Over the years that I have assisted women who are actively trying to conceive, I have been astounded by the lack of inquiry into the patients' sleeping habits. Sometimes I am the first person to ask about a patient's sleep (or lack thereof), despite the fact that the patient has seen multiple doctors, consultants, and even undergone countless treatments.
Have you overlooked this vital piece of the fertility puzzle?
Sleep is crucial to our health and wellbeing.
Sleep deprivation has been linked to a variety of health problems, which could directly and indirectly affect fertility.
Sleep and the circadian system exert a strong regulatory influence on the immune system and its functions. Prolonged lack of sleep can lead to chronic, systemic, low grade inflammation and contribute to an increased risk of various conditions such as
Weight gain
Anxiety
Depression
Fertility issues
Hypertension
Atherosclerosis
Diabetes
Heart disease
Neurodegeneration
Is it possible that we're overlooking a critical contributing factor for delayed conception and increased miscarriage risk by not enquiring and addressing sleep issues during fertility consultations and investigations?
Getting enough good quality sleep is essential for hormonal regulation in conception preparation for both men and women. Sleep quality and duration have both direct and indirect effects on fertility, according to a growing body of studies.
Sleep and the immune system
The immune system is strongly influenced by sleep and the circadian cycle. The immune system is a highly complex system which is critical to all all areas of health protecting you from chronic life threatening illnesses, tumours and infections. During sleep, your immune system releases proteins called cytokines which help to combat inflammation and infections. Sleep enables T cells to work more efficiently, T cells are a type of white blood cell and also the front line immune cells. Research has demonstrated that sleep makes the T cells ‘stickier’ and therefore more effective at activating sticky proteins called intigrins which allow the T cells to attach to and killing cells. [1]
Decreased sleep also means less activation of inflammatory cytokines. Lack of good quality sleep contributes to risk of inflammatory disorders. The better quality of sleep, the more cytokines can tackle inflammation in the body. [2]
What does this have to do with fertility?
Everything, immune system health is vital in reproductive health, it is the even more important around the time of conception. The fathers seminal fluid primes the female immune response to be tolerant to accept the pregnancy. The immune system that lacks ‘immune tolerance’ can reject a pregnancy when there is a high activation of natural killer (NK) cells is an example of TH1-type cytokines which research show are harmful to a pregnancy. These cells detect self from non self, and when there is a presence of highly activated NK cells the body may reject the pregnancy as foreign and attack the embryo which can result in implantation failure or early miscarriage due to implantation issues. Autoimmune diseases effect the immune system in different ways and can work against your attempts to conceive, and may even increase your risk of miscarriage.
Circadian disruption may impact reproductive outcomes through dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, insulin resistance, oxidative stress, and systemic inflammation[3 ]. Sleep is largely regulated by the autonomic nervous system (ANS) which has two main components, the sympathetic (fight or flight) and the parasympathetic (rest, digest and procreate). A parasympathetic domination during sleep is vital for restorative sleep. Studies have suggested that ANS dysfunction may be an under-recognised cause of female fertility disorders. [4] An Insufficient shift to sympathetic in the luteal aspect of the menstrual cycle (from ovulation to menstruation) has also shown to suggest an inability for the immune response to shift from TH1 to TH2 which is more accommodating to pregnancy.
Sleep and fertility hormones
Sleep modulates both male and female fertility hormones. A lack of sleep can effect sperm production by lowering a key male fertility hormone called testosterone. Sleep deprivation can also reduce the release of hormones in women that influence ovulation such as luteinizing hormone which determines when a woman ovulates and therefore will effect the cycle length. Menstrual irregularity may increase the time it takes for you to conceive.
And it’s not just how long we sleep, it’s also important when we sleep. Sleep disregulation and circadian misalignment (like seen in shift work) can also impair the regulation of fertility hormones and in some cases cause amenorrhea. A 2002 study demonstrated just that when following 68 nurses under 40 on shift work. 53% of these nurses had menstrual changes when their shift-work started. These findings suggest that sleep disturbances may lead to menstrual irregularities, and changes in menstrual function which will impair fertility. [5]
A more recent study in 2013 also indicated that working shift patterns is associated with an increased risk of menstrual disruption and subfertility. [6]
Night shift work during pregnancy may raise the incidence of miscarriage, according to a 2018 cohort study of 22744 women. Compared to women who did not work night shifts, women who worked two or more night shifts the prior week had a significantly higher chance of miscarriage after pregnancy week eight. [7]
Too much sleep
Too much sleep can also hinder fertility. In a study involving 656 women undergoing Ivf, they categorised sleepers as ‘short sleepers (4-6 hours) moderate sleep sleepers slept 7-8 hours and long sleepers (9-11 hours) the moderate sleepers had significantly the highest pregnancy rate. It’s interesting to note that excessive sleep caused negative outcomes [8]. most likely due circadian rhythm disruption.
