Polycystic ovary syndrome (PCOS) affects 6-20 % of reproductive-age women depending on the population studied and the diagnostic criteria used. It is one of the most common causes of anovulatory infertility in this population. PCOS is strongly associated with obesity and its prevalence in the PCOS population may be as high as 75%. Diet-induced weight loss and insulin-sensitizing agents are shown to improve ovulation. The ketogenic diet (KD) has garnered increasing attention for its ability to cause significant weight loss and improve metabolic syndrome, both of which are characteristics of PCOS.
The ketogenic diet (keto diet) is becoming so popular and is spilling over to the reproductive world. And when trying to conceive, there are special considerations you need to make - like knowing which keto ttc supplements you should take and which nutrients to focus on. As a fertility registered dietitian, I generally do not proactively recommend a keto diet for fertility.
The internet is a wonderful resource for information on fertility, but not all advice on what to eat or avoid is helpful. Good nutrition plays a significant role in boosting fertility, but it’s important to seek guidance from registered dieticians and qualified practitioners who specialise in fertility.
Understanding the Ketogenic Diet
Simply put, a ketogenic diet is a very low carb and high fat approach to eating. When done correctly, a ketogenic diet changes the body’s metabolism from using glucose (sugar) as the primary fuel source to ketones (fat). The diet consists of eating large amounts of healthy fats such as olive oil, avocados, flaxseed, nuts, seeds and very very small amounts of carbohydrates - typically from fruits and low carbohydrate vegetables. Dairy products such as heavy cream, butter and cheese are allowed (of course unless you are following a vegan ketogenic diet) as well. Protein is also included on the plan but shouldn’t be consumed excessively because then the body will process it similar to glucose. A typical breakfast may be bacon, eggs and avocado. Lunch a salad with chicken, cheese, avocado, bacon, and an olive oil based dressing. Dinner may be a steak with butter and asparagus.
Currently, the term KD is used broadly because of its many variants. The original KD was designed to treat pediatric epilepsy and is composed of a 4:1 ratio of fat to protein plus carbohydrates (in grams). Modified versions of this have been adapted for weight loss and diabetes. Feinman et al. Investigations regrading the effects of KD on patients with PCOs are limited to small and short-term studies.
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A ketogenic diet - which is high in fat, moderate in protein, and low in carbohydrates- puts your body into a natural metabolic state called ketosis. By dramatically reducing your intake of carbohydrates (its primary source of energy), your body is forced to become super efficient at burning fat for energy instead.
Popularity and Potential Benefits
It has primarily been used for the treatment of medication resistant epilepsy for over 100 years but has recently become a popular weight loss diet as well. Every day on social media there is a link to a new celebrity or influencer losing loads of weights and quickly on a ketogenic diet. While the diet can be very effective for weight loss as it eliminates about 60% of foods we typically consume thus creating a calorie deficit…the bigger question is…is it sustainable? And what happens if you stop eating the ketogenic diet way and go back to eating carbs? Weight gain??? Probably! Weight loss isn’t the only reason it has become so popular in the last few years though as claims have been made that ketogenic diets can help a variety of disease states including but not limited to diabetes, migraines, traumatic brain injury, autism, acne, chronic pain, cancer and autism. Some of these diseases do have good evidence/studies for ketogenic diets helping while others are purely speculation and need a lot more research.
Preliminary research suggests this shift can enhance weight loss temporarily, as well as help reduce systemic inflammation, which is important because “inflammation can reduce overall fertility,” says Kristin Kirkpatrick, RDN, a wellness nutrition services consultant at the Cleveland Clinic Wellness Institute in Ohio. “Using a ketogenic diet to improve body weight can definitely help women who do not ovulate - release an egg - regularly, including those with polycystic ovary syndrome ,” explains Rashmi Kudesia, MD, a reproductive endocrinologist and infertility specialist at CCRM Houston.
