Can Be Good for You

Don't be afraid to eat snacks between meals. Choose snacks that are low in fat and salt, taste good, and make you feel satisfied, so that you can override any yearnings for high-sugar, high-fat foods. Keep several on hand for those times when your energy is flagging or you have the greatest cravings for junk food. See the box that follows for ideas for between-meals foods.

To make a snack more satisfying, combine carbohydrate foods with protein foods. If you don't want to gain weight, check the portion size and calorie amount listed on the food label to help you determine how big a snack to eat.

Snacks are also more satisfying if you eat them slowly and mindfully. Be aware of how much you're eating, how full you feel, and how it tastes. Avoid eating while you're doing something else to lessen the risk of thoughtless munching. Serve yourself one portion and put the rest of the food away. When you're very hungry and preparing a meal, nibble on chunks of raw vegetables such as sweet red or green peppers, cucumbers, or celery instead of reaching for potato chips. A more nutritious substitute for chips are whole-grain crackers such as Wasa Crispbreads, Kavli, Finn Crisp, whole wheat matzos, and Whole Foods Baked Woven Wheats.

Food Supplements Help

In addition to eating a fruit- and vegetable-rich diet, both men and women should take a multivitamin/mineral supplement. Taking a single multivitamin/mineral tablet avoids the danger of taking too much of one vitamin or mineral. Megadoses of vitamins should be avoided, especially if they're fat soluble. Fat-soluble vitamins, such as vitamin A or vitamin D, are not readily excreted and can build up to toxic levels in your body, a particular concern if you're trying to get pregnant. This doesn't mean you should avoid these important vitamins, but just be sure not to take doses that are over the federal recommended daily allowance (RDA) without the advice of a nutritionist or doctor. RDAs are listed on the labels of vitamin bottles.

WARNING: LIMIT YOUR VITAMIN A

At any time it's wise not to take too much vitamin A, but this is especially important when you are expecting to have a child. A study of 22,000 women showed an apparent increase in the number of birth defects when pregnant women took over 10,000 international units (IU) of this vitamin. To be on the safe side, nutritionists recommend you choose a multivitamin that contains only 5000 IU of this vitamin. This allows you to also eat a lot of foods every day that are rich in this vitamin and in beta carotene, its precursor.

Folic Acid. A woman hoping to get pregnant should take a daily supplement that includes at least 400 micrograms (mcg) of folic acid. Folic acid is a synthetic form of folate (one of the B vitamins), and is now available in most multivitamin/mineral tablets and as a supplement in a few food products. Folic acid helps prevent anencephaly and spina bifida, birth defects of the brain and spinal cord, respectively. It's vital to have enough of this vitamin in your body before you conceive as well as afterward because such defects can occur within the first thirty days after the egg is fertilized. (It's also important, however, not to take more than 1000 mcg of folic acid unless your doctor or other health care provider clearly advises it.) Although you can get folate from foods, it is only half as available to the body as folic acid. The simplest approach may be to get the recommended minimum of 400 mcg every day in a multivitamin and think of the folate in foods as a bonus.

Calcium. During their reproductive years (and afterward) women also should consume about 1200 milligrams (mg) of calcium every day. To get that much, you will need to eat or drink at least three 8-ounce servings of dairy products, such as low-fat or nonfat yogurt and milk, or healthy fortified foods such as calcium-fortified orange juice. Read the product labels — they list serving size and the amount of calcium per serving.

If you can't eat enough calcium-rich food every day, a good way to make sure you're getting enough of this important bone preserver is to take a supplement. Calcium carbonate, calcium lactate, calcium citrate, or calcium citrate malate all are good, readily digested supplements. They are best absorbed when taken with a meal in doses of 500 mg or less. If you can't take your supplement with meals, calcium citrate is the form most easily digested on its own. Check the labels to make sure the form you buy is low in lead. Calcium derived from bonemeal or oyster shells can contain higher levels of lead. At all ages, everyone, male and female, should consume at least 1000 mg of calcium every day.

