Nutrisi pada

Infertilitas
Fiastuti Witjaksono
Department of Nutrition Faculty of Medicines Universitas Indonesia/
Cipto Mangunkusumo Hospital
Kasus
• Ny M 31 tahun G0P0A0, sudah menikah selama 3 tahun, menstruasi
tidak teratur, dikonsulkan oleh dr SpOG dengan diagnosis infertility ec
PCOS dan obesitas
• Dikonsul untuk pengaturan pola makan dan penurunan berat badan
• Ny M merasa BB nya naik terus, sudah mengurang makan nasi, tapi
karena seing merasa lapar, os banyak mengonsumsi makanan kecil
seperti gorengan ditambah minum kopi 3 in 1. Jarang makan sayur
dan buah.
Nutrition and Female Fertility
MAJOR LIFESTYLE FACTORS NUTRITIONAL DISORDERS
• Age • Malnutrition
• Smoking, coffee, alcohol • Overweight and obesity
• Stress
• Nutrition
• Environmental pollutant

NUTRITIONAL RELATED DISEASES OTHERS:

• Obesity and anovulation Celiac Disease
• PCOS
• Syndrome Metabolic

Erica Silvestris, Domenica Lovero and Raffaele Palmirotta. Nutrition and Female Fertility: An Interdependent.
Correlation . REVIEW published: 07 June 2019
Juan Sebastian LASA, Ignacio ZUBIAURRE and Luis Oscar SOIFER. RISK OF INFERTILITY IN PATIENTS WITH CELIAC
DISEASE: a meta-analysis of observational studies. Arq Gastroenterol v. 51 no. 2 - abr./jun. 2014
PCOS: Sign and Symptom
Obese
(50%)

Insulin
Hirsutsim
Recistance
(70%)
(70%)

Hyper- Oligo
androgen anovulasi
(70%) (70%)
Bagaimana status nutrisi ?
• BB : 69 kg
• TB : 155cm
• IMT : 28,72
• LP : 92 cm
• Pemeriksaan komposisi tubuh (bila ada)
Klasifikasi Overweight and Obesitas berdasarkan Indeks Massa
Tubuh dan Lingkar Pinggang
Risiko penyakit penyerta
Klasifikasi BMI (kg/m2) Lingkar pinggang
< 90 cm (Pria) ≥ 90 cm (pria)

< 80 cm (wanita) ≥ 80 cm (wanita)

Berat badan kurang < 18.5 Rendah (peningkatan Rata2
risiko penyakit lain)

Normal 18.5 – 22.9 Rata2 Meningkat

Berat badan lebih ≥ 23.0
- Risiko 23.0 – 24.9 Meningkat

- Obes I 25.0 – 29.9 Sedang Berat

- Obese II ≥ 30.0 Berat Sangat berat

PCOS/SOPK dan Obesitas
• 38-88% wanita dengan SOPK adalah
overweight dan obes
• Peningkatan berat badan umumnya terjadi
pada saat dimulainya gejala
oligomenorhea dan hiperandrogen

• Alvarez-Blasco F, Botella-Carretero JI, San Milla JL, Escobar-

Morreale HF. Prevalence and char- acteristics of the polycystic
ovary syndrome in overweight and obese women. Arch Intern
Med 2006; 23:2081-2086.
• Pasquali R. Obesity, fat distribution and infertility. Maturitas
2006; 54:363-371.

Richard S. Legro MD. Obesity and PCOS: Implications for Diagnosis and Treatment.
Semin Reprod Med 2012;30:496–506
 PROPORSI BERAT BADAN LEBIH
DAN OBESE PADA DEWASA >18 TAHUN, 2007-2018

Berat badan lebih (overweight) Obese

13,6 21,8
11,5
14,8
8,6
10,5

2007 2013 2018 2007 2013 2018

Indikator berat badan lebih dewasa yaitu IMT ≥25,0 s/d <27,0 Indikator berat badan lebih dewasa yaitu IMT ≥ 27,0

11
PROPORSI OBESITAS SENTRAL
PROPORSI PADA
BERAT DEWASA
BADAN LEBIH≥15 TAHUN, 2018
DAN OBESE PADADI INDONESIA
DEWASA >18 TAHUN, 2007-2018 DI
INDONESIA
2007 2013 2018
Berat badan lebih (overweight) Obese
31,0
13,6 21,8
26,6
11,5
14,8
8,6 18,8
10,5

