SART Fertility Experts - Wellness and Fertility: Diet, Sleep and Exercise

Drs. Timothy Hickman and Rashmi Kudesia discuss the links between lifestyle and fertility. This conversation covers diet, physical activity, stress and sleep management, and common-sense approaches to incorporating wellness and lifestyle medicine into a clinical approach to infertility treatment.

Okay, welcome. This is Dr. Timothy Hickman. I'm the current president of SART.

I'm very pleased today to be meeting with one of my colleagues, Rashmi Kudesia. Now, Dr. Kudesia is not only double-boarded in reproductive endocrinology and infertility and obstetrics and gynecology, but also in lifestyle medicine. So that's very pertinent to our topic today, which is going to be on things one can do in an evidence-based fashion to improve one condition for an IVF cycle.

So, Rashmi, would you mind telling us a little bit about what lifestyle medicine is? Wonderful. Thanks, Tim, and it's great to be having this chat, and I would love to start with that. So, lifestyle medicine is a fairly new board certification that is available and growing rapidly, actually.

There's an increasing number of board-certified physicians across all specialties. They also offer certifications through the American College of Lifestyle Medicine for other healthcare providers. But as for physicians, I think it's a really attractive board certification because lifestyle medicine is really common-sensible.

So, it's kind of focused on six pillars of well-being that include healthy eating patterns, really focusing on a whole-food, plant-based diet, getting sufficient sleep, sufficient physical activity, stress management, reduction of toxic substances, and achieving social connectedness. So, those are kind of the six areas that we try to encourage. And truthfully, you know, I can't think of a single field or specialty of medicine where at least one, if not all of those things, is definitely relevant to our patient's overall health.

So, it's kind of been a nice adjunct to my REI certification. Well, perfect. Well, with that information, tell us what you would do if you had a patient approach you and was getting ready for IVF.

What are some of the things you'd help her along with as far as preparation? Yeah, and I think this is really important because there are a number of studies that have tried to look at, you know, what component of perhaps unexplained infertility may be due to lifestyle factors. And obviously, that's a difficult question to answer, but you know, some studies have indicated that there could be a substantial portion of unexplained infertility or IVF failure that could be related to or potentially responsive to lifestyle interventions. So, you know, when we look at the body of data, there's oftentimes more than people are aware of.

So, I always start with diet as the first thing. You know, there are a number of studies that have looked at a Mediterranean-style diet as a component of, you know, sort of a management plan that can assist in getting better embryos, higher quality embryos in the context of IVF. And so, that's the first thing I always talk about and kind of go into with patients what that means.

And one of the things I really like to clarify about that is that a Mediterranean diet isn't about eating Mediterranean cuisine, it's about the components of what you're eating. So, really trying to get lots of fresh vegetables and fruits in there, reducing consumption of processed junk food, fast food, trying to get those healthy fats in there, you know, watching ultra-processed white flour carbohydrates, so more whole grains rather than the white rice, white bread, white pasta. And then also, from a proteins perspective, you know, plants and fish being better than, let's say, red meat.

And, you know, there is also a whole body of literature just around, you know, other terminology, but similar fertility and pro-fertility diets that have been studied that really all revolve around that same piece of what we're doing. And in fact, also a separate study that showed that increasing fast food consumption and decreasing fruit consumption were both associated with a longer time to pregnancy. So, there's kind of a lot of different studies we could pull together to make the argument that the type of eating that we would generally advise folks to do for their overall health can definitely benefit their reproductive health, whether they're trying to get pregnant on their own or, you know, in the preparation for IVF.

So... Well, let me challenge you a little bit there, saying, you know, we've all seen we have a relative or something who they don't mind their diet, they don't exercise, they don't do any of these things you've talked about, yet they're as fertile as can be. So, how much do you think this is really helping as far as someone's ability to get pregnant? And then tell us the extent. So, for example, if you did this, all these interventions for someone that was 46, probably wouldn't have much of a benefit.

So, can you kind of go into that a little bit? Yeah, sure. So, you know, I think there's a number of components to that. So, first is, I think that, you know, we all see that with the reproductive system, just like any other organ system, there are levels of susceptibility that folks have.

