In the United States, an average of 10 percent of people of reproductive age have experienced infertility challenges, regardless of gender.1 Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse” according to the World Health Organization.2
In 2018, the Centers for Disease Control and Prevention reported that total fertility rates (estimated number of lifetime births expected per 1,000 women) fell 18 percent in large metro counties and 16 percent in small or medium metro counties between 2007 and 2017.3
Whether the root cause is due to a preexisting condition or an unknown etiology, the process of becoming pregnant can become frustrating, heartbreaking and expensive for those wishing to become parents.
In my clinical experience, the two misconceptions that I see most often when working with clients struggling with infertility are:
1. Infertility can be cured with nutritional supplementation and vitamins
2. Infertility is due to a female issue, and dietary modifications should only be implemented by the woman
There is no quick fix when it comes to overcoming infertility. Although many nutraceutical companies claim to have a fertility “miracle pill,” the bottles are unfortunately often filled with empty promises.
Diet and Fertility
Dr. Nezhat provided a thorough update on specific nutrients and how they may play a role in fertility outcomes in the previous section. Increased antioxidant, Vitamin D, omega-3 fatty acids, seafood, produce, and nut/legume intake may be related to improved fertility outcomes.4,5 These recommendations have been shown to support certain aspects of fertility in both men and women. Trans fats, high glycemic index food, high carbohydrate diet and high animal protein intake is inversely related to fertility. Whole milk improves women’s fertility, but men benefit from skim milk.6 (To learn more about specific nutrients and how they may play a role in fertility outcomes, see “The Impact of Nutrition on Endometriosis and Reproduction Health” by Dr. Ceana H. Nezhat and Dr. Pavan K. Ananth on page 22.
Importance of BMI
More than 35 percent of men and 40 percent of women in the United States are obese. In Georgia, 35.2% were considered overweight, and 30.5 percent were considered obese.7
One is classified as overweight with a body mass index (BMI) of 25-29.9 and obese with a BMI of 30 or higher.8 With all of the known risk factors associated with a sub-optimal BMI, one lesser-known affect is how excess weight affects fertility in both men and women.
For women, many studies have confirmed that an increased BMI is associated with ovulatory infertility.9
One review article provides a thorough recap of evidence supporting advising women to maintain a healthy BMI to possibly overcome fertility issues. Results from some of those studies include, but are not limited to the following:
• Increased miscarriage rates
• Reduced pregnancy rate with donor insemination
• Poorer embryo quality
• Decreased fertilization rate
• Higher incidence of Polycystic Ovarian Syndrome (PCOS)
• Poor response to ovulation induction
• Normalized menstrual cycle with appropriate gradual weight loss
• As little as 5 percent to 10 percent weight loss can improve fertility outcomes.10
Overweight and obese women should be informed about the importance of pre-pregnancy weight reduction and how it relates to poor outcomes related to fertility due to obesity. There are several proposed mechanisms to explain how obesity may lead to infertility; however, the exact pathophysiology is not clearly understood.11 Weight loss programs through lifestyle modification in obese women have been proven to restore menstrual cyclicity and ovulation and improve the likelihood of conception.9
On the other end of the spectrum, low BMI (<18.5) may result in menstrual disorders and fertility challenges as well.11
Interventions to increase fertility awareness, including infertility risk factors, are warranted, especially those targeting men.13
In a review of 30 studies totaling 115,158 men, researchers found the following results:
• Obesity was associated with more incidence of sperm with DNA fragmentation and abnormal shape (among other sperm-related issues).
• The rate of live birth per cycle of assisted reproduction
technology (ART) was reduced compared with men who were not considered obese.
• There was a 10 percent absolute risk increase of pregnancy non-viability.14
Present data consistently show that obesity is associated with reduced reproductive efficiency in men.15 Obesity has a negative influence in male fertility, and weight loss improves male fertility.16
No supplement can help someone achieve a healthy weight that will support a pregnancy. Personalized medical nutrition therapy is an effective component to help obese patients achieve a desirable BMI. New innovations like video conferencing with a multidisciplinary team have been shown to result in favorable changes in weight loss.17,18,19
The Mediterranean diet is a generic term for a diet that mimics how many people who live close to the Mediterranean Sea eat. There are slight variations, but for medical purposes, certain guidelines remain consistent. Below are some of the basic principles of the Mediterranean diet:
• High consumption of fruits, vegetables, whole-grain bread and other cereals, potatoes, beans, nuts and seeds.
• Olive oil is an important monounsaturated fat source.
• Fish and seafood are consumed at least two times a week.
• Dairy products and poultry are consumed in low to moderate amounts, and little red meat is eaten.
• Eggs are consumed zero to four times a week.
• Wine is consumed in low to moderate amounts.
