Low-carb gynecologist

I met infertility specialist, Dr. Michael Fox, on Jimmy Moore's low-carb cruise just this past March.

Dr. Fox is quiet and unassuming, but had incredible things to say about his experience with carbohydrate restriction in female infertility and pregnancy. While readers of The Heart Scan Blog already know that I advocate a diet free of wheat, cornstarch, and sugar for heart health and correction of multiple lipoprotein abnormalities, it was fascinating to hear how a similar approach seems to yield extraordinary benefits in this entirely unrelated area of female health. Obviously, female infertility and pregnancy are unrelated to heart health, but the extraordinary benefits witnessed by Dr. Fox in this area suggest that some fundamental lessons in human physiology can be learned. The results are so incredible that we are all sure to hear more about this approach as experience grows.

So I tracked Dr. Fox down in his busy Jacksonville, Florida practice to fill us in on some details.

WD: Dr. Fox, could you tell us something about yourself and what led you to use carbohydrate restriction in your female patients?

MF: I have been in practice as a reproductive endocrinologist for 15 years. During that time, I have seen our specialty move from a broad based practice of reproductive endocrinology to a narrow IVF [in vitro fertilization] focus, with patients being pushed through IVF in a cookie-cutter fashion without any emphasis on non-medical therapy.

Our focus has been to remain as a broad practice where we individualize care and attempt in every case to achieve pregnancy short of IVF. Five years ago, this continued quest for better care led us into the insulin resistance, low-carbohydrate metabolic world that has transformed our practice, although our practice offers all aspects of reproductive endocrinology including sub-specialized minimally invasive surgery, and all available infertility options.

WD: I have been intrigued by your comments about improved fertility with the low-carb diet. Could you elaborate on this?

MF: Yes, five years ago, as more information regarding Polycystic Ovarian Disease or Syndrome (PCOD/S) and its relationship to insulin resistance (high insulin levels) was emerging, we had a simple realization. As we've known for some time, insulin stimulates excess male hormone levels in the ovary, which disrupts ovulation and fertility. Then our job was to lower or virtually eliminate high insulin levels. Again, in simple fashion, we looked at physiology and realized that insulin is released only in response to dietary carbohydrates. Thus, elimination of carbohydrates should resolve the problem. This, in fact, is the effect that we have seen.

In our previous approaches to PCOD, we utilized oral ovulation medicines generating pregnancy rates in the 40% range overall. Now, with the nutritional approach, for those patients that follow our recommendations, our pregnancy rates are over 90%! This has dramatically reduced the need for in vitro fertilization in these patients.

To extend this idea further, we first started with relative low-carbohydrate diets, such as the South Beach diet, but quickly realized this didn't produce a metabolic effect. Over time, it has borne out that only the very low-carbohydrate diet (VLCD) approach produces significant metabolic change. Our impression then was that the current U.S. nutritional exposure probably increases insulin levels and that this has a detrimental effect on fertility.

To counter this effect, we now recommend the VLCD to all fertility patients and their spouses. The pregnancy rates do seem much better overall, as well as seeing a reduction in miscarriage rates. For the first time at our national meeting last year, there were three articles that showed improved pregnancy rates in patients without PCOD or insulin resistance in IVF when Glucophage was used. This drug decreases insulin. This supports the idea that our entire population is subjected to fertility-reducing high-carbohydrate diet.

WD: Do you see any other changes in these patients on the diet?

MF: Yes. All metabolic parameters, as well as many common complaints, improve. Cholesterol and triglyceride levels improve, while "good" HDL cholesterol levels increase. Weight drops at a pace of 12 lbs per month very steadily and we have many many patients who have experienced 50lb wt loss. Blood pressure decreases steadily in these patients and we are often able to get them off of cholesterol and blood pressure medicines. Common symptoms such as anxiety, sleep disturbances, decreased energy, migraine headaches and depression all dramatically improve. Again we can often get patients off depression and migraine suppression medications. So this approach helps in a multitude of areas.

WD: I was also interested in hearing more about your experience with morning sickness and the effects of a low-carb diet. Could you tell us more about this? Also, any thoughts on why this happens?

