Exercise and Fertility

Very interesting article from the Norwegian University of Science and Technology: Original article is at http://www.ntnu.no/news/hard-workouts-reduced-fertility, I copied the text below as I don't know how long the article will be up for.

Hard workouts -- reduced fertility
New research from the Norwegian University of Science and Technology (NTNU) shows that the body may not have enough energy to support both hard workouts and getting pregnant.

NTNU Info/Rune Petter Ness

Are you a female athlete – or just someone who likes challenging workouts -- who also wants to get pregnant? It may make sense to ease off a bit as you try, according to new research from NTNU.

Roughly seven per cent of all Norwegian women are believed to have infertility problems, which means that they are unable to become pregnant during the first year of trying - even if they might later become pregnant.

Infertility can have many causes, both medical and lifestyle-related. Known risk factors include smoking, stress, and alcohol. Being extremely under- or overweight can also play a role.

It is known, however, that elite sports women have more fertility problems than other women. But does extreme physical activity play a role in fertility among other women as well? NTNU researchers examined precisely this question in a study involving nearly 3,000 women. They found that overly frequent and hard physical exercise appears to reduce a young woman's fertility. But the decrease in fertility probably lasts only as long as the hard training.

Two vulnerable groups
The study was based on material from the Health Survey of Nord-Trøndelag from 1984-1986 and from a follow-up survey in 1995-1997. All of the women who participated were healthy and of childbearing age, and none had a history of fertility problems.

In the first survey, women responded to questions about the frequency, duration and intensity of their physical activity - and ten years later were asked questions about pregnancy and childbirth. The NTNU researchers also recorded other information that could have significance for the study.

“Among all these women, we found two groups who experienced an increased risk of infertility,” says Sigridur Lara Gudmundsdottir, a PhD candidate in NTNU's Human Movement Science Programme. “There were those who trained almost every day. And there were those who trained until they were completely exhausted. Those who did both had the highest risk of infertility.”

Age an important factor
If the women also were under 30 years old in the first study, the relationship became even more evident in both groups. Among those who reported training to exhaustion (regardless of frequency and duration), 24 per cent had fertility problems. In the group that had trained almost every day (regardless of the intensity and duration), 11 per cent reported the same.

Even when the data were adjusted for other possible contributing factors (such as body mass index, smoking, age, marital status and previous pregnancies), the researchers found that women who trained every day had a 3.5 times greater risk of impaired fertility as women who did not train at all.

“And when we compared those who trained to exhaustion to those who trained more moderately, we found that the first group had a three-fold greater risk of impaired fertility,” says Gudmundsdottir.

In women who reported moderate or low activity levels, researchers found no evidence of impaired fertility.

A transient effect
But the negative effects of hard training do not appear to be permanent, the researcher says.

“The vast majority of women in the study had children in the end. And those who trained the hardest in the middle of the 1980s were actually among those who had the most children in the 1990s,” she adds.

There may be various explanations for why the women who first were least fertile ended up with the most children. “We do not know if they changed their activity level during the period between the two surveys. Or if they just had trouble getting pregnant the first time, but afterwards had a hormonal profile that made it easier to get pregnant again,” Gudmundsdottir said.

Too demanding?
Scientists have a theory that high levels of physical activity are so energy intensive that the body actually experiences short periods of energy deficiency, where there simply is not enough energy to maintain all the necessary hormonal mechanisms that enable fertilization.

On the other hand, previous research shows that moderate physical activity gives women better insulin function and an improved hormonal profile - and thus better conditions for fertility - than total inactivity, particularly in overweight people.

Forget the easy chair
But Gudmundsdottir says that women who want to become pregnant shouldn’t give up all physical activity.

“We believe it is likely that physical activity at a very high or very low level has a negative effect on fertility, while moderate activity is beneficial,” she says.

But as far as identifying how much is “just right”, the researcher is careful. “An individual’s energy metabolism is a very important factor in this context. The threshold can be very individual,” Gudmundsdottir says.

She also recommends that physically active women be particularly aware of their menstrual cycles. “A long cycle or no menstruation at all is danger signals,” she says.

