Preconception Care Part 1: The holistic approach to healthy pregnancies and beyond

Dr. Bethany Mattson, ND

Preconception care is an essential component of reproductive healthcare but is often under-utilized in the primary care setting. A holistic and integrative approach to preconception care is comprehensive with an emphasis on patient education and optimizing foundations of health prior to pregnancy. The primary goal of preconception care is focused on risk-reduction. For the patient, preconception care can reduce the risk of developing gestational diabetes, gestational hypertension, preeclampsia, postpartum thyroiditis, anemia, and mood disorders such as postpartum depression during pregnancy, postpartum, and long-term health. 

For the fetus, preconception care reduces the risk of teratogenic exposures, neural tube defects, pre-term labor, and reduces their chance of developing future chronic health conditions such as heart disease, insulin resistance, obesity, and hypertension. Research has shown that maternal and paternal health status directly impacts future health of the fetus, so adequate preconception care is not only aimed at reducing pregnancy risks but also setting both parents and their children up for optimal long-term health outcomes. 

Initiating preconception care before actively trying to conceive allows for ample time to focus on key areas of health including gut and endocrine health, diet and nutrient intake, improving egg and sperm quality, and to work towards optimal hormonal balance. 

Optimizing preconception care timing:

The ideal time to start preconception care is at least 3-6 months before trying to conceive. For patients with chronic health conditions or with substantial pre-pregnancy health goals (including PCOS, thyroid imbalance, or weight loss goals), up to 12 months of preconception care may be ideal. It’s important to note that preconception care is essential for both male and female parents. It is known that sperm quality affects pregnancy rates and outcomes, but there is also a link between paternal health and future offspring health including neurological development, toxin exposure, and metabolic syndrome. 

For the male partner, preconception care can make an impact in as little as 2-3 months, which is the time that spermatogenesis takes (74 days). For females, more time is needed as folliculogenesis can take about 1 year to complete. However, follicle maturation increases as ovulation approaches, and improvements in egg quality can be seen in as little as 2-4 months. 

Another reason preconception care should be started early is to allow time for cycle tracking education and implementation to take place. Cycle tracking is a valuable tool that can help detect potential fertility issues before time is spent trying to conceive. Examples of what can be uncovered with cycle tracking include presence of anovulatory cycles, luteal phase defects, and suspicion of endocrine imbalances such as thyroid or adrenal health. For patients over age 35, this is especially important, as the window for trying to conceive before referral to a reproductive endocrinologist is shorted to 6 months, compared to 12 months for patients under 35.

Optimizing GI and endocrine systems:

A comprehensive gut health evaluation is a core component of naturopathic preconception care. Gut health is related to many aspects of preconception care and optimal fertility including facilitating nutrient absorption, toxin elimination, immune system regulation, neurotransmitter synthesis, and hormone regulation including thyroid hormone and estrogen metabolism. Additionally, adequate microbiome diversity impacts the microbiome of the fetus. 

Balancing the endocrine system including thyroid gland function is also a main priority. The gut-thyroid connection is strong and thyroid pathology, including autoimmune, is more commonly being treated with gut healing interventions. The microbiome regulates immune function through the gut-associated lymphatic tissue (GALT), and imbalances in gut health can interfere with immune regulation as well as nutrient absorption and in turn thyroid function. 

Thyroid imbalance can directly interfere with a healthy pregnancy, maternal health, and fetal health outcomes. Prior to pregnancy, significant thyroid imbalance including autoimmunity such as Hashimoto’s thyroiditis and Graves’ disease can contribute to infertility, miscarriage, and recurrent pregnancy loss. The presence of thyroid peroxidase (TPO) antibodies has been found to increase miscarriage risk by almost double compared to patients without antibodies. If a patient has an autoimmune thyroid condition prior to pregnancy, her risk of developing postpartum thyroiditis increases significantly within 1 year postpartum. This risk increase includes women with normal TSH levels but positive TPO antibodies. Finally, adequate thyroid hormone levels are required to prevent congenital hypothyroidism in the fetus, which can cause significant developmental delays and complications. 

Additional endocrine considerations include insulin resistance management and cortisol regulation. Presence of insulin resistance prior to pregnancy increases the risk of gestational diabetes significantly. In turn, gestational diabetes increases the risk of future progression to diabetes, so the optimal time to intervene is in the preconception period. 

