Integrative Nutrition and Fertility - Today's Dietitian Magazine (2023)

Integrative Nutrition and Fertility
By Kayli Anderson, MS, RDN, DipACLM, ACSM-EP
Today’s Dietitian
Vol. 25 No. 4 P. 26

A whole-person approach is the best road to take.

A woman’s ability to conceive often remains unknown until she begins planning a pregnancy. For many women, this is an exciting and special time. For others, it can be fraught with disappointment, frustration, and confusion. Infertility, defined as the inability to conceive after at least one year of unprotected sex or after at least six months for women over age 35, is fairly common, affecting about one in five women in the United States.1

Causes of female infertility include irregularities in ovulation, fallopian tube obstruction, and anatomical abnormalities of the uterus. Anovulation, the absence of normal ovulation during a menstrual cycle, is the most common cause of female infertility. Some potential causes of anovulation include polycystic ovary syndrome (PCOS); hypothalamic amenorrhea, or a lack of menstruation for six months with no other known medical cause as a result of excessive exercise, weight loss, stress, or eating disorders; and other hormonal imbalances.1

The good news? Many instances of anovulatory infertility can be addressed through integrative nutrition and lifestyle approaches. A pivotal 2007 study on fertility, diet, and lifestyle followed more than 17,000 women without a history of infertility over an eight-year period as they tried to become pregnant. The researchers concluded that the majority of ovulatory disorder infertility cases may be preventable through modifying diet and lifestyle.2 Although this landmark study didn’t explicitly point to integrative nutrition as an intervention, many of the approaches fall under this modality. It’s known through other research that fertility outcomes are associated with diet and exercise habits, psychosocial health factors, such as stress levels and sleep quality, plus other environmental factors—all of which play a role in integrative nutrition.3

What Is Integrative Nutrition?
Integrative nutrition takes a whole-person approach, considering genetic, environmental, physiological, and psychological factors that contribute to health and disease. In other words, an integrative nutrition approach seeks to identify root causes of health concerns. This approach usually blends conventional and alternative therapies, mixing evidence-based nutrition guidelines that RDs are well-equipped to use with everything from botanicals to acupuncture. You’ll often see integrative nutrition paired with functional nutrition, as is the case in the Integrative and Functional Medical Nutrition Therapy Radial, a framework that helps dietitians implement both forms of MNT.4 The framework represents the whole-person approach of integrative nutrition with the categories of community, earth, body, mind, and spirit.

In the case of fertility, integrative nutrition has much to offer, as it enables dietitians to blend their evidence-based nutrition knowledge with other approaches that have been shown to support fertility. These include the use of botanicals, supplements, and other mind-body practices to form a comprehensive fertility protocol. In this article, Today’s Dietitian explores various integrative nutrition approaches to fertility and how RDs can create a plan to support all aspects of their clients’ fertility health and well-being.

Whole Foods for Fertility
Foods associated with positive outcomes are the cornerstone of integrative nutrition for fertility. Many foods and food components are associated with shorter time to conception and help address root causes that may be contributing to infertility.

Phytonutrient-Rich Foods
Many conditions that affect fertility, such as PCOS, are accompanied by higher levels of oxidative stress in the body, and increasing intake of phytonutrient-rich foods may help counter that. Where can clients find an abundance of phytonutrients? Fruits and vegetables, of course. Dietary patterns high in fruits and vegetables are associated with better fertility in women and better semen quality in men.5 Lower intakes of fruit and higher intakes of fast food, which may increase oxidative stress in the body, are associated with infertility and increased time to conception.6 To help clients maximize their phytonutrient intake, encourage them to make their plates as colorful as possible because the various colors found in produce represent different phytonutrient families.

