Nutrition and Infertility: Improving Your Fertility Diet

Nutrition and Infertility: Improving Your Fertility Diet

Nutrition is key to our overall health, and with the recent ‘Food is Medicine’ movement, there has been a strong interest in how food may impact fertility. Struggling to have the family you desire when you want it can be frustrating, stressful, and make you feel out of control. This can often trigger poor eating habits as a way to cope with the stress of infertility, which can then spiral into weight gain and more worry. Learning about what foods can be beneficial for fertility and how simple daily choices can improve health can help you take some control back in your fertility journey. 

Warning: nutrition is essential, but a laser focus on eating habits associated with guilt about not conceiving can lead to disordered eating (especially if someone has a history of eating disorders), so be careful about associating foods as ‘good’ or ‘bad’ or judging yourself at the end of the day if you’ve made some food decisions that are listed here as less than ideal for your fertility. Make nutrition a positive goal for your week, and empower yourself with healthy choices, but don’t beat yourself up if you enjoy a treat sometimes! Everything in moderation.

Now let’s review some diets and foods that are associated with improved fertility and those that have been shown to potentially decrease chances of conceiving. We all know in general how to eat well, with less processed food and more fruits and veggies, but reviewing the evidence around fertility can be a powerful reminder of just how important your food choices can be. 

 Are Certain Diets Better for Fertility?

We’ll review the research into the impact of different dietary patterns on fertility but first let’s clarify the diets we are discussing. 

Western Diet – typically consists of a high intake of red meat, fast and processed food, refined grains including white rice and bread, high amounts of refined sugar including soda.

Mediterranean Diet – typically consists of more vegetables, fish, fruits, poultry, low-fat dairy products, olive oil and less red meat, fast and processed food.

The Fertility Diet – a diet recommended by researchers who examined fertility among married women trying to conceive in the large prospective Nurses’ Health Study. These scientists found more regular ovulatory function and lower infertility rates among couples with a diet higher vegetable protein sources than meat protein sources, low glycemic carbohydrate intake, whole-fat dairy products, higher in monounsaturated trans fatty acids than transfats, multivitamins, and iron from plants and supplements (Chavarro 2007). 

Pro-Fertility Diet – a diet designed by researchers in Boston as a part of the Environment and Reproductive Health (EARTH) Study, which includes prioritizing intake of low-pesticide fruits and vegetables, whole grains, seafood, dairy, and soy foods and limiting intake of high-pesticide fruits and vegetables. The diet includes supplemental folic acid (>800 micrograms/day), vitamin B12 (>15.8 micrograms/day), and vitamin D (>843 IU/day),  (Gaskins 2019).

Ketogenic Diet – also called the Keto diet or Atkins diet – there are many variations on the same theme: low carbohydrate intake in favor of fats and proteins (usually animal proteins). This diet was wildly popular for weight loss a few years ago, and people loved the idea of piling up eggs and bacon over carbs with the idea that it takes more energy (weight loss) to burn calories from fats and proteins than carbs. 

Paleo Diet – a diet based on the types of foods presumed to have been eaten by early humans like meat, fish, vegetables, and fruit which excludes dairy or grain products and processed food.

Vegetarian Diet – according to the Vegetarian Society, a vegetarian is someone who does not eat any meat, poultry, game, fish, shellfish, or by-products of animal slaughter. Vegetarian diets contain various levels of fruits, vegetables, grains, pulses, nuts, and seeds. The inclusion of dairy and eggs depends on the individual following the diet.

Vegan Diet – can be described as the strictest form of vegetarianism. Veganism is defined by the Vegan Society as a way of living that attempts to exclude all forms of animal exploitation and cruelty as much as possible. Therefore, a vegan diet not only excludes animal flesh, but also dairy, eggs, and animal-derived ingredients. These can include gelatin, honey, carmine, pepsin, shellac, albumin, whey, casein, and some forms of vitamin D3.

 Which diet is best for fertility?