2007 2013 2018 2007 2013 2018

2007 2013 2018
Indikator berat badan lebih dewasa yaitu IMT ≥25,0 s/d <27,0 Indikator berat badan lebih dewasa yaitu IMT ≥ 27,0
Indikator lingkar perut wanita yaitu ≥ 80 cm; dan pria yaitu ≥ 90 cm
1 diantara 3 orang Indonesia menderita kelebihan berat badan dan obesitas

RISET KESEHATAN DASAR 2018

RISET KESEHATAN DASAR 2018 512
 Kriteria kelebihan lemak

Massa lemak normal

Wanita 20 – 35%
Pria 12 – 22%
Bagaimana pola asupan pasien?
• Os makan besar 2 kali sehari, nasi hanya 1 kali perhari, lauk selalu digoreng,
seringnya ayam goreng, susis, makan ikan jarang
• Os suka sekali makan mie, spageti, dan berbagai makanan siap saji
• Os lebih sering membeli makanan dari pada memasak sendiri
• Os juga suka snak, terutama snak manis spt cake, kue coklat, tiramisu
• Minum kopi sehari 2-3x, kadang2 kopi 3 in 1
• Minum soft drink kadang2
• Os kurang makan sayur dan buah, biasanya hanya 1-2 kali perhari
• Asupan pasien sekitar 2100 kalori perhari, protein 30 gram, lemak 90 gram,
sebagian besar lemak jenuh, karbohidrat refined dan gula
Sugar Consumption
• USDA Report (2009) : sugar consumption of Indonesian people is 15,6
kg per cap/year or 43 g per cap/d (9.4 % energi of 2000 kkal)
• USDA Report (2016) : sugar consumption of Indonesian people is
11,47 kg per cap/year or 32 g per cap/d (6.4 % energi of 2000 kkal)

PUGS Recommendation: 5% of total calorie

 .
Rata2 asupan lemak jenuh dan lemak tidak jenuh di 40 negara
Rajwinder K. Harikaa Ans Eilandera Marjan Alssemaa Saskia J.M. Osendarpc Peter L. Zock. Intake of Fatty Acids in General Populations Worldwide Does Not Meet
Dietary Recommendations to Prevent Coronary Heart Disease: A Systematic Review of Data from 40 Countries
 Consumption of total fat and saturated fat

Hardinsyah, Analisis komsumsi lemak, gula dan garam penduduk Indonesia, Gizi Indon 2011
• Pedoman Umum Gizi Seimbang (PUGS) Indonesia recommend to consume fat
less than 25 % of total calories (2000 kal-56 g)
• Consumption of saturated fat of WHO recommendation is less than 10%
Riskesdas,2013
Terapi nutrisi pada SOPK
Perbaikan sensitifitas insulin
• Penurunan berat badan pada pasien obes
• Hindari makanan tinggi gula atau karbohidrat simplex
• Tingkatkan asupan serat
• Tingkatkan asupan makanan dengan indeks glisemik rendah
• Tingkatkan asupan lemak baik seperti lemak omega 3 dan cukupi
asupan protein
Pilihan Terapi obesitas pada berbagai level IMT pada populasi Asia
Diet Activity Drug VLCD Surgery
BMI 23-25 kg/m2:
No additional risk Ö Ö X
Increased WC† Ö Ö X
DM/CHD/HT/HL* Ö Ö Ö

BMI 25-30 kg/m2:

No additional risk Ö Ö Ö (consider)
Increased WC Ö Ö Ö (consider)
DM/CHD/HT/HL Ö Ö Ö
BMI > 30 kg/m2:
No additional risk Ö Ö Ö(consider) Ö(consider Ö (consider
Increased WC Ö Ö Ö Ö in severely Ö in severely
DM/CHD/HT/HL Ö (intensive) Ö (intensive) Ö Ö obese) Ö obese)

KEY : DM: Type 2 diabetes CHD: coronary heart disease HT: hypertension HL: hyperlipidaemia
Ö = yes X = no
† Waist circumference > 90 cm (men). > 80 cm (women)
* Specific therapies relating to the risk factor or condition (DM. CHD. HT, HL) may be necessary
NOTE: if two or more diseases present eg. hypertension, then an anti-obesity drug may be used.

