How do you counsel patients about fertility supplements?

I tell patients about these supplements and I use them myself. It’s encouraging when patients ask, because they’re advocating for their own health and actively participating in their care. I try to respond with respect and consideration — and with data. The evidence is mixed. I place these supplements in a category of “might help some people” and “probably not harmful for most,” but the standard of care does not support routine use.

Most studies have been done in IVF patients who are low responders. Some studies suggest a possible benefit for low responders, but results overall are inconsistent and we do not see a clear, significant improvement across the literature. A lot of patients ask about supplements before trying medications like Clomid; it’s important they know where the evidence comes from.

For fertility, most CoQ10 studies used 600 mg per day of CoQ10 or 300 mg per day of ubiquinol. For DHEA-S, studies used micronized DHEA at 25 mg three times a day. DHEA-S is a mild androgen; androgens appear to provide fuel for the ovary and can improve response. The best-quality studies, however, have used testosterone and showed benefit, but testosterone can cause masculinization, so it’s not a practical option for most patients. DHEA-S is milder and may be considered for patients who have failed IVF and are low responders.

Patients should know the risks and limitations. Many people do experience side effects from DHEA-S, including acne and increased hair growth; they should stop immediately if these occur. DHEA-S is teratogenic and can masculinize a female fetus or interfere with male fetal development, so it must be discontinued before embryo transfer and pregnancy.

If a patient wants to try these supplements — for example, along with acupuncture or melatonin — that can be reasonable as long as it does not cause side effects, they accept the extra cost and effort, and they understand the uncertain benefits.

This conversation is also a good opportunity to counsel about an anti-inflammatory, healthy lifestyle, which often has clearer benefits: achieve a healthy weight, eat more vegetables and whole foods with a lower glycemic load, improve sleep quality, build muscle and do regular cardiovascular exercise, manage stress, and minimize toxin exposures. Practical steps include choosing more organic or less-processed foods, avoiding microwaving food in plastic, using glass or stainless-steel water bottles, and reducing exposure to endocrine disruptors.

Patients who show interest in supplements are usually receptive to lifestyle counseling, and that can often make a meaningful difference.

I think for supplements it's important not to overpromise. Patients struggling with infertility are a vulnerable population; if you tell them to stand on their head they'll do it. There is some evidence for certain supplements, but it's not robust and hasn't been shown in every study. As long as a supplement hasn't been associated with harm, I'm okay with my patients taking it. Many aren't covered by insurance, but supplements like CoQ10, DHEA, and OmniTrope (growth hormone) have some studies suggesting potential improvement in outcomes. I tell my patients I'm okay with them taking those. It's not something I automatically discuss at the first visit for every patient; often they ask about them, or they've had a poor cycle and want to try everything. We also talk about acupuncture as a complementary therapy. I tell them there's no silver bullet or magic pill to reverse the clock—age remains the most important predictor of outcomes.

Randomized controlled trials are expensive. RCTs are not the end-all for fertility studies generally, but for supplements they've been done. The most robust studies have not shown a significant difference for most of them. Many studies showing a positive impact are observational or retrospective rather than RCTs. They exist, but there need to be more that are not sponsored by the company. RCTs are costly and time-consuming; the number of patients has to be very high to detect a difference. Often the patients taking supplements are poorer-prognosis patients, and when outcome incidence is relatively low it's difficult to find a difference.

Generally, if something hasn't been shown to be harmful, I'm okay with it. I counsel patients about the limited data behind supplements and allow them to make that choice.

I counsel patients about fertility supplements like DHEA and CoQ10 to emphasize that it’s important to consider factors we can control, such as diet and vitamins. When people ask whether they should take a particular supplement, I encourage them to think about what they can control. Many medical aspects of fertility are out of our control, which is difficult, especially when the outcome is so important.

As researchers, we also want to control and understand how to improve eggs and sperm, but our understanding remains limited. I tell patients we are trying, and their question is valid. There is biological plausibility for some of these medications and supplements. For example, CoQ10 could lower oxidative stress and DNA damage in an egg or any cell, which might help. DHEA is a substrate for ovarian hormone production and could be important for oocyte development, although we don’t know for sure.

Many plausibly helpful interventions are introduced into fertility medicine quickly. The upside is that we have more options to try; the downside is that they are often poorly substantiated—uncertain whether they help, have no effect, or cause harm. For the most part, I think DHEA and CoQ10 are unlikely to cause significant physical harm. They’re also unlikely to cause major financial harm, though I caution people about spending time and money on unproven IVF add-ons or new techniques. When something seems biologically plausible, I can see why people want to try it, but we don’t always know the outcome. It could be helpful, harmful, or indifferent.

I partner with patients to discuss whether something seems reasonable. I rarely recommend many supplements outright, but I would put CoQ10 and DHEA in the “seems reasonable” category.

If someone gets pregnant after taking supplements, I tell them not to present those supplements as the reason for their pregnancy. My concern at a public health level is that anecdotal reports—friends or online posts—can lead people to believe a particular vitamin or behavior guarantees pregnancy. Fertility is a matter of probability; it is rarely zero or 100 percent for most people. Vitamins might change someone’s chance of pregnancy by a small percentage, but it’s hard to study. If a supplement is inexpensive and appears safe, it might make a small difference. What worries me is when people rely on anecdote and delay seeking medical help—for example, trying for years and moving from age 37 to 41 before coming to see us—which can make a big difference in success rates. Supplements can be an adjunct to other treatments, but they are unlikely to be the sole answer.