Adherence to a Mediterranean Diet has been associated with many health benefits, including reduction in cardiovascular disease, cancer, neurodegenerative disease, and overall mortality. Some studies have shown improved fertility benefits for this diet. One study comparing the diets of approximately 500 Spanish women with a history of infertility to about 1600 women who had a child found that the women with a more Mediterranean-type diet with high amounts of fruits and veggies had a higher fertility rate compared to women with a Western diet high in processed foods and red meat (Toledo 2011). An interesting prospective study out of the Netherlands showed a 40% increased probability of success with IVF treatment in couples whose diet followed the typical Mediterranean pattern described above (Vujkovic 2010). The authors of this study suggest that the high intake of vegetable oils with linoleic acid (a precursor for prostaglandins) may improve ovulation and endometrial receptivity. Another study from the Netherlands showed a lower miscarriage rate in women who ate a Mediterranean diet while pregnant (Twigt 2012). And for men, the Mediterranean Diet has been shown in several different studies to be associated with better sperm counts and parameters (Ricci et al. 2019). 

What about the other diets? The Nurses’ Health Study is the largest and longest prospective cohort study designed to examine causes and outcomes of chronic disease in women. Started in 1976 and still ongoing, with over 200,000 participants and into its third generation of women, it is quite a wealth of information, and many studies (including fertility studies) have come from this larger cohort study. Several studies have examined specific foods and their impact on ovulation function (and subsequent fertility) based on the Nurses’ Health Study and found that higher consumption of monounsaturated trans fatty acid intake, vegetables as a protein source more than meat protein sources, low glycemic carbohydrates, whole-fat dairy products, multivitamins, and iron from plants and supplements was associated with regular ovulation and thus higher fertility over time. This list of food choices has been called the Fertility Diet. 

A group of researchers from Boston, combining Harvard School of Public Health and Massachusetts General Hospital Fertility Clinic, developed and studied their own take on a diet for fertility called the Pro-Fertility Diet. This group has studied the impact of many lifestyle factors, including nutrition, on fertility in a group of studies collectively called the Environment and Reproductive Health (EARTH) Study. In 2019, they published a study in over 300 patients undergoing iVF treatment and showed higher success rates and lower miscarriage rates in the group of patients following their Pro-Fertility diet compared to the typical Mediterranean diet (Gaskins 2019). The Pro-Fertility Diet is similar to the Mediterranean Diet and the Fertility Diet listed above but includes decreasing exposure to pesticides in fruits and veggies and taking supplements like folic acid and vitamin D. 

Formal studies comparing a Ketogenic diet or a Paleo diet to other diets in regard to fertility could not be found in the medical literature for this article. However, lowering highly processed carbohydrates in the diet has shown benefits in cardiovascular disease, some cancers, diabetes, skin disease, and more. Data compiled from the Nurses’ Health Study showed a higher intake of carbohydrates was associated with ovulatory dysfunction and infertility (Chavarro 2009). Research has shown that women with PCOS benefit from lowering carbohydrate intake; they have improved hormonal profiles, more regular ovulation, and maintain weight loss (Moran 2013). These diets typically recommend avoid processed foods, which can be beneficial for fertility because high intake of fast and processed food has been associated with lower fertility rates (Grieger 2018).

There is limited data on vegetarian or vegan diets for fertility, but many studies looking at overall nutrition for fertility include some analysis of the impact of animal protein on reproduction. Most studies find diets high in animal proteins are associated with higher ovulatory dysfunction (Chavarro 2008), lower fertility rates, and poor sperm parameters (Giahi 2015). An important thing to remember about a plant-based diet is that just because someone is avoiding meat, it does not mean their diet is as nutritious as it should be. We think of vegetarian or vegan as healthier – and it can be if the diet is full of varied fresh fruits, vegetables, nuts, and more, but a diet full of processed, high glycemic carbohydrates is not nutritious. Remember: just because an Oreoä cookie is vegan doesn’t mean it’s healthy. 

 Can Specific Foods Improve Fertility?

