Elsevier

Sleep Medicine Reviews

Volume 22, August 2015, Pages 78-87
Sleep Medicine Reviews

Theoretical review
Sleep, sleep disturbance, and fertility in women

https://doi.org/10.1016/j.smrv.2014.10.005Get rights and content

Summary

Sleep and sleep disturbances are increasingly recognized as determinants of women's health and well-being, particularly in the context of the menstrual cycle, pregnancy, and menopause. At present, however, little is known about whether fertility is affected by sleep quantity and quality. That is, to what degree, and by what mechanisms, do sleep and/or its disturbances affect fertility? The purpose of this review is to synthesize what is known about sleep disturbances in relation to reproductive capacity. A model is provided, whereby stress, sleep dysregulation, and circadian misalignment are delineated for their potential relevance to infertility. Ultimately, if it is the case that sleep disturbance is associated with infertility, new avenues for clinical intervention may be possible.

Introduction

The relationship between sleep and fertility is largely unknown. This paucity of research is surprising, given that sleep is such a critical component to one's physical and emotional health and well-being. Among both women and men, it is well established that sleep disorders, particularly insomnia, contribute to, or are associated with, myriad health conditions, including cardiovascular disease, hypertension, glucose dysregulation, depression, and anxiety disorders. Specific to women, sleep disturbances coincide with premenstrual dysphoria, pregnancy, postpartum depression, and the menopausal transition [1]. While there appears to be a relationship between sleep disturbance and reproductive health, little is known about which form of sleep disturbance is related to reproductive capacity and which specific aspects of reproductive capacity are particularly affected. With respect to sleep disturbance, the relevant domains could include sleep fragmentation, sleep continuity disturbance, short or long sleep duration, circadian dysrhythmia, and/or hypoxia. With respect to reproductive capacity, the relevant domains could include problems with fertility, conception, implantation, gestation, delivery, and/or neonatal health. Finally, it is possible that the relationship between these domains is reciprocal in nature, such that sleep disturbances and their associated sequelae may not only ensue from, but also interfere with, reproductive processes.

To date, the majority of evidence for the association between sleep disturbance and diminished reproductive capacity has been within the area of shift work [2], [3], [4], [5], [6]. In general, adverse reproductive health outcomes were observed (e.g., menstrual irregularities, dysmenorrhea, increased time to, and reduced rates for, conception, increased miscarriages, lower birth weights) and were taken to implicate the negative effects of circadian misalignment, and/or the sleep disturbance that coincides with shift work. There is a more limited literature with respect to sleep disordered breathing and infertility. Polycystic ovary syndrome (PCOS) is known to reduce reproductive potential and is believed to be one of the most common causes of female infertility. Two key studies demonstrate the association between sleep disordered breathing and PCOS. One seminal study showed that premenopausal women with PCOS were 30 times more likely to suffer from sleep disordered breathing (SDB) than controls [7]. Another key study similarly showed obstructive sleep apnea (OSA) was prevalent in 44% of obese women with PCOS, compared to 6% of age- and weight-matched reproductively normal women [8]. OSA is believed to contribute to the metabolic abnormalities (insulin resistance and decreased glucose tolerance) in women with PCOS [9]. Therefore, it is possible that OSA contributes to one form of female factor infertility. Finally, with respect to sleep continuity disturbance, only two studies have evaluated the direct association between sleep continuity disturbance and infertility. First, Pal et al. found that sleep disturbance, assessed using the single item query “do you experience disturbed sleep?”, occurred in 34% of infertile women [10]. In addition, women with diminished ovarian reserve were found to be 30 times more likely to have disturbed sleep, while controlling for race, body mass index (BMI), and vasomotor symptoms. Second, Lin and colleagues [11] found that greater than 35% of women receiving intrauterine insemination reported disturbances in their sleep. While these studies are among the first to examine sleep disturbance in relation to successful pregnancy outcomes and in populations of infertile women, sleep disturbance was assessed globally (i.e., is phrased in such a way to be all-inclusive and non-specific with respect to individual sleep disorders). Further, the direction of the findings suggests that the observed sleep disturbance is a consequence of infertility. The purpose of the present paper is to examine the reciprocal proposition, that sleep disturbance may adversely affect fertility.

In order to lay the foundation for the possibility that sleep disturbance contributes to infertility, several domains of information are provided. First, the prevalence and significance of infertility are highlighted. Second, three proposed pathways by which sleep disturbance could contribute to infertility are presented. Theoretical and empirical support for each is reviewed. Third, clinical relevance and implications, not only for extending sleep medicine practices to this population, but also for addressing infertility from a behavioral sleep medicine perspective, are discussed.

Section snippets

Definition and prevalence

Infertility is defined as “the failure to achieve a successful pregnancy after 12 mo or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 mo for women over age 35 y” [12]. An estimated 72.4 million women worldwide currently encounter infertility, with approximately 6.1 million having difficulty becoming pregnant or carrying a pregnancy to

How might sleep affect fertility?

Provided here is both a) a synthesis of literature that relates sleep and/or sleep disturbance to reproductive indices and b) a framework encompassing the pathways by which sleep disturbance can interfere with fertility (see Fig. 2). There are at least three possible pathways by which sleep disturbance may be related to infertility: 1) the hypothalamic-pituitary-adrenal (HPA) activation that precipitates sleep disturbance may also interfere with reproduction; 2) altered sleep duration and/or

Clinical and research implications

Insomnia disorder disproportionately affects women compared to men. Reproductive transitions (menstrual, pregnancy, menopause) are thought to precipitate sleep continuity disturbance, hence heightening women's risk for sleep problems throughout their lifespan. Traditional ways of thinking are that the endocrinology, mood dysregulation, and/or lifestyle changes that accompany reproductive transitions present a vulnerability to insomnia. It is posited here that the converse may also be true.

Conflict of interest

None.

Practice point

  • 1)

    Targeted treatment for sleep dysregulation (e.g., sleep continuity disturbance, abnormal sleep duration and/or sleep disordered breathing), or circadian misalignment may contribute to enhanced reproductive capacity, and barring this, will certainly enhance quality of life for individuals struggling with infertility.

  • 2)

    It is possible that stress affects fertility and that chronic insomnia, to the extent that it produces stress responses, also affects fertility. Thus, targeted

Acknowledgments

First, we would like to acknowledge Caterina Mosti and Diana D'Argenio for their work on literature searches. Second, we like to thank Dr. Mary Spiers for her feedback on an earlier draft of this manuscript. Third, we would like to thank the reviewers for their considerate and comprehensive feedback. This manuscript is immeasurably better because of their thoughtful review. Finally, we would like to thank Mahendra De Silva, Ph.D for helping to inspire this idea so many years ago.

This work was

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