Plant Proteins
A predominantly plant-based eating pattern, especially when it comes to protein, also may enhance fertility. In one study, each additional serving of meat per day was associated with a 32% increased risk of infertility.5 In another study that looked at people undergoing in vitro fertilization (IVF), eating red meat before IVF had a negative effect on embryo development.5 The power of plant proteins includes soyfoods, too. In a study that looked at soy consumption and fertility outcomes, women with the highest intake of soy isoflavones had 77% higher odds of having healthy babies after undergoing IVF compared with women who ate no soy.5

Monounsaturated Fats
The type of fat women eat also plays a role in fertility. Trans fat intake is associated with greater risk of ovulatory infertility, and replacing 2% of energy from monounsaturated fats with trans fats is associated with twice the risk of ovulatory infertility.2 The lesson? It’s wise to advise clients to avoid trans fats and instead focus on monounsaturated fat sources like avocados, olives, pecans, almonds, pumpkin seeds, and their respective oils. Eating a diet rich in these monounsaturated fats has been shown to increase the odds of a successful pregnancy 3.5 times for people undergoing IVF compared with those eating a diet low in monounsaturated fats.7

Omega-3 Fats
Another important fat source includes omega-3 fatty acids. These essential fats should be included in every woman’s diet when trying to conceive. In one study, women with the lowest omega-3 fatty acid intake had lower probability of achieving pregnancy.2 Help clients increase omega-3 intake by encouraging them to eat flaxseeds, chia seeds, walnuts, and low-mercury fatty fish. Because heavy metals are a concern, clients may consider an algae-based DHA supplement instead of fatty fish.

Low-Glycemic Diet
Eating for fertility isn’t a time to shun carbohydrates, but it is a time to choose the right kinds of carbs. High-fiber, low-glycemic, carbohydrate-rich foods are associated with a lower risk of infertility, so help clients identify low-glycemic foods to add to their diets, such as nonstarchy vegetables, berries, oatmeal, whole grain rice, beans, and legumes.2

Botanicals
Botanicals have been used for their medicinal and therapeutic properties for thousands of years, and they’re often a key part of integrative nutrition. The caveat with herbal remedies is that their widespread use sometimes is based on tradition rather than scientific evidence. Here are a few herbs with evidence to support their use in an integrative approach to fertility. Clients should work closely with a clinical herbalist and their health care team when incorporating botanicals into their regimens.

Vitex (Chasteberry)
Vitex, or chasteberry, is a well-known fertility herb. Although evidence is limited, one study showed improved fertility in women taking a supplement containing chasteberry for five months compared with placebo.8 Experts recommend beginning chasteberry three to six months before trying to conceive.

Adaptogens
Adaptogens are a class of plants and mushrooms thought to help the body correct imbalances caused by stress, anxiety, and fatigue. When it comes to fertility, certain adaptogens are believed to help rebalance infertility caused by hypothalamic amenorrhea. However, evidence is limited. Shatavari and ashwagandha root are commonly used for infertility in the Ayurvedic tradition. Ashwagandha may help modulate the body’s stress response, which could be an underlying issue in infertility.9 Shatavari may improve female reproductive health issues that contribute to infertility, such as PCOS and hormonal imbalances.10 There’s not enough evidence regarding the safety of adaptogens during pregnancy, so they should be stopped as soon as a woman suspects or confirms a pregnancy.

White Peony
White peony is used in traditional Chinese and Japanese medicine to regulate ovulation, which can help enhance fertility. It has been shown to improve low progesterone levels and reduce elevated testosterone.11 It’s available as a capsule, tincture, or powder.

Nutritional Supplements
Nutritional supplements also are part of an integrative nutrition fertility protocol. The following commonly used supplements have been shown to be beneficial for fertility. Because supplements undergo limited FDA regulation, be sure to help clients identify reliable products.

