Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Optimizing natural fertility in couples planning pregnancy

Mark D Hornstein, MD
William E Gibbons, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Healthcare providers are frequently consulted by couples concerned about their fertility potential. Some couples seek this information even before attempting pregnancy or meeting criteria for subfertility. These couples are especially motivated to listen to advice concerning the impact of lifestyle factors on fertility, as well as their general health.

Epidemiologic studies suggest that some lifestyle factors have small, cumulative effects that prolong the duration of time before achieving pregnancy [1]. Conversely, modifications of these factors appear to improve fertility potential, although this has not been evaluated by randomized trials [2-4].

The impact of lifestyle on fertility, and the implications of these findings for a couple planning pregnancy, will be reviewed here. The evaluation and treatment of subfertile couples are discussed separately. (See "Overview of infertility".)


The following discussion reviews basic terminology and questions about the reproductive process.

Terminology — The following terms are used when discussing fertility:


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: May 24, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Hassan MA, Killick SR. Negative lifestyle is associated with a significant reduction in fecundity. Fertil Steril 2004; 81:384.
  2. Anderson K, Norman RJ, Middleton P. Preconception lifestyle advice for people with subfertility. Cochrane Database Syst Rev 2010; :CD008189.
  3. Huang H, Hansen KR, Factor-Litvak P, et al. Predictors of pregnancy and live birth after insemination in couples with unexplained or male-factor infertility. Fertil Steril 2012; 97:959.
  4. Homan G, Litt J, Norman RJ. The FAST study: Fertility ASsessment and advice Targeting lifestyle choices and behaviours: a pilot study. Hum Reprod 2012; 27:2396.
  5. Joffe M, Key J, Best N, et al. Studying time to pregnancy by use of a retrospective design. Am J Epidemiol 2005; 162:115.
  6. Gnoth C, Godehardt D, Godehardt E, et al. Time to pregnancy: results of the German prospective study and impact on the management of infertility. Hum Reprod 2003; 18:1959.
  7. Zinaman MJ, Clegg ED, Brown CC, et al. Estimates of human fertility and pregnancy loss. Fertil Steril 1996; 65:503.
  8. Gnoth C, Godehardt E, Frank-Herrmann P, et al. Definition and prevalence of subfertility and infertility. Hum Reprod 2005; 20:1144.
  9. Dunson DB, Baird DD, Wilcox AJ, Weinberg CR. Day-specific probabilities of clinical pregnancy based on two studies with imperfect measures of ovulation. Hum Reprod 1999; 14:1835.
  10. Keulers MJ, Hamilton CJ, Franx A, et al. The length of the fertile window is associated with the chance of spontaneously conceiving an ongoing pregnancy in subfertile couples. Hum Reprod 2007; 22:1652.
  11. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med 1995; 333:1517.
  12. Trussell J, Rodríguez G, Ellertson C. New estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception 1998; 57:363.
  13. Weinberg CR, Gladen BC, Wilcox AJ. Models relating the timing of intercourse to the probability of conception and the sex of the baby. Biometrics 1994; 50:358.
  14. Masarotto G, Romualdi C. Probability of conception on different days of the menstrual cycle: an ongoing exercise. Adv Contracept 1997; 13:105.
  15. Bilian X, Heng Z, Shang-chun W, et al. Conception probabilities at different days of menstrual cycle in Chinese women. Fertil Steril 2010; 94:1208.
  16. Tiplady S, Jones G, Campbell M, et al. Home ovulation tests and stress in women trying to conceive: a randomized controlled trial. Hum Reprod 2013; 28:138.
  17. Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility. Optimizing natural fertility: a committee opinion. Fertil Steril 2013; 100:631.
  18. Manders M, McLindon L, Schulze B, et al. Timed intercourse for couples trying to conceive. Cochrane Database Syst Rev 2015; :CD011345.
  19. Elzanaty S, Malm J, Giwercman A. Duration of sexual abstinence: epididymal and accessory sex gland secretions and their relationship to sperm motility. Hum Reprod 2005; 20:221.