Inoue & Zimmet, 2000, ʻThe Asia-Pacific Perspective: Redefining Obesity and Its Treatmentʼ
Keseimbangan energi
Keseimbangan energi
 Tata Laksana Energi- Konten energi
0
Starvation

Very low-calorie -5 Weekly Biweekly

behavior therapy behavior therapy
Diets (VLCD)
Low-calorie diet (1200 kcal/d)
Intake < 800 kcal -10 Very-low-calorie diet (420 kcal/d)

Weight Loss (kg)

Low-calorie Diets
-15
Intake 800-1200 kcal
-20
Moderate energy
deficit Diets -25
Intake ≥1200 kcal 0 26 52 78
Time (wk)
Wadden et al. J Consult Clin Psychol 1994;62:165.

LCDs are recommended for weight loss in overweight and obese persons (Evidence category A)
VLCDs produce greater initial weight loss than LCDs. However longterm (>1 year) weight loss is not different with the
LCDs. (Evidens category A)

Inoue & Zimmet, 2000, ʻThe Asia-Pacific Perspective: Redefining Obesity and Its Treatmentʼ
Perbandingan Efek Berbagai Jenis Diet
(Marion J Franz, 2007)
• Partisipan yang menerima intervensi diet
saja memiliki rata-rata penurunan berat
badan 4.9 kg dalam 6 bulan dan 4,4-3 kg
pada bulan ke 12, 24 dan 48
• Penambahan olahraga terhadap intervensi
diet akan menyebabkan rata-rata
penurunan berat badan 7,9 kg pada 6
bulan, plateu pada bulan ke 12 dan
penurunan sebesar 3,9 kg pada bulan ke 36
dan 48
• Diet dengan energi sangat rendah akan
menyebabkan penurunan berat badan
sebanyak 17.9 kg pada 6 bulan diikuti
peningkatan kembali sehingga rata-rata
penurunan pada 12 bulan adalah 10,6 kg
• Olahraga tanpa intervensi diet tidak efektif
dalam menurunkan berat badan dengan
rata-rata penurunan sebesar 2.4 kg
 Effects of lifestyle modification in polycystic ovary syndrome compared to
metformin only or metformin addition: A systematic review and meta-analysis
• Polycystic ovary syndrome (PCOS) is a common disease that has an effect on
approximately 10% of women of childbearing age. Although there is evidence
regarding the role of lifestyle factors in the development of PCOS, the exact etiology
remains unclear. Additionally, metformin is used in the treatment of PCOS but its
role remains unclear. We compared the effects of lifestyle modification (LSM) +
metformin and metformin alone on PCOS. We performed a systematic review by
searching electronic databases for publications until December 2019. The primary
endpoints were clinical outcomes, such as menstrual cycles and pregnancy rates,
and the secondary endpoints were anthropometric, metabolic, and androgenic
parameters. The meta-analysis revealed that there was no significant difference in
the improvements in the menstrual cycles between LSM and metformin alone
(weighted mean difference [MD] = 1.62) and between LSM + metformin and LSM
(MD = 1.20). The pregnancy rates and body mass indices were not significantly
different between LSM and metformin alone (MD = 1.44 and −0.11, respectively).
LSM reduced insulin resistance (MD = −0.52) and increased serum levels of sex
hormone-binding globulins (MD = 8.27) compared with metformin. Therefore, we
suggest recommending lifestyle modifications actively to women with PCOS if they
do not have indications for metformin.
Chan Hee Kim 1, Seung Joo chon2 & Seon Heui Le. Effects of lifestyle modification in polycystic ovary syndrome compared to
metformin only or metformin addition: A systematic review and meta-analysis. Scientific RepoRtS (2020) 10:7802
Recommended Nutrient Content of a Weight-Reducing Diet

8%-10% Saturated fatty

Protein acids
15%
<10% Polyunsaturated
Fat fatty acids
Carbohydrate
<30%
>55%
<15% Monounsaturated
fatty acids
Calories: 500-1000 kcal/d reduction
Cholesterol: <300 mg/d
Fiber: 20-30 g/d
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and
Obesity in Adults– The Evidence Report. Obes Res. 1998;6 (suppl 2).
Karbohidrat