Cycles

I've been cycling reasonably regularly since that first post-Timmy O, if it's possible to say that after three cycles. The next cycle I O'ed on CD44, after *nine* days in a row of EWCM. I did start temping because I had a couple of days of EW at CD17-18, then at about CD23 I wanted to know if I had O'ed yet... and down the slippery slope I went. My temps then were higher than my pre-O temps had been before Timmy, although not quite as high as my post-O, so I had to keep doing it to make sure, right? So I O'ed CD44, and my EWCM dried up that day. Which made me re-evalute my O date from the cycle I mentioned below, I think it was a couple of days later resulting in a four day LP. My CD44 cycle my LP was six days - heading in the right direction!

We've been debating on whether to try and have a third baby for a long time, and after much angst (mostly on my part - I really really would like another baby, but practically it doesn't make a whole lot of sense. I decided that I've been practical all my life and this is one choice I really don't want to regret), have decided to go for it. So... the next cycle was the first that we actually 'tried'. I O'ed CD22 (yay!), but still only had a six day LP (boo!). I have to wonder if my body will ever have a normal LP. We're probably not going to find out for a while though, as I'm going to call my RE and get back on progesterone again after I O the next time.

Commencement

I don't post here much anymore, but I figure I'll keep updating with HA related stuff, as well as things related to my cycle so I remember them. I do come back to this blog quite frequently when I'm wondering about what happened when, or details about things that are no longer easily accessible to my poor addled brain, it's great to have as a reference.

So... I think I'm about to O again! I'm super excited about it, as I'm still BFing Timmy 2x/day (at 10.5 months old). I also weigh about six pounds less than I did when Timmy was conceived, so I was a little worried that my HA would be back again. (Although I'm not exercising nearly as much now, I'm lucky if it's 3x/week, so I've been hoping that would mitigate the weight loss).

Anyway, I've had a day of EWCM every two weeks since April, which suggested to me that things were slowly revving up. The first time freaked me out a bit as DH and I had been less than careful just a few days before, but it was just a random day (with a BFN a couple of weeks later). So I had it 7/2, 7/16, then every day since 7/24. And in copious amounts, more than I've ever had before! I'm not doing OPKs or temping or anything like that, I figure I'll have a good sense of when I might have O'ed based on drying up, and then I'll find out in somewhere from 5-15 days for sure if the good old CB (crimson bitch aka AF for any new readers) arrives. Fingers crossed!

Update: CB arrived on 8/3. So, I definitely O'ed! I would guess it was Monday night, 7/27, as I had some cramping that night, EWCM the following morning but nothing after that. So that's probably a 6-ish day LP. Not too bad... although I would have thought it would be longer than that based on all the egg-white. eh. now hopefully on to the next cycle!

Hypothalamic Amenorrhea Recovery / Treatment Summary

I have been posting on the hypothalamic amenorrhea (HA) bulletin board over at fertilethoughts forums for almost three years now - I wished when I was diagnosed and starting treatment that there was someone who had already been there that I could talk to about what I was going through. It makes me warm and fuzzy inside to be able to provide that input and insight to others who are going through the same things now.

Over those three years, I've learned a lot, and also collected some pretty interesting stats that I thought I would share here for anyone who finds this blog searching for info on HA.

There seem to be two different flavors of HA, both with the same manifestations. The first variety comes in women who are normal to low weight, and undereat / overexercise to a BMI anywhere from 21 on down. The second happens in women who were overweight to begin with, then lost a significant amount of weight; in some cases going to low BMIs as well, but occasionally just to a 'normal' BMI of 23-25.

In the first case, gaining weight and cutting exercise seem, without fail, to restore natural cycles. This is despite what many doctors have told women on the board, "You could gain 50lbs and still not start cycling again." This is NOT TRUE. I'm finally starting to see posts from some women who say that their doctors won't treat them until they've gained some weight. The thing is, not only does gaining weight and cutting exercise help with complete recovery from HA, it also helps with treatment cycles if the natural approach isn't fitting in with timelines. There have been a number of women on the board who have either tried Clomid with no success, or injectibles with cancelled cycles for overstimulation, and even multiple failed IVFs. After weight gain, Clomid works in *many* cases despite the traditional wisdom in the literature that it won't work for HA because of the low estrogen. Injectible cycles go significantly better after weight gain. And IVF cycles seem to be much more successful as well. Also, the weight gain that comes with pregnancy is mentally much easier when some of the disordered eating / exercise / body image issues have been conquered prior to pregnancy.