Zinc. Men, too, may benefit from taking a daily multivitamin supplement, particularly one that contains the RDA of zinc, which some researchers found is associated with the production of healthy sperm. An adequate level of zinc in the body is needed for the testicles to function normally. A deficiency in this important mineral also may decrease libido and contribute to impotence, probably by reducing testosterone levels. Other studies have found that a lack of zinc can reduce sperm count; however, the benefit of oral zinc on male infertility is still uncertain.

Increase Your Body Fat

For a change, this is not a suggestion to lose weight, unless you are very overweight. Like too much exercise, being too thin can delay puberty or slow down or stop menstrual periods entirely. To be able to reproduce, you must store a minimum amount of body fat. Teenagers need to have a certain amount of body fat in order to start having periods. A decrease in body fat can cause menstruation to stop. Women whose body mass index is below 17 are more likely to find that their periods have become further apart, are light, or have stopped, compared to women of normal weight for their height.

Body mass index describes body weight relative to height and is strongly correlated with total body fat content in adults. Its numbers apply to both men and women. The normal body mass index for adults is between 20 and 27. A six-foot-tall person who weighs 221 pounds or a person who is five feet six inches and weighs 186 pounds will each have a BMI of 30 — and both would be considered excessively heavy. The new BMI guidelines, as developed by an expert panel, define overweight as a BMI of 27 to 29.9 and obesity as a BMI of 30 or more.

You can calculate your own BMI by multiplying your weight in pounds by 703 and dividing that amount by your height in inches squared. (For example, the square of 68 inches tall is 68 x 68, or 4624 inches.) If your weight is 150 pounds, and you multiply that by 703 you'll get 105,450. Dividing 4624 into 105,450 reveals a body mass index of 22.8 — well within the normal adult range.

The hypothalamus, which governs reproduction in both women and men, receives information from other sensors located in the brain. External factors such as stress, temperature, nutrition, and physical effort influence the hypothalamus. A combination of intense exercise and little body fat affects women and men much the same way: the hypothalamus secretes too little gonadotropin-releasing hormone (GnRH) or releases it in an abnormal pattern, which in turn affects the timely secretion of other reproductive hormones that are important to normal fertility in either sex. Produced in the hypothalamus, GnRH controls the production and secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which in turn stimulate the ovaries and testicles.

In our female ancestors, this action of the hypothalamus probably evolved to ensure that conception would occur only when the woman's body had enough fat calories stored to nourish a fetus and then allow ample breast-feeding. Women who became pregnant when they were thin probably lost their babies or didn't survive themselves. This may have been the process of natural selection that led to the fact that women today carry more fat than men — about one-fourth of female weight normally is in fat.

Excessively thin women have difficulty reproducing. We can see the effect of too little body fat today in women athletes who don't ovulate or who ovulate but can't get pregnant, even though their body mass index may be in the normal range. That's because most of their body is made up of muscle and, despite having a normal BMI, they don't have enough fat. Men's bodies, too, need some fat for them to maintain normal testosterone levels and healthy sperm. Body weight doesn't always reflect the amount of fat a body contains.

In addition, having a lower than normal BMI, even without strenuous exercise, may cause ovulation to stop "silently" — menstruation may continue and may seem normal, but ovulation doesn't occur. According to Harvard scientist Rose E. Frisch, the infertility that could result from this can be reversed by weight gain or less exercise, or both. Furthermore, a very restrictive diet can lead to low levels of progesterone, slow the growth of egg follicles (the fluid-filled pockets in which eggs grow), and inhibit the surge of luteinizing hormone (LH) that facilitates ovulation.

More recently, researchers have found that very thin women who gain weight and increase their body fat in order to conceive need to wait until their BMI is in the normal range before they try to get pregnant. Women who are on the low end of the BMI normal range may have difficulty in maintaining a pregnancy. Women need sufficient fat reserves to nurture a fetus.