• 50-60% dari kalori total

• Merupakan sumber tenaga
• Karbohidrat kompleks dan rendah indeks glisemik : beras merah, gandum,
buah2an dan sayuran
• Serat dianjurkan 14g/ 1000 kal/.hari
• Konsumsi buah dan sayur 5 porsi perhari
• Hindari gula sederhana dari minuman dan snak manis (Maksimal 4 sendok
makan perhari) dan karbohidrat yang diproses
presentasi dokter fiastuti final.ppt
Contoh Diet Tinggi Lemak

1 porsi Fast Food 1 porsi nasi padang

28 gr lemak 25-30 gr lemak
(41.2%) (37- 45%)

2 buah gorengan
18.8 gr lemak
(28.1 %)
 Indeks Glisemik

Postprandial glycemia following

(A) Slow absorption of starchy fiber-rich meals and
(B) Rapid absorption of refined, fiber-depleted CHO foods
31
 Effect of a low glycemic index compared with a conventional
healthy diet on polycystic ovary syndrome
• Background: Women with polycystic ovarian syndrome (PCOS) are intrinsically insulin resistant and have a high risk of
cardiovascular disease and type 2 diabetes. Weight loss improves risk factors, but the optimal diet composition is
unknown. Low-glycemic index (low-GI) diets are recommended without evidence of their clinical effectiveness.
• Objective: We compared changes in insulin sensitivity and clinical outcomes after similar weight losses after
consumption of a low-GI diet compared with a conventional healthy diet in women with PCOS.
• Design: We assigned overweight and obese premenopausal women with PCOS (n = 96) to consume either an ad
libitum low-GI diet or a macronutrient-matched healthy diet and followed the women for 12 mo or until they achieved
a 7% weight loss. We compared changes in whole-body insulin sensitivity, which we assessed using the insulin
sensitivity index derived from the oral-glucose-tolerance test (ISI(OGTT)); glucose tolerance; body composition; plasma
lipids; reproductive hormones; health-related quality of life; and menstrual cycle regularity.
• Results: The attrition rate was high in both groups (49%). Among completers, ISI(OGTT) improved more with the low-GI
diet than with the conventional healthy diet (mean +/- SEM: 2.2 +/- 0.7 compared with 0.7 +/- 0.6, respectively; P =
0.03). There was a significant diet-metformin interaction (P = 0.048), with greater improvement in ISI(OGTT) among
women prescribed both metformin and the low-GI diet. Compared with women who consumed the conventional
healthy diet, more women who consumed the low-GI diet showed improved menstrual cyclicity (95% compared with
63%, respectively; P = 0.03). Among the biochemical measures, only serum fibrinogen concentrations showed
significant differences between diets (P < 0.05).
• Conclusion: To the best of our knowledge, this study provides the first objective evidence to justify the use of low-GI
diets in the management of PCOS.

Kate A Marsh 1, Katharine S Steinbeck, Fiona S Atkinson, Peter Petocz, Jennie C Brand-Miller. Effect of a low glycemic index
compared with a conventional healthy diet on polycystic ovary syndrome. Am J Clin Nutr . 2010 Jul;92(1):83-92
Omega-3
n-3
 Effectiveness of Omega-3 fatty acid for polycystic ovary syndrome: a
systematic review and meta-analysis
• Objective: To assess the effectiveness and safety of omega-3 fatty acid for patients with PCOS.
• Methods: In this meta-analysis, data from randomized controlled trials were obtained to assess
the effects of omega-3 fatty acid versus placebo or western medicine in women with PCOS. The
study’s registration number is CRD42017065859. The primary outcomes included the change of
homeostatic model assessment (HOMA) of insulin resistance, total cholesterol (TC), triglyceride
(TG) and adiponectin.
• Result: Nine trials involving 591 patients were included. Comparing with the control group,
omega-3 fatty acid may improve HOMA index (WMD -0.80; 95% CI -0.89, − 0.71; P < 0,00001
decrease TC and TG level [TC: (WMD -9.43; 95% CI -11.90, − 6.95; P<0,00001: (WMD -29.21; 95%
CI -48.08, − 10.34; P = 0. 002)], and increase adiponectin level (WMD 1.34; 95% CI 0.51, 2.17; P =
0. 002).
• Conclusion: Based on current evidence, omega-3 fatty acid may be recommended for the
treatment of PCOS with insulin resistance as well as high TC (especially LDL-C)