In this first type of HA, what happens is that as the body goes into a semi starvation mode with a constant energy deficit due to the undereating/overexercising, leptin levels decrease (see Welt CK et al. for the full article). This then leads to decreases in the levels and pulsatile frequency of LH, and estradiol, and the natural hormonal cycle stops. Increases in eating, particularly in carbohydrates and fats (good and bad) restore the natural leptin levels within a reasonable amount of time - usually 6 months to a year after making wholehearted changes (in many cases cycles are restored even more quickly than that; the quicker the weight is gained, the more quickly the cycles return).

In the second type of HA, in women who were overweight and then lost a significant amount, it seems take much longer for cycles to return. I believe this is because in people who are overweight, leptin receptors become desensitized, and not as responsive to the leptin signals. When the weight loss occurs, leptin levels decrease, just as in the first variety. But when eating is resumed / overexercising moderated, the increase in leptin levels is not registered as quickly by the body because the leptin receptors are not as responsive. This is my own theory, but it's the only thing I've been able to come up with to explain why women who were overweight seem to have a less tractable form of HA.

So the upshot is, if you have HA having been normal weight / thin most of your life, you can restore your cycles reasonably easily by gaining weight to a BMI of around 23. For most women that has done the trick; many have resumed cycling at a lower BMI than that. It takes committment, it takes handling feeling "fat" (although as a whole we tend to have quite skewed body images - many of our significant others and friends comment on how much better we look after gaining weight - and they do mean it!), buying new clothes in larger sizes really helps. If you have HA and were overweight before losing / exercising, weight gain will still help with treatment, but it will likely take longer before your cycles will return naturally.

If you want to be pregnant NOW (and who doesn't after deciding it's time?), weight gain can still really help. As you can see by checking the stats below, Clomid DOES work in many women with HA after weight gain. Sometimes even without a positive response to Provera. If you have HA, and don't have insurance that covers injectibles, I think you should absolutely 100% give Clomid a try before putting down the cash for an injectibles cycle. If your OB or RE will go for it, the extended Clomid protocol seems to have great results; if not, even a standard Clomid protocol will often work.

Starting in October 2007 I kept track of (just about) all the women who posted on the HA board, how they got their BFP's (which almost everyone has, still working on some of the recent joiners) and other random information.

So far, there have been 82 BFP's in total. Unfortunately, 14 (17%) of those have resulted in miscarriage, which is fairly close to the rate that is normally quoted for miscarriage. Of those 82 pregnancies, the breakdown by method of conception is as follows:

Natural: 31 (38%)
Clomid (including extended protocol): 22 (27%)
Injectibles: 20 (24%)
IVF: 5 (6%)

Also, these stats do include some women second pregnancies after recover from HA. By and large, if weight loss post partum is moderated and the patterns of undereating/overexercising are not resumed, natural cycles are restored after weaning (it is extremely rare for a former sufferer of HA to resume cycles while nursing). Most of the subsequent pregnancies are falling into the natural category.

As you can see, this totally belies both the assertion of medical professionals that you can gain an infinite amount of weight and still not cycle again, as well as the idea that Clomid will not work. In fact, 70% of the pregnancies achieved (after 10/2007) on the HA board have been through one of those two methods. And I am firmly convinced that many of the women who did use injectibles or IVF could have gotten pregnant either naturally or with Clomid had timetables been different.

