Investigating perceptions and usage of fertility supplements: a mixed methods analysis of a large online forum

TL;DR

This study explores how people using fertility treatments discuss supplements online, revealing common choices and a need for better guidance.

Contribution

The study provides new insights into patient attitudes and behaviors regarding fertility supplements through analysis of online forum discussions.

Findings

Commonly mentioned supplements include ubiquinone, vitamin D, and omega-3 fatty acids.

Many users seek advice or express concerns about supplement use and perceived effects.

There is a clear need for evidence-based guidance on supplement use in fertility treatments.

Abstract

This study aims to characterize assisted reproductive technology patients’ online discussions of fertility supplements to better understand how this audience uses supplements, their attitudes toward perceived effects of the supplement, and the topics patients sought advice on regarding supplements.

This study used mixed methods, sequential exploratory design. We extracted public posts from the Reddit forum, “r/IVF.” Posts about fertility supplements were categorized by the described use of supplements and perceived effect of the supplement. Posts in each qualitative category were then quantified, and post author characteristics were analyzed using descriptive statistics.

Three hundred sixty-nine posts were included in the analysis. Two hundred nine posts identified specific supplements, and the most frequently mentioned included ubiquinone, vitamin D, omega-3 fatty acids, dehydroepiandrosterone, and myo-inositol. Two hundred seventy-nine authors reported taking supplements; 9.3% reported a positive perceived effect, 12.9% reported a negative perceived effect, and 21.1% asked for advice regarding their supplements. In the remaining 90 posts, 10% of authors expressed concerns and 90% expressed interest in taking supplements. One hundred ninety-seven posts included the indication for using assisted reproductive technology, the most common being diminished ovarian reserve or male factor infertility.

Many patients are using supplements with the goal of increasing their chance of assisted reproductive technology success and are seeking guidance on their use online. Some frequently mentioned supplements have limited research and unknown efficacy. The extensive discourse about supplements observed in this study reflects a need for increased guidance and evidence-based medical advice on how patients may use supplements safely and appropriately.

The online version contains supplementary material available at 10.1007/s10815-025-03625-z.

Full text

Introduction

Since the inception of in vitro fertilization (IVF) in 1978 and the development of embryo freezing and Intracytoplasmic Sperm Injection (ICSI) in the 1990 s, the availability and effectiveness of treatment for male and female infertility have increased dramatically. The 2022 SARTCORS national summary reported approximately 43–52% live birth rate from IVF cycles started in 2022 [1]. The success rates of assisted reproductive technology (ART) vary based on patient prognostic factors [2]. Modifiable lifestyle risk factors for IVF failure are obesity, smoking, and alcohol use [3]. IVF patients and providers are searching for interventions that may improve the outcomes of their fertility treatment [4].

Dietary supplements are defined as any product labeled as such containing ingredients, typically micronutrients, intended to be taken by mouth [5]. Their popularity is growing in the USA, with over 40% of American adults taking dietary supplements [5]. The FDA warns consumers to beware of infertility supplements that make false or exaggerated health claims but does not proactively regulate these products so long as they do not claim to treat, cure, or prevent diseases. [6].

A burgeoning market for fertility supplements, marketed as supporting egg health, sperm health, or increasing the chance of pregnancy, is readily available in consumer marketplaces despite limited evidence to support their efficacy [7]. Lack of data makes it difficult for providers to determine clear guidelines regarding their use, leading to an absence of consensus in the field of reproductive medicine [4, 8]. The ASRM guidelines only recommend prenatal supplementation with folic acid during IVF treatment [9].

The objective of this study was to analyze the online discussion of fertility supplements by ART patients to identify supplements of high use and interest, characterize patient’s perceived experiences, and identify supplement discussion themes.