Kailin Yang1†, Liuting Zeng1†, Tingting Bao2 and Jinwen Ge. Effectiveness of Omega-3 fatty acid for polycystic
ovary syndrome: a systematic review and meta-analysis. Reproductive Biology and Endocrinology (2018)
Kailin Yang1†, Liuting Zeng1†, Tingting Bao2 and Jinwen Ge. Effectiveness of Omega-3 fatty acid for polycystic ovary
syndrome: a systematic review and meta-analysis. Reproductive Biology and Endocrinology (2018)
 Effect of omega-3 fatty acids supplementation on testosterone levels in
women with polycystic ovary syndrome: Meta-analysis of randomized
controlled trials
• Background: Scientific literature has shown evidence that omega-3 polyunsaturated fatty acids (PUFA) have
anti-androgenic action, and for this reason could be useful as an adjuvant in hyperandrogenism conditions
including polycystic ovarian syndrome (PCOS). However, the possible effect of eicosapentaenoic acid (EPA)
and docosahexaenoic acid (DHA) supplementation on testosterone concentration still remains
undetermined. Therefore, we performed a meta-analysis to investigate effects of EPA/DHA supplements on
testosterone hormone in PCOS women. Methods: Randomized controlled trials (RCTs) published until end
May 2015 were searched through a comprehensive search of the PubMed and Scopus electronic databases.
Included RCTs evaluated omega-3 fatty acids supplements compared with control in patients with PCOS and
reported circulatory androgens. The meta-analysis quality assessment was conducted by the Jadad scoring
criteria. Results: Four RCTs were analyzed in this meta-analysis. The dose range for EPA and DHA was 0.9-3.6.
Follow-up ranged from 6 to 8 weeks. Meta-analysis on testosterone levels revealed a significant lowering
effect (weighted mean difference - 0.264; 95% confidence interval = −0.39, 0.14; p < 0.001) of omega-3 fatty
acids for PCOS subjects. Conclusion: The results of our study revealed benefits on total testosterone with the
use of omega-3 PUFA supplements on PCOS patients. Further, high-quality RCTs are required to definitively
draw a causal interpretation of our finding.

Neda Forouhia , Sakineh Shab-Bidarb , Kurosh Djafarian. Effect of omega-3 fatty acids supplementation on testosterone levels
in women with polycystic ovary syndrome: Meta-analysis of randomized controlled trials. JNSD 2015; Vol.1, No. 3: 165-170
Effect of omega-3 fatty acids supplementation on testosterone levels in women with
polycystic ovary syndrome: Meta-analysis of randomized controlled trials
Neda Forouhia, Sakineh Shab-Bidarb, Kurosh Djafarian. J Nutr Sci & Diet 2015; 1(3): 165-70.

The dose range for EPA and DHA was 0.9-3.6. Follow-up ranged from 6 to 8 weeks
Aktifitas fisik
• Os bekerja dikantor sebagai programmer dari pagi sampai sore,
kadang2 lembur
• Berolah raga hanya 1 bulan 1 kali
Olahraga
• Olahraga secara regular selama 150 menit / minggu, dengan
minimal 90 menit aktivitas aerobik dengan intensitas sedang.
Kombinasi terapi nutrisi dan aktifitas fisik
Weight maintenance can be achieved with Physical activity help preserve
either programmed or lifestyle activity fat free mass during weight loss

*P<0.05
Treatment
Maintenance Phase 35 Men
Phase
Women
0 30
Diet + programmed activity 25
-2

Loss of Fat-Free Mass

(% Total Weight Loss)
Diet + lifestyle activity
Weight Change (kg)

20
-4
15
-6
10
-8 P=0.06 5
0
-10 Diet Only Diet Plus
0 8 16 28 36 44 52 60 68
Physical Activity
Time (months)

Andersen et al. JAMA 1999;281:335. Ballor and Poehlman. Int J Obes Relat Metab Disord 1994;18:35.
Kesimpulan
Nutrisi untuk sindroma ovarium polikistik
• Pilih karbohidrat kompleks, hindari gula dan karbohidrat simpleks
(refined)
• Pilih lemak sehat (MUFA, PUFA, Omega-3)hindari lemak jenuh dan
lemak trans
• Cukupi protein tanpa lemak
• Cukupi sayur dan buah agar vitamin dan mineral tercukupi
Cukup altifitas fisik/olah raga
Terima kasih
atas
perhatiannya

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