  20. Levitas E, Lunenfeld E, Weiss N, et al. Relationship between the duration of sexual abstinence and semen quality: analysis of 9,489 semen samples. Fertil Steril 2005; 83:1680.
  21. Check JH, Epstein R, Long R. Effect of time interval between ejaculations on semen parameters. Arch Androl 1991; 27:93.
  22. Stanford JB, Dunson DB. Effects of sexual intercourse patterns in time to pregnancy studies. Am J Epidemiol 2007; 165:1088.
  23. Jurema MW, Vieira AD, Bankowski B, et al. Effect of ejaculatory abstinence period on the pregnancy rate after intrauterine insemination. Fertil Steril 2005; 84:678.
  24. Agarwal A, Deepinder F, Cocuzza M, et al. Effect of vaginal lubricants on sperm motility and chromatin integrity: a prospective comparative study. Fertil Steril 2008; 89:375.
  25. Frishman GN, Luciano AA, Maier DB. Evaluation of Astroglide, a new vaginal lubricant: effects of length of exposure and concentration on sperm motility. Fertil Steril 1992; 58:630.
  26. Anderson L, Lewis SE, McClure N. The effects of coital lubricants on sperm motility in vitro. Hum Reprod 1998; 13:3351.
  27. Goldenberg RL, White R. The effect of vaginal lubricants on sperm motility in vitro. Fertil Steril 1975; 26:872.
  28. Kutteh WH, Chao CH, Ritter JO, Byrd W. Vaginal lubricants for the infertile couple: effect on sperm activity. Int J Fertil Menopausal Stud 1996; 41:400.
  29. Sandhu RS, Wong TH, Kling CA, Chohan KR. In vitro effects of coital lubricants and synthetic and natural oils on sperm motility. Fertil Steril 2014; 101:941.
  30. Steiner AZ, Long DL, Tanner C, Herring AH. Effect of vaginal lubricants on natural fertility. Obstet Gynecol 2012; 120:44.
  31. Dunson DB, Baird DD, Colombo B. Increased infertility with age in men and women. Obstet Gynecol 2004; 103:51.
  32. Dunson DB, Colombo B, Baird DD. Changes with age in the level and duration of fertility in the menstrual cycle. Hum Reprod 2002; 17:1399.
  33. Cramer DW, Goldman MB, Schiff I, et al. The relationship of tubal infertility to barrier method and oral contraceptive use. JAMA 1987; 257:2446.
  34. Phipps WR, Cramer DW, Schiff I, et al. The association between smoking and female infertility as influenced by cause of the infertility. Fertil Steril 1987; 48:377.
  35. Louis GM, Cooney MA, Lynch CD, Handal A. Periconception window: advising the pregnancy-planning couple. Fertil Steril 2008; 89:e119.
  36. Practice Committee of the American Society for Reproductive Medicine. Smoking and infertility: a committee opinion. Fertil Steril 2012; 98:1400.
  37. Howe G, Westhoff C, Vessey M, Yeates D. Effects of age, cigarette smoking, and other factors on fertility: findings in a large prospective study. Br Med J (Clin Res Ed) 1985; 290:1697.
  38. Hughes EG, Lamont DA, Beecroft ML, et al. Randomized trial of a "stage-of-change" oriented smoking cessation intervention in infertile and pregnant women. Fertil Steril 2000; 74:498.
  39. Hughes EG, Brennan BG. Does cigarette smoking impair natural or assisted fecundity? Fertil Steril 1996; 66:679.
  40. Curtis KM, Savitz DA, Arbuckle TE. Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecundability. Am J Epidemiol 1997; 146:32.
  41. Augood C, Duckitt K, Templeton AA. Smoking and female infertility: a systematic review and meta-analysis. Hum Reprod 1998; 13:1532.
  42. Bolumar F, Olsen J, Boldsen J. Smoking reduces fecundity: a European multicenter study on infertility and subfecundity. The European Study Group on Infertility and Subfecundity. Am J Epidemiol 1996; 143:578.