Men whose BMI is 18 or less also may have reduced fertility. They are likely to experience a loss of libido and have decreased amounts of the prostate fluids that carry the sperm out of the penis and protect them after ejaculation. In addition, their sperm will be less active and shorter-lived. As in women, weight gain restores these losses.

Reduce Your Body Fat

The other extreme — having too much body fat — in women, at least, is also associated with long periods between menstruation (thirty-five days or more), a lack of menstruation, and infertility. An overweight body produces higher than normal levels of certain hormones that then inhibit ovulation. The pregnancy rate for overweight women — women who have a body mass index that's higher than 27 — often is reduced.

Exactly what hormonal changes take place when women have too much body fat is not entirely known, but researchers have seen that hormone levels return to normal and menstrual cycles become more normal when overweight women lose even as few as fifteen pounds. It appears that many women must be within a certain BMI range to have normal ovulatory cycles. Just as gaining weight can restore ovulation if you're too thin, losing weight can be very effective if the cause of your ovulation problem is overweight.

Drinking: Women Should Stop; Men Should Be Moderate

The effects of drinking beer, wine, or liquor on pregnancy have been studied for many years, but until recently there was little information available on the specific effects of moderate or no alcohol intake on reproductive capability. Studying more than 1000 infertility patients and 3800 women who recently gave birth, Harvard researchers in 1994 found that women who were "moderate" drinkers — who usually had one drink a day — experienced a slightly greater rate of ovulatory infertility. This risk was greater in women who had more than one drink a day. Endometriosis, however, in which fragments of the lining of the uterus are found in other parts of the pelvic cavity, was more common in women who drank, regardless of the amount. Both of these problems are linked to hormone function, which appears to be affected by alcohol intake.

Furthermore, in 1998, two studies emphasized the negative effects of alcohol on fertility: In a Danish study of 430 couples, women who drank moderately (fewer than five drinks a week) reduced their chances of conception, compared to women who didn't drink alcohol at all. In fact, the ability to become pregnant decreased steadily in a direct relationship to the amount of alcohol intake. Among women who had more than ten drinks a week, the odds of getting pregnant were about half those of the women who had fewer than five per week. The couples studied were between the ages of twenty and thirty-five and were trying to conceive for the first time. Among the male partners no association was found between alcohol intake and the couple's rate of conception. Most of the women in this study drank wine.

Research at Johns Hopkins University reinforced the Danish findings: Women who avoided both alcohol and caffeine were more than two and a half times as likely to conceive as women who consumed any alcohol and drank more than one cup of coffee a day. The highest conception rate was among women who didn't drink, didn't smoke, and had less than a cup of coffee or its equivalent per day.

Alcohol and Miscarriage

Alcohol also can endanger a pregnancy. According to some studies, the risk of spontaneous abortion (miscarriage) appears to increase with moderate drinking during the early weeks of pregnancy, particularly the first ten weeks. If a woman has one drink a day during the first trimester of pregnancy, her risk of a spontaneous abortion is about double that of the woman who doesn't drink at all. Other research, however, particularly in Europe, has not confirmed this association, so more studies are needed to resolve the issue.

In addition to the possibility that moderate alcohol intake may lead to ovulatory infertility or to a miscarriage, two or three bottles of beer or glasses of wine or two mixed drinks per day can have a detrimental effect on fetal development. Babies may be born with fetal alcohol syndrome, a combination of birth defects that result from this level of alcohol consumption by the mother during pregnancy. An embryo can be affected by any toxins in its mother's system, especially during the first two to six weeks of its development, a time when many women don't realize they are pregnant. And a chronic high blood-alcohol level during the third trimester may cause a growth deficiency and contribute to mental retardation in the infant. Practically speaking, there is no safe level of alcohol intake during pregnancy.