Materials and methods

Data source

Reddit is a worldwide online forum platform which allows its users to create discussion boards called a “subreddit” for any topic of interest. Several subreddits relating to infertility and ART were considered as data sources for this study. One titled “r/IVF” identifies itself as a “supportive and positive community to discuss your IVF journey” with the preface by its creator to “please be sensitive and kind.” This subreddit has high user volume by both women and men, with over 47,000 users as of August 15, 2024. The members who post in this forum consistently self-identify as patients undergoing ART treatments. Despite the title, users were not limited to those undergoing IVF—many discuss oocyte/embryo cryopreservation and intrauterine insemination (IUI). The forum was moderated based on a series of rules outlined in the forum guidelines, which prohibited the sale of medication and discouraged posts by self-identified experts in the field. These rules were beneficial to the study as it prevented posts promoting supplement products and discouraged posts by medical providers, respectively.

A preliminary search for the word “supplement” revealed a high volume of posts which mentioned fertility supplements. The researchers determined that the content of these posts provides a broad picture of patient experiences with fertility supplements during and in preparation for ART treatments. Authors freely express themselves within the forum rules, allowing the subreddit to serve as a window into their perspectives [10]. For these reasons the subreddit r/IVF (https://www.reddit.com/r/IVF/) was ultimately selected as the data source for this study.

Data collection and extraction

The Reddit application programming interface (API), which allows users to sort posts based on whether they contain an input “keyword.” A search within the r/IVF subreddit was conducted three times over the course of two months using the keyword “supplement.” The conjured posts were then sorted by “most recent” to avoid the filtering of posts based on low audience engagement. A search for posts on the r/IVF subreddit was conducted three times over the course of two months, and 449 posts published between April 10, 2024, and June 27, 2024, were found. The posts were extracted and organized using Excel. Comments on the post by other Reddit users were not included in our analysis.

The data collected were from posts published autonomously online by anonymous Reddit users. Obtaining formal consent by Reddit post authors for use by researchers is not possible. Based on the precedent of numerous published studies using Reddit posts for qualitative research with similar methods, this study was not reviewed by an IRB. The post authors’ usernames and any personal identifiers from their posts were not recorded during the study.

Qualitative data analysis

A mixed methods, sequential explanatory design was used to collect qualitative data of Reddit posts and then make sense of these findings using quantitative analysis [11]. Qualitative analysis was completed using a combined deductive and inductive approach. Two researchers began by analyzing a small, random subset of posts and identifying areas of interest and emerging themes. Preliminary inclusion and exclusion criteria were to include posts if their use of the word “supplement” was in reference to fertility supplements and to exclude duplicate posts and posts that used the word “supplement” in contexts unrelated to fertility. The preliminary codebook, including one code which established meeting inclusion criteria, included 9 codes.

During analysis, inclusion criteria were revised based on emerging understanding of the dataset to include over-the-counter medications used off-label for fertility purposes, and the exclusion criteria were updated to exclude posts that referred to prescribed IVF protocol medications (i.e., progesterone) or prescription medications (i.e., metformin) as “supplements.”

To establish interrater reliability, both researchers coded the first 50 posts and met to resolve discrepancies. The code was revised, and this process was repeated until the standard for acceptable reliability (> 80%) was met. All remaining posts were coded by researchers individually using an inductive approach, with researchers collaboratively developing further code based on emerging themes. As new code was added, the researchers returned to previously coded posts to complete analysis, with the final codebook containing 12 codes. The final data sets of both researchers were compared at the end of data coding for interrater reliability due to the addition of new codes. The researcher’s codes were found to have “excellent” (> 80%) agreement. All remaining disagreements were discussed and resolved.

Quantitative data analysis

Descriptive statistics were used for quantitative assessment of the number of applications of each code to a post via Excel. Named supplement mentions were quantified to identify which supplements were discussed most often. Named supplements in posts containing positive or negative mention of supplements and posts categorized as seeking advice related to supplements were quantified.