Fruits

o   One study evaluated pre-conception diet in over 5000 women in Australia and found a 19% improved time to conception in women who ate three or more servings of fruit per day compared to women who ate very little fruit (Grieger 2018).

o   A high fruit intake has been associated with improved sperm parameters (Giahi 2015).

o   Higher fruit intake (especially citrus fruit) was associated with lower risk of endometriosis in the Nurses Health study. One study showed women with 1 or more servings of fruit per day had a 22% lower risk of having endometriosis (an inflammatory condition associated with painful menses and infertility in women) (Harris 2018). The authors propose that diets rich in fruits and vegetables include higher levels of pro-vitamin A nutrients (alpha-carotene, beta-carotene, beta-cryptoxanthin) and women with endometriosis have been reported to have lower intake of vitamin A than women without endometriosis.

o   A Note on Fruit: Fruit is delicious and seems to help fertility, but it can be full of pesticides which can harm fertility. Try to choose organic when possible and wash fruits thoroughly before eating to decrease exposure to pesticides and preservatives added to keep fruit looking fresh longer.  

Whole Grains

o   A diet full of whole grains in favor of processed carbohydrates has been associated with improved male fertility (Giahi 2015).

o   A diet higher in whole grains is associated with increased fertility and higher chances of success with assisted reproduction (Gaskins et al. 2019). 

o   Whole grains are a source of fiber, which can help with hormone balance in your body. Some studies have shown fiber can help eliminate excess estrogen and improve ovulatory function (Chavarro 2007). 

Dairy

o   The Nurses’ Health Study showed that intake of high-fat dairy had a protective role in regular ovulation but that regular intake of low-fat or reduced-fat dairy products were associate with ovulatory dysfunction (Chavarro 2007). This study showed that women who consumed at least one or more servings of high-fat dairy per day were 27% less likely to be infertile.

o   Some studies have shown a protective effect of dairy on risk of endometriosis. Harris et al. showed an 18% lower risk of endometriosis in women who consumed 3 or more portions of dairy per day (compared to women who consumed less than 2 servings per day). Vitamin D3 has been associated with lower risk of endometriosis and the authors found a 24% lower risk of endometriosis in women with a higher vitamin D3 concentration in the study (Harris 2013). 

o   A preference for high-fat dairy products has shown improved sperm parameters (Giahi 2015). 

o   Dairy may have a negative impact on fertility but studies evaluating this were not discovered by the time of the writing of this blog post.  Dairy has been flagged as a pro-inflammatory food by some. It may be a sensitivity that certain people have to something in the dairy (similar to lactose intolerance) or a reaction to something in the way in which a lot of dairy is processed (stored in containers with plastic). Regardless, some fertility nutritionist recommend limiting dairy and the evidence supporting higher fat dairy suggests that when choosing dairy product – go for the full fat kind!

 Foods Full of Antioxidants

o   Our cells are constantly producing energy and, in the process, producing by-products like free radicals that can lead to cell damage over time. Antioxidants help clean up free radicals and decrease the risk of cellular damage.

o   A male diet full of antioxidant-rich fruits and vegetables is associated with improved sperm parameters. Antioxidants are thought to have a protective function for sperm against endogenous oxidative damage by neutralizing damaging free radicals (Giahi 2015). 

o   Most studies in reproductive health and success with assisted reproduction show improved success with a diet full of fresh fruits and vegetables full of antioxidants like vitamin C, vitamin E, and folate (Gaskins 2019). 

o   One quick way to get a dose of antioxidants is a handful of walnuts for a snack. One randomized trial showed that 75g of walnuts every day improved sperm parameters in approximately 100 men eating a typical Western diet (Robbins 2012).  

Can Specific Foods Harm Fertility?

Fast Food

o   One study evaluated pre-conception diet in over 5000 women in Australia and found a 41% increased risk of infertility in women who ate fast food four or more times a week compared to women who ate it less than two times a week (Grieger 2018).

o   Processed food has been associated with poor sperm parameters (Giahi 2015). 

o   The processing of food to make it ‘fast food’ drains nutrients and spikes blood sugar but the harm of fast food goes beyond the lack of nutrition. The plastic packaging of most fast foods is usually full of toxic endocrine disrupting chemicals like BPA (bisphenol A). The heat of the food allows the chemicals in the food containers to leach into the food and right into our bodies. High levels of BPA are associated with poor egg quality, low sperm parameters, infertility, and higher rate of miscarriage. Please see my blog post on BPA to learn more about how this chemical harms reproductive health and ways you can decrease your exposure).

