Summer School | What to Eat for Fertility

Welcome back to Summer School. I'm Colleen Sloan, a PA and dietitian, and for this special series of the Exam Room Nutrition Podcast, I'm bringing back a few of my favorite conversations from the archives. Today's lesson is all about fertility. I'm joined by Jessica Boone, an infertility PA, to talk about why fertility care should involve both partners, what a more complete workup can look like, and how nutrition, sleep, movement, and environmental exposures may all play a role. And congratulations, you have officially made it through summer school. Brand new episodes return next week. But for now, grab your coffee, take your seat, and welcome to your final class. Jessica, thank you so much for coming on to my show. I can't wait to get into this topic. Welcome to the show.

Thank you so much. I am so excited to be here today and shine light on some infertility discussions.

I'd love to hear your opinion on why we are always so focused on women's infertility when men actually do contribute to the infertility struggles that couples are going through.

Yeah, absolutely. Thank you so much for just asking that question because I don't know why it's racket science, but so many people forget that it takes two people to make a pregnancy happen. You need a sperm and an egg. And there was actually a recent study that came out that showed that it takes about 22 months before the male partner will actually get a semen analysis, which is shocking. And I think this is due just to a big mix of historical, cultural, and societal factors. And unfortunately, there's still a ton of stigma surrounding infertility. And traditionally, when we kind of think about our typical American society and even just worldwide, the responsibility of child rearing and childbearing has really fallen on the woman. And so when there's fertility struggles, it's like, well, obviously it's the female's problem. But that's not true. Culturally, men are just even more reluctant to start with testing. And so I can't tell you the number of couples I've seen who have been trying to have a baby, which feels like forever, like years. And then usually the woman's gone through all sorts of testing. And after a bit of nudging, the male partner finally gets a semen analysis. And lo and behold, he has a low sperm count. The reason behind his low sperm count, then we have to kind of do a workup for that and figure out what's going on to give them that best chance of success.

So I'm really curious if you can just give us a little background on causes of infertility and what are some commonly missed diagnoses that clinicians should be considering.

Yeah, so the big one, male infertility, don't mean to, you know, be a broken record here, but male infertility is huge and it can really be a silent issue. I personally think the MVP of testing is a semen analysis. It's the most cost-effective and least invasive test to kind of kickstart that fertility workup and gets that male partner involved right from the beginning. Another really common factor that often really just doesn't get addressed in fertility is thyroid disorders. And this can impact both men and women. And so, you know, thyroid health really plays a huge factor in reproductive health. I like to think of it as like your conductor of your hormonal orchestra. So for both men and women, if your thyroid's not working efficiently, we can start to see impacts on ovulation, sperm production, all of these things can start to get affected and can cause major issues with reproductive health. And the last one is gut health. Now, this one's starting to be a little bit more trendy. We're still learning a lot of this. I know you've um shared a lot of this in your podcast as well. But the gut we're starting to figure out is a lot kind of like the body's second brain. There's a lot of health issues that are linked to our gut, and it's been shown to impact fertility. And so when your gut health is off, inflammation can start to flare up, your hormones can start to get out of whack. And so there's a lot more research that needs to go into this, but understanding that how we fuel our body and our gut health can impact essentially everything in our body, which of then trickles down to our fertility. And so having a healthy gut microbiome is imperative.

And those are definitely three things that people probably don't think about. So I think that's really, really helpful. Now I'm curious too the general fertility advice that like most patients are receiving. What are practitioners saying to patients about in improving their chances of fertility?

So often they start with the basic. So they are, you know, semen analysis again should be, I think, number one, but oftentimes it's not until later. They're checking to see if there are eggs. So they're checking to look at egg quality and egg quantity. Our quantity check is going to be our AMH or anti-malarian hormone, as well as an ultrasound to check for the baseline or anteral follicles. And that is a transvaginal ultrasound. So often women are a little bit hesitant to get that one done. They're also checking to be sure that there's a way for the sperm and the egg to meet. And this is done through the HSG, which is an X-ray dye test to basically assess the fallopian tubes. It also gets a gives us a look at the uterus as well. And then they'll also kind of check to see, you know, is there a uterus that's healthy to carry a pregnancy? So those are kind of the basic things. Everyone's kind of focused on, you know, anatomy and sperm and eggs, which are fundamental and hugely important. However, we need to be sure that we're taking a look at the other things that could be potentially causing infertility that may not have to do with the anatomy itself.

What are those other things that you think about besides the that initial workup?