Results

Three hundred sixty-nine of 447 posts examined were included in analysis. Seventy-eight posts were excluded as they did not meet our inclusion criteria. Two hundred seventy-nine post authors, or 75.6%, stated that they were taking supplements, while 90 post authors (24.4%) were not taking supplements (Table 1). One hundred ninety-seven post authors (53.4%) had taken two or more different supplements, and 31 post authors (8.4%) stated that both they and their partner had taken supplements (Table 1). Table 1. Supplement usen(%)Post author or partner takingBoth partners taking27931(75.6)(8.4)Identified specific supplements209(56.6)Did not identify specific supplements160(43.4)Total posts369(100)

Of the 369 included posts, 209 posts identified specific supplements in their post (Table 1). The supplements most mentioned on the posts analyzed were ubiquinone (CoQ10), vitamin D, omega-3 fatty acids (omega 3), dehydroepiandrosterone (DHEA), and myo-inositol. All supplements with 5 or more mentions are reported in Table 2. Table 2. Supplements mentionedSupplements mentionedn(%)CoQ10119(32.2)Vitamin D83(22.5)Omega-359(16.0)Dehydroepiandrosterone (DHEA/DHEA-S)34(9.2)Myo-inositol34(9.2)Vitamin E27(7.3)Vitamin C25(6.8)Acai25(6.8)“It Starts with the Egg”25(6.8)NAD + 24(6.8)Melatonin22(6.0)Aspirin20(5.4)N-Acetylcysteine (NAC)17(4.6)Probiotics13(3.5)L-arginine12(3.3)Magnesium10(2.7)Vitamin B1210(2.7)Alpha-lipoic acid7(1.9)Iron7(1.9)Beet root6(1.6)Pineapple core/bromelain5(1.4)Pomegranate juice5(1.4)*All references to molecular and pharmacological formulations of the enzyme ubiquinoneAll references to molecular and pharmacological formulations of omega-3 fatty acid chain supplementsAll references to molecular and pharmacological forms of myo-inositol “It Starts With The Egg” represents a combination of supplements discussed and recommended in the book of the same title*****All molecular and pharmacological formulations of the enzyme nicotinamide adenine dinucleotide (NAD +)

The code used identified posts written by people who had taken supplements, their perception of the effect of supplements as positive or negative, and identified advice-seeking posts (Table S1). Ninety posts (24.4%) were written by authors who did not specifically state that they were taking supplements. Of those 90, 9 (2.4%) expressed concerns about supplement use, while 81 (21.9%) expressed interest in taking them or stated that fertility supplements had been recommended to them by friends, members of the subreddit, or providers (Table 3). Of the 279 authors who stated that they were taking supplements in their post, 26 (7.0%) reported a direct positive perceived effect of the supplements used and 36 (9.8%) reported a direct perceived negative effect of the supplements used (Table 3). Fifty-nine posts (16.0%) directly asked for advice about supplements (Table 3). Table 3. Post content**n*(%)Interested81(21.9)Concerns9(2.4)Neutral158(42.8)Positive experience26(7.0)Negative experience36(9.8)Seeking advice59(16.0)Total369(100)*For further information regarding the code by which post contents were categorized, please refer to Table S1: Code Used to Analyze Data Posts in the Supplementary Materials