In men, some studies have found a link between heavy drinking and a reduction in testicle size, infertility, and/or decreased libido and impotence. Although the Danish study we mentioned shows no relationship between drinking alcohol and male fertility, other researchers have found that alcohol consumption produces significant changes in the shape of sperm and their ability to move. Furthermore, in men who are chronically heavy drinkers, the sperm production structure of the testicles becomes damaged so fewer mature sperm develop. Research shows that having more than one drink a day can interfere with testosterone secretion, reducing a man's sex drive and ability to produce mature sperm.

If you want to enhance your chances of conceiving, the bottom line seems to be that women should give up alcohol, coffee, and cigarettes and men should moderate their use of these stimulants.

Decrease Your Caffeine Consumption

Since 1988 there have been numerous studies regarding the effects of caffeine on a woman's fertility. Although the results are not totally definitive, there is enough information to recommend that you be cautious in your caffeine intake. A 1997 report on more than 3000 women in five European countries said that women who drank more than five cups (500 mg) of brewed coffee a day experienced delays in conceiving. This delay was increased if the woman was a smoker. The Johns Hopkins research on alcohol and caffeine consumption shows that more than a single cup of coffee a day can have a negative effect on fertility. And an earlier U.S. study found that a woman's chances of becoming pregnant were reduced if she drank more than three cups (300 mg) of brewed coffee daily. Furthermore, the combination of smoking and coffee drinking was associated with a significantly increased risk of delayed conception. We should point out that most coffee today is sold in 8-ounce cups that, on the average, hold 135 mg of caffeine, which is more than the 100 mg cups the studies describe. Three cups of takeout coffee will equal 405 mg of caffeine.

Caffeine also may be linked to a higher-than-normal risk of miscarriage, but the jury still seems to be out on this issue. A recent large study in Connecticut found a strong link between caffeine consumption and spontaneous abortion, while an even larger study in California found no such association.

Figure Out Your Caffeine Intake

If you want to estimate your caffeine intake, measure what your mug or cup holds. A full 8-ounce cup of most brewed coffees has approximately 135 mg of caffeine, a cup of instant coffee has 65 mg, a cup of tea 50 mg, 12 ounces of a soft drink contain 60 mg, and 12 ounces of a diet soft drink provide 78 mg of caffeine. Decaffeinated coffee has only 2 mg per 8 ounces. Cups of coffee offered at some coffeehouses may supply more than 135 mg of caffeine, however. The amount can vary from one establishment to another and from one type of coffee to another.

Some over-the-counter drug products also contain significant amounts of caffeine. These include NoDoz, a product designed to help people stay awake, and the headache painkillers Excedrin and Anacin. One tablet of Maximum Strength NoDoz provides 200 mg and one tablet of Regular Strength has 100 mg of caffeine. Two tablets of Excedrin add up to 130 mg of caffeine and two tablets of Anacin together have 65 mg.

Even though the question of the effect of caffeine on the length of time it takes to conceive is not entirely settled, you may want to enhance your chances by switching to decaffeinated coffee or tea. If you're a serious coffee drinker, reduce your consumption very slowly — by a half cup per week — to avoid withdrawal problems such as headaches or fatigue.

Give Up Nicotine, Marijuana, Cocaine, and Steroids

Tobacco smoking has been linked to reduced fertility in both women and men. In addition, a recent British study has found an association between smoking and stillbirths, low birthweight babies, and sudden infant death syndrome (SIDS). A woman who smokes is likely to have less chance of becoming pregnant and giving birth when treated with in vitro fertilization (IVF) than a woman who doesn't smoke. This is especially true if she smokes twenty or more cigarettes a day. A mechanism that may link cigarette smoking and reduced pregnancy rates following IVF is the observation that smoking appears to accelerate the rate of egg loss. Women who smoke have the elevated hormone levels that indicate a depleted supply of eggs and prematurely aged follicles.

For men, anything that may lead to atherosclerosis, such as untreated diabetes or hypertension or even health habits such as smoking and a high-fat diet, may damage blood vessels and impair blood flow, leading to impotence. A good blood supply to the penis is necessary to achieve an erection.