  43. Bouyer J, Coste J, Fernandez H, Job-Spira N. [Tobacco and ectopic pregnancy. Arguments in favor of a causal relation]. Rev Epidemiol Sante Publique 1998; 46:93.
  44. Cramer DW, Barbieri RL, Xu H, Reichardt JK. Determinants of basal follicle-stimulating hormone levels in premenopausal women. J Clin Endocrinol Metab 1994; 79:1105.
  45. Adena MA, Gallagher HG. Cigarette smoking and the age at menopause. Ann Hum Biol 1982; 9:121.
  46. Paszkowski T, Clarke RN, Hornstein MD. Smoking induces oxidative stress inside the Graafian follicle. Hum Reprod 2002; 17:921.
  47. Sinkó I, Mórocz M, Zádori J, et al. Effect of cigarette smoking on DNA damage of human cumulus cells analyzed by comet assay. Reprod Toxicol 2005; 20:65.
  48. Sharpe RM, Franks S. Environment, lifestyle and infertility--an inter-generational issue. Nat Cell Biol 2002; 4 Suppl:s33.
  49. Weinberg CR, Wilcox AJ, Baird DD. Reduced fecundability in women with prenatal exposure to cigarette smoking. Am J Epidemiol 1989; 129:1072.
  50. Storgaard L, Bonde JP, Ernst E, et al. Does smoking during pregnancy affect sons' sperm counts? Epidemiology 2003; 14:278.
  51. Vine MF. Smoking and male reproduction: a review. Int J Androl 1996; 19:323.
  52. Zitzmann M, Rolf C, Nordhoff V, et al. Male smokers have a decreased success rate for in vitro fertilization and intracytoplasmic sperm injection. Fertil Steril 2003; 79 Suppl 3:1550.
  53. Nizard J. [What are the epidemiological data on maternal and paternal smoking?]. J Gynecol Obstet Biol Reprod (Paris) 2005; 34 Spec No 1:3S347.
  54. Grodstein F, Goldman MB, Cramer DW. Body mass index and ovulatory infertility. Epidemiology 1994; 5:247.
  55. Rich-Edwards JW, Goldman MB, Willett WC, et al. Adolescent body mass index and infertility caused by ovulatory disorder. Am J Obstet Gynecol 1994; 171:171.
  56. Gaskins AJ, Rich-Edwards JW, Missmer SA, et al. Association of Fecundity With Changes in Adult Female Weight. Obstet Gynecol 2015; 126:850.
  57. Clark AM, Ledger W, Galletly C, et al. Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod 1995; 10:2705.
  58. Norman RJ, Noakes M, Wu R, et al. Improving reproductive performance in overweight/obese women with effective weight management. Hum Reprod Update 2004; 10:267.
  59. Clark AM, Thornley B, Tomlinson L, et al. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 1998; 13:1502.
  60. Dixon JB, Dixon ME, O'Brien PE. Pregnancy after Lap-Band surgery: management of the band to achieve healthy weight outcomes. Obes Surg 2001; 11:59.
  61. Nelson SM, Fleming R. Obesity and reproduction: impact and interventions. Curr Opin Obstet Gynecol 2007; 19:384.
  62. Marceau P, Kaufman D, Biron S, et al. Outcome of pregnancies after biliopancreatic diversion. Obes Surg 2004; 14:318.
  63. Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding. Obstet Gynecol 2000; 95:927.
  64. Weiner R, Blanco-Engert R, Weiner S, et al. Outcome after laparoscopic adjustable gastric banding - 8 years experience. Obes Surg 2003; 13:427.
  65. Eid GM, Cottam DR, Velcu LM, et al. Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005; 1:77.
  66. Teitelman M, Grotegut CA, Williams NN, Lewis JD. The impact of bariatric surgery on menstrual patterns. Obes Surg 2006; 16:1457.
  67. Mutsaerts MA, van Oers AM, Groen H, et al. Randomized Trial of a Lifestyle Program in Obese Infertile Women. N Engl J Med 2016; 374:1942.
