Annchen Weidemann | Dietician Western Cape

Infertility

Annchen Weidemann, Dietician, Western Cape

November 29 2017

Dear Colleagues, friends and readers – Before I start writing this post, please note this interesting fact: The incidence of infertility is almost equal amongst males and females.

Unfortunately as history attests, it is mainly the females that bear the brunt of the unsubstantiated stigma attached to infertility, especially in less developed countries. I am writing this post with mainly anovulatory infertility and polycystic ovarian syndrome (PCOS) in mind.

The problem with infertility nutrition is that certain concepts have to be explained first, and this will need a bit of your concentration.

Until about a decade ago, it was thought that females who suffer from polycystic ovarian syndrome (PCOS) were largely offspring from diabetic parents. Today we know this is not entirely true, and that it is can happen to any woman anywhere, regardless of a familial history of diabetes. PCOS occurs in 10 – 15 % of all females of childbearing age, making it the leading cause of infertility in this population. As PCOS is being diagnosed more and more in teenagers who might not want to conceive a child yet, these statistical figures are probably higher.

Very often PCOS is only diagnosed with the wanting to conceive, but it is important to understand is that PCOS is not only an infertility condition but a metabolic disorder, meaning that although it affects fertility, its effects are much more widespread than that. The sufferer is at risk for diabetes, cardiovascular disease, ovarian cancer, and if pregnancy occurs, gestational diabetes. The incidence of miscarriage is also higher in females who suffer from PCOS. Although problems with weight might manifest early in the onset of the syndrome, the sufferer might try various options for weight loss, mostly unsuccessful. Although weight loss in overweight or obese PCOS improves the chances of fertility, not all overweight or obese females are infertile. But, in the overweight/obese population of women of childbearing age, infertility is much more common.

Sadly but aptly, the condition of PCOS is also referred to in the literature as “the thief of womanhood” because of its classic features, including irregular menstrual cycle, unwanted hair growth on the face and elsewhere, acne outbreaks, accelerated loss of scalp hair and of course weight gain, which mostly manifests in the abdominal region.

In 2003, in Rotterdam, international consensus was reached about the diagnosis of PCOS, and the following guidelines were agreed:

Dietary intervention is more effective (and COST effective) than single or combined drug treatments. Lifestyle intervention should prove some effectivity before any drug treatment is started A loss of 5 – 10 % of the original body weight shows benefit for fertility treatment, and can even lead to spontaneous pregnancy. There is no doubt that anovulation (absent or weak ovulation) is related to obesity The Consensus document has been reviewed and updated, but the general message still remains – LOSE 5 – 10 % WEIGHT!

In latter updates of the 2003 Rotterdam criteria, the issue of lifestyle and weight loss is emphasised.

IMPORTANT TO NOTE: Although PCOS accounts for a large portion of the infertile female population, not all women with PCOS are insulin resistant or overweight. Studies have demonstrated a higher incidence in the occurrence of diabetes and cardiovascular disease in PCOS of normal weight than overweight. Dietary intervention with guidance to optimize nutrition and health thus applies to all females suffering from infertility, whether they are overweight or not.

How is lifestyle related to PCOS and anovulation?

With the onset of overweight and obesity, the human body carries a considerable amount of inflammatory stress, and it is thought that fertility is the one body function which is expendable, without the compromise of the survival of the individual. This not only holds true in the overweight and obese, males and females, but also in couples who have poor habits of lifestyle in general, even though the body weight might be close to normal. Especially with the syndrome of PCOS, there is dispute whether the inflammation originates from the overweight per se, or the metabolism of the PCOS. Nonetheless, there is no doubt that overweight and poor lifestyle affects fertility negatively.

A very large percentage (95 %) of overweight people have high levels of insulin, which is merely the result of the higher amount of body fat, but it does not necessarily mean that the person is insulin resistant . The higher levels of insulin have a direct effect on the theca cells of the ovarian and uterine tissue, negatively influencing ovulation, and increasing the amount of androgens (male hormones) produced. Insulin also reduces the amount of a binding hormone (SHBG), which would otherwise have bound excessive androgens in the bloodstream.

The effect of high insulin levels on the function of the ovaries:

The cells of the ovaries are the only cells in the human body that do not become insulin resistant with rising insulin levels. Ovarian cells respond by stopping the process of maturation of follicles, and increase the production of male hormones. When the follicles are not matured, they cannot be released to move down the fallopian tubes for fertilisation, and remain on the surface of the ovary, creating a “cyst”. Through each menstrual cycle more cysts develop as the follicles remain unmatured, and the typical picture of PCOS, as seen from an internal scan, also known as the “string of pearls”, develops. The increased production of male hormones or androids, make the maturation of a female follicle all the more unlikely, since the hormonal environment becomes unfavourable.

Fat cells produce hormone-like compounds, medically known as cytokines, which are the cause of the inflammatory condition of overweight and obesity. The larger the fat cells, the more the inflammation. The production of these inflammatory cytokines also varies by the region in which the fat is deposited. An apple-shaped overweight female with fat situated mostly around the midline would be more prone to infertility from anovulation.

Cytokine production also interferes with the hunger and satiety cues that help regulate normal weight, and it is speculated that it is this dysregulation of eating hormones that make weight loss particularly difficult in females struggling with infertility, including those with diagnosed PCOS.

THE BATTLE AGAINST WEIGHT

Several hundreds of studies have been done in order to compare different diets with each other to find the easiest, most effective and best guaranteed way to lose weight and keep it off. The answer so far? There doesn’t seem to be one, although we are certainly getting there. Prevention seems to be the best cure. The only medical consensus that exists, though, is that an overall restriction in caloric or energy intake has to be imposed on the overweight individual to bring about weight loss. Exactly HOW to do this with least effort, hunger and restriction in food intake also eludes us, but we might be closer to the answer now. This is what is generally (tragically !!!) referred to as “dieting”. “Dieting” has given the endeavour to lose weight a restrictive, negative connotation, which will probably never be outlived in our lifetime. Different methods of lifestyle improvement to bring about weight loss will be discussed later on, and there is a lot of good news in this area, so keep reading…

There is good evidence that the hunger- and satiety ques of the female suffering from PCOS are deranged in tandem with their hormonal abnormalities, and although this seems to be consistent, the remedy is not within our reach yet. What we DO know is to stop putting our money on the financial-gain industries promising fairy-tale weight loss, and get back to basics. And just lastly – there is little value in over-excercising. And this counts for males as much as for females. 30 – 40 minutes of brisk walking per day, maybe a bit more if you love the gym, but ultra-excercise should be avoided during the time that you are trying to conceive.

Until my next update on fertility.

Warm regards, Annchen

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