And one of the things that I often talk to my patients about is, for example, you know, stress is a very good example of this. And that's actually what I wrote my fellowship thesis on. So, it's an area I'm very passionate about.

So, if you think about stress, right, we know that, you know, there's going to be some 45, 50 year old CEO somewhere that has a super high stress job. And, you know, there's going to be two of them, and they may have the same exact job description. And one of them is going to have a heart attack at 50.

And the other one is going to be just fine and have perfect cardiovascular health, you know, indefinitely. And that's just the cardiovascular system having different susceptibility. There's genetics, there's maybe other components of lifestyle, there's, you know, a whole host of things that we might identify.

And I think the reproductive system is similar. I mean, we all see that we have patients that, you know, I often say, you know, okay, if you had final exams, and you were stressed when you were in college, and your cycle, you know, skipped a cycle because you were stressed, then you might be the kind of person that's susceptible to that, as relates to how it manifests in your reproductive health, and other people have, you know, all kinds of things that they're doing, and they managed to get pregnant. So it's not a one to one, I don't think that every person that makes poor lifestyle choices is going to have infertility as such.

But I think of it more the other way, which is that ultimately, when patients are coming through, they're struggling a lot, you know, we know that infertility inherently, you know, imparts a lot of psychological distress on our patients. And I think that many of them are searching for, you know, what are all the things that they can do. And in addition to kind of putting their faith in their fertility specialist, I think it can actually be really empowering to give them something to do to and to give them back a sense of control over, you know, the components that they can do to try to help themselves to succeed.

And in fact, some of the research that I've done did demonstrate that that just by talking about lifestyle and giving patients, potentially some avenues for improving their lifestyle that they reported an increased sense of control and diminished distress over their infertility moving forward. And so I think it really behooves us in terms of the patient experience and their quality of life and anxiety levels to think about these topics from that aspect as well, whether or not it makes, you know, all of the difference. And, of course, you're absolutely right that, you know, it's not going to undo the impacts of, you know, age related fertility decline, or we're not going to go from, you know, complete azoospermia to a totally normal sperm count.

But I think, you know, when it comes to IVF, especially sometimes we're talking about one extra egg or one extra embryo making the difference between success and not. And so sometimes, you know, tweaking on the margins is enough to get somebody to where they're going. And there's never a harm to making these lifestyle changes.

These are all common-sensical, good things for us. So I definitely feel that the benefits outweigh the risks in this situation. Fair enough.

So you mentioned some things about diet. Are there any other interventions that you would suggest? Yeah, absolutely. So along the lines of things we eat and drink, there are also studies that have showed that more moderate or more than moderate alcohol consumption can reduce egg and sperm quality through that entire fertility process.

So that's one thing that I talk to patients about. And, of course, you know, all of this in terms of what we're consuming in lifestyle, you know, can, it's, you know, not a perfect measure, but obviously body mass index is one way that we have to think about, you know, somebody's overall health status. And we do know that, you know, as the body mass index rises into the more severe obesity classes, that there can be an impact on IVF success from that angle as well.

So, you know, there's multiple angles from which to come at this. But I think, you know, focusing on habits and lifestyle change is probably the most patient sensitive way. But the data kind of supports it, you know, in a number of ways that we might look at it.

Aside from those things, sleep, there's a number of studies and actually even a systematic review and meta-analysis that looked at sleep, demonstrating that if we get below six hours of sleep for men or for women can definitely have an impact on fertility. And even sort of that thing that we often maybe all experienced as residents, where you go back and forth between night shifts and day shifts. So that kind of rapid switch in terms of our circadian rhythm can potentially have a negative impact on fertility as well.

So, you know, always talk about sleep and then finally stress management. I already mentioned that stress is a really difficult thing to talk about. You know, what people perceive is not something that we can necessarily measure, doesn't always correlate with objective measures, which is why we're not running around measuring cortisol levels necessarily for folks, you know, thinking about fertility.