High Glycemic Carbohydrates

o   Higher intake of high glycemic index carbohydrates in place of naturally occurring fats was associated with ovulatory dysfunction and difficulty conceiving in the large prospective cohort Nurses’ Health Study (Chavarro 2009).

o   Women with PCOS have been shown to have improved hormonal profiles, more regular menstrual cycles and ovulation, and success with desired weight loss with lower intake of highly processed carbohydrates (Moran 2013).

o   A diet lower in processed carbohydrates improves sperm parameters (Giahi 2015).

o   Carbohydrates are an important part of nutrition but choosing which ones to include in your diet can have an impact on your reproductive health. Carbohydrates with a high glycemic index like white rice, white bread, and refined sugar will cause high spikes in insulin and blood sugar levels that overload your body’s ability to keep up. Lower glycemic index carbohydrates like those in vegetables and whole grains don’t cause such a spike, and your body is able to process them without the highs and lows of spiking blood sugar levels. Avoid sugary sodas and fruit juices that can also spike your insulin levels and put your body on a roller coaster of spiking blood sugars and overload.

Animal Protein

o   A higher intake of animal protein was associated with ovulatory-dysfunction-related infertility in the large prospective cohort Nurses’ Health Study (Chavarro 2008). This study found that when 5% of total calories came from vegetable protein instead of animal protein, the risk of ovulatory infertility decreased by more than 50%.

o   Women with PCOS had lower inflammation markers with a vegetarian diet compared to the higher levels of inflammation measured in age-matched controls with PCOS who ate meat regularly (Ganie 2019).

o   High intake of red meat has been associated with poor sperm parameters (Afeiche 2014).

o    A diet full of red meat (ham, beef, and more processed red meat) has been associated with a higher risk of endometriosis (Parazzini 2014). 

o   Non-animal sources of protein can be vegetables, beans, lentils, and nuts.

o   Another thought surrounding why animal protein may decrease fertility is the way in which most meat is processed and handled from the farm to our kitchen. The processing and handling of meat and dairy often involves wrapping, processing through PVC pipes, plastic containers, and more on the way to our homes, and plastics are full of chemicals that when leaked into the food we ingest can harmfully impact our fertility. Please see my blog posts on BPA and phthalates to learn more about how these chemicals harm reproductive health and ways you can decrease your exposure to them.

Trans Fats 

o   Trans fats are formed when manufacturers use a process called hydrogenation to convert liquid vegetable oils into solid fats. This process increases the shelf life and stabilizes the flavor of many foods you can find packaged at the grocery store, like margarine, crackers, cookies, candy, salad dressing, fried food, granola bars, and more. Many foods advertised as being ‘healthy’ may have these harmful trans fats. The ingredient ‘partially hydrogenated oil’ is a trans fat. FYI, foods can call themselves trans-fat free if they contain less than half a gram of trans fats per serving.

o   Higher intake of trans fats was associated with ovulatory dysfunction and infertility in a cohort of over 17,000 women followed for eight years as they tried to conceive and became pregnant (Chavarro 2007).

o   Increased intake of trans fats has been associated with decreased male fertility (Giahi 2015). 

o   A diet full of trans fats has been associated with a higher risk of endometriosis, an inflammatory condition associated with painful menses and infertility in women (Missmer 2010).

Caffeine

o   Studies vary on how much caffeine is too much. One study suggests that women who consume over 500mg of caffeine a day take 9.5 months longer to conceive (Bolumar 1997). Other studies do not show an impact on female fertility (Fenster 1999). 

o   One cohort study in a fertility clinic showed no impact of caffeine consumption in over 300 women and men going through IVF (Ricci 2018).

o   High caffeine intake in pregnancy has been associated with increased risk of miscarriage – one study showed a significantly higher risk of recurrent miscarriage in women consuming >900mg of caffeine per day pre-conception (Tolstrup 2003).

o   A Note on Amount of Caffeine in Drinks

• One 8 oz brewed cup of coffee has about 70-140mg (95mg on average)

• One shot of espresso has about 60mg

• One cup of tea has about 30mg

• Soda has approximately 30-40mg

 Soy 

o   The data on soy and the phytoestrogens found in soy products is varied and debated. Some findings show health benefits like reduction in breast cancer, fibroids, menopausal symptoms, cardiovascular disease, inflammation, and obesity while other data explores potential endocrine disruption in the reproductive system. Some studies show menstrual cycle disruption with soy, and others do not. 