Keto Diet and PCOS
Polycystic ovary syndrome (PCOS) affects up to 20 % of reproductive-age individuals and is strongly linked to obesity. Patients with polycystic ovary syndrome (PCOS) on a high-carbohydrate diet intrinsically suffer from exacerbated glucotoxicity, insulin resistance (IR), and infertility. Lowering the carbohydrate content has improved fertility in patients with IR and PCOS. Women with polycystic ovary syndrome (PCOS) often struggle with weight gain and infertility. However, conventional treatment options for infertility are not designed for PCOS patients. These treatments are associated with a high failure rate and a high risk of pregnancy complications. In addition, medications such as birth control pills often cause unwanted side effects.
In a small study, patients with obesity and PCOs who underwent KD for 24 weeks, had significant reductions in body weight (−12%), fasting insulin (−54%), percent free testosterone (−22%), and LH/FSH ratio (−36%). Insulin, glucose, testosterone, HgbA1c, triglyceride, and perceived body hair didn’t differ from baseline. Two patients conceived despite previous infertility problems. Same changes were demonstrated in another study involving 12 patients with PCOs and overweight who underwent KD for 12 weeks had significant reductions in body weight, BMI, fat body mass and visceral adipose tissue with slight reduction in lean body mass. Significant reductions in insulin, glucose, HOMA-IR, total cholesterol, triglycerides, LDL, LH/FSH ratio, LH, total and free testosterone, and DHEAS levels were observed. HDL, estradiol, progesterone and SHBG levels increased.
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Cleveland Clinic researchers led a study of a fertility treatment tailored to PCOS patients that targeted one of the main causes - insulin resistance. Patients with insulin resistance have high levels of insulin, which suppress ovulation. The goal of the study was to see if the ketogenic diet would improve the outcome of fertility treatments by significantly reducing insulin levels and their harmful effects to the ovaries.
In fact, some research suggests that besides helping women with PCOS lose weight, the ketogenic diet may help rebalance their hormones - and in some cases help women who had previous infertility problems become pregnant on their own. In a small study published in the September-October 2018 issue of the journal AACE Clinical Case Reports, researchers followed four overweight women with PCOS who were trying to conceive follow a ketogenic diet, monitoring their progress monthly. Within six months, all four women lost weight, ranging from 19 to 36 pounds, and resumed regular menstruation (they’d all had irregular periods before they started the diet).
After approval from the Institutional Review Boards of Cleveland Clinic, a retrospective analysis was conducted using the electronic health record system. We analyzed data from thirty patients (n = 30) with polycystic ovary syndrome who followed a ketogenic diet for at least 3 months at the Cleveland Clinic, Cleveland, Ohio, USA. All women (n = 30) had restoration of regular menstrual cycles. The overall pregnancy rate of women desiring pregnancy (n = 18) was 55.6% (n = 10). Pregnancy rate was 38.5% for women on metformin and 100% for those who were not (P = 0.036). Pregnancy rate was 62.5% for women using ovulation induction agents and 50.0% for those who did not (P = 0.66).
Study on Keto Diet for PCOS
This study aimed to investigate the use of a KD to help women with PCOS restore regular menstruation and achieve pregnancies. The ketogenic diet involved limiting carbohydrate intake to 20 grams daily, with specific protein and fat guidelines. The study excluded those who did not adhere to the diet for at least three months, those who used contraception, or postmenopausal women. Participants had monthly check-ups to monitor their weight, overall health, and menstrual cycles. The study's main focus was on the return of regularity to menstrual cycles and pregnancy rates, with additional attention on the time taken to conceive and any weight changes.
The average age of participants was 31 years, and their average body mass index (BMI) was 43.4. After six months, 92% of the women regained regular menstrual cycles; by 15 months, all had regular cycles. Of the 18 women who wanted to conceive, 55.6% became pregnant, with 63% achieving pregnancy within 12 months. Interestingly, all women who did not take metformin achieved pregnancy, compared to 38.5% in the metformin group. For women with available anti-mullerian hormone (AMH) data, those with lower AMH levels struggled to conceive, even with fertility treatments.
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This study highlights that a KD may improve menstruation regularity and increase pregnancy rates in women who have PCOS. The study contributes valuable insights as one of the first to examine the effects of KD on fertility in women with PCOS. However, the sample size was relatively small, and the long-term effects of KD on fertility were not evaluated.
