Your TTC Strategy 1: Prepare to Be PregnantDeborah Metzger, MD
Why Prepare before a Pregnancy?
Most prospective parents take the process of procreation for granted as natural and practically automatic. The idea of consciously preparing for conception and pregnancy is a rather recent phenomenon, but well worth the effort.
Preconception care encompasses the health services provided to women and men of reproductive age in preparation for a future pregnancy. Preconception care provides a window of opportunity to optimize both partners’ health and identify any risks and take steps to reduce them.
Many of the recommendations included in preconception preparation can be done by the individual or in concert with a healthcare professional, including your own OB-GYN, or programs that specialize in this type of care.
Research has shown that every aspect of our reproduction is adversely affected in some way by our 21st century lifestyle and living conditions. The food you eat, the environment you live in, and the lifestyle you lead in the months before you conceive a child can have profound effects on the well being of your baby. Preconception healthcare can help prevent miscarriage, stillbirths, premature births, and congenital abnormalities, and can enhance fertility even with couples who have had difficulty conceiving on their own. In addition, preconception care can allow women to have a healthier pregnancy, recover more quickly after birth, and decrease your child’s risk for certain adult health problems.
Large numbers of studies with animals show that when either parent is deficient in one or a number of essential nutrients, the offspring will be miscarried or will suffer from a variety of malformations. These malformations, which in the past were believed to be genetic, can be manipulated in the lab by inducing a deficiency or deficiencies in one or more of the essential vitamins and minerals.
All this means there are many things you can do to improve your physical health and psychological readiness in the critical six- to 12-month period before conception.
What Factors Should We Consider to Prepare for Conception?
Anyone, really. But if you fit any of the descriptions below, you’re a good candidate.
- Normal healthy, fertile couples who want to do the best for their babies.
- Couples who have had difficulty conceiving, including couples with low sperm count or motility, ovulation problems, endometriosis, etc.
- Couples who have had one or more miscarriages.
- Couples with a personal history of birth defects, prematurity, low birth weight, stillbirth, or sudden infant death syndrome.
- Couples seeking treatment for infertility through in vitro fertilization, gamete intrafallopian transfer, or intrauterine insemination who want a healthy baby as well as an increase in their chance to conceive (success rates for advanced reproductive technologies are relatively low—25 percent per cycle at best).
- Older couples, including women over 40 years.
Protecting your fertility potential should really begin in your teens. Preconception preparation for both partners should begin six to 12 months prior to attempting to conceive.
You may be wondering why certain baby-friendly actions must be implemented in the months prior to conception. For one thing, the formation of sperm may take up to four months, so that any change in diet, lifestyle, or chemical exposure should allow at least that much time for them to have the greatest effect on conception and the health of the baby.
You must also take into account the amount of time required to realistically assess your health needs, to implement changes, adopt new habits, and have them become part of your lifestyle. The added bonus is that your future children will benefit from the healthy lifestyle they grow up with.
Three organizations have made significant contributions to defining what needs to be considered before conception. The US Centers for Disease Control and Prevention (CDC) recommendations include at least an 18-month time period between pregnancies, 400 mcg or more of folic acid a day, cessation of smoking, avoidance of alcohol, testing and treatment of sexually transmitted diseases, HIV testing, up-to-date immunizations, assessment of chronic conditions, avoidance of unsafe drugs during pregnancy, and achieving a healthy weight. The March of Dimes, the CDC, and 34 partner organizations are working together to educate health providers, women, and men about the importance of preconception risk reduction and healthcare .
Foresight, the Association for the Promotion of Preconception Care based in Surrey, England, has been the gold standard for preconception care in the UK since the 1970s. Starting six to 12 months prior to attempting to conceive, its client couples undergo a thorough health assessment that includes medical history, lifestyle, and assessment for allergies, nutritional imbalances, heavy metal loads, genitourinary infections, and intestinal parasites. Men are assessed for prostate infections and sperm count. The couples are advised to eat a diet of low glycemic, organic food. They are also counseled on fertility timing.