  68. Pasquali R, Gambineri A. Metabolic effects of obesity on reproduction. Reprod Biomed Online 2006; 12:542.
  69. Luke B, Brown MB, Missmer SA, et al. The effect of increasing obesity on the response to and outcome of assisted reproductive technology: a national study. Fertil Steril 2011; 96:820.
  70. Bates GW, Bates SR, Whitworth NS. Reproductive failure in women who practice weight control. Fertil Steril 1982; 37:373.
  71. Sallmén M, Sandler DP, Hoppin JA, et al. Reduced fertility among overweight and obese men. Epidemiology 2006; 17:520.
  72. Nguyen RH, Wilcox AJ, Skjaerven R, Baird DD. Men's body mass index and infertility. Hum Reprod 2007; 22:2488.
  73. Mitchell M, Bakos HW, Lane M. Paternal diet-induced obesity impairs embryo development and implantation in the mouse. Fertil Steril 2011; 95:1349.
  74. Hofny ER, Ali ME, Abdel-Hafez HZ, et al. Semen parameters and hormonal profile in obese fertile and infertile males. Fertil Steril 2010; 94:581.
  75. Duits FH, van Wely M, van der Veen F, Gianotten J. Healthy overweight male partners of subfertile couples should not worry about their semen quality. Fertil Steril 2010; 94:1356.
  76. Hammiche F, Laven JS, Twigt JM, et al. Body mass index and central adiposity are associated with sperm quality in men of subfertile couples. Hum Reprod 2012; 27:2365.
  77. Belloc S, Cohen-Bacrie M, Amar E, et al. High body mass index has a deleterious effect on semen parameters except morphology: results from a large cohort study. Fertil Steril 2014; 102:1268.
  78. Green BB, Daling JR, Weiss NS, et al. Exercise as a risk factor for infertility with ovulatory dysfunction. Am J Public Health 1986; 76:1432.
  79. Gudmundsdottir SL, Flanders WD, Augestad LB. Physical activity and fertility in women: the North-Trøndelag Health Study. Hum Reprod 2009; 24:3196.
  80. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Diet and lifestyle in the prevention of ovulatory disorder infertility. Obstet Gynecol 2007; 110:1050.
  81. Wise LA, Rothman KJ, Mikkelsen EM, et al. A prospective cohort study of physical activity and time to pregnancy. Fertil Steril 2012; 97:1136.
  82. Morris SN, Missmer SA, Cramer DW, et al. Effects of lifetime exercise on the outcome of in vitro fertilization. Obstet Gynecol 2006; 108:938.
  83. Bullen BA, Skrinar GS, Beitins IZ, et al. Induction of menstrual disorders by strenuous exercise in untrained women. N Engl J Med 1985; 312:1349.
  84. Ellison PT. Salivary steroids and natural variation in human ovarian function. Ann N Y Acad Sci 1994; 709:287.
  85. Puder JJ, Monaco SE, Sen Gupta S, et al. Estrogen and exercise may be related to body fat distribution and leptin in young women. Fertil Steril 2006; 86:694.
  86. Prentice AM, Jebb SA. Obesity in Britain: gluttony or sloth? BMJ 1995; 311:437.
  87. Rich-Edwards JW, Spiegelman D, Garland M, et al. Physical activity, body mass index, and ovulatory disorder infertility. Epidemiology 2002; 13:184.
  88. Wise LA, Cramer DW, Hornstein MD, et al. Physical activity and semen quality among men attending an infertility clinic. Fertil Steril 2011; 95:1025.
  89. Jensen TK, Hjollund NH, Henriksen TB, et al. Does moderate alcohol consumption affect fertility? Follow up study among couples planning first pregnancy. BMJ 1998; 317:505.
  90. Eggert J, Theobald H, Engfeldt P. Effects of alcohol consumption on female fertility during an 18-year period. Fertil Steril 2004; 81:379.
  91. Hakim RB, Gray RH, Zacur H. Alcohol and caffeine consumption and decreased fertility. Fertil Steril 1998; 70:632.
  92. Olsen J, Bolumar F, Boldsen J, Bisanti L. Does moderate alcohol intake reduce fecundability? A European multicenter study on infertility and subfecundity. European Study Group on Infertility and Subfecundity. Alcohol Clin Exp Res 1997; 21:206.
