By: Jen Walpole, mBANT rCNHC Registered Nutritional Therapist
Anovulation is the lack of ovulation (release of an egg) and is a common cause of infertility amongst women. It is closely associated with polycystic ovary syndrome (PCOS) as well as irregular cycles. Understanding the cause of anovulation is the first step in supporting anovulatory infertility. From there, there are many nutritional and lifestyle interventions that may help to support ovulation and conception naturally.
Polycystic ovary syndrome is a common cause of anovulation and accounts for 90% of cases of anovulatory infertility (1). PCOS can be confirmed by the presence of two out of three of the following criteria:
- Elevated androgens (such as testosterone)
- Irregular cycles
- Polycystic ovaries
Signs and symptoms vary greatly among women and may change over time. Nutritionally there is a lot that can be done to support the presenting signs and symptoms including anovulation. Since PCOS is closely associated with metabolic syndrome, keeping blood sugar levels balanced is key to restoring ovulation. Omitting refined sugar from your diet and choosing mostly low GL foods can make all the difference.
PCOS is also often linked to other drivers such as inflammation and stress so getting to the root cause of your symptoms is important. In my clinic I routinely run the DUTCH test, a dried urine test that helps identify hormone imbalances, which can be hugely beneficial to understanding more about the drivers in your PCOS and anovulation picture.
Hyperprolactinaemia & Hypothyroidism
Hyperprolactinemia happens when there are high levels of the hormone prolactin in the blood. Prolactin is normally associated with pregnancy as it plays an important role in breast development and milk production. However, elevated prolactin levels can be seen in nonpregnant women and may result in a reduction in LH and FSH, therefore causing irregular or no ovulation in some women (2).
Hyperprolactinaemia is linked with thyroid issues as about 40% of those with hypothyroidism (underactive thyroid) also have elevated prolactin (3). Elevated TSH (seen in hypothyroidism) causes an increase in prolactin levels. Therefore, it’s important to assess all aspects of hormone balance to support anovulatory infertility, including prolactin and thyroid hormones. Stress can also play a role in the onset of both hyperprolactinaemia (4) as well as hypothyroidism (5).
In addition to lifestyle factors, supporting thyroid function with some of the key nutrients required for thyroid hormone production would be advisable. For a targeted approach, it’s best to work with a nutritional therapist to support.
Obesity & Low Body Weight
There is an increased prevalence of infertility in obese women due to an impaired ovarian follicular development. One study found that anovulatory infertility was higher in overweight and obese patients whose body mass index (BMI) was greater than 26.9 (6). Obesity affects hormone levels due to an increase in oestrogen, resulting in anovulation (7). Therefore, reducing BMI to under 26.9 would be a good idea if you are not ovulating and are overweight or obese.
Similarly, studies have linked low body weight (considered a BMI of less than 18.5) with anovulation and infertility. One study highlighted that low BMI was associated with negative outcomes in fresh IVF transfers, particularly in women over the age of 35 (8). Another study highlighted that in both obese and low BMI women, hormone imbalances impacted menstrual function (9).
Body fat regulates reproduction, while fat cells produce sex hormones (as well as the ovaries and adrenal glands). Higher fat cells can increase oestrogen levels, whilst lack of fat cells have the opposite effect (10). Therefore, it is advisable to maintain a healthy BMI of between 20-25 and aim to reduce excessive abdominal fat to support hormone production and therefore reduce the risk of anovulatory infertility (although it’s important to note that a little bit of abdominal fat is normal).
Nutritionally, it’s important to avoid cutting out major food groups and ensure your diet includes variety. If trying to conceive, the best strategy would be slow weight loss, to ensure that this does not have the opposite effect. Working 1:1 with a nutritional therapist would be beneficial here to support individual needs whilst losing weight. Portion control, eliminating snacking and processed foods, time restricted eating (ideally of no more than a 12-14-hour fasting window) and increasing exercise are all good strategies to support weight loss.
In relation to weight gain, increasing carbohydrates, particularly complex carbohydrates and ‘healthy’ fats may help. If exercise is high, then reducing this would benefit those of a low BMI, which brings me on nicely to my next point.
Studies (11) show that there is an increased risk of anovulation in women that partake in extremely heavy exercise (more than 60 minutes per day). However, there is also evidence that in women suffering with anovulatory infertility or PCOS, 30-60 min/day vigorous exercise may lead to the resumption of ovulation.
Positive effects were seen on insulin and hormone levels. So when it comes to supporting ovulation, daily exercise of at least 30 minutes may be considered beneficial. There is limited evidence on the impact of specific exercise on ovulation, but we do know that intense workouts increase cortisol (stress hormone) levels, which down regulates sex hormone production.
Walking, swimming, weight training, cycling, yoga and Pilates and similar low impact workouts would be most suitable to support hormone production and therefore ovulation.
Stress-induced anovulation (SIA) often termed functional hypothalamic amenorrhea (FHA) may present in various ways. For example, polymenorrhea (cycles shorter than 24 days) or an otherwise healthy cycle except for reduced progesterone secretion, oligomenorrhea (irregular cycles) or amenorrhea (absence of menstruation for at least 3-6 months). Cortisol (stress hormone) levels are found to be higher in women with anovulation. Trying to conceive is for many, a stressful journey so it may help to talk to a fertility counsellor.
In addition to psychological stressors, nutrition plays a role in stress-induced anovulation, especially when energy expenditure exceeds energy intake. Chronic energy deficiency leads to altered thyroid function, which works on slowing the metabolism and retaining more energy. When trying to conceive, it’s important that the thyroid is functioning optimally. In addition, if the body has shifted towards a coping mechanism, it makes perfect sense that reproductive function may be reduced. When women with SIA/FHA were supported with therapy and nutritional interventions for a 20-week period, up to 88% resolved their anovulation (12). In relation to managing stress, as mentioned, counselling is a useful tool.