MF: As we continued to expand our thoughts about VLCD and fertility/pregnancy, we began to extend the nutritional approach into pregnancy. We know that pregnancy hormones dramatically worsen insulin resistance that is responsible for the condition, gestational diabetes. If insulin resistance is worsened, then reactive hypoglycemia is worsened. One of the biggest symptoms of hypoglycemia is nausea. So, in response to this, we have counseled our patients on the diet in pregnancy and have found a dramatic reduction in nausea. We recommend snacking every two hours in pregnancy.

The other "traditional" issue in pregnancy are cravings. These also likely stem from hypoglycemia. I have had many husbands tell us later that their wives, in contrast to friends etc, were calm and not moody or anxious during their pregnancies. Hypoglycemia probably is a serious issue for the fetus as well and may be the "signal" that turns on the insulin-resistant gene. Many theorists feel this might be an activated gene during the pregnancy.

WD: Do you use any unique approaches to the low-carbohydrate approach, e.g., inclusion of dairy, meal frequency, "induction" strategies (i.e., induction to the diet, not of labor!), etc.?

MF: Yes. As I'm sure everyone who works in the VLCD world does, we also have some tricks to make this work better. My biggest push, although hard to get patients to agree, is to see a counselor along with our follow-up in order to deal with "addictive behaviors" and "stress eating" that so many of our patients relate to us. Good stress management and cognitive behavioral therapy go a long way in helping this become a permanent change.

We also really push frequent calorie intake or "snacking." I think again that hypoglycemia produces an inborn drive to "cure" or "fix" starvation and leads to dramatic overeating. We have a short list of snacks that we recommend. The concept of hunger is offered as a failure of the program. We aim to eliminate hunger, as it represents hypoglycemia. The analogy I use is, if you drove your car until you ran out of gas before you ever sought to find gas, your life would be miserable. So it is the same with your metabolic engine: If you let it run out, the measures your system takes to fix it are very detrimental to life and certainly to nutritional health.

Our other big push is fat. People can wrap themselves around protein and vegetables, but they totally miss the high-fat (animal fat) part of the conversation. We have to really push that aspect. In regards to dairy, we allow for non-processed cheeses and minimal milk. An alternative is to mix about 4 oz whole milk with 4 oz of heavy whipping and 4 oz of water to create a "milk" with less sugar. Similarly, shakes and smoothies can be made with heavy whipping cream with pure whey protein powder added to create a liquid meal for those who "don't have time" to cook.

WD: Thanks, Dr. Fox. We look forward to hearing more about your approach in future.

Contact information:

Michael D. Fox, MD
Jacksonville Center
Reproductive Medicine
Phone 904-493-2229

Comments (36) -

  • Jim Purdy

    6/6/2010 6:31:08 PM |

    "While readers of The Heart Scan Blog already know that I advocate a diet free of wheat, cornstarch, and sugar for heart health and correction of multiple lipoprotein abnormalities ..."

    And I do know that, but it has been hard for me to give up wheat.

    However, I am getting chest pains more and more frequently after big meals, so I'm gong to have to make some major changes in my diet.

    Jim Purdy
    The 50 Best Health Blogs

  • Richard A.

    6/6/2010 9:07:09 PM |

    A high-fat, adequate-protein, low-carbohydrate diet is being used to treat difficult-to-control (refractory) epilepsy  in children.

    There is good theory that the ketogenic diet would also benefit those with Alzheimer's, but don't expect big pharma to fund the control studes. What is needed is for a foundation or the government to fund such studies.

  • DrStrange

    6/6/2010 10:02:32 PM |

    Well lets start the fun here:

    "Again, in simple fashion, we looked at physiology and realized that insulin is released only in response to dietary carbohydrates. Thus, elimination of carbohydrates should resolve the problem. This, in fact, is the effect that we have seen."

    published in American Journal of Clinical Nutrition, 1997

    Beef raises insulin level more than oatmeal, fish raises it more than popcorn, and cheese more than white pasta.

    Has there been a change I missed?

  • Anonymous

    6/6/2010 11:04:25 PM |

    Does he test for gluten intolerance or celiac?