Studies have shown that too little and too long sleep has also shown to have an impact the thyroid [9] Sleep Deprivation has shown to elevate Thyroid stimulating hormone (TSH) [10] a thyroid dysfunction (especially undiagnosed) can effect conception and pregnancy as it can impair the release of fertility hormones such as luteinizing hormone and Follicle stimulating Hormone (FSH) . Dysregulated thyroid function can also effect male factor fertility by damaging sperm quality and motility.
Melatonin
The hormones responsible for the sleep- wake cycle are melatonin and cortisol. Melatonin production increases in response to darkness and helps to induce sleep.
Melatonin regulates the production of prolactin, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in gonadotropic cells. Melatonin is known as an anti-estrogen hormone and has been shown to influence the reproductive health of both women and men [11,12]
Circulatory melatonin is made in the pineal gland snd the production is stimulated from darkness resulting in the experience of tiredness. Melatonin is powerful antioxidant, anti inflammatory, circadian rhythm resetting, free radical scavenging hormone aka the sleep hormone) It actually triggers other antioxidants networks including glutathione and has recently been considered an immune modulator. Sleeplessness suppresses melatonin production as well as excessive HPA activation which could contribute to early pregnancy loss, failed embryo implantation, anovulation and amenorrhea. [13]
Melatonin has been used as a supplement for fertility in many parts of the world, in the UK it requires a prescription as it’s classified as a drug. It’s a supplement that will suit some more than others, however, it’s not without potential drawbacks which may include the potential to disrupt ovulation. Endogenous melatonin is also a powerful antioxidant with the ability to improve egg/sperm quality and reduce DNA fragmentation. [14] It’s important to note that endogenous melatonin supports sperm health and supplementation of melatonin long term has been shown to possibly even reduce semen quality. [15]
Luckily, there’s a lot you can do to improve sleep with simple smart changes.
My top 12 tips to get on top of your sleep:
1. Get out in the morning
Get out in the morning for early daylight, ideally if you can, within the first hour of waking.. The majority of melatonin in our bloodstream is sub cellular in the mitochondria which is stimulated by near infrared (our glorious sun!) this is why infrared lasers and led’s are so effective at reducing inflammation and helping sleep. Get out in nature! Whether it’s a stroll to the park, or choosing to drink your morning cuppa alfresco. Connect to your surroundings and soak up morning rays.
2. Red light therapy
In addition to the suns healing infrared rays. You could consider Near Infrared (NIR) light therapy. Red/NIR light therapy has also been shown to increase mitochondrial melatonin. I frequently use Photobiomodulation tools in my clinic primarily for pain, cellular function and wound healing. Low level light therapy (LLLT) was initially developed by NASA to grow plants in space. Home devices are becoming more affordable and readily available, from the hand held tools, door panel’s to the infrared saunas. It’s important to note that research on Red light sleep quality is still in its infancy, it’s one to watch [16] another benefit to note is that LLLT has shown the reduction of sleep inertia (that groggy just woke up feeling) [17]
3. Lights out
Lights off in the evening, yes especially your electrical devices like mobile phones, laptops, televisions and tablets (they emit melatonin blocking blue light). A minimum of 1-2 hours before bed is the general rule, however if you are having difficulties with your sleep I would encourage a minimum of 2 hours. In addition to the cortisol stimulating blue light, these devices will keep your brain stimulated and are therefore not conducive to sleep. Circulatory Melatonin, found in our blood stream, created in your pineal gland stimulated by darkness, it’s supplementary to the sub cellular melatonin. Reading from a book or having a soak in the bath would be a better way to end the evening, ban mobile phones and TV’s from the bedroom.
4. Limit screen time
Duration of screen time is also Important. Studies show two or more hours of screen time in the evening can seriously disrupt the melatonin surge needed to fall sleep. In addition to the blue light, emails and messages in themselves especially work emails can sometimes trigger a stress/anxiety response which will undo all of your hard work.
5. Eat to Sleep
Consuming foods that promote melatonin production in the evening can help you on your way to the land of nod. Foods such as tart cherries (and tart cherry juice) eggs, fish, Goji berries, olives, asparagus, pomegranate, raspberries, milk and nuts (especially walnuts and pistachios). Generally foods rich in tryptophan, magnesium, calcium, and B6 are also known to promote melatonin production. Goji berries (Gǒu Qǐ Zi) are a fabulous addition are also high in antioxidants, they are used heavily in Chinese medicine to nourish, benefit the immune system in addition as regulate the urinary and reproductive system.
