Co-authored by Dina Cohen, MS, RDN, CEDRD
This is an article about nutrition, but it is also about motherhood. More specifically, it’s about the journey to motherhood. As moms and dietitians, we know that the path to becoming a mother may not be straightforward. Because we’re moms, we’d like to help navigate some of the challenges women face when trying to conceive. Because we’re dietitians, we want to tell you what food has to do with all of this.
Many of the strong women in our faith have been affected by fertility struggles. Sarah, Chana, Rivkah, Rachel—all of these women experienced painful journeys to motherhood. While trying to start a family, a woman will do everything in her power to see those two pink lines or that blue plus sign. But as the journey gets longer and longer, as questioning looks from friends and family become commonplace and marriages are tested, we begin to explore other options for managing our fertility. Doctors are consulted, diagnoses rendered, and what starts as a confusing experience turns into an all-consuming journey. Eventually, we learn to listen to our bodies, partner with our doctors, and make the best of this bewildering experience.
Many women who are trying to get pregnant start to change their diets in an attempt to improve their fertility. This is no surprise, as we live in a culture which blames poor eating habits as the source of just about every health issue imaginable. What exacerbates this issue is the lack of control often experienced by women with infertility. A woman may have felt somewhat in control of her life up until trying to get pregnant, but this is one thing she cannot “make” happen. Understandably, it can be very tempting for her to believe that if she just follows the perfect diet, she can solve her problem. We see women do all kinds of things with their eating in an effort to improve their fertility. They may have the best of intentions, but unfortunately, dietary changes that are not indicated are not always helpful and can actually be harmful. Dietary changes that may improve one condition can actually worsen another. Any nutrition changes a woman considers must be based in her health, her experience, and her diagnosis. In short, changing up what you eat may not seem like a big deal, but it can profoundly impact your health and fertility.
An infertility diagnosis is based on subjective experiences and objective lab tests. A simple conversation with your healthcare team may offer some clarity but is not enough to warrant changes in behavior or diet. Conversations with family or friends may offer some emotional support, but given the individual nature of medical and fertility needs, these casual conversations will unlikely result in useful medical and nutritional information.
The following stories are true. For someone out there. The details have been pieced together from personal and professional experiences, but since one in six couples experience obstacles to parenthood, there have been many couples who have lived these experiences.
The Story: Since childhood, Shira had been one of the larger girls in her peer group. She enjoyed being active and felt good in her body. She had friends of all sizes who dieted throughout high school, but Shira never felt the urge to join them. When she came home from her seminary year in Israel, though, she faced a lot of pressure from relatives to lose some weight. “It’ll help with shidduchim,” they urged. And so, Shira embarked on her first-ever diet. She religiously followed her nutritionist’s weight-loss plan and lost ten pounds.
The compliments began to rain down on her. “You look amazing!!” “I’m so jealous!” Even though Shira had never been preoccupied with her appearance in the past, all the attention she was getting for her weight loss served to make her more focused on her weight and her eating. Suddenly, ten pounds didn’t feel like enough. In addition to following her diet plan, Shira began to increase her exercise. An active person to begin with, she began spending more time at the gym in an effort to get thinner. By the time Shira got engaged, she had lost 20 pounds.
During her engagement, Shira realized that being so rigid about her diet was no fun, and she began to liberalize her diet so that she could enjoy eating out with her chosson. However, she continued to hold on to many of her diet rules and exercised as often as her busy schedule allowed. After her marriage, she kept her caloric intake low and her activity level high. She knew she had felt fine about herself at her higher weight but was afraid of what others would think were she to gain the weight back. After a year had passed with no sign of pregnancy, Shira confided in a good friend. “My cycles are messed up,” she said, “and I’m afraid that’s why I’m not getting pregnant.” She told her friend that while she had had normal cycles as a teenager, in the past couple of years she would only get a period every 2-3 months. “Oh, you must have PCOS,” her friend replied. “Irregular periods are a classic sign of PCOS. I read about it once. Are you careful about your carbs? People with PCOS need to avoid carbs.”
The Psychology: Shira listens to her well-meaning friend’s advice, but hears, “It’s your fault. You eat too many cookies. That’s why you’re having trouble.” Shira, already feeling guilty, begins to fully blame herself. She cuts out all sugar—from sweets, from fruit, and from starchy vegetables, as well. She feels deprived and her cycles continue to be sporadic. She continues to blame herself.
