2. Give it TIME
Preconception care involves making sure there is an adequate supply of all those factors which are essential to your sperm and ova and to the development of a baby, and as much as possible, an absence of those things which have been shown to be harmful. Sperm take up to 116 days to form, and ova are susceptible to damage during their period of maturation which is around 100 days before ovulation (1).
Therefore, both you and your partner need to enjoy a period of pretty solid health which spans a period of at least four months immediately preceding any attempt to conceive. Yes, I know, you don't wanna wait that long! But trust me, it's worth it.
To be honest, 1 to 2 YEARS is optimal, but 4 months is the minimum. The more time you can give yourselves to prepare, the less stressful it can be to implement some of the health behaviours that are conducive to a healthy conception, pregnancy, birth and beyond, as well as treat any pre-existing conditions that might affect your fertility.
Oh and in case the plural pronouns I've used so far weren't any hint, it takes two to tango - the male is important here, too! More about the guys in a bit.
3. EAT ALL THE MACROS - AND EAT ENOUGH
Also, all the macronutrients i.e. carbs, fat AND protein are important. Diets that restrict or eliminate any one of these will not best support your fertility goals. So eat ALL the macros! Let's start with the importance of getting enough food overall...
Some women under eat because they're ridiculously busy with work, family, or study and do not, or cannot, prioritise meals. Some under eat because they have issues with food security and literally cannot afford enough food. Others under eat because they're trapped in the diet cycle and/or have some form of disordered eating patterns (diagnosed or not). Others still may not consider that they're "weight loss dieting" but are eating clean, paleo, or low carb and they're going too hard - which isn't hard to do on these innately restrictive diets. And some people are over exercising, or just not eating enough to meet their activity requirements.
Whatever your reason is for under eating, there is a price to pay for under nourishing your body in both the short and long term.
Besides the short term effects of low blood sugar levels (fatigue, headaches, brain fog, dizziness, and moodiness), a long term caloric deficit wreaks havoc with your HPA (Hypothalamic-Pituitary-Adrenal) axis, i.e. it burns your adrenals to a crisp and can lead to long term adrenal fatigue. It increases your risk of hypothyroidism, which only worsens the fatigue picture. It can disrupt your menstrual cycle (in women) and reduce fertility (men and women).
If you're in an energy deficit before falling pregnant and when you conceive, it's going to be harder to have a healthy pregnancy and postpartum period. Ditto if you undereat whilst pregnant, which is sadly all too common in this day and age. Humans are a resilient lot, and babies will grow under some amazingly harsh conditions - cocaine addicted mothers, alcoholics, and malnutrition for instance. But whilst babies may survive this, the mother will invariably suffer.
"No diet will remove all the fat from your body because the brain is entirely fat. Without a brain, you might look good, but all you could do is run for public office."
- George Bernard Shaw
But fat is critical for reproductive health! We need fat to make hormones, build our tissues, enhance metabolism, direct nutrients into the nervous system and keep ourselves warm. Vegetarians often find themselves getting the majority of their fats from nuts and nut butters which are oh-so-convenient and snacky-yummy, but not conducive to helping you get the right ratio of omega-6 to omega-3 fats.
All natural fats have a role to play in our health, and what matters in the end is proper balance. A ratio of 2:1 omega-6 to omega-3 fats is a good goal, and we can get closer to this by increasing our intake of dark green leafy veggies, walnuts, flaxseed, sustainably caught oily fish and whole free range eggs.
Hundreds of studies have shown the health benefits of increasing your intake of omega-3 fats while also decreasing (but not necessarily eliminating to the point of unhealthy obsession) trans-fats, omega-6 fats, and highly refined carbohydrates. You can read more details about the importance of fats, here.
When sugar and insulin levels are normalised and your diet has the right balance of omega-3 and omega-6 fats and micronutrients from whole foods, then there’s no need to worry about the impact of dietary fat intake on overall health.
Interestingly, studies have shown that full-fat dairy is very supportive for fertility, as opposed to low-fat dairy foods which may increase the risk of anovulatory infertility (2). Whilst not everyone can tolerate dairy, if you can do so then swap your low fat dairy foods for full fat yoghurt, for example. The great thing about yoghurt, labneh, kefir and other fermented foods is that you also get the health benefits of the probiotics in them!
Nowadays we're subject to an overt societal carbophobia which is heightened in paleo, keto, weight loss dieting, and some sports (e.g. crossfit, body building) circles. Some people are afraid to eat more than half a banana a day "because of the sugar", or think that broccoli is a good main carbohydrate source!