Implementing the Keto Diet
Patients with PCOS who were referred to the Endocrinology and Metabolism Institute’s Integrated Weight Management Program for management of PCOS and obesity were identified. The KD plan implemented in our SMA consists of up to 20 g of net carbohydrates, protein intake of 1.6 x weight in Kg = grams/day, Fat intake up to 40 grams/day. At least 64 oz of water intake is required. The use of ketogenic supplements was discouraged. However, potassium chloride supplement of 10 meq per day were prescribed.
Throughout the six-month study, the patients attended monthly shared medical appointments with Dr. Abed Alwahab and a dietitian. “Since the ketogenic diet is quite restrictive, close monitoring is vital to ensure that patients are following it correctly without experiencing side effects (e.g., dehydration) or injury,” notes Dr. Abed Alwahab. Monthly monitoring included checking each patient’s labs. In addition to health monitoring, the shared medical appointments focused on patient education. “Each month, we covered different topics related to PCOS, including diet and women’s health issues,” explains Dr. Abed Alwahab. “We are constantly educating patients on potential pregnancy, so they fully understand how to manage the diet and avoid gaining too much weight.”
Considerations and Potential Risks
While a ketogenic diet may help a woman who wants to get pregnant drop pounds quickly, it would be best to use it “to kick-start a new health routine and lose weight” before trying to conceive, Dr. Kudesia says, because you don’t want your body to be in a state of ketosis around conception (or any part of pregnancy). Also, for a healthy conception and pregnancy, it’s important to eat enough nutrient-dense whole foods, rather than to restrict calories, Cole says. Indeed, it can be hard to follow the keto diet in a healthy way, as many people eat foods high in saturated fat, such as butter and bacon, to stay in ketosis. Too much saturated fat can increase total cholesterol, which strains the heart, according to the American Heart Association.
As a woman embarks on the path to motherhood, she should be nourishing her body-not inducing a state of metabolic starvation like ketosis. In contrast to the keto diet, a fertility friendly diet is nutrient dense, low-glycemic and anti-inflammatory. While it is important to focus on incorporating protein and healthy fats and eliminating processed carbohydrates and added sugars, it is equally important to balance your diet with nutritious fruits, starchy vegetables, legumes and whole grains. For instance, whole grains and legumes provide B-vitamins which are crucial for optimal egg development and ovulation. Folate, another B vitamin, found in vegetables, fruits, dairy and grains, is essential for fetal development and prevention of neural tube defects. Berries and cherries are packed with strong antioxidants that combat inflammation in the body and protect cells against oxidative stress. Beans and lentils are good sources of protein, potassium and folate and while they do have carbohydrates, they’re net carbohydrate load (net carb = total carbohydrate - dietary fiber) is low because they’re packed with fiber. Soluble fiber from whole grains and legumes help bind excess hormones and cholesterol so the body can excrete them instead of absorbing them. It also attracts water to stool which can improve bowel regularity and prevent constipation.
Another concern: Adhering to a restrictive diet like the ketogenic plan could add to a woman’s stress while she’s having fertility treatments, or it could have a negative impact on her relationship with food, Mallik says. “To cope with nausea during pregnancy, women often reach for carbohydrates, like plain crackers or pretzels,” she notes.
Keto During Pregnancy
Great question and one that is difficult to study because it is difficult to conduct research on pregnant women for the obvious reasons. Unfortunately we do not know exactly what happens with a women is pregnant and in ketosis (again the body/brain functioning off of fat). What does that give the baby in terms of energy - glucose/sugar or fat/ketones? Will the baby grow normally? Will the baby develop normally? Those are the research questions we just don’t have answer to at this point in time. So I cannot recommend ketogenic diets for pregnant women at this time. Of course my answer may be different in 5 years as research in this area continues to evolve.
Now what I do think can be done during pregnancy without detriment to the baby is a lower carb diet. So not a very low carb/high fat diet that induces ketosis (again remember that is when your body is functioning off of fat instead of sugar) but a lower carb diet than most Americans eat is not a bad idea. I think using some of the “rules” of the ketogenic diet while pregnant would be fine. Such as cut out bread, pasta, sweets, treats and all of those really heavy carbs and junk food. Focus on eating more berries and low carb vegetables - never hurt anyone!! Getting a good intake of organic protein sources such as meats, eggs, nuts and seeds are all great foods. Eating an avocado a day (something I often recommend to my clients) is super low carb/keto friendly and crazy healthy. So In general I think a modified version of a ketogenic diet can be healthy for pregnancy with the caveat of your body should not be in ketosis but you can still eat very clean and low carb.