Other techniques that I discuss with my clients include meditation, yoga, walking in nature and journaling – all of which encourage mindfulness and aid relaxation. When managing stress, it is important to consider nutrient status and adjust accordingly.
Low Nutrient Status
Preconception care of about three months ahead of conception is important in relation to fertility prep and reducing the risk of anovulatory infertility. A large study of over 12,500 people concluded that female and male periconceptional nutritional status influenced fertility and perinatal conditions (13). In relation to anovulation, another study concluded that adherence to a ‘fertility diet’ pattern was associated with a lower risk of ovulatory disorder infertility by 69% (14).
We know that macronutrient intake is vital to support healthy ovulation. For example, protein consumption from vegetable sources such as nuts, seeds and legumes were associated with a lower risk of ovulatory infertility (15). A small study of just over 250 women found that consumption of polyunsaturated fatty acids and specifically omega 3 is associated with a decreased risk of anovulatory infertility (16). In relation to carbohydrates, higher GL options increase the risk of anovulation and so low GL such as complex carbohydrates are the way to go to support ovulation (17).
- Balen, A. Michelmore K. (2002). ‘What is polycystic ovary syndrome? Are national views important?’ Human Reproduction, 17(9), pp. 2219-27.
- Kaiser, U. (2012). ‘Hyperprolactinemia and infertility: new insights’. Journal of Clinical Investigation, 122 (10), pp. 3467-3468.
- Huang I, Gibson M, Peterson CM. (2007). ‘Endocrine disorders’. In: Berek and Novak's Gynaecology. 14th edition, pp. 1069–136
- Levine, S. and Muneyyirci-Delale, O. (2018). ‘Stress-Induced Hyperprolactinemia: Pathophysiology and Clinical Approach’. Obstetrics and Gynaecology International, pp.1-6.
- Mizokami, T. Wu Li, A. El-Kaissi, S. and Wall, J. (2004). ‘Stress and Thyroid Autoimmunity’. Thyroid, 14 (12), pp.1047-1055.
- Grodstein, F. Goldman, M. and Cramer, D. (1994). ‘Body Mass Index and Ovulatory Infertility’. Epidemiology, 5 (2), pp.247-250.
- Ozcan Dag, Z. and Dilbaz, B. (2015). ‘Impact of obesity on infertility in women’. Journal of the Turkish German Gynecological Association, 16 (2), pp.111-117.
- Cai, J. Liu, L. Zhang, J. Qiu, H. Jiang, X. Li, P. Sha, A. and Ren, J. (2017). ‘Low body mass index compromises live birth rate in fresh transfer in vitro fertilization cycles: a retrospective study in a Chinese population’. Fertility and Sterility, 107 (2), pp. 422-429.e2.
- Aladashvili-Chikvaidze N, Kristesashvili J, Gegechkori M. (2015). ‘Types of reproductive disorders in underweight and overweight young females and correlations of respective hormonal changes with BMI’. Iran Journal of Reproductive Medicine, 13 (3), pp.135-140.
- Walter K. H. Kuchenbecker, Henk Groen, Tineke M. Zijlstra, Johanna H. T. Bolster, Riemer H. J. Slart, Erik J. van der Jagt, Anneke C. Muller Kobold, Bruce H. R. Wolffenbuttel, Jolande A. Land, Annemieke Hoek, (2010). ‘The Subcutaneous Abdominal Fat and Not the Intraabdominal Fat Compartment Is Associated with Anovulation in Women with Obesity and Infertility’, The Journal of Clinical Endocrinology & Metabolism, volume 95, Issue 5, (1), pp. 2107–2112.
- Hakimi, O. Cameron, LC. (2017). ‘Effect of Exercise on Ovulation: A Systematic Review’. Sports Medicine 47, pp. 1555–1567.
- Berga, S.L. Loucks, T.L. (2007) ‘Stress Induced Anovulation’ Emory University School of Medicine, Atlanta, GA, USA.
- Inskip, H. Godfrey, K. Robinson, S. Law, C. Barker, D. and Cooper, C. (2005). ‘Cohort profile: The Southampton Women's Survey’. International Journal of Epidemiology, 35 (1), pp.42-48.
- Chavarro, J. Rich-Edwards, J. Rosner, B. and Willett, W. (2007). ‘Diet and Lifestyle in the Prevention of Ovulatory Disorder Infertility’. Obstetrics & Gynecology, 110 (5), pp.1050-1058.
- Chavarro, J. Rich-Edwards, J. Rosner, B. and Willett, W. (2008). ‘Protein intake and ovulatory infertility’. American Journal of Obstetrics and Gynecology, 198 (2), pp. 210.e1-210.e7.
- Mumford SL, Chavarro JE, Zhang C, Perkins NJ, Sjaarda LA, Pollack AZ, Schliep KC, Michels KA, Zarek SM, Plowden TC, Radin RG, Messer LC, Frankel RA, Wactawski-Wende J. (2016). ‘Dietary fat intake and reproductive hormone concentrations and ovulation in regularly menstruating women’. American Journal of Clinical Nutrition, 103 (3), pp. 868-77.
- Chavarro, J.E. Rich-Edwards, J.W. Rosner, B.A. Willett, W.C. (2007). ‘Diet and lifestyle in the prevention of ovulatory disorder infertility’. Obstetritics and Gynaecology, 110 (5), pp. 1050-8