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From the Townsend Letter
April 2015

The Impact of Diet and Nutrition on Ovulatory Infertility
by Aviva Romm, MD
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Case Study: Ovulatory Fertility Problems
Mattie was 28 when she first began struggling with fertility issues. After 8 months of her attempting to get pregnant, a fertility evaluation led to a diagnosis of ovulatory infertility: Mattie's ovulation was inconsistent, though she had always considered her periods regular at 26 to 34 days apart. A workup was negative for medical causes of her irregular ovulation: she had normal prolactin, gonadotropins, and sex hormones. She did not have clinical features of polycystic ovary syndrome (PCOS).
For another year, Mattie tried without success to become pregnant. Another consultation with a fertility specialist revealed no major medical issues for either Mattie or her husband, and medical fertility treattments were discussed. Mattie preferred a more natural approach, so she came to me for a consultation.
Most notably, my new patient was tall and thin – too thin, in fact. At a height of 5 feet, 8 inches, and a weight of just under 120 pounds, her BMI was 17.9 – putting her in an underweight category. A careful review of her labs showed mild iron deficiency anemia, normal thyroid function, a normal female hormone panel (done on days 3 and 21 of her otherwise normal menstrual cycle), and no other problems. She had no history of pelvic infection, congenital issues, or other issues that might have led to mechanical problems with fertility. While she also had no history of an eating disorder, she described her current eating habits as erratic due to her busy lifestyle and professional commitments, and her BMI was too low (something that one might also see in an eating disorder) – another possible etiology for infertility.
A thorough review of her diet revealed that breakfast largely consisted of a cup of coffee and sometimes a pastry; lunch a vegetable salad or a fast food meal; and dinner generally no more than 4 to 6 oz. of red meat or chicken, some rice or potatoes, and a small amount of steamed broccoli or a salad. Snacks included, on occasion, a muffin, a candy bar, some nuts, or an energy bar. A second cup of coffee midafternoon was common on weekdays when she worked. She often experienced periods of what she described as "low blood sugar," which her subjective symptoms corroborated, and she often craved sugar.
My initial approach with my generally healthy but undernourished patient was to focus on optimizing nutrition and healthful weight gain, to encourage an optimal preconception diet to promote natural fertility. She was instructed to include a wide variety of healthful protein sources at each meal, including legumes, organic poultry, and low-mercury-containing fish; to increase her intake of monounsaturated fats, particularly olive oil; to add additional healthful fats such as avocado and some coconut oil to her diet; to include whole grains for complex carbohydrates; and to emphasize nuts, organic whole-fat yogurt, and vegetables with hummus for snacks.3 She was asked to discontinue drinking coffee and decrease her sugar intake substantially. If she was in a rush and unable to make breakfast, she was instructed to make a protein shake using a pea source containing 15 grams of protein per serving. Additionally, she was started on a prenatal multivitamin and mineral supplement with methylfolate, and she was given fish oil. Her diet was enhanced with iron-rich foods, and she was started on iron chelate and buffered vitamin C to resolve anemia.
A little over 2 months later, Mattie had happily gained 8 pounds (BMI now 19.5). She was no longer anemic. She enjoyed her new dietary choices and had added light exercise – walking and yoga – to her lifestyle. At 4 months after the time we met, she conceived without additional intervention and remained on the prenatal vitamin/mineral supplement and fish oil. Mattie bore a healthy son after an uneventful full-term pregnancy and uncomplicated birth in her own home.
While elaborate supplement and botanical options are available for women struggling with infertility, remembering that food is often our best medicine is an important basis for improving fertility.

The Role of Nutrition in Fertility Problems
Currently, 1 in 6 women in the US struggles with a fertility problem. Ovulatory infertility accounts for as many as 30% of all cases of infertility.

Many women prefer to avoid the expense and potential adverse effects3 of medical infertility treatment. Nutrition not only plays an important role in achieving pregnancy, but the mother's nutritional status at the time of conception can determine the health of her pregnancy as well as affect embryonic and fetal growth and development. In fact, placental and embryonic development is most vulnerable at the time of conception and can be influenced by maternal nutritional status.1  For most women, making simple dietary modifications is more affordable; relatively easy compared with the effort involved in conventional fertility treatments; and, for a subset of women preferring natural options, may be more consistent with their personal beliefs about health.
Most notably, a cohort of 18,555 nurses without a history of infertility were followed for dietary habits over 8 years as they attempted to become pregnant, or became pregnant, as part of the Nurses' Health Study II (NHS).2  Their nutritional habits were analyzed twice during the course of this study. Using a multivariate-adjusted relative risk of ovulatory disorder comparing women in the highest and lowest quintiles (confidence interval 95%, p value <0.001) the authors drew several important conclusions about dietary and nutritional patterns that may prevent, or promote, ovulatory infertility. This article is a brief review of their essential findings, which can be implemented in the treatment of women with ovulatory fertility disorders including, but not limited to, PCOS.

Weight and Fertility
Women who are either underweight or overweight are at increased risk for infertility, particularly ovulatory infertility.2  While PCOS is typically associated with women who are overweight, it can in fact occur at any weight, as can its underlying pathophysiology, insulin resistance. The relationship between weight loss and resolution of fertility challenges in women with PCOS is well established in the medical literature. Maintaining a BMI between 18.4 and 24.4 appears to be optimal for promoting fertility and preventing or reducing insulin resistance.

