Q&A about fertility claims with Sense About Science
We ran a Q&A with Sense About Science about fertility claims. Sense about Science has recently teamed up with Progress Educational Trust and the British Fertility Society to help people Ask for Evidence behind fertility claims.
Fertility is a global industry and there are hundreds of claims out there. But which ones are based on evidence that they work? A team of experts answered your questions about claims against fertility enhancing foods, supplements, policies and products. They also spoke about the effects of age and stress on fertility.
Dr Allan Pacey - senior lecturer in andrology and chairman of the British Fertility Society
Allan's research interests cover the biology of human spermatozoa and aspects of semen quality and fertility in males, including occupational and environmental influences on semen quality.
Dr Gillian Lockwood - medical director of Midland Fertility
Gillian has a special interest in age-related infertility, Polycystic Ovary Syndrome and nutrition.
Dr Susan Avery - director of assisted conception at Birmingham Women's Hospital
Susan has been working in the field of infertility for 30 years as a clinical embryologist.
Q. raydown: Is there anything that can be done to improve a very low sperm count or to improve poor morphology? There are lots of supplements that claim to help but is there any evidence that they do?
When going through IVF [in vitro fertilisations] and ICSI [intra-cytoplasmic sperm injection], is there anything the couple should do to prepare themselves? Is there a special diet that should be followed?
A. Allan Pacey: There is very little evidence to suggest that specific diets or supplements can improve the sperm count, although there is some evidence that men who have diets which are high in antioxidants on average have better quality sperm. Although many of the supplements aimed to boost male fertility have been formulated on reasonable assumptions, there have been no head-to-head comparisons to recommend one above the other. The best advice anyone can give is to make sure a man has a well-balanced diet and is consuming at least five portions of fruit and veg per day.
Q. joycep: At my fertility clinic all IVF women were given strict instructions to drink at least a litre of milk per day, before and during IVF. They said getting a lot of protein was imperative. Is there any truth behind this? Is milk really the best way to get your protein quickly, especially as there are question marks about whether dairy is actually good for humans?
A. Susan Avery: Fertility is affected by general health in the same way as every other function of the body, so a healthy diet may help to optimise your chances. If your diet is lacking in protein then you should address this in the interests of general health and a balanced diet. There is no evidence that milk in particular will help. Milk can cause problems for some people, aside from those known to be lactose intolerant, in particular people who suffer from acid reflux. Just aim for a balanced diet in a way that suits you. There's nothing magic about milk.
Q. Triplespin: Can we take supplements to improve egg quality or can this not be altered? If so, what do you recommend?
A. Gillian Lockwood: It is unlikely that egg quality can be improved, the best we can do is avoid damaging it by smoking, obesity etc. I always recommend a multi-vitamin (with folic acid and iron) for all patients having fertility treatment (or trying to get pregnant naturally). There has been very interesting work published in Fertility and Sterility which found that women on a high carbohydrate diet where less than 25% of their daily calories came from protein, even when they were not overweight, had a significantly lower pregnancy rate and higher miscarriage rate than women on a high protein, low carbohydrate diet.
Q. joycep: Should people undergoing IVF quit refined sugar? There are claims that it has a negative impact on the way the follicles develop. Is this true?
A. Susan Avery: Everyone should aim for a healthy diet, and that includes reducing refined sugar. There is a huge amount of advice out there – some of it contradictory, and very little of it underpinned by evidence. Aim for a healthy balanced diet rather than focussing on a particular aspect of your diet.
Q. Bue: What are some concrete, evidence-based actions (if any) you can take to improve motility and morphology of sperm?
A. Allan Pacey: The quality and quantity of sperm men ejaculate is a function of many factors such as the size of testicles, the time since last ejaculation as well as aspects of lifestyle, illness, infections and diet. It would be a tall order to devise an intervention to improve sperm health. A better way of looking at it is for the man to remove himself from known harm so that the sperm he ejaculates are the best possible quality. We know that men who work with solvents such as glycol ether or who wear tight underwear generally ejaculate lower numbers of motile sperm. In addition, men who have used cannabis in the last 30 days are more likely to have sperm of poor morphology. Smoking cigarettes is likely to damage sperm DNA. If these risks are removed and the man has a healthy diet, then this is likely to have a positive impact on sperm health, although the exact study to show that has not been done.