The most mentioned supplements across all posts that named supplements were CoQ10 (32.2%), vitamin D (22.5%), omega-3 (16.0%), DHEA (9.2%), and myo-inositol (9.2%) (Table 2). Posts which described positive perceived outcome with supplements most frequently mentioned CoQ10 and vitamin D (Table S2). The most common positive outcomes cited were improved number or quality of embryos and improved sperm quality (Table 4). Interestingly, posts which described negative perceived outcomes with supplements also most frequently mentioned CoQ10 and vitamin D (Table S3). The most frequent negative experience was perceived lack of efficacy of the supplement, followed by menstrual irregularities and lab abnormalities (Table 5). Posts coded as seeking advice related to supplements most often cited CoQ10, omega-3, and vitamin D (Table S4). The most frequent advice themes were which supplements to add to existing regimens, followed by when to start and stop supplement use in relation to ART processes, such as stimulation cycles and oocyte retrievals (Table 6). Table 4. Positive themesPositive themesnExamples from postsMore/higher-quality embryos6“…from 6 embryos sent to testing 5 are Euploid… made sure I was on all the Supplements…”“…we got 6 embryos!!! All that we changed was added a high quality coq10 supplement…and added a high quality fish oil supplement.”Improved sperm analysis6“My husband’s counts were initially around 1 million, 3% normal morphology…as he took more supplements and better care of his diet…his counts would go up to about 10 million.”Achieving pregnancy5“…followed a strict regime of supplements like you—CoQ10, omega 3, DHEA, etc.…I had two embryos for transfer, one a 6BB and one a 6BC…6BC turned into the most perfect wonderful baby girl”Improved/increased oocyte retrieval4“Things I did differently that might help someone improve egg quality with PCOS: … took Ovasitol, CoQ10, NAC, Alpha Lipoic Acid, Fish Oil, Acai, Pine Bark Extract, Acetyl L-Carnitine, Vitamin C, D, E for 3–5 months. Last round I only did metformin and prenatal.”Improved AMH4“I know levels can fluctuate and supplements can increase them but can they triple????”Endometrial thickness1“We added some supplements and switched to a modified natural cycle, and it seems to have done the trick—I was at 7.2 mm today for the first time!”Improved adenomyosis1… I went in for my baseline today and suddenly my ovaries are inview… they normally have a super difficult time seeing anything because of my adenomyosis…I’ve also reached the 4 month mark for changing lifestyle/adding all the supplements.”Improved ovarian response1“I made huge lifestyle changes, got on all the supplements, etc. Everything seemed to be going much better. Had bigger response to stims, our hope was back.”Total28Table 5Negative themesNegative themesnExamples from postsLacking efficacy15“I’ve tried all the supplements for egg quality recommended. I know it takes 3 months for them to help but it hasn’t helped.”Menstrual irregularities5“My cycles are so messed up from the DHEA that it's doubtful I could conceive on my own. How can this be good for egg health?”Lab abnormalities5“DHEA supplementation caused my DHEA-S and total testosterone levels to skyrocket”Side effects (e.g., acne, night sweats, and vaginal odor)3“The days I’ve taken [CoQ10], I’ve had horrible night sweats to the point I’m waking up drenched. I did a mini experiment and stopped taking for 4 days which made them stop.”Cost3“My acupuncturist recommended I add two supplements to my already long list. They are EXPENSIVE and it feels iffy.”Less embryos3“We tried all the things this go around to improve quality (supplements, acupuncture, exercise, decrease alcohol/caffeine intake) and our results were worse!”Scam1“The labeling on the package has the brand name misspelled. And critic websites list it as one of the supplements that may be fraudulent.”Pill burden1“Anyone else feel like they are constantly shoving pills down their throats?”Allergic reaction1“I have two mostly full bottles of Açaí capsules. Turned out I was allergic and so I couldn’t take them.”Total36Table 6Advice-related themesAdvice themesnExamples from postsAdd25“I have a good quality prenatal and take myo-inositol for my pcos. Should I add in Coq10?Start/stop22“I specifically asked [the doctor] about chaste and he said to keep taking… I looked it up and a couple sources say it’s not good to take it with stims due to OHSS…do I keep taking it?” General11“Any advice on supplements or otherwise anyone found helpful in their journey? I feel like a freshman onthe first day of school again!” Is there ANYTHING I should be considering doingdifferently? Probably a conversation that's that’s betterfor my doctor than the internet (lol) but time just keepsticking....“I just don’t understand how there can be so much conflicting info, and how every doctor has a completely different theory about these things.”“I’m desperate for any advice. I feel like my time is running out.”Brand4 ““My wife and I are considering this brand. Have been taking cheap ones sold by Costco but want to make sure we get quality supplements... Is this what everyone's” everyone’s been taking?Dosage2“I have been taking 100 mg of Coq-10 over the past year…Should I be upping my dose?”Total65