Marijuana has been linked to an inability to perform sexually and to diminished fertility. It also has been associated with increased levels of female hormones in men and to the development of abnormally shaped sperm. This has the effect of reducing the production of LH and therefore decreasing the levels of the male hormone testosterone.

Cocaine may have a negative impact on sperm development. Recent animal experiments have shown that it damages the cells that produce sperm.

Steroids commonly used by men to build more muscular bodies can also inhibit the ability to have a baby. Thought by some to improve sexual performance, they actually act as a male contraceptive by depressing hormone secretion and interfering with normal sperm production.

Men should avoid using a testosterone patch, pills, or shots unless they are under a physician's supervision. In addition, men should be aware that their use of testosterone may have the effect of depressing or shutting off the secretion of follicle-stimulating hormone and luteinizing hormone, which govern the production of sperm.

In most cases, if you stop using these substances, sperm production eventually returns to normal, although it can take at least one full cycle of sperm production — seventy-four days — before most sperm are healthy and show up in normal amounts in your semen.

Check Out Your Medicines

A number of prescription drugs have been reported to have a negative effect on the male reproductive systems, including the ulcer drug Tagamet (cimetidine), some antibiotics, and antihypertensive medications. For example, the use of a class of high blood pressure medicines known as calcium channel blockers can interfere with the ability of a sperm to penetrate the outer membrane of an egg.

In women, thyroid replacement therapy may affect ovulation, depending on how carefully thyroid hormones are maintained at normal levels. Ovulation may be impaired in women who have low thyroid hormone levels, so when they are on thyroid replacement therapy, the levels of pituitary hormone (which controls the thyroid) in their blood should be monitored regularly and carefully kept in the normal range.

As a couple, tell your physicians early on the you're trying to get pregnant and that you're concerned about the effects of medicines on your fertility. It's a good idea to remind your doctors about this every time they start to write a prescription for either of you.

MEDICATIONS LINKED TO MALE INFERTILITY

Chemical or Generic Name

Spironolactone is a component of several antihypertensive drugs; it may impair production of testosterone and sperm.

Sulfasalazine is found in a few medicines used for irritable bowel disease, colitis, or Crohn's disease. It adversely affects normal sperm development. Drugs with mesalamine can be substituted, instead.

Colchicine and allopurinol are used to control gout and can affect the ability of sperm to fertilize.

Antibiotics including tetracyclines, gentamicin, neomycin, erythromycin, and nitrofurantoin (in extremely high doses) can negatively affect sperm generation, movement, and density.

Cimetidine, the active ingredient in Tagamet, can sometimes cause impotence and semen abnormalities. Drugs with ranitidine and famotidine, however, do not seem to have the same effect.

Cyclosporine is used to improve graft survival in organ transplants but may have a detrimental effect on male fertility.

Be Careful with Herbal Remedies

Several popular herbal preparations probably should be added to the list of substances to avoid if you want to protect your fertility. Although many people believe that because herbs are "natural" they're safe, those that have druglike effects on the body do contain potent chemicals. Like some over-the-counter or prescription medicines, some herbal remedies may interfere with normal reproduction.

Three herbs that were tested in laboratory studies on human sperm and on hamster eggs produced adverse effects in either the sperm or the eggs, or both. Researchers at Loma Linda University School of Medicine in California have found that tiny amounts of St. John's wort, echinacea purpurea, and ginkgo biloba made the eggs impossible or difficult to fertilize, changed the genetic material in sperm, and reduced a sperm's viability.

The researchers pointed out that their laboratory work indicated only a potential risk. They said it was possible that people who did not exceed the recommended doses would not experience negative effects, and in the human body such doses might not actually reach eggs and sperm. However, it should be noted that, in the lab, the eggs and sperm were exposed to only minute fractions of the herbal preparations.

Blue cohosh, an herbal dietary supplement long used by some midwives and American Indians to induce labor, is also sold as a menstrual remedy and could be dangerous for women of childbearing age.