For anyone on a ketogenic diet (both preconception and during pregnancy) just make sure you are supplementing with the following and gaining appropriate weight: · A great prenatal vitamin · A calcium supplement if you don’t drink cow or nut milk fortified with calcium· Fish oil supplement with a nice blend of EPA and DHA
Supplementation Plan for Keto/Fertility
Suggested supplementation plan for keto/fertility:
- Prenatal Vitamin with choline
- CoQ10
- Carnitine
- DHA
Addressing Constipation
Oh yes good old constipation. The #1 side effect to the ketogenic diet. Well first ladies you aren’t alone! Here are some tips:
1.) Eat an avocado daily. They are natural laxatives.
2.) Use coconut oil. Coconut oil is 66% medium chain triglycerides which is a special type of fat that can have a laxative effect as well.
3.) If coconut oil doesn’t help, then use pure MCT oil. You can add this to your decaf tea or coffee or add to a smoothie. Just don’t cook with it.
4.) Make sure you are drinking enough fluids.
5.) Spend your carbohydrates on leafy green vegetables. Most ketogenic diets allow 20-40 grams of carbohydrates. Personally for me I educate people to count net carbs so total carbohydrates minus fiber (not everyone in the keto community agrees on whether we should be counting total carbohydrate or net carbohydrates) but either way you get a certain amount of carbohydrates a day (you have to eat some!) so spend those carbohydrates on vegetables so you get lots and lots of fiber to help you stool.
6.) Start a good probiotic with at least 5 different strains of bacteria for overall gut health.
Keto Diet and Egg Quality
Ohhh..you know I really don’t know. It’s a great question. When considering antioxidants though, the diet (when done correctly - starting to sound like a broken record) is anti-inflammatory so in theory your antioxidants would be put to better use than clearing the body from inflammation and “pro-oxidants.” In other words they would be freed up to do other bodily functions. In addition the foods people should be eating on a ketogenic diet such as berries, vegetables, dark chocolate (this can fit into a well planned ketogenic diet in small quantities…so good),nuts and seeds all contain large amounts of antioxidants. So it’s possible that the supply of antioxidants would be higher than the body’s demand which isn’t a bad thing and certainly could improve egg quality.
Let’s remember though that it’s not just about the egg…it could be the sperm quality. A typical diet full of those junk carbohydrates (think bread, chips, etc - not talking fruits and vegetables here) can impact sperm health. So for men who go on a ketogenic diet full of healthy fats sperm health can improve.
Alternative Dietary Approaches
For these reasons, Rachelle Mallik, RDN, who specializes in reproductive nutrition in Chicago, believes that following the Mediterranean diet or a so-called Dutch-style diet- which emphasizes fruits, vegetables, meats, fish, whole-wheat bread (and cereals), and healthy fats - is a better approach to preconception because it has a more balanced distribution of macronutrients. So there’s no good reason to play the how-low-can-you-go game with healthy carbohydrates, she says.
Diets other than KD are reported to have benefits in patients with PCOs. Low-carbohydrate diet (carbohydrates accounts for less than 45% of the three major nutrients) demonstrated significant reductions in BMI, HOMA-IR, total cholesterol, LDL and T levels while increasing FSH and SHBG levels. The question of whether a specific type of diet improves fertility in women with PCOS more than others is unknown. In a randomized trail, Mediterranean/low carbohydrate diet (maximum carbohydrate intake of less than 20%, a maximum carbohydrate intake of 100 g throughout the day and an increased intake of protein and fat) showed similar metabolic benefits when compared to low fat diet (less than 30% of total dietary calories from fat, less than 40 g of fat intake throughout the day and up to 10% saturated fat). Head-to-head studies comparing KD to other diets in patients with PCOs are scarce.