But there have been studies that have showed that salivary alpha amylase, which is one marker of stress, correlates with time to conception. So the higher the levels of salivary alpha amylase, the longer the time to conception. And so, you know, I think there's some interesting data there.

And then also a really interesting study out of the Oba Health Study that looked at affect and coping mechanisms and how that impacts ovarian aging. And so it was a cross-sectional study, so not the most perfect setup for this, but it's a really, I think, enticing proposition that suggested that those patients that had a higher positive affect had a mitigation in terms of how ovarian reserve dropped over time. And so it's really interesting to think that, you know, when we think about what are the reasons why somebody may have lower ovarian reserve at any given age, that possibly there's kind of a psychological component to that as well, definitely needs more research, but kind of an interesting hypothesis.

So tell us some things you might be able to do to decrease those stress levels. Are there any things that seem to work? Yeah. So, you know, I'm a big proponent of acupuncture for that.

You know, I think I often tell patients that, you know, acupuncture is not data-driven to necessarily say that everybody that does it is going to necessarily have, you know, a positive pregnancy test, but there are the data on stress management as relates to acupuncture, especially, you know, in the case as we have and as many fertility specialists have of, you know, acupuncture providers that are well-versed in women's health and fertility acupuncture, you know, that that can have a positive impact on stress. But there's also supportive data for peer support groups. And so I often refer patients to RESOLVE, the National Infertility Association.

And obviously, again, for us, you know, and many others, we're fortunate to have a local expert-led support group, which is another thing that's been demonstrated to also help reduce patient distress during the fertility journey. And so that's another thing that I think can be really helpful. Lots of research coming from Alice Domar on sort of the patient experience and the ability for mind-body interaction and interventions to help improve IVF outcomes and patient experience during all of that.

I've heard a couple of things about exercise and massage being stress relievers. Can you speak to those? Yeah, I do recommend exercise as part of my stress management routine for my patients. Obviously, within reason, we don't want people to necessarily be pushing themselves too hard.

You know, there is an entire wealth of basic science data looking at women, you know, just in their natural menstrual cycle and showing, you know, subtle defects and the luteal phase and all this stuff for folks that are over-exercising. So, you know, trying to be thoughtful about that. And obviously, the activity restrictions we have during an IVF cycle, taking those into account as well.

But absolutely, I mean, we all know kind of from a physiological standpoint that exercise releases endorphins, is, you know, good for all the tension that we get from sedentary behavior in our muscles. And so there's just multiple good aspects to exercise on top of which we know that in our country with an obesity epidemic and, you know, the majority of women perhaps gaining more weight than they need to during pregnancy and the concerns over maternal mortality and complications during pregnancy that, of course, you know, maximizing fitness levels or at least improving them a little bit prior to pregnancy is only a good thing. So that's definitely something I would advocate.

You know, for those that I always say, you know, it can look, stress management can look a variety of ways and it has to be individualized and I think feel authentic to that person. So I usually say whether it's physical exercise, massage, yoga, meditation, mindfulness, acupuncture, or some combination thereof, you know, it just has to be, I think, something that somebody's giving credence to and making a plan for. And that's usually what I encourage my patients to do is to have a plan and to, of course, involve their partner in that.

You know, I think for those that have a partner going through this process, I think it's really important to address these things together as a couple. Excellent. Well, let's take an example of a patient.

Let's say a patient walks into you and she's diagnosed with polycystic ovarian syndrome. What are some specifics that you might suggest to her? Yeah, so I think PCOS is the perfect example and we have lots of, you know, big multi-center trials to look at, you know, some of these topics. So one of the big studies that looked at PCOS patients had three arms of intervention.

You know, one was four months of birth control, one was a very intensive lifestyle intervention with an aim of, you know, six to seven percent weight loss, meal replacements. There was a lot of support in that lifestyle intervention. So it was multi-modal and pretty intensive and then a combination of birth control and lifestyle.

