The role of exercise and physical activity in improving fertility, quality of life and emotional well-being

THE FERTILITY SOCIETY OF AUSTRALIA - The role of exercise and physical activity in improving fertility, quality of life and emotional well-being.

Overweight and obesity impair male and female fertility and reduce the chance of spontaneous
and assisted conception. Weight management (preventing weight gain, achieving weight loss
and maintaining a reduced weight) is crucial in preventing and treating infertility. Both physical
activity (any movement by the body over the day) and exercise (planned or structured physical
activity) are key components of weight management.

EVIDENCE REVIEW:

Exercise and female fertility
Evidence suggests that moderate regular exercise positively influences
fertility and ART outcomes. In 26,955 women, vigorous activity (70-89
per cent of maximum heart rate or a rate of perceived intensity of 14-16
on the BORG 6-20 scale [1]) was associated with reduced risk of ovulatory
infertility [2]. Among 216 obese women undergoing ART, those who
exercised regularly had better outcomes than their sedentary counterparts,
independent of weight loss. Exercisers’ pregnancy and live birth rates were
39 per cent and 16 per cent respectively compared with non-exercisers’
16 per cent pregnancy and 7.4 per cent live birth rates [3]. A systematic
review of eight studies in 3,683 couples assessed the relationship between
maternal physical activity before IVF/ICSI cycles and ART outcomes.
Women who were physically active (variously defined) had higher clinical
pregnancy (OR 1.96, 95% CI 1.40, 2.73) and live birth rates (OR 1.95,
95% CI 1.06, 3.59) compared to physically inactive women [4].
However, high volume or intensity exercise regimes appear to reduce
fertility. A systematic review of 14 studies reported an increased risk of
anovulation in women exercising >60 minutes/day while those undertaking
vigorous activity for 30-60 minutes/day had a reduced risk of ovulatory
infertility [5]. A case-control study of 346 women reported that ≥60
minutes/daily exercise in the year prior to attempting conception was
associated with an increased risk of infertility compared to never exercising
[6]. A population-based health survey found that subfertility was associated
with vigorous (exercising daily or to exhaustion) but not with lower
intensity or frequent exercise [7].
There are few studies of the effects of exercise interventions prior to
assisted or spontaneous conception. A systematic review identified three
exercise intervention studies in infertile women or women undergoing
fertility treatment. Pooled data showed that the physical activity intervention
groups had higher pregnancy (RR 2.10 95% CI 1.32, 3.35) and live
birth (RR 2.11 95% CI 1.02, 4.39) rates compared to no treatment
controls [8]. However, the interventions were very variable and ranged
from health-promoting lifestyle education, aiming for 10,000 steps/
day to structured programs of up to six times/week walking or resistance
training. Furthermore, two of the interventions also achieved differences
in weight loss (3.3-5 kg) between intervention and controls. It is therefore
difficult to draw any conclusions regarding the amount or type of exercise
required or if exercise independent of weight loss would also achieve
reproductive benefits.
A systematic review identified seven studies examining the effect of exercise
(ranging from low impact aerobics, cycling and combined aerobic/
resistance training either in isolation or in combination with dietary
changes) on fertility in overweight and obese women with polycystic
ovary syndrome (PCOS) or anovulatory infertility [5]. The interventions
improved reproductive outcomes including ovulation, menstrual patterns,
pregnancy and fertility. While one study reported that exercise resulted
in greater improvements in menses and ovulation frequency compared
to diet alone [9], another reported that diet was as effective as aerobic or
combined aerobic and resistance training in improving menstrual regularity
[10]. Most studies also report reproductive improvements associated with
weight loss. For example, studies of the effects of 12-24-week lifestyle
interventions comprising diet, exercise and/or behavioural change in
overweight infertile women with or without PCOS report modest weight
loss, improved ovulatory and menstrual regularity and reduced risk of
miscarriage compared to pre-intervention [11-14]. Most participants
in these studies conceived and gave birth after spontaneous or assisted
conception [11,12].

