Maggie McKay (Host): Welcome to Fertile Edge, a podcast from the Reproductive Science Center of the San Francisco Bay Area. I'm your host, Maggie McKay. Today, we're going to discuss supplements and vitamins as they relate to fertility with Dr. Mary Hinckley, IVF, Medical Director, and Bonnie Burgess, Fertility and Perinatal Nutritionist and Founder of Burgess Wellness. Thank you both for being here today.

Mary Hinckley, MD, REI: You're welcome. I'm so glad to get this opportunity to talk today to both of you.

Bonnie Burgess: Thanks for having me.

Host: All right. Let's just start right in with what nutrients are important for fertility and where do we source them, like food versus supplements.

Bonnie Burgess: So, this is a hugely long list, and I will spare everyone the long list. Generally, you could think about eating a diverse diet of whole real foods, but I'll just call out a few specifics that people might be interested to know about, especially as they relate to supplementation.

So, B vitamins are very important, and I'll call out specifically B12, vitamin B12, which supports DNA production, and then folate, which is one of the B vitamins. It's very well known for preventing neural tube defects, but it's also been studied in fertility to support egg quality. So, it's hard to get enough folate from food regardless of your diet. Leafy greens, legumes, and liver are good sources. But during this life stage, helpful to supplement, part of the reason why a lot of prenatals have them. And then, B12 is critical if you're vegan. And then, if you're plant-based, you'll probably want to supplement too.

Vitamin D is another one that I want to call out. It's hard to get enough of that one from food. And it's critical for ovulation support. It touches on embryo implantation and then each stage of pregnancy. There's not a set amount that you want to supplement because each person's skin is different and where they live is different, how much sun they get. So, you want to test, and then supplement accordingly.

And then, the last one I'll call out because this one's also quite person-dependent, it's iron, critical for red blood cell production, very important in pregnancy. And now, when you get it from food, you can get enough. But plant sources and animal sources, completely different absorption rates. So again, if you're a vegan or mostly plant-based, it's going to be hard to get enough. And those people are almost definitely going to have to supplement. And even people that are eating the high absorption, they're called heme sources, they're probably going to need to supplement too. Now, an excess of iron has adverse effects. You don't want to just supplement willy-nilly with iron. So, testing there is also helpful to dial in.

Mary Hinckley, MD, REI: Those are good ones to point out. And I think one things so important that I love having you board with patients when we consult with you or when patients really take on nutrition to learn about it themselves, is that it does so much depend on what their diet, their lifestyle, what their ethnicity is as to where they might be deficient, what their diets really might be missing.

So, coming to see a fertility doctor, we usually will run a panel of tests to get them ready for pregnancy and ready for their journey for maybe egg freezing or any other treatments that they may need to do. And that's going to include vitamin D. I mean, the amount of us even here out in sunny California that are deficient in vitamin D is really high. And if you have an inside job, if you wear your sunscreen when you go outside, you're not getting a lot of vitamin D. And vitamin D is also important with calcium for your bones. So, these are things that we need just for our general health, but especially in regards to fertility.

You also mentioned the B vitamins. B vitamins are so important. And, I think, while many of us may be trying to optimize our diet for fertility by staying away from too many simple carbohydrates, or avoiding this or avoiding that, some of those, if we're not getting enough whole grains or other foods, we may be missing out. And so, taking a supplement is a good idea. Most prenatal vitamins or conception, preconception vitamins are going to have some of those. But there are certain groups that will need more vitamin B12 and there's different ways to source it. So, that's such an important one too.

The other one you said that I was thinking about with the iron, I was reading some information from the NIH recently about, you know, the first thousand days of a child's development and how critical that is and why preconception nutrition is so important, so that those first thousand days from conception all the way up to about the child's second year of life, we've totally optimized them going forward. And that also does include iron. And you know, if you're a menstruating woman, if you have heavy periods or fibroids, these are things that are going to be low. We always check them. We check it with a complete blood count. But optimizing that is really important. And so, the vitamins can be a helpful way as well as food sources. And personally, I'd always rather get my nutrients from food sources than vitamins. It's much more fun. But I love some of the suggestions you had, Bonnie, for different ways and thinking about whether it's plant or meat based.

Host: I have to say, when I was taking those prenatal vitamins, my hair never looked better. I just wanted to keep taking them for the rest of my life. My goodness. I don't know what's in those, but they should just put a different label on it and say hair growth. So, you mentioned if you're a vegan, what types of diets need to consider special supplementation?