As this is my summary of all I've learned about HA over the past three plus years, a few other things that seem to come up frequently:

* As our cycles return, they tend to be quite a bit longer than normal cycles, with ovulation in the CD40's (or higher) for the first cycle not uncommon. As weight gain is maintained, cycles get shorter. This isn't a surprise, as it takes a while for the body to respond to the restored hormonal levels.
* A BFP on a late ovulation is not a problem at all, despite what you may read online. The thing is, that the follicle is not sitting around with a mature egg in it; once the follicular recruitment really takes off, ovulation is actually occurring in a normal timeframe; it just takes longer to get to the follicular recruitment phase.
* Speaking of which, it's not uncommon to go through 2-3 follicular recruitment waves accompanied by changes in cervical fluid / temp prior to actual ovulation occurring, especially as cycles are returning.
* Estradiol is NOT the be-all-end-all as far as HA diagnosis goes. In fact, estradiol levels don't really seem to correlate much with whether natural cycles will return or Clomid will work. For me personally, my e2 when I was not cycling was 32; the two cycles where I got pregnant it was 27 and 34 respectively. It seems that the LH number is much more indicative of HA status - LH below 2 is likely to indicate HA; as recovery continues, that number rises much more reliably than e2 does.
* If Clomid is used, we *still* tend to have longer than normal cycles, often not ovulating until somewhere between CD20-30, so that should be your expectation. Monitoring is a great idea if you can afford it / your doc will do it - there are cases where women have grown good sized follicles but just not been able to muster the LH support to surge properly to ovulate. If you're being monitored and this seems to be the case, a shot of Ovidrel can be given at relatively low expense, to induce ovulation.
* If you want to move on to treatment and have the option of using the GnRH pump or patch, jump on it! They seem to be far the best ways to induce follicle growth without overstimming.
* In injectible cycles, it is extremely easy to overstimulate as our bodies are not used to the hormones that are being injected. First, your injectible should absolutely include LH (so Menopur or Repronex) - the cycles that have been completed on the board with FSH alone (e.g. follistim, bravelle etc.) are generally much less successful. Second, your protocol on your first cycle should be to start with a single vial (75U, or even less) for at least 4-5 days. Increase the dosage after that, preferably by just a half vial at a time. I have seen too many cases where either a higher dosage (common in injectible cycles for non-HA women) or too quick/big jumps in dosage lead to multiple follicles and either cycle cancellation or multiple pregnancy. In most cases we tend to be quite fertile once ovulation is induced, so the goal on the first cycle should be one mature follicle, or at most two. Of those 82 pregnancies, 3 were triplet pregnancies (two from Clomid) and one was a quadruplet; prior to 10/2007 there were two other triplet pregnancies and another quadruplet on the board. *Many* of the women on the board who moved to injectible treatment were successful on the first cycle.
* Injectible cycles following the recommended low/slow protocol DO tend to be quite long, with stimming for two-three weeks not out of the ordinary. There's nothing wrong with this, and no reason for the cycle to be cancelled - you will find a dosage at which you respond, and your follicle(s) will take off from there. Generally once a follicle gets to be 12mm+ / e2 goes over 100, the stimming will just take a few more days until trigger.
* For subsequent cycles, if needed, you should NOT start with the dosage that you finally responded at; that will almost certainly lead to recruitment of too many follicles. Start at least half a vial lower than that for the first 4-5 days, then bump up to the dose you respond to.

If anyone comes across this post and has questions or comments, I'd be happy to respond, feel free to use the comments section.

SO NOT THE POINT!!!

I posted over on my other blog about how I am having a hard time figuring out how to teach my kids to appreciate the things they have as I did, where things come to them so much more easily than they did to me. One of the things I mention is that I really wanted a Cabbage Patch doll growing up, but never did get one.

My MIL reads the post. And what does she take from it? NOT the point I was TRYING to make about the extravagance of their gifts to the kids:

"...how will they learn about delayed gratification? That they aren't always going to get everything they want (like my cabbage patch)? How will they learn to appreciate what they do have? If Christmas and their birthdays are always extravaganzas of presents (not necessarily from us), how do we teach them to be thankful?""

She shows up on Tuesday with an early birthday present for me. Of said Cabbage Patch kid.

I'm going to be fricking 35, what on earth am I supposed to do with a doll at this stage in my life????? SOOOOOOOOO not the point of my post. Which was apparently completely and totally lost on her. So much for a subtle hint.