Eating for Fertility

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 Nutrition is an important piece of the Infertility puzzle

A 29-year-old married professional in a high-stress job was referred to me by an infertility specialist for nutrition advice on lowering her serum carotene and optimizing her fertility status. At age 14, she had her first menstrual period, and at age 18 she started taking an oral contraceptive.

When she discontinued the Pill to try and get pregnant, her menstrual periods did not return, even after two years. She was amenorrheic on our first visit.

Her highest adult weight was 115 lbs (age 17) and her lowest was 99 lbs (age 27). She described her activity level as "very active," but the infertility specialist asked her to reduce her exercise from four times per week for 60 minutes to a more moderate three times per week for 45 minutes.

She raised suspicions of exerciseinduced amenorrhea and risk for early osteoporosis when she said she could no longer run due to a hip injury.

The year before, she had followed the advice of an alternate health professional who asked her to omit wheat and dairy from her diet. Following this "strict diet" for almost a year brought no success in getting pregnant.

Breakfast was kamut bread, almond butter, honey and oatmeal; lunch was a vegetable sandwich on kamut bread or a vegetable salad; and dinner was vegetables and rice or spelt (a whole-grain flour) pizza with pesto and occasional goat's cheese. She ate chicken about three times a week.

After assessing her diet, it became clear it was unbalanced and low in energy, high-quality protein, B vitamins, iron, zinc and calcium. In addition to the high plant-based diet, she was supplementing with 15,000 IU beta-carotene daily, which no doubt was contributing to her high serum carotene level.

She also took a calcium/ magnesium supplement (250 mg calcium per day), but this did not meet the adult recommendation (1,000 mg per day) or the 1,200 to 1,500 mg per day for those at risk for osteoporosis.

She used almost no dairy products or appropriate alternatives. The infertility specialist recommended 1 mg folic acid per day to prevent the risk of neural tube defects. Folic acid needs of adult women are 0.4 mg per day and for pregnancy 0.7 mg per day. Taking more than 1 mg per day is generally not recommended. Hypercarotenemia, one of the diagnostic criteria for anorexia nervosa and often identified by yellow-orange palms, has been linked to amenorrhea and infertility, although the mechanism is unknown. High serum carotene may also exist in other women with low body weight and body fat but who do not have a frank eating disorder. They may be classed as "disordered eaters."

Disordered eating is described as a spectrum, where poor eating is on one end and anorexia and bulimia on the other. Anywhere along the spectrum can be risky to health. Amenorrhea can lead to early osteoporosis, since low estrogen levels trigger the loss of calcium from bones.

Scientists report diets high in deep green, yellow-orange vegetables and fruit as well as high-dose supplements can elevate serum carotene levels. It has been suggested a high serum carotene might be a marker for a diet rich in isoflavones or phytochemicals that compete for estrogen receptors, and thus interfere with fertility in certain individuals.

While high carotene levels are generally not considered harmful, in the case of infertility it can be problematic for some. There is no daily recommended level or an upper limit for safety/toxicity for beta-carotene, a plant precursor to vitamin A. On the other hand, vitamin A as retinol can be teratogenic (upper limit 3,000 μg).

 "I strongly believe it was my improved nutrition and weight gain that got me pregnant . . . Instead of asking her to totally avoid all carotene-rich foods, which might seem like a logical first reaction, it was more appropriate to discontinue her supplement and to improve her energy and protein intake for weight gain. She was educated about carotene-rich foods and advised to eat a wider variety of vegetables and fruit to keep the carotene intake low for the time being.

Since her body mass index (BMI) was 18.8, I explained an optimum index may be closer to 20, or 115 lbs, the low end of the healthy range for a small-framed adult.

She also confessed she was too tired and stressed at the end of the day to plan, prepare or eat balanced meals at home and was skipping lunch due to her hectic work schedule. Strategies for meal planning and stress management were resolved with the help of the health-care team.

This woman did not have a true allergy to wheat or dairy, since she tolerated kamut and spelt and feta cheese (a milk product). She told me she was happy to consume the recommended three servings per day from milk or milk products and she could consume a variety of grains—iron-fortified breakfast cereals, breads, starchy vegetables and legumes for adequate carbohydrate calories.

She also agreed to include more lean red meat to help build up the lining of her endometrium — supplying heme iron, zinc, vitamin B12, essential amino acids and a little cholesterol to help synthesize sex hormones.

She began to gain more weight on her new balanced meal plan, which included all four food groups plus beneficial fats, some desserts and treats. Her breakfast now was an iron-fortified cereal, milk and fruit; lunch was a sandwich (turkey, tuna, ham, salami or cheese with mayo), vegetables and fresh fruit; and dinner was poultry, lean meat or fish with a starchy vegetable, rice or pasta and a salad with vinaigrette. She added an evening snack of milk, yogurt, fruit juice or occasional pie and ice cream. Caffeine and alcohol were rarely consumed, in keeping with her physician's guidelines for optimum fertility.

In three months, she had gained 8 lbs, to reach her 115 lbs target, her serum carotene returned to normal and she happily reported she was pregnant. During her pregnancy, she gained about 35 lbs and produced a healthy baby whom she breastfed during her year's maternity leave.

Two years later, she returned for help in trying for a second child. She was convinced nutrition was the key to her success. This time, her initial weight had dropped to 103 lbs, she was amenorrheic and skipping meals back at work again. I helped her get back on track and after six months, she reached 115 lbs and got pregnant on her first cycle.

She claimed reducing her rigorous postpartum exercise helped her gain at least five of the 12 lbs needed to reach her target weight. At the end of this prenatal visit, her parting comments were: "I strongly believe it was my improved nutrition and weight gain that got me pregnant . . . the first time . . . and this time too."

Not all infertile or sub-fertile women are as fortunate. However, early nutrition education is a key factor. Unreliable information in best-selling books and on the Internet abound—misleading the unsuspecting couple desperate for advice.

Each patient has unique problems and nutrient needs and should be counseled on an individual basis. Attention to weight and exercise history, use of supplements and level of stress can yield important clues.

Avoidance of major food groups without good reason, or lack of education on alternate food sources to assure key nutrients is all too common. Use of all dietary supplements and herbals should be monitored.

Quick-fix remedies and fad diets touted as a "one-size-fits-all" approach to pregnancy can delay progress and should be carefully scrutinized by the infertility specialist or experienced registered dietitian.