Bonnie Burgess: Yeah. I would say plant-based, vegan, vegetarian are kind of the first thing. I called out a few nutrients that they're going to need to think extra hard about, but also zinc, omega-3s DHA, choline, iodine, selenium. Some of those, you know, if they're vegetarian, but they're eating full fat dairy and eggs, they can get a lot of those. And then, if they're taking a good omega-3 supplement or maybe a pescatarian, getting a lot of these whole foods, they might not need to have special supplementation. But for sure, vegans, it's almost impossible. You know, it's nothing against those diets, it's just a fact that they would be nutritionally deficient when it comes to fertility.

I recently read, you know, somebody who might be ethically opposed to eating animal products, that oysters or something, that a lot of those folks consider eating, just because they don't have the same awareness perhaps of other living beings. And so, if that's something that someone would be willing to compromise on, they are so packed in a lot of the key fertility nutrients. So, that's a hot tip.

I would say somebody who's just not eating a lot of whole fresh foods would probably be missing out on good antioxidants, omega-3 fats. So if you're somebody who maybe you look at your diet and you count the number of produce items that you eat, fruits and vegetables that you eat in a day and it's coming up closer to zero, under five, then that's something that you could probably either amp up on or you're going to have to make sure that you're getting those nutrients through supplements, like Dr. Hinckley mentioned. So, somebody who just, for whatever reason, they're avoiding certain foods, so maybe it's an intolerance or just a preference. But those, we need to make sure that we're filling those nutrient gaps if we can't do it creatively through food, doing it through supplementation.

And then, within the fertility space, you know, there's health concerns that specifically are affecting someone's fertility and that gives me insight into what nutrients that they might need ratcheted up. So, somebody who has no problem conceiving might not need to take an extra magnesium, might not even need to think about their vitamin D, they just are able to carry on without special supplementation.

But for example, PCOS, that's one to call out because commonly correlated with difficulty with fertility and also positively impacted by diet. And so, deficiencies in vitamin D, magnesium, zinc, and selenium, just from a deficiency perspective is all really common. And then there's other supplements that we might use to not only affect their PCOS, but then help them to conceive as well.

Mary Hinckley, MD, REI: Bonnie, I have a question for you about zinc and selenium. A lot of us maybe saw those on our vitamin list on the back of our vitamin bottle, but don't even know where to get those if we wanted to source them naturally. What foods are good in those?

Bonnie Burgess: Selenium is a lot of the meats, animal products, and then Brazil nuts. Brazil nuts are a great way to get it in. The problem, I mean, this kind zoom out into this whole discussion, is that our food supply chain compared to what it was maybe 50, a hundred years ago, or just our soils are a lot more depleted. So, I often recommend Brazil nuts, but you don't necessarily know if you're getting quite enough selenium in those. And then zinc, also animal products. For example, oysters are very high in zinc, but also eggs, shiitake mushrooms and pumpkin seeds.

Host: Backtracking a little bit. You mentioned PCOS. And just very quickly, what is that for people who don't know?

Bonnie Burgess: Yeah. It's polycystic ovarian syndrome. And Dr. Hinckley can--

Mary Hinckley, MD, REI: Oh yeah, this is where I get to come in. So, PCOS is a really common diagnosis for women that present with infertility. You also could know you have PCOS because you have irregular cycles. Maybe you have acne or hair growth, and you might present to your gynecologist in your late teens or early twenties. But for my patients, thinking about fertility, it's often a diagnosis that's made because women are not ovulating regularly. And therefore, it's quite hard for them to get pregnant. So when we diagnose that and we diagnose it through irregular cycles, acne or hair growth, or elevated androgens like testosterone or polycystic ovaries on ultrasound, and women need to have two of three of those possible things. Then, we can tell them they have PCOS, and we have a certain way of treating women with PCOS that helps them conceive.

Host: Are all prenatal supplements created equally?

Mary Hinckley, MD, REI: Ooh, that's a good one.

Bonnie Burgess: So, interesting personal story, on my first pregnancy when I walked in for that pregnancy confirmation appointment, my OB asked, "Are you taking a prenatal?" And she didn't know I was a nutritionist who worked in this space. And I said, "Yes," like waiting for, "What else are you going to ask me about it?" And she just goes, "Capsule or gummy?" I was like, "That's it? That's all you're going to ask?"

