Considerations of Fertility in Elite Sportswomen: A Narrative Review

Increasingly more women are participating in professional and recreational sports. Whilst vigorous intensity physical activity is considered beneficial, evidence demonstrates higher rates of menstrual disturbance in elite athletes. There is less clear evidence on the impact of elite-level exercise on fertility outcomes. It is critical to understand this given the optimal age for fertility is likely to coincide with the age of peak performance for many athletes.

To perform a narrative review summarising the impact of elite-level exercise on reproductive function and fertility outcomes, highlighting the importance of relative energy deficiency in sport (REDs). Additionally, to outline the reproductive options for female athletes and summarise the fertility treatment outcomes and challenges for athletes.

A literature search of Medline, Embase, Google Scholar and Web of Science was performed.

There is clear evidence that elite-level training causing increased risk of menstrual disturbance. This is likely due to REDs, with evidence that increasing energy intake can improve menstrual dysfunction. Whilst there is limited data in athletes, data from the general population suggests exercise may be beneficial for both fertility and assisted reproduction outcomes up to a certain point, beyond which there may be a negative impact, particularly if there was prior menstrual disturbance. It is crucial to be able to counsel athletes on the effect of age upon reproductive outcomes, the impact of their training on reproductive health, and the implications of fertility treatments, including the impact upon training and performance, and whether the medications involved comply with anti-doping regulations.

Elite-level exercise can have a negative impact on menstrual function, however the impact on fertility is less clear. Restoring energy balance may re-establish menstruation and enhance fertility, but some individuals may need fertility treatment. Athletes wishing to wait until after retirement to conceive may encounter age-related reproductive decline, hence some may wish to consider oocyte/embryo preservation. Giving athletes evidence-based information regarding their reproductive health remains challenging due to their underrepresentation in exercise-related research.