  • Anonymous

    6/7/2010 1:54:58 AM |

    Here's a great recipe for Low Carb Bread


  • Matsmurfen

    6/7/2010 4:29:46 AM |

    Take a look at the Swedish "Kostdoktorn" blog (The Food Doctor?)


    There you can see a video with Dr. Fox!

  • Anonymous

    6/7/2010 8:12:02 AM |

    Interesting!! My sister-in-law is obese, always has been. She carries an extra 60 pounds yet she has had 4 children and never has had a problem getting pregnant. Although in the last pregnancy she was diagnosed with gestaional diabetes (6 years ago). Many of my co-workers are overweight and I see what they eat on a daily basis. High carb foods, lots of junk mixed in with some vegetables, no fruits whatsoever. All of my very overweight co-workers have had numerous pregnancies. No infertility problems at all.  I'v known only 2 women (skinny) with good diets who have had infertility problems.

  • Ed

    6/7/2010 2:25:55 PM |

    This sort of stuff is very interesting.

    Note that Dr Lindeberg has been able to correct type-II diabetes in a number of patients in trials through the application of a not-low-carb "paleo" style diet. See Stephan's reporting here: http://wholehealthsource.blogspot.com/search?q=paleolithic+diet+clinical+trials

    I applaud Dr Fox for his work and I hope his patients appreciate how lucky they are to have him.

    I'm in the camp that believes that liver dysfunction caused by excess vegetable oil consumption over an extended period of time is a very key component in modern society's explosion of insulin resistance. I hope that Dr Fox is paying attention to omega-3 and omega-6 consumption in his patients.

  • Meredith

    6/7/2010 2:39:32 PM |

    Hi Dr. Davis,  Is there a link to Dr. Fox's VLCD diet?  I looked on the website you listed for him and the nutrition section was not available. Or is there some other way to get the information on the diet he recommends?

    Thank you!

    Sincerely, Meredith

  • Jonathan

    6/7/2010 5:31:27 PM |

    I definitely don't feel guilty if I eat a LC snack but if I eat enough, good quality fat, I'm not hungry enough for a snack and my blood sugar barely varies (though the ultra stable blood sugar took a couple of months on HFLC to level out so well; but I was really messed up with highs of 300's).

  • Miki

    6/7/2010 8:15:17 PM |

    Amazing results. Thanks for spreading the word. It reminds me that Weston Price in NAPD mentions tribes that used to prescribe a special diets for newly married couples and pregnant women. We are relearning...

  • Sarah V.

    6/7/2010 10:21:56 PM |

    I'm interested in the "short list of snacks" Dr. Fox recommends to his patients.

  • Anonymous

    6/7/2010 10:39:20 PM |

    Interesting that he is on the high saturated fat bandwagon.  Ready to finally hop aboard now, Dr. D?

  • Emily

    6/7/2010 11:29:44 PM |

    this is really interesting, thanks for posting this interview.

  • Jennifer

    6/7/2010 11:55:42 PM |

    Very informative post and interview. I am a first-time reader and I hope to become pregnant agian after suffering from terrible "morning" aka for me, all day sickness. I am going to reaserch VLCD more! Thanks

  • Anonymous

    6/8/2010 1:08:17 AM |

    Could you please explain the hormonal connection? I, like other women undergoing IVF, have experienced rapid weight gain that is very hard to lose, even though I have been on LC for 5 years.

  • Anonymous

    6/8/2010 1:11:46 AM |

    Could you please explain the hormonal connection? I too have experienced rapid weight gain while doing IVF, even though I have been LC for 5 years.

  • Dr. William Davis

    6/8/2010 1:46:00 AM |

    As I suspected, Dr. Fox's unique experience has triggered a lot of interest.

    I will track him down again in future to see if there are resources or places that he will be continuing his conversation.

    More to come.

  • LeonRover

    6/8/2010 10:20:24 AM |

    Tut, tut, DrStrange, cherry picking ?

    The abstract quotes the following:

    "Total carbohydrate (r = 0.39, P < 0.05, n = 36) and sugar (r = 0.36, P < 0.05, n = 36) contents were  positively related to the mean insulin scores, whereas fat (r = -0.27, NS, n = 36) and protein (r = -0.24, NS, n = 38) contents were negatively  related."