The Science: There is no science here since there is no diagnosis. PCOS (Polycystic Ovarian Syndrome) is one of the most common conditions affecting fertility and it manifests in many different ways. Shira may indeed have PCOS. However, considering that she had regular cycles up until the time during which she modified her diet and exercise, it is more likely that those lifestyle changes are affecting her fertility and that further restriction would only exacerbate her problem. Shira knows that women with anorexia may stop getting their period, so she realizes that under-eating can affect a woman’s cycles, but because her own weight is in the “normal” range and she still gets her period every few months, she doesn’t think that her dieting history is relevant here. The truth is that rapid weight loss and/or consistent under-eating can affect cycles in women of any size. Functional Hypothalamic Amenorrhea (FHA), a condition in which a woman stops getting her period, is commonly caused by inadequate nutrition and over-exercising, and does not only occur in very thin people. If a woman’s cycles have become irregular or go missing entirely, her eating and activity levels should be examined.
The Solution: Lab work can reveal what Shira’s reproductive hormonal status is and can help indicate whether her lifestyle choices are a problem. It is also possible that she has an entirely different problem that is affecting her fertility. Shira would benefit from a full work-up by a reproductive endocrinologist (RE). A good RE will do the appropriate testing and also take Shira’s history and lifestyle factors into consideration in order the make an appropriate diagnosis. The RE may then refer her to a dietitian specializing in fertility struggles who can properly guide Shira toward a nutritional plan appropriate for her body and her medical status.
The Story: Devorah had one of those romantic stories you usually read about in magazines. She met her husband when they were just kids. They grew up in the same shul, attended the same simchas throughout their childhood, and when it came time to date, they both knew what they wanted right away. They thought that having kids would be just as easy. Why wouldn’t it be?
Devorah has always been a little bigger. She was happy with her curves, but after a year of not conceiving, her primary care physician advised her to lose weight. A friend of hers was on the ketogenic diet, so she tried that. She started exercising. A lot. Devorah took a daily Zumba class, started running every morning, and hired a personal trainer to help her with weightlifting. She became tired often. She noticed some hair loss. She felt cold all the time. Her supportive husband complained about her breath. Something just wasn’t working.
Devorah went for a workup with her OBGYN who ran some blood work and noted elevated TSH. Diagnosis? An underactive thyroid gland, also known as hypothyroidism. While the doctor wanted to prescribe Synthroid, Devorah wanted to start with some thyroid-healing diets she found online. She eliminated sugar entirely. She increased her protein intake drastically, having a protein smoothie with breakfast and including a grilled chicken breast with every lunch and dinner. She ate two tablespoons of unrefined coconut oil, right out of the container. Devorah then eliminated all processed carbohydrates and shunned all starchy vegetables. In short, Devorah had returned to the ketogenic diet and was more committed than before.
Devorah wasn’t able to go anywhere without packing her own food. She didn’t have a piece of wedding cake at her sister’s wedding. While her husband enjoyed a slice of pizza, she ate her roasted chicken and broccoli, way on the other side of the table from him. All of a sudden, Devorah realized that her food had become extremely unappealing and unsatisfying. She knew there had to be a different way. Devorah went back to the OBGYN and accepted the prescription. After a few weeks, a couple of dosage adjustments, and a consultation with a dietitian specializing in hypothyroidism, Devorah felt more energy, was happier, and able to think a bit more clearly. She asked her husband to go with her to see a reproductive endocrinologist.
By this point, Devorah and her husband had been trying for two years. Devorah’s workup came out clean, following the appropriate medication and dosage for her underactive thyroid. Her hypothyroidism was well under control. So what was the concern? If everything looked healthy on her part, why wasn’t it happening?
The doctor requested to examine Devorah’s husband, and he found a diagnosis—male-factor infertility. Now they could move forward with an appropriate medical path and start the family they had been davening for.
The Psychology: There is so much guilt associated with fertility troubles, and often it falls on the woman. Devorah tried restrictive diets and extreme exercise in order to lose the weight that actually wasn’t an obstacle to pregnancy. Taking an unhealthy path in the pursuit of health will never end well. By restricting her diet and over-exercising, Devorah could have disrupted her cycles, causing a larger problem on their road to parenthood. The restriction Devorah imposed upon herself causes rebound overeating, which could also lead to a dangerous relationship with food (and ironically, weight gain in the long-term). Joyful movement is necessary for sustainable health and happiness, but over-exercising can have the opposite effect.