One hundred seventy-two posts (46.6%) did not identify the indication or reason for using ART; however, of the 197 posts (53.4%) which stated their reason for using ART or the cause(s) of infertility, the most common causes were diminished ovarian reserve (DOR) (13.0%), male factor infertility (MFI) (12.5%), and PCOS (9.0%) (Table 7). Table 7. Indications for ARTIndicationn(%)Diminished ovarian reserve (DOR)48(13.0)Male factor infertility (MFI)46(12.5)Polycystic ovary syndrome (PCOS)33(9.0)Advanced maternal age (AMA)29(7.9)Endometriosis/adenomyosis25(6.8)Unexplained infertility22(6.0)Tubal factor15(4.1)Thin endometrium8(2.2)Heritable conditions7(1.9)Thyroid disease6(1.6)History of miscarriage5(1.4)Low egg quality4(1.1)Amenorrhea3(0.8)Fertility preservation2(0.5)Structural uterine issues (i.e., scarring and septate)2(0.5)Cystic fibrosis1(0.3)Same-sex partner1(0.3)

Discussion

Mechanism of action of supplements and efficacy

The most common class of supplement mentioned was antioxidants. Oxidative stress has been hypothesized as a mechanism of oocyte aging, and antioxidants have been theorized to improve oocyte and sperm quality by scavenging reactive oxygen species (ROS) and preventing gamete damage by oxidative reactions [12, 13]. The most frequently mentioned supplement in this study was CoQ10, an antioxidant which occurs naturally in ovarian follicles [14]. The quantity of CoQ10 in the ovarian follicle diminishes with age and is believed to contribute to eventual depletion of ovarian reserve [14]. Randomized-controlled trials (RCTs) and other studies have been performed to assess the effectiveness of CoQ10 with promising results, such as increased number of retrieved oocytes, higher fertilization rates and more high-quality embryos [15, 16]. Importantly, CoQ10 has shown potential to increase clinical pregnancy rates but has not shown significant increase in live birth rates or decrease in miscarriage rates [17]. Similarly, an RCT of infertile men taking CoQ10 found improved sperm parameters [18]. However, antioxidants have not all been well studied in their ability to improve gamete quality or increase rates of successful ART outcomes. Acai berry has been recommended based on a study demonstrating an effect on oocyte aging in mice and an ongoing RCT in human subjects [19]. However, there are no complete human studies in our literature search demonstrating acai’s effect on ART treatment outcomes.

Other supplements theoretically improved endometrial thickness and receptivity through vasodilatory effects, increasing blood flow to the uterus [20]. The most common “supplements” with this desired effect were low-dose aspirin (LDA), followed by L-arginine [20, 21]. Beet root juice and other natural juices with vasodilatory effects have been studied as a supplement to IVF with positive results [22]. Brazil nuts are supplemented for their selenium content, which has a mild anticoagulative effect and may improve endometrial thickness [23, 24]. While these effects may be beneficial, combining vasoactive supplements may incur bleeding risk or otherwise be harmful [25, 26].

Anti-inflammatory medications such as prednisone are thought to decrease the immune response after embryo transfer or oocyte retrieval and have been recommended to improve endometrial receptivity [27]. Antihistamines, such as Benadryl, are taken off-label for this purpose by some patients [28]. Their use is controversial, as some studies have reflected that they may inhibit implantation and may also increase risk of subchorionic hematomas in the first trimester [28–30].

Researchers believe the vaginal microbiome may affect overall reproductive health [31]. Probiotics are being studied to target dysbiosis of the vaginal or endometrial flora, which may be detrimental to implantation in infertility patients; however, more data is needed to determine the impact of probiotics on ART outcomes [32]. Our study recorded 12 mentions of probiotics (Table 2), with 4 mentions associated with posts seeking advice (Table 6), suggesting that this is another area of study that would benefit patients.

Several underlying causes of infertility have been targeted by supplements. Myo-inositol has been studied as a supplement for patients with PCOS due to its insulin sensitizing effects [33]. DHEA, an androgen precursor necessary for ovarian stimulation and response, decreases with age and may be supplemented in patients with diminished ovarian reserve [34]. An association between vitamin D deficiency and infertility has been observed, particularly in patients with PCOS [35]. Vitamin D is required for calcium absorption, which is necessary for oocyte maturation [36]. The supplementation of vitamin D in deficient patients is often recommended by providers and the posts analyzed in this study frequently noted a perceived positive effect on labs and outcomes.