Prenatal Multivitamin
Most women start taking a prenatal multivitamin supplement when they become pregnant, but taking a multivitamin containing folic acid during the preconception period has been associated with a higher likelihood of conception and a lower risk of ovulatory infertility.5

Vitamin D3
Vitamin D insufficiency and deficiency is common in many women, and the nutrient is available in few foods. When it comes to fertility, women with higher serum vitamin D levels demonstrate higher embryo quality and pregnancy rate compared with women with low serum levels. Because of this, testing serum vitamin D levels and taking a vitamin D3 supplement may help support fertility.12

Other Lifestyle Practices
Because integrative nutrition is a whole-person approach, food, botanicals, and supplements usually aren‘t enough to address all that may be going on in a woman’s mind, body, and spirit when trying to conceive. This is where other alternative therapies and lifestyle practices come in to play. Unless dietitians are well-trained in these areas, recommendations for integrating
other lifestyle practices likely will include a referral to another expert. Some of the additional issues that may impact fertility include environmental toxins and stress, and another alternative treatment modality to consider is acupuncture.

Environmental Chemical Exposure
In our modern world, we’re surrounded by chemicals in plastics, cleaning products, body care products, pesticides, and herbicides. They can interfere with the body’s endocrine system and impact reproductive health and fertility. Women who use an average of 12 or more personal care products may be exposed to as many as 168 chemicals per day from those products alone. In one study, women in areas where water is contaminated with “forever chemicals,” or highly persistent chemicals, such as those found in nonstick cookware, had 15% to 25% lower fertility rates.13 While it’s impossible to escape exposure to these chemicals, minimizing exposure is important. The Environmental Working Group has resources to support clients in switching to safer cosmetics, body care, and household products. Dietitians can help clients navigate when to buy organic and how to avoid chemical exposure from plastics and nonstick cooking equipment.

Stress Reduction
Infertility and stress can be a “chicken or the egg” conundrum, meaning stress can affect the ability to conceive and the ability to conceive can affect a woman’s stress levels. Stress also is associated with hypothalamic amenorrhea and reduced egg fertilization.11 This makes stress reduction an important part of an integrative fertility protocol, and stress reduction techniques may include cognitive behavioral therapy, time in nature, meditation, breathwork, and other mind-body practices.

Acupuncture
Acupuncture has been used for centuries to support infertility. In this traditional Chinese medicine practice, a trained professional inserts tiny needles into specific points on the body to stimulate blood flow and move energy. In one study, women who underwent acupuncture before IVF embryo retrieval were more likely to have successful pregnancies compared with women who did not receive acupuncture.14 Although there isn’t much research supporting its use in infertility treatment, acupuncture has been shown to reduce depression, anxiety, and stress levels. This is significant since approaching fertility through an integrative lens requires dietitians to see all aspects of their clients’ lives as interconnected and recognize root causes that may be contributing to their health concern.

Developing an Integrative Nutrition Fertility Protocol
1. Perform a Whole-Person Assessment. One of the biggest differences between an integrative nutrition approach and a conventional nutrition approach is taking a client’s physical, mental, and spiritual health into consideration. When performing an initial assessment for a new fertility client, include questions about all areas of her life. Ask about the quality of her relationships, spiritual practices, her sleep, stressors, and emotional well-being. The information gathered from these unconventional questions will help connect the dots and enable RDs to better suggest appropriate complementary therapies to support fertility holistically.

2. Look for Root Causes. Integrative nutrition requires looking below the surface, going beyond a simple dietary recall and health history. To look for root causes of a client’s fertility struggles, map out their health and wellness timeline. Ask when certain symptoms first appeared and what life events or emotional states occurred during those points in time. Look for common root causes such as inflammation and environmental chemical exposure.

3. Develop an Individualized, Holistic Plan. Once a dietitian has completed a whole-person assessment and identified potential root causes, develop an individualized integrative nutrition plan for the client, which includes holistic recommendations that go beyond food. If RDs are knowledgeable about supplements and botanicals, suggest products that may address the root causes and support fertility. Recommend trusted providers in other health care fields to assist clients in their fertility journey.