Preconception Care Checklist
Foresight’s results are impressive. The organization followed 367 couples between the ages of 22 and 45 years of age. At the end of the study, 89 percent had given birth. These results are impressive considering that 37 percent of the couples had a history of infertility, 38 percent had a previous miscarriage, 15 percent had had small-for-dates babies, and 70 percent had never been pregnant.
- Are you and your partner emotionally and financially ready for a baby? Does you health insurance cover pregnancy? Do you need a bigger place to live? How long can you afford to take maternity leave? Who will you be able to count on for help with childcare?
- Are there unresolved issues in your relationship? Now is a good time to get some counseling.
- If you have pets, how compatible will they be with a baby? Does your dog need obedience training?
- Stop smoking, drinking, caffeine, and recreational drugs. All of these are toxic to sperm and eggs.
- Both partners should schedule appointments for complete exams with their healthcare providers.
- Assess your level of exercise: Is it too much, too little, appropriate for pregnancy?
- Is your weight close to ideal? If not, plan a sensible weight loss regimen.
- Get a handle on stress. Simplify your life. Delegate. Avoid excesses in work hours, exercise, overfilled calendars, etc.
- Make sure vaccinations are up to date, including tetanus, rubella, chicken pox, hepatitis, and flu. If you are unsure whether you are immune you can take a simple blood test to measure antibodies.
- Have a dental checkup. Gum and dental disease can adversely affect your pregnancy.
- Get tested for hepatitis B and C, genitourinary infections, and HIV.
- Assess the status of chronic illnesses (diabetes, asthma, high blood pressure, epilepsy, thyroid problems, or chronic pain). Are they controlled as well as possible?
- Review your medications, supplements, and herbs with your healthcare provider and determine whether they are safe in pregnancy.
- Develop a plan for transitioning from birth control pills, IUD, or injected contraceptives to other types of contraception while you prepare.
- Review your diet. Remove refined foods, chemicals, and additives. Eat organic as much as possible. Three meals a day.
- Start taking prenatal vitamins, including folic acid, calcium, and omega-3 fatty acids.
- Avoid chemicals such as household cleaning agents, pesticides, herbicides, and work-related chemicals.
- Consider having an assessment for heavy metal, chemical exposures, allergies, and parasites.
- Determine whether you have other risk factors for infertility: DES exposure, abdominal or pelvic surgery, or past secually transmitted disease.
- Do you and your partner know your blood types?
- Assess your family history. Do you and your partner need genetic counseling?
- Do you have fertility factors that need to be addressed even before you attempt conception?
- Do you know how to determine the most fertile days of the month?
Not all couples seeking fertility assessment are ready to conceive immediately. Some just want to know for their own peace of mind that there are no obstacles to conceiving. Others, who have delayed childbearing, want to know if they still have enough eggs and sperm. While no method of testing is 100 percent accurate, there are many approaches from low tech to high tech that provide valuable information.
For both men and women it is important to assess risk factors that may interfere with conception. Potential problems for women include a history of cancer treatment, endometriosis, sexually transmitted infections, age, polycystic ovarian syndrome, smoking, early menopause, and prior abdominal or pelvic surgery. Men should be concerned about age, chemical exposure, heat exposure, prior cancer treatment, certain prescription medications, sexually transmitted infections, surgery on reproductive organs, varicocele, and smoking.
A woman’s menstrual patterns provide an indication of fertility potential. If periods occur regularly every 28 to 32 days, if ovulation predictor kits indicate ovulation, if there are some premenstrual symptoms, and if she experiences mild to moderate cramps it is quite likely that she is ovulating and producing an egg each month. The absence of these signs and shortening or lengthening of menstrual cycles may indicate a problem.