Yeah. So I like to think of our fertility as kind of a window into our overall health. And so when we kind of view that way, it really makes sense that our bodies, you know, are really smart and they start to prioritize things like brain function, heart function, lung function, all of that over our fertility. And so sperm and egg production ovulation really become kind of the bottom of the totem pole. So when we start to see those things impacted, we really want to take a look upstream to see what's going on. And so, aside from, you know, the things that we talked about with thyroid disorders, gut health, inflammation, you can have major hormone imbalances, PCOS, endometriosis is a big one as well. So there's a lot of common medical conditions, but we need to be kind of really getting to the root cause of what's causing the infertility. Instead of thinking of infertility as just as a diagnosis, I like to think of it more as like a symptom. So what's causing this infertility? Let's get the answers to that first before we just dive into treatments.

And that is the best kind of medical care, right? Really getting to root cause analysis because that's how you can find solutions. So if I were a new clinician or if I wanted to transition to fertility care as a provider, walk me through like some questions that I should absolutely be asking all of my patients.

Yeah, so fertility care, it can be really daunting to a lot of people because we just don't learn much about it. If you have a great collaborating physician, they will teach you the ropes. But when you're approaching a couple or even an individual who's struggling with fertility issues, what you want to do is really get a good history. I know we say this time and time again in medicine, but listening to what the patient has to say about their journey can be just profound. So you obviously you want to get the basics, you want to, you know, understand her cycle length, how long they've been trying to conceive, any medical conditions that she may be having, as well as him. Get an idea of what they do for occupation, if they're exposed to any kind of toxins on a regular basis. But some questions that I really love to ask that many providers, even in fertility care, often forget is you know, everyone talks about how long have you been trying to conceive? And they give you their answer. But what we should also be asking is has there ever been a time in your relationship that you haven't been using contraception and or a method to prevent pregnancy? And this can really be profound. Um, for example, I had a couple yesterday come in and I asked them, you know, how long have they been trying to conceive? And they said, Oh, seven months. And I was like, Oh, okay. And then then I asked this follow-up question and they said, Oh, well, we've been married for seven years and we've never used contraception during that time. And so now this fertility picture changes dramatically, right? Instead of this young couple who's been trying to conceive for seven months, they now have had almost eight years of pregnancy exposure. And statistically, they should have gotten pregnant maybe at least a couple times over the course of those eight years. And the fact that it didn't happen is gonna really change the way I approach their fertility workup and change the way that I approach their treatment recommendations. Another really good follow-up question, and one that I think we often forget to ask, even in the fertility community, is you know, what is the ultimate family planning goal? I like to say that this is like the swing set test. So if you and your partner are sitting on the back porch watching the kiddos play on the playground out back, you know, how many kids do you see playing on the swing set? And this can be really triggering for a lot of people because obviously they are like just hopeful for one. But if the ultimate family planning goal is, you know, three kiddos and this couple is 37 and they've been trying to conceive for seven years, you know, my intuition is gonna say there's probably a bigger picture thing going on here. And we need to be talking about, you know, optimizing their fertility, but we may want to consider having a conversation about IVF. Not that I think IVF is necessary for them to get pregnant, but the benefit of IVF is that it can preserve their fertility in that moment. And so let's say they decide to go through IVF, create embryos, and they happen to have extra embryos uh remaining and can be frozen, those embryos can remain frozen indefinitely, preserve the age at age 37 that they were created. And that way by the time they go through and try to try for baby number two or even baby number three at age like 39 or 42, they're gonna have a that much better chance of success. So I think bringing that question into your fertility discussion not only, you know, gives that couple, you know, hope and that chance to kind of really think about what their family planning goals are, but it gives them the opportunity to achieve those goals if we're thinking about IVF and preserving their fertility and using it as a tool that way.

I really like how you're creative in your solutions and you ask the right questions to really determine how you can best help the family that's sitting in front of you. Because, you know, if you didn't ask that question about what their goals are and what they're really looking forward to, you might not have come up with that solution of IVF. And I think that's a really great point to asking good, curious questions to help direct your recommendations. I think that's a really key piece that you mentioned.

Yeah, I feel like especially when it comes to like egg freezing and couples who may be, you know, getting towards the end of their 30s and wanting to have a larger family. I feel like we're doing a disservice, actually, if we're not asking that question. I've had many couples who, you know, did a bunch of lifestyle stuff, you know, did I, had baby number two at, you know, like 38, and then they wish that someone had had this conversation with them earlier because trying to conceive at age 39 or 40 is a bit of a different picture compared to 37, 38. And so I think it's really important to be having these whole family perspective questions.