The Science: Male-factor infertility accounts for 40% of infertility cases. While hypothyroidism can also affect fertility, each path to parenthood is unique and must be treated accordingly. Hypothyroidism can be caused, and treated, in different ways for different cases. The restrictive eating and over-exercising that Devorah subjected herself to could result in a disrupted cycle, altered heart rate, poor mood and increased stress, and altered appetite unrelated to biological needs. Additionally, when Devorah does eventually become pregnant, a carbohydrate-restricted diet would not be suitable for pregnancy. Not only will she be missing out on valuable nutrition and likely undercutting her overall nutrition intake, but very often morning sickness can be mitigated with carbohydrate-based foods. Restriction of these foods could result in increased nausea, as well as guilt, as she indulges her body’s need to maintain a healthy pregnancy.
The Solution: When a couple experiences trouble starting a family, both partners should get a workup by a reproductive endocrinologist. Even if there is a recognized concern with one spouse’s biology, the other spouse still needs the “all clear” from a specialist. It’s not uncommon for obstacles to be present on both sides.
The Story: Beth got married in her mid-thirties and was eager to start a family right away. When six months had passed without conceiving, Beth went to see her OBGYN. If there was a problem, she wanted to know about it early on. After running some labs and doing an ultrasound, her doctor told her that she had PCOS and prescribed a medication called Metformin. She told her this medication would help with her condition, but that she also needed to “watch her diet”. Beth was happy to have an answer as to why she was not yet pregnant and scoured the internet for nutrition advice for PCOS. She was surprised by just how much information was out there, from food plans to supplements to exercise routines. Beth wanted a baby as soon as possible. She didn’t want to wait around and take the slow route. She decided that she would be the best PCOS dieter ever. She created a strict daily regimen for herself, cutting out her favorite foods in an effort to outsmart her PCOS and help her body do what it was supposed to do. For several weeks, Beth was able to white-knuckle it. But one evening, she caught herself nibbling on her husband’s dinner leftovers, which contained “forbidden” foods. Ashamed, she promised to do better tomorrow. She was dismayed to find herself rummaging through the pantry late at night the following evening, and was even more horrified after she ate two donuts at the work party the next day. She felt miserable. Having a baby was her life’s most important goal right now. Why couldn’t she stick to her diet?
The Psychology: Beth was doing her best to find a fix for her situation. When she didn’t know why she has having trouble conceiving, she felt stuck. Once she heard that there was something she could do about it, she threw all her energy into creating a plan of action. However, what Beth was missing was a personalized approach, which would blend the science of nutrition therapy with the art of counseling. She was lacking crucial information; she didn’t know that a restrictive diet is not only very difficult to maintain but is actually quite likely to lead to overeating in the long run. She also didn’t realize that PCOS symptoms can be improved without a militant diet.
The Science: PCOS is a complex hormonal condition. The medical world is still in the process of identifying the various forms of PCOS. It is a common condition but can manifest in a variety of ways. PCOS can affect fertility, metabolism, and overall health. Symptoms are caused by high circulating levels of hormones called insulin and androgens. This condition is also associated with chronic low-grade inflammation. PCOS can be improved with lifestyle modifications, which include changes to diet, but do not require the extreme measures taken by Beth. Not eating enough food and increasing her overall stress levels are things that can actually worsen Beth’s condition, as well as contribute to rebound overeating. Women with PCOS are more vulnerable to mood disorders like depression and anxiety, and so the shame and guilt Beth felt after setting her expectations too high are even more problematic.
The Solution: Beth needs to channel her desire to make healthy changes in a more effective direction. Consulting with a registered dietitian with experience treating PCOS as well as a non-diet philosophy* can help Beth make healthy changes without running the risk of triggering overeating. She might also benefit from seeing a psychotherapist to help her with stress reduction and navigating the emotional challenges of having PCOS and experiencing infertility.
*A non-diet approach is one that is focused on behavior change for the sake of health rather than achieving a particular weight. A professional with a non-diet approach will not promote restrictive eating for the purpose of weight loss. Rather, he or she will assist the individual in implementing lifestyle changes to result in better health. In some cases, weight loss may occur, but that would be a side effect rather than a goal. This kind of approach is also known as weight-neutral practice, because it promotes better health for individuals at every size.