Q. victoria401: My husband and I have been classed as infertile as he has 100% antisperm antibodies. I was surprised to find out that many labs don't routinely test for this, and maybe this could explain some of the unexplained cases of infertility. I've read that taking high doses of vitamin C and a supplement called Tribulus Terrestris could help unbind the antibodies and give us a chance of conception. Can this do him any harm to try?
A. Allan Pacey: Testing for sperm antibodies in the laboratory is very difficult to perform with any certainty, and moreover the national quality control programme was stopped a few years ago because it was almost impossible to provide what we call 'external quality control'. If you combine this with the fact that doctors are uncertain about the role of sperm antibodies in male fertility and it is not clear how to use the data to guide clinical decisions, you can appreciate why many laboratories no longer perform the test. Indeed in 2004 NICE (National Institute for Health and Care Excellence) recommended that the test was not done and as far as the World Health Organisation recommendations are concerned, it has only been an optional test for many years. I am unaware of any supplements or potions that can remove sperm antibodies and would be most cautious about using them for this purpose.
Q. FizzyFeet: Are there any supplements that can have a negative effect on your chances of conceiving? I'm thinking of herbal ones like agnus castus which seem to have a powerful effect.
A. Gillian Lockwood: There are two problems with supplements. The most significant is that they can act as hormone mimics and interfere with baseline hormone assessments and monitoring. The best example is soya extract, which can be helpful with menopausal symptoms because it acts a little like oestrogen. Agnus castus has been found to help with a wide range of female problems including pre-menstrual dysphoria, lumpy breasts and even hyper-sexuality (it is the fruit of the chaste tree, after all). The second problem is the source and purity of the supplements. This is especially relevant for traditional Chinese medicine, as the practitioner may be treating in good faith but using imported substances of dubious provenance (one pile of powdered bark looks much like another).
It is reasonable to assume that if the supplement seems to be having a powerful effect then it is active, and women should not take these supplements during active fertility treatment.
Q. MoreTeaPenguin: Is there any evidence that DuoFertility is more effective than placebo?
A. Gillian Lockwood: The current crop of smart fertility aids like DuoFertility, Fertilicare Conception and Kindara fertility tracker are all designed to make measuring BBT [basal body temperature] more accurate (and possibly more fun). I feel that anything that takes the spontaneity out of love-making is more likely to be counter-productive however. Partners often get performance anxiety when told it is the right time, and sex can become a chore to make babies rather than a glue to stick couples together.
Sperm works best when young, and waiting for the right time can result in a large number of half-dead sperm being delivered. Frequent intercourse (every two to three days) from the end of one period to the start of the next is probably better than anything electronic. For women with very irregular cycles (probably PCOS – polycycstic ovary syndrome), then weight loss (if required) and ovulation induction are likely to be the way forward.
Q. onelubelife: I'm interested in the claims around sperm-friendly lubricants. What's the evidence or otherwise for using sperm-friendly lubricants when trying to conceive?
A. Allan Pacey: We know that some lubricants used by couples during intercourse can be bad for sperm when ejaculated sperm are incubated with those lubricants in the laboratory. This also includes human saliva which is also used by some couples as a lubricant. However, there is no epidemiological evidence to suggest that these actually reduce the chances of conceiving, although it is a reasonable assumption. There are some sperm-friendly lubricants available on the market and under laboratory conditions these do not appear to be detrimental to sperm survival. However, to my knowledge they have never been tested in couples to see if they enhance conception, but it would seem reasonable to assume they do not do any harm if they are used according to the manufacturers instructions.
Q. Anon (via Sense About Science): Is there evidence that folic acid and inistol together assist fertility and the chances of IVF working?