All right, let's talk about those lifestyle changes because this is a big one in fertility care. But I would just love to hear what exactly do you talk about with your patients when you tell them, you know, quote, lifestyle modifications, which is what we write in school, which is so basic. But give us kind of how do you educate parents on this and what can you help them do to improve their chance of fertility?

The biggest thing that I talk to my couples about is, you know, what is within our control to optimize? And I think if we're able to pick one thing for both of them to optimize together, again, this needs to be a unified approach. That one thing should be focusing on improving mitochondrial health. And the reason being is that creating healthy eggs and healthy sperm requires a lot of energy. And so mitochondria, I remember going back to our you know old anatomy, really provides the essential energy to ensure that these processes are happening correctly at the cellular level. So if mitochondria are not functioning well, it can really lead to poor egg and poor sperm health and can really decrease those chances of conception. So for women, the egg is less likely to result in fertilization or even proper development if the mitochondria aren't developing well. So this is why we see when you know women are younger, they have better egg quality. And then as we age, we get less mitochondria in our cells, and then we have poor egg quality. In men, similar things, but men are constantly making new sperm every day, and it's a highly energy efficient process. So we have millions of sperm that are being made, and the mitochondria are essential for movement. So oftentimes we see that as men age, when we have a lower number of mitochondria or those not working as efficiently, we see that we start to have motility issues. And so it's really important that we're taking important steps to make sure that we're helping our mitochondria and try to, you know, make them work as efficiently as possible. And so when we try to think of ways that we can improve that, it comes down to four main things. One of them, nutrition, the second one, elimination pathways, three is environmental toxins, and four is prioritizing sleep. So let's take a step back and really dive into each one of these things. So, nutrition, you have all the amazing nutrition tips here. But when I'm counseling clients, I try to take things like a little stepwise, because it can be a lot to kind of get just this laundry list of handout and say, okay, do all these changes. And so I give them three main things to focus on. The first being eat the rainbow. So a lot of what's gonna fuel your mitochondria are antioxidants, and we can get those in our leafy greens and our colorful fruits and vegetables. Another thing to focus on is eating foods that are probiotic rich foods. So that's like yogurt, kefir, sauerkraut, kimchi, things like that are gonna help with that gut health, which we talked about being as a really important function and fertility. And then lastly, we want to focus on omega-3. So this is what's gonna help with mitochondria function and reduce inflammation. So you can find these in like fatty fish like salmon, flax seeds, and walnuts. If we dive into the elimination pathways, a lot of my clients here are like, what in the world's an elimination pathway? So that's my fancy way of saying, you know, being sure that we're like sweating, being sure that our bowel movements are irregular, being sure that we are not having super concentrated urine. That's what we mean by elimination pathways and being sure that our lymphatic system is working correctly. And so the best way to do that is just to get out for regular movement 30 minutes a day. This doesn't have to be full-blown, intense exercise. It's actually better if it's kind of like moderate exercise. Those HIT workouts are not great for fertility purposes, actually. So I recommend that they do that as a couple, ideally, helps build connection, being sure that you're getting good hydration. That's important for just overall health, mitochondrial function, but a huge part of the ejaculate for semen is made of water. Cervical mucus is mostly made of water. Those things need to be optimal in order for our fertility to be at its best. And then the next thing we want to talk about is environmental toxins. So this is just comes down to being really intentional about what we put into our body. So this means avoiding all those things that your mom told you to avoid when you're growing up. So avoid alcohol or limit it at least, avoid tobacco, marijuana, recreational drugs. You really want to try to limit the use of plastics when you can. And so that means if you're gonna be warming up food, be sure you're switching to glass. And then if you're cooking, you know, try to stay away from those like nonstick stuff, ceramics or metals or what's gonna be best for you. And then there are a lot of, you know, toxins that are in our beauty products and chemicals and things like that. And so just trying your best to look for more natural solutions and just being intentional about what we're putting inside of our body. And then the last thing, prioritizing sleep. This can be really challenging for many of my clients just because of the nature of our typical American societal life. Life is busy, it's hard for us to fall asleep, we're stressed. You know, we always have like our phones with us and they're stimulating and constantly thinking about everything. And so I really try to set my clients up for, you know, having a sleep routine, ideally where they fall asleep, you know, before 10 and aim for about seven to nine hours of sleep if they can. This is easier said than done, and probably the hardest thing for my clients to implement on a regular basis.

