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Clinical case – Infertility and Environment

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Learning Objectives

  • Gynaecological related Planetary Health conditions

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  • Environmental impact on reproductive health

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  • Considering environmental and planetary health on infertility

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Clinical case

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Patient demographics – 34-year-old woman, nulligravid

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Chief complaint – Primary infertility (18 months)

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Clinical case –

    • Regular menstrual cycles
    • No dysmenorrhea or dyspareunia
    • Timed intercourse
    • No previous pregnancies

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Past medical / surgical / social history –

    • No relevant medical history
    • No prior surgeries
    • Non-smoker

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Current medications – None

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Physical exam – Normal gynaecological examination

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  1. What is the most appropriate next step in the evaluation of this patient?�
  1. Start fertility treatment immediately�
  2. Order a complete hormonal panel

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  • Take a detailed history, including environmental exposures

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  • Request genetic testing

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  1. What is the most appropriate next step in the evaluation of this patient?�
  1. Start fertility treatment immediately�
  2. Order a complete hormonal panel

​

  • Take a detailed history, including environmental exposures

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  • Request genetic testing

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History taking / Patient risk factors

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Environmental and occupational exposure –

    • Lives <100 m from high-traffic road
    • Works in urban high-pollution área

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Air quality exposure –

    • Daily outdoor running during rush hours
    • Chronic exposure to traffic-related pollution

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Housing / infrastructure –

    • Limited ventilation at home
    • No air filtration system

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Vulnerability factors –

    • Age >30 years
    • Cumulative exposure over time

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History taking / Patient risk factors

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Environmental and occupational exposure –

    • Lives <100 m from high-traffic road
    • Works in urban high-pollution área

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Air quality exposure –

    • Daily outdoor running during rush hours
    • Chronic exposure to traffic-related pollution

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Housing / infrastructure –

    • Limited ventilation at home
    • No air filtration system

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Vulnerability factors –

    • Age >30 years
    • Cumulative exposure over time

Before moving forward, we should identify potential modifiable factors, including environmental exposures

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  1. Which aspect of this case is most relevant from an environmental health perspective?
  1. Age over 30 years

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  • Physical activity

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  • Chronic exposure to urban air pollution

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  • Absence of toxic habits

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  1. Age over 30 years

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  • Physical activity

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  • Chronic exposure to urban air pollution

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  • Absence of toxic habits

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  1. Which aspect of this case is most relevant from an environmental health perspective?

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Climate-Related Pathophysiology

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Underlying disease – Reduced ovarian reserve contributing to infertility

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Mechanisms related to climate change –

    • Air pollution (PM2.5, NO₂):
      • Oxidative stress → follicular damage
      • DNA damage → granulosa cell apoptosis
      • Endocrine disruption → altered AMH
    • Urban environmental exposure:
      • Chronic low-level pollutant exposure
      • Cumulative reproductive impact

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Evidence –

    • ↑ PM2.5 → ↓ AMH (~2–9%) / ↓ AFC (~7%)

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History taking / Patient risk factors

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Environmental and occupational exposure –

    • Lives <100 m from high-traffic road
    • Works in urban high-pollution área

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Air quality exposure –

    • Daily outdoor running during rush hours
    • Chronic exposure to traffic-related pollution

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Housing / infrastructure –

    • Limited ventilation at home
    • No air filtration system

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Vulnerability factors –

    • Age >30 years
    • Cumulative exposure over time

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  1. What is the main biological mechanism by which air pollution may affect fertility in this patient?�
  1. Mechanical disruption of ovarian function

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  • Inherited genetic abnormalities

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  • Oxidative stress and endocrine disruption

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  • Chronic infection

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  1. What is the main biological mechanism by which air pollution may affect fertility in this patient?�
  1. Mechanical disruption of ovarian function

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  • Inherited genetic abnormalities

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  • Oxidative stress and endocrine disruption