Just to clarify: BROCCOLI IS NOT A GOOD CARBOHYDRATE SOURCE.
I recommend you eat adequate amounts of nutrient dense complex carbohydrates to keep your energy levels constant as well as provide important micronutrients - try sweet potatoes, brown rice, white rice, quinoa, corn, any of the amazing ancient grains, potatoes, bananas, and the like, along with plenty of good fats and protein.
Follow your body's cues of hunger and fullness to work out which forms and amounts of carbohydrates work best for you. You might find for instance, if you're very active, that carbohydrates make up around 50% of your total energy intake. Or your body may prefer to hover around a lower carbohydrate intake of 30% - just make sure you're listening to your body and not some preordained macro ratio from some diet.
Carbohydrates are hell important, and cutting them out before, during, or after you've had a baby (a la Beyonce or Kim Kardashian) is not conducive to healthy pregnancy and breastfeeding. Cutting them out in general is not a good idea, either.
You need an average-sized serving of protein-providing foods at least twice a day. Both excessively high protein diets (hello, extreme paleo people) and protein deficient diets (talking to you, devout raw vegans) are BOTH going to create problems, so you need to get enough without going overboard on daily bacon and egg breakfasts, or (highly protein-deficient) juice fasts lasting days or weeks (or months - it happens).
Protein needs to be balanced with plenty of colourful, antioxidant-rich vegetables and fruit, and healthy fats like extra virgin olive oil. Meat, fish, seafood, eggs full fat dairy, nuts, and legumes are all sources of protein. Go for the best quality you can find, and can afford.
If you're not confident about your ability to get the right balance of all these goodies and are hell bent on improving your fertility (which I hope you are), come see me or another dietitian who can guide you!
4. ADDRESS MICRONUTRIENT DEFICIENCIES
So often people focus on the very trendy macro ratios... and don't give a toss about everything else they need to be getting in their food. That means, the vitamins, minerals, coenzymes, and other little things that are crucial for setting you up for a healthy pregnancy and beyond.
For a dietitian, I'm very liberal when it comes to food rules and strict eating regimes. I'm all about the non-diet approach, believe there is room for "sometimes" foods (my vice is hot chips and tim tams), and will take intuitive and mindful eating, over the latest fad diet, any day.
That said, in the few months you put aside for pregnancy you can afford to be a little more mindful, as long as it doesn't put additional stress on you. Basically, focus on eating MORE of the things that contain all those valuable vitamins and minerals - the colourful produce, whole foods, and nutrient-dense stuff.
This doesn't mean you can never enjoy a chocolate biscuit (hell no!), as long as you're getting plenty of the nutrient-dense goods from your food, most of the time.
You can run a specific micronutrient panel to give you insight into your nutrient and antioxidant status, but your typical GP blood test can pick up valuable stuff too: iron, zinc, vitamin D, cardiac labs (e.g. cholesterol, which plays a huge role in fertility as it's needed to make hormones). If cholesterol is too low it can be hard to make the hormones needed to conceive and carry through a pregnancy. If it's seemingly too high, this can point to other conversion issues.
Below I'll cover just a few of the important micronutrients to consider. This is by no means exhaustive, but it might guide you towards a more nutrient-dense focus.
Vitamin A deficiency is really common and can be a factor in infertility. Some people can have problems converting beta-carotene to vitamin A, which has a crucial role in reproductive hormone production. Vitamin A is vital for progesterone synthesis, and has a variety of anti-oestrogen functions. Vitamin A is also an antioxidant so it is pretty crucial for detoxification. It keeps the cilia of the Fallopian tubes healthy, and is essential for testicular health and sperm production.
One of my favourite natural sources of vitamin A is liver (see a cracking recipe for liver pâté, here), which doesn't present the same risks for overdose that supplemental vitamin A can pose. I much prefer women to get their vitamin A from food sources rather than supplements.
Vitamin D status is mega important. Calcitriol (the active form of vitamin D) has a bunch of different roles in female reproduction: it controls the genes involved in making oestrogen; the uterine lining produces calcitriol in response to an embryo as it enters the uterus, before implantation. Low vitamin D is more common in the more extreme northern and southern latitudes and in darker-skinned individuals.
Studies suggest this deficiency in pregnant women worldwide ranges between 20-85% with rates of deficiency maxing out at 98% in some regions (3,4). That is a massive cause for concern, because vitamin D deficiency during pregnancy puts you at higher risk for pre-eclampsia, low birth weight babies, and gestational diabetes (5,6). Most prenatal vitamins only contain 400 to 600 IU of vitamin D, which simply isn’t enough to keep your levels normal without regular midday sun exposure. Get your GP to check if your levels are adequate.