• Red meat and sweets are rarely eaten.20,21
There is evidence to suggest that compliance with the Mediterranean diet supports both male and female fertility and also may support IVF success.22 In one perspective cohort study, 244 non-obese women undergoing IVF were evaluated. Compliance with the Mediterranean diet was positively related to clinical pregnancy and live birth among women <35 years old but not among women >35 years. Among women <35 years, better adherence to the Mediterranean diet was associated with ~2.7 times higher likelihood of achieving clinical pregnancy and live birth.22
Compliance with the Mediterranean diet may also benefit women not undergoing Assisted Reproductive Technology (ART).15,23 When comparing women aged 20-45 years old who have been struggling to become pregnant, greater compliance to the Mediterranean diet resulted in a lower risk of difficulty becoming pregnant.24
To evaluate whether the Mediterranean diet plays a role in male fertility, a cross-sectional study was conducted in 2017. The authors conclude that men who were least compliant with the Mediterranean diet exhibited below the WHO reference values for sperm concentration, total sperm count, total motility, progressive motility and sperm morphology.25
Omega-3 fatty acid intake is associated with positive fertility parameters.6 Seafood is a rich source of dietary omega-3 fatty acids, particularly DHA and EPA. However, many people of reproductive age are hesitant to consume fish and seafood due to concerns of heavy metal contamination like methylmercury.
One recent study confirmed that greater seafood intake was associated with higher fecundity among couples attempting to become pregnant.26 Additionally, seafood intake has been shown to be positively associated with semen parameters.27, 28
However, with what we know about contaminants in seafood and their effect on fertility and the impending pregnancy, choosing fish and seafood with a low mercury concentration and a high concentration of DHA and EPA is recommended.29 The benefits of eating seafood outweigh the risk if consumed in different varieties of fish in moderation.30
Nutrition and Male Fertility
Many expert panels are now confirming that preconception care should begin at least three months before trying to conceive for both the woman and the man. The role of malnutrition in men is only now emerging from research in humans and animals as an additional important and under-recognized factor.31 Until the last four decades when research findings associated roughly 50 percent of childlessness to male factor infertility, women were typically wrongly stigmatized for inability to conceive.32
Approximately half of infertility cases are due to a male factor.33 This problem is further compounded when no identifiable reason can be found. Between 1973 and 2011, an approximate decline of 50 percent has been seen in sperm counts.34 It may be one or a combination of low sperm concentration, poor sperm motility, abnormal morphology or other issues.33
Research regarding nutrition and how it relates to male fertility is inconsistent. The evidence confirming cigarette smoking’s deleterious effect on male fertility is strong. 35,36,37 However, available evidence regarding factors like alcohol consumption and caffeine intake are conflicting.38,39
When determining whether male-factor infertility is an issue for a couple, a semen analysis is a low-cost, non-invasive and logical first step. When considering interventions to support male fertility, one of the most common focuses is on antioxidant intake. The fact that sperm contains a large amount of unsaturated fatty acids makes it prone to oxidation.
Oxidative stress – essentially an imbalance between the production of free radicals and the ability of the body to counteract or detoxify their harmful effects – has been identified as one of the many causes of male infertility by causing sperm dysfunction. While small amounts of oxidative stress is required for normal sperm functioning, too much negatively impacts the quality of sperm and negatively affects the overall fertilizing ability. Oxidative stress has been shown to play a role in the following regarding sperm:
• attack DNA, lipids, and proteins in sperm
• alter enzymatic systems
• cause cell death
• cause a decline in the semen measures associated with male infertility.40
Sperm cannot repair the damage done by too much oxidative stress.
Statistics from the United States indicate that oxidative stress is one of the major causes of male infertility; that is, 30 percent to 40 percent of infertile men have elevated levels of reactive oxygen species (ROS) in their seminal plasma.41
It is generally accepted that antioxidant therapy can improve the sperm quality and male fertility by reducing oxidative stresses.40
Examples of foods rich in antioxidants include but are not limited to:
• many fruits
• many vegetables
• whole grains
• dark chocolate
To determine whether antioxidants play a role in male fertility, a review was conducted in which reviewers evaluated 35 articles and excluded any animal studies. The researchers found that, among other nutrients, intake of antioxidants vitamin E, vitamin C,B-carotene, selenium, zinc, cryptoxanthin and lycopene was related to improved semen quality.42 (See Table 1)
Another review evaluated antioxidant intake in supplement form. The researchers found that in most of the studies, antioxidant supplementation improved the number, motility, morphology and sometimes DNA integrity of sperm. Antioxidant supplements, especially a combination of antioxidants such as vitamin C, vitamin E and Coenzyme Q10 intake, can effectively improve semen parameters in infertile men.43
According to Kottle et al., only about 10 percent of physicians give advice to more than 80 percent of their patients.44 Barriers to receiving nutrition counseling include difficulty keeping appointments, location, lack of time, financial support for outpatient care, inadequate teaching materials, lack of physician knowledge, inadequate reimbursement, low physician confidence and patients’ belief in the usefulness of dietary counseling.45,46,47
Nutrition Now (nutrition counseling and support services to help people conceive via nutritionnowcounseling.com) is attempting to overcome barriers to patients receiving personalized nutrition information by offering web-based nutrition surveys and counseling to those seeking evidence-based recommendations according to their personal needs. It is a low-cost service with a minimal time investment, in which the patient will receive recommendations for diet and lifestyle modification recommendations from a registered dietitian based on responses they provide from a web-based survey via a HIPAA-compliant and secure server. The patient will also have an opportunity to have any supplements they are taking be evaluated, as well as be able to ask any nutrition-related questions to a registered dietitian.