    The insulin AUC data for beef was collected for 13 subjects and with reported values of 7910 +-2193. All one can say is that individuals show a wide variation in insulin response to beef.

  • DrStrange

    6/8/2010 4:19:55 PM |

    Okay then.  So beef CAN cause a very high spike in insulin, just does not necessarily that it does so always for everyone. No blanket statements.  Carbs (and the definition of "carbs" as word is generally used, is pretty sketchy as used) maybe are not the only thing causing high insulin levels.  Definitely refined carbs, the "whites", are problematic to say the least!

    A closely related issue is the protective effect of the antioxidents etc with the "carbs" in non-starchy vegetables vs the lack of those nutrients in meat/dairy

  • Lucy

    6/8/2010 5:17:51 PM |

    Thanks for posting this!  I went through GD in my second pregnancy, and successfully low-carbed (against the advice of the pregnancy diabetes counselors) after the diagnosis.  Third pregnancy I just track the blood sugar and watch the carbs with my primary.  It's a marvelous tool and so little information about low carbing during pregnancy, unless you want negative info.  

    Perhaps Dr. Fox could address the persistent messages that ketosis during pregnancy increases the risk of retardation in the baby?

    I keep running into that line of logic (fortunately i don't think I had to go so low in carbs as to stay in ketosis to control GD so I don't worry much).

  • Rabbi Hirsch

    6/8/2010 6:30:31 PM |

    This is a most read for all infertile couples...

    Rabbi Hirsch Meisels
    Jewish Friends With Diabetes international.

  • Anne

    6/9/2010 3:55:42 AM |

    There is a link between infertility and celiac disease. Could some of the success with the low carb diet be related to the elimination of gluten grains.

  • Anonymous

    6/9/2010 12:02:23 PM |

    Dr. Davis could you kindly shed some light on gram flour viz a viz your recommendation against wheat?

  • Anonymous

    6/10/2010 7:21:24 AM |

    Fascinating post.  Thanks.

  • PeterVermont

    6/11/2010 3:42:35 PM |

    I was surprised at Dr. Fox's emphasis on frequent snacking. My experience is that reducing carbs has all but eliminated sharp food cravings. I interpreted this as meaning that my body was efficiently switching from carbohydrate to fatty acid metabolism -- in that context lower blood sugar does not trigger hunger since the cells have an adequate alternate energy source in the fatty acids.

  • V. Alium

    6/12/2010 12:05:25 PM |

    The heart conditions can cause lightheadedness or fainting and may lead to a life-threatening irregular heart beat known as ventricular fibrillation.

  • Anonymous

    6/13/2010 10:37:25 PM |

    I am a woman with PCOS, and have been following a very low carb diet for some time now, though admittedly not perfectly. I have experienced the benefits the Dr. mentions, specifically as related to anxiety, depression, mood fluctuation, cravings, binging, and alcohol. I have also lost some weight. Also, to the commenter who posted about knowing only two women (skinny) who had fertility issues, that is really only a small circle of aquaintences and does not reflect the fact that as many as 1 in 10 women in the USA have PCOS. Cheers.

  • Amber

    7/1/2010 3:53:41 AM |

    PeterVermont, In general you are right, but pregnancy hormones change everything.  Even under severe carbohydrate restriction, I suffered intense frequent carbohydrate cravings.

  • LA Pharma

    5/3/2011 11:25:10 AM |

    T3-Cytomel (from LA Pharma) can cause an increase in basal metabolic rate.

  • Lyndee

    7/10/2011 2:57:07 AM |

    Cheers pal. I do apprecitae the writing.

  • Johnette

    7/10/2011 4:29:04 AM |

    All of my questions settled—tanhks!

  • Destry

    7/10/2011 4:45:06 AM |

    Check that off the list of things I was counfsed about.

  • Tori

    7/10/2011 2:25:06 PM |

    Great comomn sense here. Wish IÂ’d thought of that.

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  • Datherine

    7/11/2011 4:17:53 PM |

    AFAICT you've covreed all the bases with this answer!