Optimizing diet and nutrients

Diet and nutrition considerations are a core feature of preconception care. Priority should always be placed on finding the optimal diet for each patient, but in general, a Mediterranean style diet is ideal. The diet should also be high in fiber to facilitate proper nutrient assimilation and toxin elimination. Increasing plant food diversity is an important tool to help improve microbiome diversity and a goal of 30 different plant foods per week is often recommended. If known or suspected food sensitives are present, an elimination diet with subsequent reintroduction phase may be indicated. The goal of an elimination diet in the preconception period is to reduce inflammation, which may be contributing to intestinal permeability or other GI imbalances. 

Emphasis on proper vitamin, mineral, and nutrient intake should be placed in any preconception diet plan. Patient education is key to facilitate nutrient repletion prior to pregnancy. Key nutrients to prioritize include: 

• Iron
• Folate
• Choline
• Vitamin B12
• Vitamin D

*For more detail on optimal nutrients and metabolic markers, see part 2 of this blog series. 

Optimizing egg and sperm quality:

Focusing on optimizing egg and sperm quality in the preconception time is vital to support fertility and future health of the fetus. There are known factors that negatively impact both egg and sperm quality including alcohol, caffeine, drug use, and environmental toxin/heavy metal exposure. Caffeine should be limited to 200mg daily. Alcohol use should be limited to less than 4 drinks per week. Cannabis use has been found to negatively impact sperm quality and quantity and should be discontinued at least 3 months prior to conception. 

Reducing environmental toxin exposures is vital to preconception care. Toxins such as phthalates, parabens, PFAS, and heavy metals are known endocrine disruptors and can negatively impact fertility rates, sperm morphology, and can promote estrogen dominance. Additionally, heavy metals can accumulate and pass through the placenta, causing future health risks to the fetus. 

Some tips for patients to reduce environmental exposures include:

• Reducing plastic use and avoidance of heating plastic
• Avoid use of canned goods or plastics with BPA, phthalates, PFAS, or parabens  
• Use of a water filter that eliminates lead and other heavy metals 
• Limit use of nonstick cookware, choosing stainless steel or glass instead 
• Limit use of household cleaning products or skincare products with synthetic fragrances, parabens, methylisothiazolinone, triclosan or sodium lauryl sulfates.

There are several supplements that support egg and sperm quality and should be a component of any preconception care plan. The emphasis of these supplements is on their antioxidant properties. Some common supplements include: 

Optimizing hormonal health:

Identifying an ovulatory cycle is the first step in cycle tracking, but much deeper hormonal evaluations are often needed to complete preconception hormonal health. It is important to obtain serum labs timed correctly to the cycle day. Most labs are drawn on cycle day 3 and include estradiol, follicle stimulating hormone (FSH), luteinizing hormone (LH), anti-Mullerian hormone, and prolactin. Progesterone is an important hormone that must be tested after ovulation, ideally 7 days post-ovulation, or between cycle day 19-21 if ovulation day is unknown. Cycle day 3 labs are important to predict fertility outcomes and potential estrogen dominance. Keep in mind that elevated estradiol levels can falsely suppress FSH levels. The importance of progesterone testing is to rule out potential luteal phase defects or suboptimal progesterone levels prior to conception. 

There is a role for bioidentical progesterone supplementation in the presence of suboptimal levels or with history of prior miscarriage. Supplementation is most effective when initiated before implantation occurs, so it is advised to start supplementation with ovulation confirmation. Progesterone supplementation is safe and can help support healthy pregnancies. It should be supplemented through the first trimester and discontinued once the placenta is fully formed and can take over progesterone production, which typically occurs by week 12. Progesterone is often prescribed to be inserted vaginally beginning with ovulation through to the start of the next cycle. If a positive pregnancy test is confirmed, the dose is often increased and continued through week 12. 

Conclusion:

Preconception care and holistic, integrative care go hand in hand due to the powerful impact of foundational health changes on pregnancy, maternal, and fetal health outcomes. Patient education about the importance of early intervention for preconception care can help to reduce high risk pregnancies and future chronic health conditions. Focusing on evaluation of gut health, nutrient status, egg and sperm quality, and hormone balance provides a thorough starting place to guide patients and their families towards optimal wellness.