In the laboratories of the U.S. Food and Drug Administration, blue cohosh produced significant birth defects in rat embryos, such as nerve damage, twisted tails, and poor or absent eye development. The research was done in 1996-98 by Dr. Edward J. Kennelly, now at the City University of New York. The herb is also known as blueberry root, squawroot, or papooseroot.

Have Infections Treated Right Away

Women should have any vaginal or cervical infection, such as bacterial vaginosis, trichomoniasis, chlamydia, or yeast, treated immediately because the discharge may stop sperm from entering the uterus.

Men should have urinary tract infections treated promptly because some urinary tract infections, especially those involving the epididymis, may diminish long-term fertility.

Avoid Exposure to Toxins Such as Solvents and Pesticides

Studies have linked specific pesticides, chemical solvents, dusts, and other substances in the environment to instances of infertility in women and abnormal sperm or low sperm production in men.

Pesticides. Frequent exposure to lawn and farm chemicals can be harmful, especially those applied as a spray, because the sprays can drift some distance and be inhaled unknowingly. When using any sort of weedkillers, fungicides, or pesticides, wear a mask, long pants, long shirtsleeves, and vinyl (not latex) gloves. If you work on a farm, or in any environment where toxins may be present, you may want to invest in a mask with replaceable charcoal filters (available at hardware stores) and to wear protective clothing consistently.

Dust and Solvents. Protect yourself not only around chemicals but in situations where there's a lot of dust in the air, including dust from grains and from woodworking, particularly when the wood has been pressure-treated with preservatives. You should also wear similar protection when using volatile solvents such as paint thinners and turpentine and make certain that your work area has extremely good ventilation. To be on the safe side, this concern should apply to home projects as well.

Lead and X rays. Severe lead intoxication — seen most often among lead battery workers — can have a negative effect on both male and female reproductive systems. In addition, the reproductive organs of you and your partner should be protected against radiation when medical X rays are taken.

Men — Avoid Hot Water and Tight Pants!

The germ cells in the testicles that produce sperm work best in temperatures slightly below normal body temperatures. If the temperature within the testicles is elevated by only two, three, or four degrees Fahrenheit, both sperm and testosterone production are negatively affected. To keep the testicles cool, the scrotum (the skin sac that holds them) loosens up so that the testes are held away from the body. But if you wear tight jeans, bicycle shorts, or leather pants that hold the testicles close against your body, their temperature may rise. This also may happen if you wear undershorts made of nylon or other artificial fibers, even if they're not tight. Such fabrics hold in more heat than cotton and wool, materials that "breathe." Keeping your genital area cool also helps avoid infections that thrive in warm, moist places.

Spending time in hot tubs, Jacuzzis, and saunas, and taking long, hot showers or baths also overheat the sperm cells and may significantly impair sperm function.

One of the many scientists in Cambridge, Massachusetts, was fond of doing much of his thinking while having a long soak in a hot bath every day. After he and his wife had tried to conceive unsuccessfully for many months, she did a little research of her own and then firmly requested that he switch to taking short, tepid showers and do his thinking elsewhere. This tactic has proved successful — they're now the parents of four children.

Maximize Your Lovemaking

Small changes in how you conduct your lovemaking can help sperm reach the uterus more easily:

* If you use a lubricant, choose it carefully. Better still, avoid them. Even though they're not designed to kill sperm, some nonspermicidal gels are gooey enough to reduce the number of sperm that get into the cervix. Even the presence of hand lotion or saliva in or near the vagina can slow down or kill sperm.
* Don't douche because it may wash out sperm you need.
* The best position for intercourse when you are trying to get pregnant is the traditional one, in which the man is positioned on top of the woman, because this allows his penis to penetrate deeply and puts the sperm close to the cervical entry to the uterus.
* After lovemaking, it's thought to be helpful if the woman lies still for twenty to thirty minutes, giving the sperm more time and opportunity to find their way into the uterus. A pillow under your hips can help the ejaculate slip toward your cervix.
* Once you know that you're ovulating, the conventional wisdom is to have intercourse every other day. There doesn't seem to be any reason, however, for not making love as often as you want during the two or three days just before and one day immediately after ovulation, when cervical mucus is receptive and your temperature chart or ovulation kit indicates that this is your fertile period. (Methods for detecting ovulation are discussed in Step 3.) However, don't feel that you need to "schedule sex" — this idea easily could have an inhibiting effect.