Over-the-counter fertility testing has recently become available. The male fertility test assesses the protein content of a semen sample to determine whether the sperm density is satisfactory. Other tests assess the sperm motility. For women, a test is available to measure follicle stimulating hormone (FSH), which gives an indication of the number of eggs in the ovary (ovarian reserve). The accuracy of the results from these tests are only as good as ability of the person to read directions and perform the tests properly.
These tests are performed by a health care provider and have a much better ability to predict fertility. Many of these tests are used to assess infertility, but they can just as easily be used by those contemplating pregnancy.
Semen analysis Semen analysis is probably the first test that is performed in men. This test determines the number of sperm and the proportion that are motile. If there are an inadequate number of sperm, additional testing may consist of an examination by an urologist, blood tests to measure hormones, chromosomal analysis, testicular biopsy, and tests to see if there are any blockages to sperm transport.
If the sperm are not moving well, you may be tested for the presence of anti-sperm antibodies, varicocele, or prostatitis. No single sperm feature can accurately predict fertilization or pregnancy potential so tests to predict whether the sperm are able to fertilize an egg are sometimes used and include a computer-assisted semen analysis, induced-acrosome reaction testing, sperm penetration assay using hamster eggs, and sperm-zona pellucida binding assays. The clinical usefulness of specialized sperm testing remains controversial.
Family Planning Boards
The most pressing issue in women is whether they have a sufficient number and quality of eggs in the ovary (ovarian reserve) to become pregnant. This is particularly important in women over 35, when fertility begins to decrease dramatically. Diminished ovarian reserve is usually age related and occurs due to the natural loss of eggs and decrease in the average quality of the eggs that remain. However, young women may have reduced ovarian reserve due to smoking, family history of premature menopause, prior ovarian surgery, or even if they have no known risk factors. Several tests are used to determine ovarian reserve.
FSH and estradiol testing Day three estradiol and FSH blood testing is the most common and easiest test to perform. The basis for the test is that as you approach menopause, your ovaries begin to respond poorly to FSH and LH. As a result, your body produces more of these hormones in an attempt to “jump start” egg development in your ovaries. High levels of FSH and/or estradiol indicate that your ovarian reserve is low, and that your chances of conception are poor, but still possible. However, normal levels of FSH do not guarantee conception. Although FSH and/or estradiol can fluctuate monthly, a single elevation is predictive of poor ovarian function.
Clomiphene citrate challenge test A variation of the day three FSH test is the clomiphene citrate challenge test (CCCT), which assesses a woman’s response to clomiphene citrate given on cycle days five through nine. Blood levels of FSH are obtained on days three and 10. Abnormally elevated blood levels of FSH on either cycle day three or cycle day 10 are associated with reduced spontaneous pregnancy rates.
Inhibin B Inhibin B is a relatively new blood test that may be more predictive of ovarian reserve. Because inhibin B is produced directly by ovarian follicles, the amount of inhibin B in your blood directly correlates to the number of eggs that you have in your ovaries, though standardized levels are still being determined. Low levels of inhibin B are associated with impaired ovulation, lower spontaneous pregnancy rates, increased risk of miscarriage, and decreased success with IVF. Women who would benefit from the test are over the age of 35, have unexplained infertility, have shown a poor response to fertility drugs, or have had a positive CCCT.
Ultrasound Transvaginal ultrasound may be performed in the early part of the menstrual cycle to count the number of small (2mm-10mm) follicles (cysts) in the ovary. The number of these follicles reflects the egg supply and chance of conceiving. A low ovarian volume and/or a low follicle count indicate a reduced chance of conceiving.
Unfortunately, even with a normal ovarian reserve test, older women may have difficulty achieving a pregnancy. Moreover, the results may vary from cycle to cycle. Any single abnormal test, however, generally indicates that fertility potential has diminished.
These tests only indicate fertility potential. Those with abnormal tests do get pregnant and those with normal tests may have difficulty conceiving. The true test of fertility potential is conceiving!