Exercise and male fertility
Being physically inactive is associated with idiopathic infertility in men
[15]. This may be through altering semen quality. A systematic review
investigated the effect of physical activity on semen parameters and identified
32 papers which overall reported recreational exercise (moderate or high
intensity) was associated with improved semen quality in both men
from the general population and men with infertility [16]. The review
also found that very high levels of exercise (for example in elite athletes)
or specific exercises (such as cycling) may have detrimental effects on
some aspects of sperm quality [16]. This is also shown in a randomised
controlled trial, where semen parameters declined in men in the high
but not in those in the moderate intensity exercise group [17]. Other
studies found no relationship between sperm quality and exercise in men
attending an infertility clinic [18,19] except for bicycling ≥ five hours/
week being associated with reduced sperm concentration and motility
[18]. This supports that the potential negative effect of exercise on semen
quality relates to intensive training or specific exercise modalities [20].
The beneficial effect of exercise on sperm quality may relate to total or
abdominal adiposity. One study found that waist circumference, independent
of exercise, was inversely correlated with sperm count [21] and in another
a 16-week exercise intervention in obese men from the general population
improved sperm parameters and reduced abdominal obesity [22]. There
is limited research examining the effect of exercise prior to assisted or
spontaneous conception in men. In 556 infertile men randomised to
resistance and aerobic exercise (60 minutes three times/week) compared
to no exercise for 24 weeks, exercise resulted in improvements in weight,
abdominal fat, semen parameters, sperm DNA fragmentation, oxidative
stress, proinflammatory cytokines, and pregnancy and live birth rates [23].

The effect of exercise on quality of life and emotional well-being.
Exercise improves psychological parameters. From a systematic review of
56 studies in healthy males and females, 3-6 months of light or moderate
intensity exercise improved quality of life related to physical health (effect
size (ES) 0.22, 95% confidence interval (CI) 0.07, 0.37, p psychological health (ES 0.21 95% CI 0.06, 0.36, p no exercise [24]. In infertile women with or without PCOS undergoing a
six-month lifestyle intervention (diet, exercise and behavioural intervention)
prior to assisted reproduction, improvements in self-esteem and symptoms
of depression and anxiety were observed [11, 12]. In women with PCOS,
three RCTs [27-29], a case control study [30] and one single-arm case
series [31] assessed quality of life following exercise interventions and
reported improvements in depression scores, body image distress and
health related quality of life. The interventions varied in time from
16-24 weeks and types of exercise which included self-directed walking
programs, continuous or intermittent aerobic exercise, resistance training
and diet in conjunction with aerobic or resistance exercise interventions.
It is therefore not possible to determine the optimal amount or type of
exercise for improving psychological health and emotional well-being.
Furthermore, quality of life was equally improved for diet alone, diet and
aerobic exercise, or diet, aerobic and resistance exercise. Psychological
improvements were associated with weight loss in some of the studies,
indicating that improvements in quality of life may also be related to
positive changes in weight or diet.

SUMMARY

There is some evidence that moderate exercise benefits fertility and that
high volume or high intensity exercise may adversely affect fertility.
There is conflicting evidence about whether exercise is more effective in
improving menstrual function, ovulation or quality of life compared to
diet in overweight women with PCOS. There is high quality evidence in
the general population and moderate quality evidence in infertile women
with or without PCOS for the effect of exercise on improving quality
of life. As many studies prescribe exercise as part of a multidisciplinary
lifestyle program, it is difficult to separate the effects of exercise from
other dietary and behavioural components. It is often not possible from
the interventions to determine the type, intensity or duration of exercise
needed to achieve optimal reproductive benefits or if exercise benefits
outcomes independent of weight loss. Further research is required to
determine the optimal intensity and modality of exercise prior to pregnancy
in fertile and infertile couples, the effect of exercise in combination with
and independent of other lifestyle or weight changes and the effect of
exercise on quality of life in infertile men.
Recommendations
National and international evidence-based physical activity guidelines
exist for the general population and are relevant to men and women
preconception. These should be highlighted to all couples seeking ART
by the medical team and accrediting bodies. Australia’s Physical Activity
& Sedentary Behaviour Guidelines for Adults recommend a minimum
of 150 to 300 minutes per week moderate intensity or 75 to 150 minutes
per week vigorous intensity or an equivalent combination of moderate
and vigorous intensity aerobic activity. In addition, they recommend
incorporating muscle strengthening exercises on two or more days of
the week, to minimise the amount of time spent in prolonged sitting,
and to break up long periods of sitting as often as possible [31]. These
recommendations are consistent with international evidence-based
guidelines for PCOS management which also apply to infertility
management in PCOS [32]. For men and women who are overweight
and obese, achieving and maintaining a modest weight loss may improve
fertility and will improve other obesity-related morbidities. Exercise is an
important component of obesity management. International guidelines
for obesity management recommend 225 to 300 minutes per week of
moderate intensity physical activity for overweight or obese adults [33].

For more information about pre-conception health visit www.yourfertility.org.au

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