Lifestyle in NICE guidance – part 3 – Fertility

Fertility is such a sensitive subject for many, with 1 in 7 couples struggling to conceive. It’s also a topic I’ve become more interested in over the past few months. I undertook a short course from Monash University (Melbourne) in the relationship between Fertility, Pregnancy and Nutrition.

I am also so, so pleased and excited to see fertility becoming more talked about on social media. By raising awareness I feel society will become more aware and educated about the issue. The Gynae Geek this week posted a really important post on a topic I often have discussions with family members who are in a similar position – being asked ‘when are you having children’? It might be the societal norm to get married, have children, maybe have another. Before you ask this question think, what good is it going to do? What if they really, really want a child, but are struggling to conceive? What if they’ve just had a miscarriage and are really hurting? What if they just don’t want children and don’t feel they need to explain this choice?

On the flip side I’ve really enjoyed seeing social media posts raising the awareness of fertility, educating people what they can do to give them in the best possible chances of conceiving – such as the work of Dr Larisa Corda, and factual non-scare mongering advice about pre-, during, and post-pregnancy Dr Brooke Vandermolen.

I’ve also felt so inspired and in awe of Dr Zoe Williams sharing her journey so openly, discussing social infertility and the questions and options people face when going through this experience. She’s also a strong advocate of fertility education in schools alongside sex-ed, which I full-heatedly support – check out this YouTube video: https://www.youtube.com/watch?v=ETwDCKBaYd4.

Fertility Youtube.png

Today, keeping along the theme of my Lifestyle Medicine in NICE Guidelines, I’m going to talk about the guidance: “Fertility problems: assessment and treatment” (clinical guideline CG156). This guidance encompasses a lot of medical treatment and investigation options. I do recommend couples who have been struggling to conceive for a year (maybe a few months less if older) go to see their GP to start investigations into possible medical causes for reduced fertility. This said, I thought these guidelines provided me with an opportunity to share some of the ‘low hanging fruit’ lifestyle measures which can increase your chances of conceiving a baby. I hope these help educate and empower people to make healthy lifestyle choices which can improve your health for now and the future, and even potentially your unborn child. I also hope they can raise awareness to any medical professionals here that this guidance exists and feel more confident discussing this with their patients.

Just a couple of things before we start:

  • This guidance relates to the UK, different countries have slightly different recommendations, such as pre- and during pregnancy nutritional supplements.
  • As always, this is a stripped-down version of the guidance, for the full guidance I’ve left a link to it at the bottom.

Principles of care

  • Couples who experience problems in conceiving should be seen together because both partners are affected by decisions surrounding investigation and treatment

Psychological effects of fertility problems

  • When couples have fertility problems, both partners should be informed that stress in the male and/or female partner can affect the couple’s relationship and is likely to reduce libido and frequency of intercourse which can contribute to the fertility problems.
  • Those who experience fertility problems should be offered counselling because fertility problems themselves, and the investigation and treatment of fertility problems, can cause psychological stress.

Chance of conception

  • People who are concerned about their fertility should be informed that over 80% of couples in the general population will conceive within 1 year if:
    • The woman is aged under 40 years and
    • They do not use contraception and have regular vaginal sexual intercourse.
  • Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate over 90%).
  • Inform people who are concerned about their fertility that female fertility (and to a lesser extent) male fertility decline with age:                                                                                                                   Annual fertiity rate per age.jpg
Picture source: https://www.nice.org.uk/guidance/cg156/chapter/Figures-and-tables-to-support-chances-of-conception-and-embryo-quality-recommendations
  • People who are concerned about their fertility should be informed that vaginal sexual intercourse every 2 to 3 days optimises the chance of pregnancy.
    • Sperm last 5 days in the woman, and an egg once released can be fertilised for 24 hours – you don’t need to be doing it every day (and in my experience discussing this with patients it can make it mechanistic and take some of the fun, joy and connection out of sex), but do do it a few times a week.

Alcohol

  • Women who are trying to become pregnant should be informed that drinking no more than 1 or 2 units of alcohol once or twice per week and avoiding episodes of intoxication reduces the risk of harming a developing foetus.
  • Men should be informed that alcohol consumption within the Department of Health’s recommendations of 3 to 4 units per day for men is unlikely to affect their semen quality.
    • Men should be informed that excessive alcohol intake is detrimental to semen quality.

Smoking

  • Women who smoke should be informed that this is likely to reduce their fertility.
    • You should offer referral to a smoking cessation programme.
  • Inform couples that passive smoking is likely to affect their chance of conceiving.
  • Men who smoke should be informed that there is an association between smoking and reduced semen quality.

Eligibility criteria for fertility treatments on the NHS does vary according to where in the country you are. The effect of smoking on fertility is so great that for some services you will not be eligible to have treatments on the NHS if either partner smokes.

Caffeinated Beverages

Obesity

  • Women who have a body mass index (BMI) of 30 or over should be informed that they are likely to take longer to conceive.
  • Women who have a BMI of 30 or over and who are not ovulating should be informed that losing weight is likely to increase their chance of conception.
  • Women should be informed that participating in a group programme involving exercise and dietary advice leads to more pregnancies than weight loss advice alone.
  • Men who have a BMI of 30 or over should be informed that they are likely to have reduced fertility.

One thing I learned in the course I did at Monash University, which I think can be encouraging and motivating, is that if someone (a man or woman) is significantly over a healthy weight, a weight loss of just 5-10% can help regulate hormones associated with sperm production and ovulation to encourage a healthy pregnancy.

Low body weight

  • Women who have a BMI of less than 19 and who have irregular menstruation or are not menstruating should be advised that increasing body weight is likely to improve their chance of conception.
    • Functional hypothalamic amenorrhea could be at play here

Tight underwear

  • Men should be informed that there is an association between elevated scrotal temperature and reduced semen quality, but that it is uncertain whether wearing loose-fitting underwear improves fertility.

Prescribed, over-the-counter and recreational drug use

  • A number of prescription, over-the-counter and recreational drugs interfere with male and female fertility.

Folic acid supplementation

  • Women intending to become pregnant should be informed that dietary supplementation with folic acid before conception and up to 12 weeks’ gestation reduces the risk of having a baby with neural tube defects. The recommended dose is 0.4 mg per day. For women who have previously had an infant with a neural tube defect or who are receiving anti-epileptic medication who have diabetes a higher dose of 5 mg per day is recommended.

Just a note about semen analysis. This will likely be conducted in initial investigations into subfertility. I often think results can be surprising, here’s what is considered normal:

sperium-2505952_1920.jpg

  • semen volume: 1.5 ml or more
  • pH: 7.2 or more
  • sperm concentration: 15 million spermatozoa per ml or more
  • total sperm number: 39 million spermatozoa per ejaculate or more
  • total motility (percentage of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility
  • vitality: 58% or more live spermatozoa
  • sperm morphology (percentage of normal forms): 4% or more.

 

I hope this helps and/or you found this interesting.

For the full guidance see here: https://www.nice.org.uk/guidance/cg156/chapter/Recommendations

Emma x

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