o   The estrogen-like properties of soy have caused worry that high consumption may increase risk of endometriosis (an inflammatory process associated with infertility and worsened with estrogen exposure). One small study in Japan (where soy is highly consumed) showed a correlation between high levels of isoflavones in urine of women with Stage 4 (severe) endometriosis but no association with less extensive disease (Tsuchiya 2007). 

o   Not all soy products are the same: less processed forms like tempeh, edamame, and miso may be better than the processed forms found in many packaged foods. The debate is still ongoing, but current professional recommendations do NOT suggest that women or men should eliminate soy from their diet when trying to conceive (Cooper 2019). 

 Pesticides and fertility

Most fertility-friendly diets recommend a lot of fruits and vegetables, but these foods can be full of pesticides, which harm your fertility. One study showed that in over 300 patients doing IVF, exposure to fruits and veggies with high pesticide residue was associated with a 26% lower live birth rate (Chiu 2018). This paper reviewed reports from the US Department of Agriculture Pesticide Data Program to clarify high and low pesticide residue foods and lists these foods as highest risk: bell peppers, raw or cooked spinach, strawberries, peaches, plums, potatoes, grapes, string beans, fresh and sauced apples, fresh pears, winter squash, kale, mustard greens, chard greens, blueberries, and tomatoes. Steps you can take to decrease exposure include buying organic if possible and being sure to wash your foods well before eating. 

 What about intermittent fasting?

There is a popular trend of intermittent fasting as a weight loss method. Recommendations vary but in general intermittent fasting involves limiting your food intake to a 10-14 hour window in a 24 hour day. A typical pattern can be skipping breakfast, so your body doesn’t process food from dinner to the next day’s lunch. Many people find that by skipping a meal – they eat fewer overall calories and fans of fasting argue that giving your body a break from processing and digesting food allows for your body to use up fat stores for fuel.

No studies on intermittent fasting and fertility could be identified while researching for this topic, but in theory – intermittent fasting is likely not a good idea while trying to conceive. Fasting in theory puts your body in a more stressful state and ovulation and fertility in general are optimal when bodies are not stressed. For now – the best recommendation is to avoid intermittent fasting or modify to shorter hours while trying to conceive. If weight loss is your goal while trying to conceive – review all options with your medical providers and find the right choices for your personal situation. 

Summary points

• Nutrition is key to your overall health and paying attention to what you eat can impact your fertility.

• Focus on a varied diet high in fruits and vegetables, which are high in antioxidants. Buy organic when possible and wash your produce well to decrease pesticide exposure before you eat.

• Opt for whole grains with fiber instead of high glycemic index carbohydrates like sugars, white bread, and white rice, which have limited nutrition value and spike insulin and blood sugar levels.

• Limit red meat and animal proteins and increase other sources of protein in your diet with vegetables, lentils, beans, and nuts.

•  Avoid fast and processed foods.

•  When choosing dairy products – opt for the full fat options.

• Avoid transfats

• A little bit of caffeine is okay, but not too much (one cup of coffee a day).

• Stay hydrated with water and avoid sugary sodas and juices. 

• Plastic food containers can increase exposure to endocrine disruptors like bisphenol A (BPA) and phthalates - read more about how these toxins impact fertility and tips on decreasing exposure here: BPA Blog Post and Phthalates Blog Post.

 Final Thoughts

There are so many different recommendations out there about nutrition and people feel passionately about the choices they feel are right for them. We’ve reviewed the evidence that’s available in the literature today, but take everything ‘with a grain of salt’ meaning learn, modify, but avoid extremes. 

Remember: Everything in Moderation, Even Moderation.

We have to eat – so make choices that optimize your health. When you’re healthy, your fertility will improve. Nutrition is important but focusing on diet too much can lead to anxiety, worry, and even disordered eating patterns. Be kind to yourself and enjoy those favorite treats every once in a while. 

 One of my favorite proverbs (I cannot remember where I heard it first) is “Perfection is 80%.” Make your goal a healthy, nutrition-rich diet 80% of the time, and you’re doing great! 

 Learn more about infertility and miscarriage with more blog posts at drlorashahine.com.

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Learn more about infertility and miscarriage with more blog posts at drlorashahine.com.

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