  93. Juhl M, Nyboe Andersen AM, Grønbaek M, Olsen J. Moderate alcohol consumption and waiting time to pregnancy. Hum Reprod 2001; 16:2705.
  94. Rostad B, Schei B, Sundby J. Fertility in Norwegian women: results from a population-based health survey. Scand J Public Health 2006; 34:5.
  95. Tolstrup JS, Kjaer SK, Holst C, et al. Alcohol use as predictor for infertility in a representative population of Danish women. Acta Obstet Gynecol Scand 2003; 82:744.
  96. Parazzini F, Chatenoud L, Di Cintio E, et al. Alcohol consumption is not related to fertility in Italian women. BMJ 1999; 318:397.
  97. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Caffeinated and alcoholic beverage intake in relation to ovulatory disorder infertility. Epidemiology 2009; 20:374.
  98. Rossi BV, Berry KF, Hornstein MD, et al. Effect of alcohol consumption on in vitro fertilization. Obstet Gynecol 2011; 117:136.
  99. Nagy F, Pendergrass PB, Bowen DC, Yeager JC. A comparative study of cytological and physiological parameters of semen obtained from alcoholics and non-alcoholics. Alcohol Alcohol 1986; 21:17.
  100. Gomathi C, Balasubramanian K, Bhanu NV, et al. Effect of chronic alcoholism on semen--studies on lipid profiles. Int J Androl 1993; 16:175.
  101. Emanuele MA, Emanuele NV. Alcohol's effects on male reproduction. Alcohol Health Res World 1998; 22:195.
  102. Showell MG, Brown J, Clarke J, Hart RJ. Antioxidants for female subfertility. Cochrane Database Syst Rev 2013; :CD007807.
  103. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Dietary fatty acid intakes and the risk of ovulatory infertility. Am J Clin Nutr 2007; 85:231.
  104. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Iron intake and risk of ovulatory infertility. Obstet Gynecol 2006; 108:1145.
  105. Chavarro JE, Rich-Edwards JW, Rosner B, Willett WC. A prospective study of dairy foods intake and anovulatory infertility. Hum Reprod 2007; 22:1340.
  106. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Protein intake and ovulatory infertility. Am J Obstet Gynecol 2008; 198:210.e1.
  107. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Use of multivitamins, intake of B vitamins, and risk of ovulatory infertility. Fertil Steril 2008; 89:668.
  108. Toledo E, Lopez-del Burgo C, Ruiz-Zambrana A, et al. Dietary patterns and difficulty conceiving: a nested case-control study. Fertil Steril 2011; 96:1149.
  109. Vujkovic M, de Vries JH, Lindemans J, et al. The preconception Mediterranean dietary pattern in couples undergoing in vitro fertilization/intracytoplasmic sperm injection treatment increases the chance of pregnancy. Fertil Steril 2010; 94:2096.
  110. Mendiola J, Torres-Cantero AM, Moreno-Grau JM, et al. Food intake and its relationship with semen quality: a case-control study. Fertil Steril 2009; 91:812.
  111. Zampieri N, Zamboni C, Ottolenghi A, Camoglio FS. The role of lifestyle changing to improve the semen quality in patients with varicocele. Minerva Urol Nefrol 2008; 60:199.
  112. Afeiche MC, Bridges ND, Williams PL, et al. Dairy intake and semen quality among men attending a fertility clinic. Fertil Steril 2014; 101:1280.
  113. Matthiesen SM, Frederiksen Y, Ingerslev HJ, Zachariae R. Stress, distress and outcome of assisted reproductive technology (ART): a meta-analysis. Hum Reprod 2011; 26:2763.
  114. Hannuksela ML, Ellahham S. Benefits and risks of sauna bathing. Am J Med 2001; 110:118.
  115. Mueller BA, Daling JR, Weiss NS, Moore DE. Recreational drug use and the risk of primary infertility. Epidemiology 1990; 1:195.