Kiwi fruits have also shown promise, studies demonstrated that a kiwi before bed improved the duration and quality of sleep. This is most likely due to the high antioxidant capacity reducing oxidative stress and also having a high serotonin and folate concentration (folate deficiency is linked to insomnia). [18]
6. Like clockwork
Try to go to bed at the same time each day to support you circadian rhythm. Quit the shift work, the women working shifts are at greater risk of miscarriage, menstrual disruption and sub-fertility. If this applies to you, you may want to work with your employer to see if you can amend your hours
7. Ditch the caffeine
Ditch caffeine especially after 2pm, it’s a stimulant. If you can’t be without coffee try Swiss water method decaf coffee grounds, the best tasting I have found is Lavazza and Rawbean, definitely decaffeinated . Tea drinkers (yes tea has caffeine and it varies greatly between brands) opt for herbal teas like camomile tea or if you like something closer try rooibos tea. A delicious sweet South African tea was never caffeinated to begin with, so no chemical process required to decaffeinate the tea, just beautiful tea you can add milk and even dunk a hobnob in!
Some teas may actually promote sleep, such as Valarian [19] Chamomile tea [20], Passion flower, lemon balm and lavender are all favourites.
8. Pen and paper brain dump
Anxiety around sleep is problematic for many, and becomes a viscous cycle. Those that struggle to switch off before bed could benefit from a pen and paper ‘brain dump’ before bed. This is particularly useful when the brain decides to attempt to solve all problems big and small before bed. Sometimes these thoughts are so trivial, they whirl around your mind all night to serve as a reminder tool to go to the post office or pack a lunch box. And sometimes, it’s much heavier stuff. Simply writing down the whirling thoughts can make you feel that you have ‘dealt’ with the situation or remembered what you must do in the morning. I recommend a pen and paper for this over an electronic device.
9. Get moving! Burn up energy
Sometimes we are not tired as we haven’t exerted ourselves enough to become tired, this mainly effects those with a sedentary lifestyle. It’s a yin/yang balance equation. Sometimes the elderly start to wake so early because 4-5 hours was restorative for the little energy used.
10. Declutter your sleep space
Create a calm and restful sleep environment. The environment you sleep in needs to be soothing and should be void of televisions, phones, laptop and ‘noise’. I would also add, DECLUTTER and keep your resting space clean. A cluttered space leads to a cluttered mind, not ideal for bed time.
11. Breathe
Try slow breathing technique’s.These techniques are known to encourage the ANS into a parasympathetic state which is more conducive to sleep. Studies have suggested that modulation of the ANS via slow breathing techniques in adjunct to relaxation techniques and sleep hygiene may be a powerful tool in combating insomnia. [21] Mindfulness meditation is also another wonderful tool for chronic insomnia. In a 2015 randomised control trial, those in the mindfulness group had less insomnia, fatigue, and depression at the end of the six sessions.[22, 23, 24]
12. Acupuncture
Acupuncture of-course! I have achieved great results with those looking to better their sleep, whether its the main reason for seeking acupuncture or a welcome added benefit for those seeking acupuncture for other issues such as fertility, anxiety and pain. Acupuncture has also shown huge promise in trials in the support of insomnia [25,26,27,28,29]
Acupuncture regulates neurotransmitters and their modulators, deactivates the analytical brain responsible for stress and anxiety and activates the parasympathetic (rest, digest and procreate) aspect of the ANS. Acupuncture is also understood to increase nocturnal endogenous melatonin secretion [30], stimulates opioid (especially b-endorphin) production and µ-opioid receptor activity [31] increases nitric oxide synthase activity and nitric oxide content, helping to promote normal function of brain tissues, which could help to regulate sleep [32] And increases cerebral blood flow [33]. Acupuncture has also shown to reduce sympathetic nervous system activity, hence increasing relaxation [34]
The British Acupuncture Council is the largest governing body of traditional acupuncture, you can locate your local acupuncturist at acupuncture.org.uk.
And finally,
If you have been struggling with insomnia for some time it would be worth a chat with your GP to rule out any underlying health condition that could be causing your difficulty with sleep such as sleep apnea, thyroid disorders, depression and anxiety.
In summary, good quality, sufficient sleep at a similar time each night is imperative for our immune, hormonal and reproductive health. Adequate sleep is even more vital if you are trying to conceive.
Wishing you health and happiness
Claire
Resources
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