Glycemic Load and the Insulin Resistance Connection
The role of insulin resistance is well established in PCOS, which is one of the primary causes of ovulatory infertility problems, and improvement in insulin resistance with weight loss in overweight women with PCOS is known to improve fertility. In the NHS, women whose diets were high in glycemic load had nearly double the risk of ovulatory infertility.4  Glucose homeostasis and insulin sensitivity appear to be central to healthy ovulatory function and fertility.

Micronutrient Deficiencies: Folic Acid and Anemia in Fertility Challenges
Adequate intake of iron supplements and sources of non-heme iron (i.e., plant-based sources) reduces the risk of ovulatory infertility, whereas this association is not seen with supplementation of heme iron (i.e., from animal sources).4  Folate is important for oocyte maturation, while zinc is important for healthy ovulation and normal menstruation. Reactive oxygen species have a negative impact on oocyte maturation and ovulation, suggesting the important role for antioxidants in fertility. Poor folate status and elevated levels of homocysteine have been associated with an increased risk of fertility problems, miscarriage, and pregnancy complications, including preeclampsia.1,5

Protein and Ovulatory Infertility
According to Chavarro et al., a high intake of animal protein leads to a 39% greaterlikelihood of ovulatory infertility than does a diet primarily based on plant protein sources. Further, women with higher protein intake from plant sources (beans, legumes, nuts, seeds) were 22% less likely to experience infertility than women with lower plant protein intake.6

Trans Fats and Fertility
The quality of energy and sources of fats appears to be important in ovulatory infertility. Pharmacologic activation of the peroxisome proliferator–activated receptor g (PPAR-g) improves ovulatory function in women with polycystic ovary syndrome, and specific dietary fatty acids can affect PPAR-g activity. According to Chavarro et al., for every 2% increase in the intake of energy from transfats rather than from carbohydrates or omega-6 polyunsaturated fats, there was a 73% increase. Also, obtaining 2% of energy from trans fats rather than from monounsaturated fats was associated with a more than doubled risk of ovulatory infertility. Unsaturated fats may increase the risk of ovulatory infertility when consumed instead of carbohydrates or unsaturated fats found in nonhydrogenated vegetable oils.7

Dairy and Ovulatory Infertility
Two or more servings per day (versus 1 or less per week) of low-fat dairy products were associated with an 85% increase in ovulatory infertility risk. It appears that a protein component of dairy causes the problem, as the effects were only observed with low-fat dairy, and in fact higher intake of high-fat dairy may decrease risk.8

Summary: Tips for Optimizing Ovulation and Fertility with Diet and Nutrition
1.  Maintaining a normal weight reduces the risk of ovulatory infertility.
2.  Maintain glucose homeostasis and insulin sensitivity with a low-glycemic diet.
3.  Address micronutrient deficiencies, particularly folic acid, and iron deficiency anemia.
4.  Emphasize plant-based proteins over animal sources of protein.
5.  Adequate intake of iron from plant sources and supplements, as well as optimal micronutrient intake, reduces the risk of ovulatory infertility.
6.  Reduce trans fat intake to decrease  the risk of ovulatory infertility.
7.  Choose whole-fat dairy, which appears to decrease the risk of ovulatory infertility, whereas low-fat daily appears to increase the risk.

These dietary strategies form the basis of what is often referred to as a Mediterranean diet, are easily implemented by most individuals, and not only prevent ovulatory infertility but also promote long-term cardiovascular health and reduce diabetes risk.

1.      Cetin I, Berti C, Calabrese S. Role of micronutrients in the periconceptional period. Hum Reprod Update. 2010 Jan–Feb;16(1):80–95.
2.      Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Diet and lifestyle in the prevention of ovulatory disorder infertility.
Obstet Gynecol. 2007 Nov;110(5):1050–1058.
3.      Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. A prospective study of dietary carbohydrate quantity and quality in relation to risk of ovulatory infertility.
Eur J Clin Nutr. 2009 Jan;63(1):78–86.
4.      Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Iron intake and risk of ovulatory infertility.
Obstet Gynecol. 2006 Nov;108(5):1145–1152.
5.      Forges T, Monnier-Barbarino P, Alberto JM, et al. Impact of folate and homocysteine metabolism on human reproductive health.
Hum Reprod Update. 2007 May–Jun;13(3):225–238.
6.      Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Protein intake and ovulatory infertility.
Am J Obstet Gynecol. 2008 Feb;198(2):210.e1–e7.
7.      Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Dietary fatty acid intakes and the risk of ovulatory infertility.
Am J Clin Nutr. January 2007;85(1): 231–237.
8.      Chavarro JE, Rich-Edwards JW, Rosner B, Willett WC. A prospective study of dairy foods intake and anovulatory infertility.
Hum Reprod. 2007 May;22(5):1340–1347. Epub 2007 Feb 28.

Aviva RommDr. Aviva Romm is the mother of four grown children, a Yale-trained physician specializing in integrative medicine for women and children, a midwife, an herbalist, an award-winning author, and the creator/owner of WomanWise, online courses dedicated to vitality and optimal health for women and children. An internationally respected expert in botanical and integrative medicine for women and children, she has spent nearly 30 years as a health-care practitioner and advocate for the health and environmental concerns of women and children.The recent past president of the American Herbalists Guild, a founder of the Yale Integrative Medicine program, and the author of seven books on natural medicine for women and children, including Botanical Medicine for Women's HealthThe Natural Pregnancy Book, Naturally Healthy Babies and ChildrenNatural Health After BirthVaccinations: A Thoughtful Parent's GuideADHD Alternatives (with her husband Tracy Romm, EdD), and The Pocket Guide to Midwifery Care, Aviva was one of the first pioneers in natural birth and botanical medicine for gynecology, obstetrics, and pediatrics in the US.

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