A. Gillian Lockwood: Inofolic (a combination of inositol and folic acid) is a new product specifically formulated to assist the fertility prospects of women with polycycstic ovary syndrome (PCOS) whether they are trying to conceive spontaneously or with IVF. Taken as a nutritional supplement, there are good clinical trials suggesting that it improves cycle regulation and reduces the hyperandrogenism (raised testosterone) that causes some of the distressing features of PCOS such as excess facial hair, acne and obesity. Taken in conjunction with Clomid, it improves the ovulation rate in women with PCOS.
Q. joycep: When I had IVF, I was given steroids and IVIG (intravenous immunoglobulin) treatment because my immune results showed I had an overactive immune system. The clinic had excellent results with this treatment, with many women finally having a successful pregnancy after multiple failed treatments elsewhere.
It is not accepted by NHS doctors and most are not even willing to have a conversation about it. Is this because there just isn't enough evidence for this treatment at this time?
A. Susan Avery: There is a lack of real scientific evidence for this type of immune therapy, and certainly in the NHS we are concerned about offering expensive treatment, for which patients would have to pay, about which we remain unconvinced. It is true that some very successful private clinics offer this treatment, get very good results and believe in this treatment. It is arguable that they would have achieved these results without IVIG, but very difficult to prove.
In the world of fertility treatment there is a great deal of criticism of the use of unproven treatment for which patients have to pay, while there is also a great deal of frustration for patients who are unable to access treatments that they have been lead to believe will help them. We would rather offer treatment supported by evidence and we hope our patients understand that we do this in their best interests as we see them.
Q. Tranquilitybaby: Why aren't progesterone levels tested as standard as soon as a woman gets a positive pregnancy test result and if deemed low, a progesterone supplement given as they do in the US?
A. Susan Avery: The majority of centres automatically give progesterone (so there is no need to do a progesterone level test) following embryo transfer and the NICE Guidelines recommend this.
Q. Magda37: Does sexual position affect chance of conceiving?
A. Allan Pacey: Unless there is a disability or an anatomical reason to prefer one sexual position over another, I cannot see the rationale for this affecting the probability of conception. When sperm are ejaculated into the woman's body, we think that the sperm that pass through the cervix quickly are the ones that will find and fertilise an egg. Any sperm remaining in the vagina probably die quickly and are lost. There is at least one study showing that after a fertility treatment called IUI, a 10 or 15 minute bed rest can improve pregnancy rates slightly, but I don't think sexual position matters as long as the male is able to ejaculate into the vagina.
Q. ballsballsballs: When we were going through fertility tests I was astonished by the number of people around me who told me that a positive attitude was everything, that if we relaxed a pregnancy would miraculously happen, or we should go on a holiday. I found no evidence that any of these things could improve sperm quantity and motility. We looked at the figures and decided not to go ahead with IVF.
A. Susan Avery: Anything that has a positive effect on your general health may impact on your chances of conception. However, if you have some identified pathology that is responsible for your infertility then no amount of relaxation will give you a pregnancy without treatment. Most people have come across a story of a couple who struggle to conceive, stop thinking about it and then achieve a pregnancy. Stress can impact on hormone levels and other aspects of physiology involved in conception, and reduction in stress might coincide with conception in couples where there is no other cause. By all means relax and have a holiday, but you will still need treatment for infertility.
Q. ballsballsballs: A lot of people on the fertility forum I used to frequent were convinced that acupuncture would help the success of IVF. Is this true?
A. Susan Avery: In 2010 the British Fertility Society published a review of the existing data/publications and found no evidence that acupuncture has a positive effect on the outcome of IVF. Another review published in 2012 saw no clear benefit, but found that the type of clinical trial influenced the outcome. In any case, it is difficult to say with any conviction that acupuncture has a direct influence on the outcome of IVF.
Q. joycep: There are so many stories out there of people who tried for years and years and then they gave up and got pregnant. Stress is known to contribute to infertility. But what about worry and negativity? Is there any evidence to suggest that it can prevent a pregnancy?