Other important micronutrients are the B vitamins, vitamin C, vitamin E, and Coenzyme Q 10 which are all cofactors in many underlying metabolic pathways. Magnesium, iron, zinc, selenium, manganese, calcium, chromium, and iodine should all be considered important minerals when gearing up for a healthy conception and pregnancy.
If you’re trying to conceive, already pregnant, or lactating and you’re ever unsure about your nutritional requirements and how to reach them, please see a university qualified dietitian, nutritionist or naturopath for advice! Setting yourself up for a healthy conception and pregnancy is possibly one of the best reasons to see a nutrition professional. I mean, you're trying to create a new life, so why not give it a bloody good crack and give yourself and baby the best possible chance at health!
What about men?
Of course there are many other issues when it comes to nutrition for male fertility. It's a huge topic that's worthy of a lot of investigation! But generally, increasing antioxidants is a first crucial step most men can take to improve chances of their partner conceiving.
Do i need a Prenatal supplement?
Considering the nutrient deficiencies of many Australian soils, and the difficulty getting everything we need in general (because LIFE), I usually suggest that women take a prenatal multivitamin as well as doing their best to get what they can from real food. In the case of specific deficiencies, I might use a combination of food, supplements, and nutritive herbs.
As a rule, ALWAYS question your prenatal supplement! There are some really good ones on the market, and some really shitty quality ones. In many of the supermarket prenatals, the form, ratio and amounts of certain nutrients are just not sufficient or even pro-inflammatory and can cause more issues if they're not suited to you. Practitioner only is best.
A word about B12 and folate
In some cases, therapeutic supplementation may be necessary. For example, if tests show that your levels of folate and B12 are deficient, as well as some of the other cofactors in methylation (which the MTHFR mutation causes) and this doesn't really line up with your diet (say you're eating good sources of these foods and other factors can be ruled out), then there's a pretty good likelihood that you might have that mutation. If you have this mutation, taking regular folic acid in a prenatal can be problematic.
Folate is a very important nutrient for preventing neural tube defects. Folic acid has been added pretty aggressively to a variety of processed foods such as breads and cereals. You'll see folic acid in many over the counter prenatal supplements, whereas your professional lines will use a different form of folate.
Due to genetic reasons, some people can have trouble converting a synthetic folic acid to usable folate. This can lead to accumulation of non-converted folic acid which can turn down natural killer cell activity, promote inflammation and more. Research has shown that approximately 45% of the population have some compromised ability to convert folic acid.
As an alternative, methyl tetra-hydro folate (or 5-MTHF) is generally well tolerated by most people, and for this reason I strongly recommend a high quality, practitioner-prescribed prenatal supplement for all women planning to become pregnant.
It's a good idea to work with a practitioner to find a suitable prenatal for you because other nutrients may need special attention too. For example, for vitamin B12 you need to choose the most suitable or preferable form from 3 different available forms. Finding the right one for you is important because you can have adverse effects from having the wrong one. If a prenatal says cobalamin on it, see a practitioner and get something better.
In the last part of this fertility series I will cover the final three crucial factors to consider for preconception care. Coming soon!
(1) Naish F & Roberts J (2000), The natural way to better babies, Milsons Point, Random House Australia.
(2) Chavarro JE, Rich-Edwards JW, Rosner B, Willett WC (2007), A prospective study of dairy foods intake and anovulatory infertility, Hum Reprod, 22(5):1340-7.
(3) Bodnar, Lisa M et al. “High prevalence of vitamin D insufficiency in black and white pregnant women residing in the northern United States and their neonates.” The Journal of Nutrition 137.2 (2007): 447-452.
(4) Dawodu, Adekunle, and Reginald C Tsang. “Maternal vitamin D status: effect on milk vitamin D content and vitamin D status of breastfeeding infants.” Advances in Nutrition: An International Review Journal 3.3 (2012): 353-361.
(5) Wei, Shu-Qin et al. “Maternal vitamin D status and adverse pregnancy outcomes: a systematic review and meta-analysis.” The Journal of Maternal-Fetal & Neonatal Medicine 26.9 (2013): 889- 899.
(6) Aghajafari, Fariba et al. “Association between maternal serum 25-hydroxyvitamin D level and pregnancy and neonatal outcomes: systematic review and meta-analysis of observational studies.”BMJ: British Medical Journal 346 (2013).