Combining supplements and risk for adverse events

More than half of the subjects in our study reported taking multiple supplements at once. There may be harmful interactions when combining supplements or taking them with medications. For example, vitamin E may increase the potency of LDA, which is sometimes taken to improve endometrial blood flow and support implantation [25, 37]. Many patients may be unaware of these risks, and the safety of the use of multiple supplements may be difficult to ascertain. The risk of adverse events from supplements can be difficult to trace given the retroactive regulation of these products [38]. Even food-based products that are generally considered safe pose risk for allergic reactions as described by one subject in this study allergic to acai (Table 5).

Patient-provider relationship

The proportion of post authors seeking advice on the IVF subreddit (16%) as well as the number of post authors interested in beginning fertility supplements (21.9%) highlights a need for guidance on their use. Many subjects had legitimate questions, and some described concern for inadvertent misuse of the supplements (Table 6). Several authors expressed dissatisfaction with the degree of knowledge and interest shown by their provider on the topic. Lack of proactivity on the part of providers to address supplement use may be damaging to the patient-provider relationship and lead patients to seek anecdotal advice online.

Patients were aware of the conflicting opinions among providers, and some appeared to be negatively impacted by the uncertainty (Table 6). The lack of literature and society guidelines available on many of these supplements may contribute to provider reluctance in providing recommendations on supplement use. Many supplements have limited studies investigating their efficacy, which leads some providers to recommend them while others are hesitant to do so without more robust studies.

A self-help book series It Starts With The Egg was written to provide patient-friendly information on supplements [39]. This book series was frequently cited in posts in the IVF subreddit, and many patients based their supplement use on the book’s supplement lists and contents. This shows that the development of standardized protocols and indications for supplementation are desired by patients. Discussing evidence-based literature and recommendations with patients may allow for joint decision-making while preserving trust in their providers.

Limitations

Due to the anonymity of Reddit users, demographic information could not be collected for the study. Therefore, the diversity of the population observed cannot be determined. It is possible the post authors represent a subset of IVF users that differ from the general population. Patients may be more inclined to post on the IVF subreddit if they have had lack of success in their fertility journey, are in an emotionally heightened state, or have a poor patient-provider relationship, all of which are a potential source of bias. Additionally, we could not verify whether a post’s author was a real patient, a bot, or a marketing employee posing as an ART patient.

One of the benefits of Reddit for social media analysis over other platforms is that it does not exclusively use an interest-based algorithm to sort posts like other social media websites. Despite this, Reddit policies may screen or hide posts based on author usership, relevance, popularity, and accordance with the subreddit guidelines, which could potentially affect the data in our study.

We examined post content with the goal to observe patient experiences with fertility supplements and identify areas where research is needed; however, we could not ask guided questions and therefore may not capture a complete picture of our subjects’ experiences. A survey or focus group is a future direction for validating our conclusions. Furthermore, despite excellent interrater agreement, the rater’s interpretations of post tone or attitude may not always reflect that intended by the author.

Finally, the claims about perceived effects of supplements on ART success by subjects are presumably anecdotal. The data in this study cannot be used to draw conclusions on the effectiveness or safety of named fertility supplements. Future studies should aim to objectively characterize the benefits and risks of supplement use by ART patients.

Conclusions

ART patients are taking a wide range of dietary supplements in hopes of increasing their chances of success. A lack of guidance by providers may lead patients to use supplements based on their community’s anecdotal experiences and recommendations. ART providers should be aware of the prevalence of supplement use and combination among their patients. This study highlights the need for the creation of evidence-based guidelines based on patient characteristics on highly studied supplements, and further research on commonly used, understudied fertility supplements such as NAD +, acai, vitamin E, vitamin C, L-arginine, and LDA.

Supplementary Information

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