1. Chandra, A., Copen, C.E., Stephen, E.H. Infertility and Impaired Fecundity in the United States, 1982–2010: Data From the National Survey of Family Growth. 2013;(67):1-18,1-19.
2. World Health Organization. Sexual and reproductive health: Infertility definitions and terminology. http://www.who.int/reproductivehealth/topics/infertility/definitions/en/. Accessed October 12, 2018.
3. Ely D, Hamilton B. Trends in Fertility and Mother’s Age at First Birth Among Rural and Metropolitan Counties: United States, 2007–2017. Center for Disease Control and Prevention NCHS Data Brief. 2018(323). https://www.cdc.gov/nchs/data/databriefs/db323-h.pdf. Accessed October 18, 2018.
4. Chiu YH, Chavarro JE, Souter I. Diet and female fertility: doctor, what should I eat? Fertil Steril. 2018 Sep;110(4):560-569. doi: 10.1016/j.fertnstert.2018.05.027.
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8. National Institutes of Health. Classification of overweight and obesity by BMI, Waist Circumference, and Associated Disease Risks. https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi_dis.htm. Accessed October 17, 2018.
9. Silvestris E, de Pergola G, Rosania R, Loverro G. Obesity as disruptor of the female fertility. Reprod Biol Endocrinol. 2018 Mar 9;16(1):22. doi: 10.1186/s12958-018-0336-z.
10. Pandey S, Pandey S, Maheshwari A, Bhattacharya S. The impact of female obesity on the outcome of fertility treatment. J Hum Reprod Sci. 2010; 3(2): 62–67. doi: 10.4103/0974-1208.69332 PMCID: PMC2970793 PMID: 21209748
11. Dag Z, Dilbaz B. Impact of obesity on infertility in women. J Turk Ger Gynecol Assoc. 2015; 16(2): 111–117.
12. Aladashvili-Chikvaidze N, Kristesashvili J, Gegechkori M. Types of reproductive disorders in underweight and overweight young females and correlations of respective hormonal changes with BMI. Iran J Reprod Med. 2015 Mar;13(3):135-40.
13. Pedro J, Brandão T, Schmidt L, Costa ME, Martins MV. What do people know about fertility? A systematic review on fertility awareness and its associated factors. Ups J Med Sci. 2018 Jun;123(2):71-81. doi: 10.1080/03009734.2018.1480186. Epub 2018 Jun 29.
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16. Silva T, Jesus M, Cagigal C, Silva C. Food with influence in the sexual and reproductive health. Curr Pharm Biotechnol. 2018 Sep 25. doi: 10.2174/1389201019666180925140400. [Epub ahead of print]
17. Johnson KE, Alencar MK, Coakley KE, Swift DL, Cole NH, Mermier CM, Kravitz L, Amorim FT, Gibson AL. Telemedicine-Based Health Coaching Is Effective for Inducing Weight Loss and Improving Metabolic Markers. Telemed J E Health. 2018 May 30. doi: 10.1089/tmj.2018.0002. [Epub ahead of print]
18. Alencar MK, Johnson K, Mullur R, Gray V, Gutierrez E, Korosteleva O. The efficacy of a telemedicine-based weight loss program with video conference health coaching support. J Telemed Telecare. 2017 Jan 1:1357633X17745471. doi: 10.1177/1357633X17745471. [Epub ahead of print]
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20. American Heart Association. Mediterranean Diet. Reviewed April 18 2018. http://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/mediterranean-diet. Accessed October 16, 2018.
21. Oldways. Mediterranean Diet. https://oldwayspt.org/traditional-diets/mediterranean-diet. Accessed October 16, 2018.
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24. Toledo E, Lopez-del Burgo C, Ruiz-Zambrana A, Donazar M, Navarro-Blasco I, Martínez-González MA, de Irala J. Dietary patterns and difficulty conceiving: a nested case-control study. Fertil Steril. 2011 Nov;96(5):1149-53. doi: 10.1016/j.fertnstert.2011.08.034. Epub 2011 Sep 22.
25. Karayiannis D, Kontogianni MD, Mendorou C, Douka L, Mastrominas M, Yiannakouris N. Association between adherence to the Mediterranean diet and semen quality parameters in male partners of couples attempting fertility. Hum Reprod. 2017 Jan;32(1):215-222. Epub 2016 Nov 14.
26. Gaskins AJ, Chavarro JE. Diet and fertility: a review. Am J Obstet Gynecol. 2018 Apr;218(4):379-389. doi: 10.1016/j.ajog.2017.08.010. Epub 2017 Aug 24.
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