So, gummies, just for that myth-busting, gummies often don't have iron, you know, as a key differentiator because it's really hard to hide that taste of the iron. But even within the gummy space or the capsule space of prenatal supplements, huge difference in terms of specific nutrients that will be included, quantities of the nutrient and format of the nutrient. And I think it's great that there's such diversity. That way, we can tailor it to the particular person because as it's supposed to be a supplement to your diet, the vegan and the heavy meat eater are probably not going to need that same supplement. And then, in terms of quality, that's also really important just because they're not approved by the FDA or anything like that, so in terms of what's actually in the supplement that they say is in the supplement is important to verify. And so, third party testing is really critical.

Host: So, maybe don't go on Amazon and order them blindly.

Mary Hinckley, MD, REI: Yeah, or have some knowledge about what a good brand is and that independent verification. And check with your nutritionist or check with your reproductive endocrinologist. Is this an okay brand? And we can usually help encourage them along from that standpoint.

Host: And speaking of help, who helps guide a patient on what vitamins or supplements they should be taking? Because you're already overwhelmed being pregnant or even trying to get pregnant. So, where do you turn for that? Your nutritionist, your OB-GYN?

Mary Hinckley, MD, REI: Well, oftentimes, patients will come into my office for infertility, and we'll be talking through what medicines they have, what supplements. And so, that's an opportunity for me to talk to them a little bit about that. I usually ask about their diet and their exercise. And sometimes, I'll notice, "Ooh, you know, you would be a great person to talk to a nutritionist to do a little more work with this." And I'll often suggest some brands, but give them range to choose from that standpoint. But a lot of times, that's when they're already struggling with fertility concerns. And so, just listening to this podcast and knowing, "Hey, this is something I can do ahead of time before I get to the doctor's office," or maybe not ever have to go to the doctor's office is a good idea as well. And so, some folks will find nutritionists online or will be referred by a friend. Bonnie, how else do you get patients coming to you?

Bonnie Burgess: Mostly word of mouth, and then from their providers for kind of sussing out who might need a little extra support. And it might be because they have. Something working against them, that nutrition can really help boost the bottom line to get them to that baby, or they just really want to optimize and make sure all their I's are dotted and T's are crossed.

Host: So with fertility, you know, we have to talk about age. I was a senior mom. I was horrified when they said senior mom. I'm like, "What?" They're like, "Anyone over 35." I'm like, "Oh my gosh." So as we age, let's say we're approaching 40 or we're over 40, are there different needs supplement-wise?

Bonnie Burgess: Yeah. So, just because our body naturally changes as we get older, and primarily the body is naturally making less of our internal or endogenous antioxidants. So, two of the big ones that go down steadily with age are melatonin and CoQ10. And when we don't have that strong internal antioxidant power protecting our cells, especially our really delicate egg cells that we want to be their top quality that they can be, that this is a detriment.

And so, from a supplementation perspective, that you can take external antioxidants and perhaps help. And I would say the two most popular are CoQ10 and NAD. So, CoQ10, strong antioxidant function, really well studied on male fertility and somewhat studied on female factor, even within ART, getting better eggs. It's a really good idea for on the older side, those mom-to-be to supplement. That's a pricier supplement, I would say, but otherwise not a huge downside.

And then, NAD, that's an enzyme that helps with mitochondrial function and DNA repair. As a capsule, it can either be supplemented as NAD usually to NAD+, which is the raw form, but also it's precursor. So, you might see, you know, an egg quality supplement formula that has either NMN or NR. Those have been shown to increase levels of that NAD in the body. And then, there's also intravenous form, IV form. And I feel like the jury's still out on that one. I'm curious to hear Dr. Hinckley's perspective that the IV NAD does raise blood levels much higher. But the question is if that equates to higher impact.

Mary Hinckley, MD, REI: From my patients, when they ask me, I say, yes, the jury is definitely still out. And it's quite involved to get intravenous. And they've got so much else going on and so many shots that they're doing. Something like in vitro fertilization that I say, "Take the oral if you're going to see if that has a benefit for you." And it may be that your own body isn't aging. I mean, we all age differently, and we know that from looking at people and from people's family histories. So, we don't have a good way of measuring these to say, "Oh, you're deficient. You need it," unlike when we're checking vitamin D levels or B12 levels. But I think we know that they're not harmful if you're taking them.

So, I do think there's a balance for people being too worried about their supplements and spending a fortune on them and having so many medicines to take in a day that that gets overwhelming versus saying, "You know what? I'm going to take some of these supplements. I'm going to try to have a balanced life. I'm going to try to get my antioxidants through fruits and vegetables. I'm going to try to reduce my exposure to things that cause all the free radical oxygen species." But the balance of not necessarily having multiple other appointments where they're getting IV infusions.

