Q&A: How women with PCOS can boost fertility

Key takeaways:

• Lifestyle interventions to improve metabolic health can help women with PCOS achieve a healthy pregnancy.
• Clinicians should focus on health, not weight, and avoid language that perpetuates bias and stigma.

Susan Weiner, MS, RDN, CDN, CDCES, FADCES, talks with Judy Simon, MS, RDN, CD, CHES, FAND, about nutrition and other lifestyle considerations for women with polycystic ovary syndrome seeking to conceive.

In this second part of Weiner and Simon’s interview about nutrition for fertility, they also discuss what to do about advice to lose weight. Read part one here: Q&A: Diet and lifestyle can promote fertility.

Weiner: PCOS is perhaps a special concern for women seeking to conceive. How much influence can nutrition have on PCOS, in general, in terms of glucose and insulin regulation, weight loss and even mental health?

Simon: PCOS is the most common reason a woman visits a fertility clinic. The 2023 international evidence-based guidelines for the assessment and management of PCOS prioritize lifestyle intervention. This latest update also highlights the increased prevalence of eating disorders among women with PCOS and weight stigma women endure.

Although there is no single perfect PCOS diet, most women with PCOS have increased insulin resistance, regardless of weight, and can benefit from high-fiber, plant-forward meals and snacks. Eating a diet rich in fiber can improve hormone dysregulation and improve reproductive health. Balancing meals to contain carbohydrates, protein, fat and fiber can be beneficial in reducing glycemic index and inflammation and promoting ovulatory cycles for fertility regardless of weight.

Sleep, movement and stress management are also fertility boosters for women with PCOS. Exposure to endocrine-disrupting chemicals — bisphenol A (BPA), phthalates, parabens, PFAS, microplastics, air pollution and pesticides — as well as alcohol and cannabis should be minimized.

Weiner: What guidance is available for health care professionals?

Simon: The new PCOS guidelines advise health care professionals to:

• recommend lifestyle intervention — exercise alone or a multicomponent diet combined with exercise and behavioral strategies — for all women with PCOS to improve metabolic health, including central adiposity and lipid profile;
• recognize that many women with PCOS experience negative biopsychosocial impacts of weight stigma in health care and other settings;
• be aware of weight stigma when discussing lifestyle management with women with PCOS; and
• adopt weight-inclusive practices that promote acceptance of and respect for body size diversity and focus on improvement of health behaviors and health outcomes for people of all sizes.

Weiner: How can women with PCOS design their eating plan for fertility? Is a complete dietary overhaul necessary?

Simon: I’ve worked with hundreds of women individually and in our Food for Fertility classes. I’ve learned that focusing on what women can add to their diet can be so impactful. Too many women have been fat-shamed and blamed for their infertility and think they must be on a restrictive diet and focus on weight loss to get pregnant. Women with PCOS are often told to “just lose weight” and given no evidenced-based guidance.

1. Instead, women should focus on fueling their body and reproductive system. In our book Getting to Baby, we share the three principles of a fertility-promoting diet: anti-inflammatory foods and those high in fiber promote a better uterine environment for implantation; low-glycemic meals and snacks reduce inflammation and insulin resistance; and foods high in antioxidants strengthen sperm and egg function.

Using our food-first fertility plan, I encourage women to build on the foundations of their preferences while focusing on inclusion of a plant-forward — not a strict vegetarian — meal plan. I encourage them to add in more plant foods while increasing their confidence in their abilities to nourish themselves. Setting small realistic goals, like including two fruits a day, can feel attainable.

Weiner: Women are often advised to reach a BMI cutoff to improve fertility and pregnancy outcomes. Is this necessary?

Simon: Reproductive and obstetric medicine are guilty of weight bias, and many clinics have BMI cutoffs. Because in vitro fertilization is a surgical procedure and many clinics operate in outpatient surgical clinics, they may have a BMI cutoff — usually 40 kg/m². Luckily, most tertiary medical centers have multidisciplinary teams of health care providers who can provide IVF services to larger women with great success.

• In 2023, I presented at the American Society for Reproductive Medicine (ASRM) Scientific Congress on a weight-inclusive approach to fertility. The ASRM obesity and reproduction committee opinion report in 2021 concluded: Weight should not be the sole criteria for denying access to infertility treatment.
• Programs should adopt specific BMI thresholds on the basis of ability to perform procedures.
• Shared decision-making should be undertaken.
• Research should define best practices to optimize retrievals in higher BMI.

Studies have not shown that weight loss prior to IVF yields better results. Focusing on health — not weight — is where our focus should be. Unfortunately, some women may need to change clinics to receive services. Many of the women with excess weight who I have worked with have been able to conceive naturally or with medications or intrauterine insemination and have healthy outcomes.

Fertility can be impacted by energy balance and disordered eating patterns that affect ovulation. Women of any size can struggle with hypothalamic amenorrhea. With these women, we work on helping them balance their physical activity and food intake to meet their higher energy needs to help them ovulate. Increasing calorie- and nutrient-dense foods and reducing physical activity to increase available energy can help these women to ovulate and conceive.

Not all women who are thin struggle with fertility and not all women with overweight or obesity do either. Medicine needs to stop conflating weight with health.

Reference s :

• Teede HJ, et al. Fertil Steril. 2023;doi:10.1016/j.fertnstert.2023.07.025.
• Yurtda G, et al. J Am Coll Nutr. 2020;doi:10.1080/07315724.2019.1657515.

For more information:

Judy Simon, MS, RDN, CD, CHES, FAND, is a registered dietitian nutritionist who specializes in reproductive health. She is the founder of Mind Body Nutrition PLLC and a clinical instructor and clinic dietitian at the University of Washington. She is co-author of the book Getting to Baby: A Food-first Fertility Plan to Improve Your Odds and Shorten Your Time to Pregnancy and co-founder of Food for Fertility program. She can be reached at judy@mind-body-nutrition.com.

Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is the owner of Susan Weiner Nutrition PLLC and the Healio | Women’s Health & OB/GYN Nourish to Flourish column editor. She can be reached at susan@susanweinernutrition.com; X (Twitter): @susangweiner.