Aliza and Malka
The Story: Aliza and Malka became close friends after meeting in an infertility support group. Both had been married about 4 years, both loved coffee and poetry, and both complained of irregular, very short cycles. Aliza, whose sister-in-law had gone through a similar struggle, went to see a reproductive endocrinologist. Aliza was diagnosed with slightly low progesterone and referred to a dietitian for nutritional management. She promised to tell Malka everything. And she did. They both figured that they had the same obstacle, so they must be able to benefit from the same solution.
Aliza met with the dietitian and came back with a plan, which she shared with Malka. After a few months, Aliza’s progesterone levels regulated enough to result in two pink lines on a pregnancy test! She would have to continue to take a prescribed progesterone supplement for at least three months into the pregnancy, but she was elated. She couldn’t wait to tell Malka. But she was apprehensive at the same time. Because although Malka had followed the dietitian’s advice to the letter, she wasn’t yet pregnant.
Nine months later, Aliza gave birth to a healthy baby boy. It was at that point that Malka decided to go see the RE for herself. Malka was diagnosed with endometriosis. Baruch Hashem, she and her husband were still able to conceive with a plan specific to their needs and medical status.
The Psychology: A short cycle could mean any number of things. The year that Malka spent following a nutrition plan specifically prescribed for Aliza is a valuable year lost to stress and disappointment. The easy answer is not always the correct one.
The Science: Symptoms of different conditions can look the same. A short cycle could mean any number of things. A short cycle often indicates a physical or chemical barrier to ovulation. A short cycle can be caused by a diminishing number of eggs, advanced age, or hormonal imbalances, such as FSH and progesterone.
The Solution: Similar symptoms don’t mean similar treatment methods. Following a plan that was created for someone else will often not yield the desired results. A comprehensive workup by a reproductive endocrinologist, followed by advice specific to the couple’s medical status, will be the most painless and direct route to parenthood.
Infertility is a long and guilt-ridden process. “Why isn’t my body working?”, “What did I do wrong?”, “If I only davened more…” are only a few of the many things a woman suffering from infertility might ask herself.
When we take advice from well-meaning individuals—people who truly do have our best interests at heart—it can prolong the journey. This increases stress, which is counterproductive in the struggle to start a family. Stress is currently attributed as a factor in 30% of all fertility struggles. There is such a thing as the mind-body connection. A person’s thoughts, feelings, and beliefs can impact their body on a chemical and physical level. The endocrine (hormonal), nervous, and immune systems speak a common chemical language, which allows constant communication between the body and mind through messengers like hormones and neurotransmitters. Experiences and emotions cause a chemical cascade that communicates with the body’s organs, resulting in a complex relationship between the mind and the body and affecting how healthy the body is.
While seeing the right doctor and following appropriate advice won’t eliminate the stress aspect entirely, it will reduce the amount of stress experienced as the whole journey is more direct. Think of inappropriate advice as a car crash on the interstate. You have to get off and find your way back by taking various side streets. You may get to the desired destination, but not as soon as you otherwise would have. The CD plays an extra time, and you get tired of that music. The side streets have lower speed limits and more potholes. You drive 15 mph in a school zone. But by relying on the educated and experienced professionals who understand your position and your desires, who can evaluate your biology while comprehending your emotional state, you can take the most direct route.
Additionally, understanding your own role in the process—and its limitations—is a critical factor in how you will experience the journey to parenthood. There might be things you can do to make your body a better vessel for pregnancy. As the above examples illustrate, lifestyle changes made with the appropriate education and guidance may have significant results. Nutrition therapy can increase the likelihood of pregnancy by improving, and sometimes even resolving, some conditions that cause fertility obstacles. However, like everything in life, becoming a parent is something that will happen on Hashem’s timeline. Infertility teaches the powerful lesson that we are never truly in control; the ultimate control lies only with Him.
Dina Cohen, MS RDN CEDRD,
is the owner of EatWellSoon, a practice that provides nutritional counseling for clients of all ages and specializes in the treatment of eating disorders. Dina utilizes a Health at Every Size approach to support her clients in adopting healthy behaviors without making the scale the boss. She is dedicated to helping families develop lifelong healthy habits and a positive relationship with food. Dina lives in Toms River, NJ with her husband and three daughters. To learn more about Dina, please visit her website at https://www.eatwellsoonrd.com/.