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  • Chronic infection

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Endocrine disruption

Oxidative stress

Mitochondrial dysfuntion

Epigenetic modifications

Disruption of meiosis and mitosis

Thermoregulation

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Blocking

Mimicking

Altering levels in blood

How hormones are made

How hormones are broken down

How hormones are stored

Changing sensitivity

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EDC’s

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EDC’s

Estradiol

Testosterone

Anti-Müllerian hormone

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Chemicals

Air pollutants

ROS

Oocytes

Granulosa cells

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DNA

Lipids / Proteins

Chromosomal instability

Atresia

Impaired ATP production

Mutation

Cell death

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Decreased ovarian reserve

Decreased antral follicle count

Lower AMH levels

Reduced succes rates IVF

Oocyte quality

Embryo development

ROS

Oocytes

Granulosa cells

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Chemicals

Air pollutants

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  1. Which abnormal finding is most likely in this patient?

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  1. Elevated FSH

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  • Low AMH

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  • Secondary amenorrhea

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  • Hyperprolactinemia

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  1. Which abnormal finding is most likely in this patient?

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  1. Elevated FSH

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  • Low AMH

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  • Secondary amenorrhea

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  • Hyperprolactinemia

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Diagnosis and Clinical reasoning

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Differential diagnosis –

    • Unexplained infertility
    • Early diminished ovarian reserve
    • Idiopathic ovarian aging
    • Environmental contribution

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Key investigations –

    • AMH: 1.1 ng/mL (low for age)
    • AFC: 7
    • FSH: normal
    • Semen analysis: normal
    • HSG: normal

DIAGNOSIS

Unexplained infertility with reduced ovarian reserve

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  1. Which of the following associations is best supported by current evidence?�
  1. PM2.5 exposure improves ovarian reserve

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  • NO₂ exposure reduces infertility risk

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  • PM2.5 exposure is associated with decreased fecundity

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  • Temperature has no impact on fertility

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  1. PM2.5 exposure improves ovarian reserve

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  • NO₂ exposure reduces infertility risk

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  • PM2.5 exposure is associated with decreased fecundity

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  • Temperature has no impact on fertility

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  1. Which of the following associations is best supported by current evidence?�

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Infertility – Air pollution

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PM2.5 exposure: 20% increased likelihood of infertility

Li Q, 2021

PM2.5 exposure: 11% decrease in fecundity per 10 μg/m³ increase

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Infertility – Air pollution

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Zhang K, 2025

NO₂ exposure (6-24 months): 17% increased risk of primary infertility

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  1. What is the most immediate and cost-effective intervention in this case?�

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  1. Proceed directly to IVF

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  • Surgical intervention

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  • Reduce environmental exposure

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  • Empirical hormonal treatment

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  1. What is the most immediate and cost-effective intervention in this case?�

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  1. Proceed directly to IVF

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  • Surgical intervention

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  • Reduce environmental exposure

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  • Empirical hormonal treatment

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Management plan

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Non-Pharmacological management –

    • Avoid outdoor activity during high pollution periods
    • Use air quality monitoring apps
    • Prefer indoor exercise

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Co-benefits –

    • Improved cardiovascular health
    • Reduced pollutant exposure
    • Long-term reproductive health protection

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  1. What is a key recommendation for this couple?�
  1. Focus only on the female partner

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  • Ignore environmental factors

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  • Include the male partner and shared exposures

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  • Limit physical activity

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  1. What is a key recommendation for this couple?�
  1. Focus only on the female partner

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  • Ignore environmental factors

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  • Include the male partner and shared exposures

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  • Limit physical activity

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Infertility – Counselling opportunity

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For ART patients – Particular attention to environmental exposures

Patients with diminish ovarian reserve – More vulnerable to cumulative environmental insults

Male partners – Avoid extreme heat exposure / smoke / occupational exposures

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Final reflection

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What message would you give this patient in one sentence?

How can we integrate environmental health into routine fertility care?

What small changes could make a meaningful difference?

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Thank you very much for your attention…

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