Okay, those four steps are so helpful because it gives your mind as the clinician like a framework to follow and kind of like a checklist to go through when you're educating patients because it feels overwhelming for the patient, but honestly, as a provider, it it's overwhelming to like educate and try to troubleshoot all these different areas. So I love those four points, but you know I'm gonna linger on nutrition because this is my wheelhouse and I love talking about it and the purpose of the podcast. But I wanted to point out something that you do really well, I think with your advice, and that is discussing what patients should be adding in and focusing on as opposed to what they should not be eating. Because no one likes to hear, oh, you can't have this, you can't have that, you can't have that. Because it feels like you're taking away something that they love and, you know, part of their identity. It's much more helpful to hear things that you can add in and foods that you can enjoy and can have. Do you have any kind of pushback with nutrition or any like troublesome areas that the patients usually struggle with?

Yeah, so a lot of times they come to me and they've act, they're actually on a really restrictive diet because they've been following like this TikTok influencer and like have been doing a lot of research and not that those aren't great resources, but they actually are coming to me. They're like dairy-free, gluten-free, and all of these things. And they feel like they've lost joy in eating and they've lost hope in the process. And so a lot of what I do is reintroducing things that are going to be, like you said, helpful and not focusing so much on the negative and switching their mindset around food just to be intentional with the way that they're fueling their body. So again, teaching them in what foods are beneficial for fertility and then also teaching them how to structure their meals. So, you know, there's a lot of data that shows that if we're eating like our fiber first and then everything else second, if we're fueling our body that way, even if we have a bunch of junk on our plate, but we've ordered a salad, that's gonna be way better than you just eating all that junk first. It helps better regulate your blood sugar levels. And so it's about teaching them how to take realistic approaches to optimizing their fertility without sucking out the joy in a process that's already so emotional and heart-wrenching. There's so much emotional benefit when we realize that a lot of our connection with the outside world comes with eating and comes with socializing. And if we are restricting ourselves and not enjoying any of that, we're just kind of further isolating ourselves on the fertility journey. And that can make a journey just so incredibly tough.

Such a good point. And I think where we're going right now with this conversation is so important because you're right, patients come in already on such restrictive diets because they're just looking for an answer. And oftentimes these patients are already coming in with disordered eating patterns. And it is your job as a clinician to really help heal their relationship with food because often they do just need to eat more. And previously, a dietitian who works in infertility, and that's episode 47, if you guys want to listen, called Nutrition and Infertility, is your diagnosis wrong? And we focused on hypothalamic amenorrhea and how these women are just underfueled. And so it is a mindset shift that we have to educate these patients on. So I find that you're right, they've lost that joy and that hope because they haven't been eating their favorite foods for so long. And I think that's a really important educational piece that to give them that food freedom.

Absolutely. Absolutely.

Jessica, this has been so helpful. I think clinicians who are either in primary care or wanting to transition over to fertility medicine will learn so much from you. So thank you for the gift of your time. I would love if you could just share where people can connect and learn more about you.

Yeah, absolutely. So you can find me at Fortitude Fertility on all social media platforms. Primarily I'm on Instagram.

Jessica, thank you so much for the gift of your time. I appreciate you being here. Thank you, Colleen. It was amazing. All right, now it's time for my nutrition notes. My dad recently asked me, so does the order I eat my food matter? And before I answered him, I dug into some research. And in fact, it might. So I want to talk to you a little bit about something that Jessica had mentioned, which is called meal sequencing, or the order in which you eat different foods during a meal. Research is actually showing promise for it as a practical dietary treatment for diabetes and obesity. Research indicates it can help with blood sugar control, nutrient intake, and satiety. Different studies have looked at consumption of protein and or fat or fiber before the carbohydrate food, and it showed promising results of glucagon-like peptide 1, GLP1, secretion, delayed gastric emptying, decreased postprandial hyperglycemia, and weight loss. Now, the exact mechanisms are still unclear, yet currently available reports strongly support that meal-sequenced dietary therapy is beneficial in controlling postprandial glucose excursion and body weight to better prevent and manage diabetes and obesity. Now, I think this strategy is both safe and potentially beneficial for your patients to explore. Additionally, it promotes mindful eating. And you know I am a big fan of mindfulness. So if your patient asks, here is one method to sequence their meals. So number one, begin with fiber, starting with those non-starchy veggies. Step two, eat your protein. That could be lean meat, fish, tofu, or a plant-based protein option like beans. Step number three, add in your healthy fats. Incorporate sources throughout the meal like avocados, nuts, and seeds, or olive oil. And lastly, finish with carbohydrates. You're gonna want to consume your whole grains or starchy vegetables last. I hope that was a helpful explanation and maybe a tactic that you can try with one of your patients. Now, didn't you love this episode? Let me know on Instagram. Send me a DM. I'm at exam room nutrition. And I hope you have a great day. And as always, let's continue to make our patients healthier, one exam room at a time. I'll see you next time.