Learn to Reduce Stress

If possible, try to cut back at work and/or reduce the amount of traveling in your schedules for a number of months. If you can't reduce your responsibilities at work, do make a point of not taking on any extra projects at home. Tip the scales in your favor — make this a special time for the two of you to kick back and relax. Several relaxation techniques are discussed in Step 4, along with other ideas for reducing stress and being good to yourselves.

Copyright © 2000 by the President and Fellows of Harvard College

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Introduction

Introduction


As doctors dealing with fertility problems, we see, listen to, and ultimately help hundreds of people to get pregnant each year. We know how concerned you become when another month passes and conception has not occurred. We know a great deal about your dreams and aspirations — and your frustrations and sense of failure. And we wanted to write this book to answer many of the questions and concerns we hear daily from you in our offices. Most of all, though, we wanted to write this book to reassure you that most of you will be able to conceive. Research has shown that although 20 percent of couples will be unable to achieve a pregnancy after a year of unprotected intercourse — the current definition of infertility — most of them will eventually achieve a successful pregnancy. Very few people have physical conditions that make it impossible to have a child, and in many cases, simple lifestyle changes and low-tech strategies can make a decisive difference. Besides, one year is far from a magic number — age and health differences and many other factors will influence your own chances of becoming pregnant.

If you do have difficulty getting pregnant, there is a great deal more you can do about it today than ever before. While assisted reproductive technology can help a large number of couples previously infertile, many couples can be helped by our greater knowledge of how lifestyle factors like stress, exercise, and nutrition affect conception, of better ways to regulate and target ovulation cycles, and of common medicines to avoid that can inhibit sperm and egg production. So much attention in the media is focusedon the latest high-tech intervention that many people forget to give nature enough of a chance.

Each of us is an expert in a particular area affecting fertility. Dr. Barbieri, chairman of obstetrics and gynecology at Brigham and Women's Hospital, specializes in physical problems women have in getting pregnant. Dr. Loughlin, professor of surgery at Brigham and Women's Hospital, specializes in physical problems men have in conception. And Dr. Domar, the director of The Mind/Body Center for Women's Health at The Mind/Body Medical Institute, specializes in how the mind and emotions affect conception. We are delighted to be able to bring our separate viewpoints and expertise to this book. Like three pieces of a puzzle, we provide information that separately shows only part of the picture, but taken together creates a clear blueprint for success.

In this book we take a step approach to dealing with infertility. Just because we have sophisticated technology doesn't mean that everyone needs to make use of it. We believe that couples should always try the simplest, safest approach first before advancing to a more complicated and often more stressful and expensive intervention. In fact, for some of the steps in this book, you don't need a doctor at all.

Along the way you will meet a number of patients who have experiences similar to your own, and a host of tips and suggestions for maximizing your natural fertility.

But we will also tell you when it is time for the next step — the kind of tests and doctors that would be most helpful — and give you enough information to be sure you are getting the best available care. And because many couples are so anxious to get pregnant that they are tempted to skip important steps and jump to procedures that may not be necessary, we remind readers to always get a second opinion after a diagnosis and before starting a course of treatment.

One of the pleasures of this book is that you can start right now — today — without making a doctor's appointment, to improve your chances of conception. We hope this book can help bring you knowledge, peace of mind, and ultimately, a successful pregnancy.

Copyright © 2000 by the President and Fellows of Harvard College

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