4. Stay Evidence Based. The world of alternative therapies is teeming with pseudoscience and lack of evidence, so it’s important to avoid falling prey to interventions with little to no efficacy. The National Center for Complementary and Integrative Health (nccih.nih.gov) provides a database of botanicals and other therapies. To learn more about integrative nutrition, join the Academy of Nutrition and Dietetics’ Dietitians in Integrative and Functional Medicine Dietetic Practice Group or consider training from the Integrative and Functional Nutrition Academy, a program developed by RDs.

5. Refer to Other Providers. Since treating infertility with integrative nutrition requires advanced knowledge of botanicals, supplements, mind-body medicine, and other alternative therapies, it’s important to recognize when certain interventions fall outside the dietitian’s scope of practice. Develop a network of trusted integrative health care providers who specialize in fertility, such as clinical herbalists, acupuncturists, bodyworkers, and mental health professionals. Because you’re aiming to address fertility holistically, a team-based approach is the best road to take.

— Kayli Anderson, MS, RDN, DipACLM, ACSM-EP, is founder of the women’s health website Plant-Based Mavens (plantbasedmavens.com) and coauthor of the lifestyle medicine textbook Improving Women’s Health Across the Lifespan. She’s trained in integrative and functional medicine for women.

References
1. Infertility FAQs. Centers for Disease Control and Prevention website. https://www.cdc.gov/reproductivehealth/infertility/index.htm. Published March 1, 2022. Accessed February 17, 2023.

2. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Diet and lifestyle in the prevention of ovulatory disorder infertility. Obstet Gynecol. 2007;110(5):1050-1058.

3. Panth N, Gavarkovs A, Tamez M, Mattei J. The influence of diet on fertility and the implications for public health nutrition in the United States. Front Public Health. 2018;6:211.

4. Noland D, Raj S. The Academy of Nutrition and Dietetics: revised 2019 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nutrition in integrative and functional medicine. J Acad Nutr Diet. 2019;119(6):1019-1036.e47.

5. Gaskins AJ, Chavarro JE. Diet and fertility: a review. Am J Obstet Gynecol. 2018;218(4):379-389.

6. Grieger JA, Grzeskowiak LE, Bianco-Miotto T, et al. Pre-pregnancy fast food and fruit intake is associated with time to pregnancy. Hum Reprod. 2018;33(6):1063-1070.

7. Comerford KB, Ayoob KT, Murray RD, Atkinson SA. The role of avocados in maternal diets during the periconceptional period, pregnancy, and lactation. Nutrients. 2016;8(5):313.

8. Westphal LM, Polan ML, Trant AS, Mooney SB. A nutritional supplement for improving fertility in women: a pilot study. J Reprod Med. 2004;49(4):289-293.

9. Chandrasekhar K, Kapoor J, Anishetty S. A prospective, randomized double-blind, placebo-controlled study of safety and efficacy of a high-concentration full-spectrum extract of ashwagandha root in reducing stress and anxiety in adults. Indian J Psychol Med. 2012;34(3):255-262.

10. Pandey AK, Gupta A, Tiwari M, et al. Impact of stress on female reproductive health disorders: possible beneficial effects of shatavari (Asparagus racemosus). Biomed Pharmacother. 2018;103:46-49.

11. Romm A. Botanical Medicine for Women's Health. Elsevier Health Sciences; 2017.

12. Paffoni A, Ferrari S, Viganò P, et al. Vitamin D deficiency and infertility: insights from in vitro fertilization cycles. J Clin Endocrinol Metab. 2014;99(11):E2372-E2376.

13. Waterfield G, Rogers M, Grandjean P, Auffhammer M, Sunding D. Reducing exposure to high levels of perfluorinated compounds in drinking water improves reproductive outcomes: evidence from an intervention in Minnesota. Environ Health. 2020;19(1):42.

14. Guven PG, Cayir Y, Borekci B. Effectiveness of acupuncture on pregnancy success rates for women undergoing in vitro fertilization: a randomized controlled trial. Taiwan J Obstet Gynecol. 2020;59(2):282-286.