Now, we may get more data in the coming years. What I really hope is that we can start to figure out which patients benefit, because as Bonnie was saying, a lot of these things are for cellular repair. You know, the eggs are in a very protected state. It's really hard to damage the eggs, short of chemotherapy, smoking and the byproducts from cigarette smoke or surgery or maybe something like endometriosis. So, we've always thought, "How can you be improving eggs if we can't even get in there to damage them?" But once we get the eggs, then we're asking a lot of them, we're asking them to do a lot of high level math of multiplication and division. And I think that's where the studies that have suggested CoQ10 may be beneficial, and really helping the mitochondria for all that work that the cell's going to need to do in the early phases of creating an embryo is really important.

And then, of course, while we're often separating the creation of embryos or freezing of eggs from the actual pregnancy, if we know a patient is soon to be getting pregnant, we're also priming their body to be able to really nourish that embryo from day one to really be in there and providing everything it needs.

So, that's where I feel a lot of the supplements may be most helpful, as opposed to thinking, "Oh, I can't do a egg freezing cycle, because I haven't been on CoQ10 for six months." I don't have patients wait to start their treatment because they haven't been on a supplement. It's often, "Let's get on them as soon as possible and let's move efficiently into treatment. And then, if unfortunately the results aren't what we hoped for, then sometimes going back and looking more closely at what else could be done to try to optimize things. No one wants to do this more than once. But on the other hand, waiting to do it can also be hard on the success rates.

Host: So, I've heard about myo-inositol and berberine-- I don't know if I'm saying those right-- for PCOS, but not sure what they are or who benefits from them. Can you talk about that a little bit?

Bonnie Burgess: Yeah. I would say myo-inositol is quite common, especially with the overlap of PCOS and also fertility. So, one of the common issues with PCOS and precursors is insulin resistance. So, also, the inositols can help with that, and they can also help potentially improve egg quality.

There's also studies within the PCOS world that metformin is a common prescription, where in inositols can result in similar effects, restoring ovulation, improving insulin resistance. It's something that is often supplemented as opposed to just eat more of the inositols food because it is in fruits and beans and nuts and grains. But therapeutically, people supplement.

And then, berberine, that's also specifically helpful for insulin resistance. I tend to use that one with a bit more caution. I don't see it quite as often. And, one, it's contraindicated in pregnancy versus inositols you could carry through pregnancy. So depending on how close people are to pregnancy, right, that would make sense. It's also a strong antimicrobial. It can be strong for the liver. So, there's a few downsides to berberine.

Mary Hinckley, MD, REI: I have so many patients that will come in saying, "What else can I do to help with my PCOS or to help with my prediabetes? I mean, it's really an epidemic here in the United States with obesity. And many of these diseases and the inflammatory conditions that can affect your infertility can be driven by insulin. And so, getting that insulin level in check, which requires getting your glucose levels in check, is a really important thing. And we can do it through diet, but sometimes there are things out there that can help. And I think that the myo-inositol, especially in the ratio that is provided in a lot of the supplements out there with D-chiro-inositol in this 40:1 ratio can be a good adjunct for people, especially people who have a family history of diabetes, who have prediabetes and have been told from their doctor that they need to watch their diet and their glucose levels. I think that can be super helpful in these early stages of the fertility workup and even in pregnancy.

Host: Thank you both so much for sharing your expertise. I mean, you both have such rewarding careers and jobs, I would think. I mean truly life-changing for the people you treat. So, we are so grateful you could make time to talk with us and to teach us some things about this very important topic. So, thank you again for being here.

Mary Hinckley, MD, REI: Thanks, Maggie. I enjoyed being here. I love getting to hear what Bonnie has to say. It's so wise, and she has such a breadth of knowledge of the different foods and how things work together. And it's more than we're taught in medical school for sure. So, I love being able to partner with nutritionists to be able to really provide whole-person care for our patients seeking to become moms.

Bonnie Burgess: Thank you for having me. It's such a pleasure to talk on this topic and to kind of get into the nuance of nutrition, because we eat every day, but there's a lot to it.

Host: Again, that's Dr. Mary Hinckley and Bonnie Burgess. To learn more about your fertility health, please visit rscbayarea.com or call 888-377-4483 to schedule an appointment with one of RSC's board-certified fertility specialists. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Fertile Edge, a podcast from the Reproductive Science Center of the San Francisco Bay Area.