And in that trial, we saw that either of the lifestyle arms had a much significantly improved ovulation rate and ultimately live birth rate over the birth control alone group. And so, you know, I think for those that have PCOS, particularly those that are trying to potentially ovulate on their own or get pregnant on their own or maybe are even trying to become responsive to ovulation induction medication, I think, you know, working on lifestyle is definitely important. And in a subsequent trial demonstrated that in women that are dealing with PCOS and obesity, that actually delaying pregnancy by two to three months to work on lifestyle actually resulted in a higher life birth rate than going straight to treatment.

So obviously, again, you know, to your point from before, we have to be thoughtful about who, you know, we're recommending what to. I think that wouldn't be appropriate for older patients. And that was, of course, not the suggestion of that study either.

But I think in young women that have PCOS, and particularly those that find that either their lifestyle is not optimal, or they're also struggling with weight management, I think it's absolutely important to talk about these issues. And I think to really emphasize the epigenetic and obstetric complications that can go along with not addressing these things prior to pregnancy. The last thing we want is, you know, to help somebody get pregnant by going straight to ovulation induction or IVF, and then boom, they end up, you know, with gestational diabetes, or maybe they had undiagnosed diabetes beforehand, you know, and end up with complications as relates to that.

And then, you know, maybe have a baby that is small for gestational age or large for gestational age, and then ends up with, you know, lifelong consequences as a result of that. So I think that's like the perfect patient population to really be thinking about lifestyle prior to pregnancy. Are there any other types of patient categories that lend themselves very well to this topic? Well, I think that ultimately, you know, interestingly, there was just a study that came out recently that was looking again at the pregnancy complications piece.

And they found in that study, that during pregnancy itself, either a Mediterranean style diet intervention, or separately, two separate interventions, a meditation oriented, or excuse me, a mindfulness oriented stress reduction intervention, both reduce the rate of small for gestational infant, small for gestational age infants in their study. And so I think, you know, from my perspective, I always think about, you know, again, what is the risk versus the benefits? And how are these things going to potentially help people to have a healthier pregnancy? And you know, I think pretty much it applies to everybody. And again, also, I think about, you know, the fact that many times our patients have these questions, and if we don't bring them up in the office, they're just googling it on their own, or they're reading about it, or talking to their friends, or they're on the forums, or whatever.

But the more I talk about it, the more I find that there's almost nobody that isn't interested in this topic that they don't want to, you know, I find it very rare that people are disinterested in what they might be able to do differently to succeed. So I guess I would argue it applies to everybody. But of course, we get some patients that already are leading a very healthy lifestyle, and they might just find it reassuring to know that they're already doing the majority of what they need to be doing.

And I think those folks need to be celebrated as well. So that would be my take. Are there any things that we haven't talked about that you want to touch on specifically? No, I think, you know, one of the things that's been really important to me about this whole topic, as I said, is that I personally, I'm a big believer that there can be positive clinical impact of really working on lifestyle or encouraging folks in lifestyle prior to pregnancy.

And I think the public health angle is a big one, which I'm surprised that, you know, more public health agencies haven't honed in on the fact that if we could help women be healthier prior to pregnancy, that it would have a big impact on maternal mortality, which is getting so much press right now. But I think not enough folks thinking about, well, what can we do prior to pregnancy to help reduce the risks of preeclampsia and gestational diabetes and whatnot. But then I also think, you know, obviously, in our specialty, a lot of it is business driven, and we're really looking to patient experience and patient retention and patient dropout.

And so I think even for the cynical amongst us, I think that it's hard to argue that, you know, paying attention to the softer sides of well being and, you know, sort of the mind body connection isn't going to attract, you know, more patients and help them to stay in treatment. And ultimately, that's how we help more people succeed by helping them be able to continue on. So I think, you know, I think no matter where you fall in your belief on how much lifestyle can make a difference, I think that there's benefits that exist.

Well, it's been an absolute pleasure to pull some of your expertise into this podcast. We hope our listeners have a great time enjoying these and all these wonderful points. We'd like to thank Dr. Rashmi Kudesia for all that she's done to get triple board certified to talk about this.

And again, this is Dr. Timothy Hickman, President of SART, and we're signing off. Thank you so much. Thank you.

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates. These are provided as a source of general information and are not a substitute for consultation with a physician.