A. Susan Avery: Most women are aware that stress can affect their menstrual cycles, just as it can affect so many aspects of our physiology. A relaxed state is a healthier state to be in, and worry/negativity are really aspects of the conditions we call stress/depression. It is certainly possible that these conditions may inhibit conception, and their removal may improve the chances of achieving a pregnancy. However, a positive attitude is not a cure for infertility where there is identified pathology. We would always encourage a positive attitude, and as relaxed a state of mind as possible for the sake of general health.
Q. Anon (via Sense About Science): Is there evidence that acupuncture and reflexology assist your chances of getting pregnant?
A. Gillian Lockwood: The evidence is conflicting and rather weak. Some studies have found a benefit but others have found that it is not helpful. One study compared real acupuncture with sham acupuncture and found no benefit of sticking the needles in the right place. Indeed an article published in Human Reproduction in 2009 found that placebo or sham acupuncture had a higher pregnancy rate than real acupuncture. Clearly acupuncture can produce strong placebo effects. The perceived benefit of acupuncture may lie with the stress reduction and relaxation it can induce.
Q. Tinkleybison: What is your view on undertaking acupuncture to help with unexplained infertility? This has been suggested to us by the NHS clinic we are attending but I would like to know if the science justifies the cost.
A. Gillian Lockwood: Acupuncture aids stress management and stress has been associated with unexplained infertility (via raised prolactin and cortisol levels). The frequency of unexpected pregnancies that occur when couples give up fertility treatment and go on holiday are good evidence for this.
Q. YouAreMyFavouriteWasteOfTime: I would like to see more scientific information about fertility decline and aging. Information in the news appears to be low on statistics and high on scaremongering, and unhelpful to people wanting to understand the real changes that will/are taking place in their body.
A. Gillian Lockwood: The science is clear. Ever since Malcolm J Faddy first dissected thousands of ovaries taken from foetuses, babies, girls and women of all ages, we have known that a baby girl is born with every egg she will ever have and that they are lost at a predetermined rate influenced principally by genetics but also by health and lifestyle. Smoking, surgery, endometriosis and infection can all damage the ovary's ability to ovulate fertilisable eggs.
The quantity and quality of eggs remains perfectly adequate until the late thirties and then there is, on average, a decline in both from the age of about 37-38. It is at this age that the risk of miscarriage starts to rise along with the risk of chromosomal problems like Down's Syndrome. It is vital to remember that biological age and chronological age can vary by three years in either direction, so if you are a life-time smoker and your mother had an early menopause (before 50), then it is likely that at age 35 you will have the ovarian reserve of a 40 year old. Don't forget that ovarian reserve is only one factor in getting pregnant successfully, and that sperm quality, tubal status, general health and uterine factors such as the presence of fibroids and polyps all play a role.
Q. LadyIsabellaWrotham: There's been a bit of a backlash recently regarding the Daily Mail's favourite scary statistics about declining fertility in age 35 plus women. Whilst much of the revisionist data seems well-founded, I do worry that all the 'stop panicking' articles concentrate on reassuringly high chances of getting pregnant at older ages, but never seem to factor in the significantly higher risks of miscarriage to give you the odds of an actual baby. What do you think?
A. Gillian Lockwood: Data from Denmark which looked at the outcome of 1.2 million positive pregnancy tests demonstrates conclusively that whereas at age 35 only 15% of positive tests will fail to produce a live birth, by the age of 40, it is 40% and by 45 the miscarriage rate is 75%. Healthy lifestyle (normal weight, no smoking or drinking or caffeine with a low carbohydrate intake) can help a little, but principally the problem is that embryos that are made (in vivo or in vitro) from oocytes that have been stuck half-way through their second meiotic division for 30 years are highly likely to be structurally genetically abnormal. The eggs will fertilise and may implant, but Mother Nature does a ruthless quality control check at about 5-6 weeks and this is when the vast majority of these early pregnancy losses or blighted ovum cases occur. When this tissue is examined cytogenetically, significant chromosomal errors are found in the vast majority of cases.
Last updated: almost 2 years ago