As you begin your preconception journey, it’s important to start taking a prenatal multivitamin. Here’s the thing – there are SO many to choose from. You’ve got your pick at your pharmacy, at health food stores, and online – and some of them with the most beautiful branding.

Choosing your perfect prenatal can be difficult, and oftentimes people will simply choose the cheapest option, or one recommended by a friend. When it comes to a supplement that you’ll likely be taking until you stop chest/breastfeeding – you want to ensure you’re taking something that has quality ingredients and sufficient dosages.

Forms of Vitamins and Minerals

Active vs. Inactive

The B vitamins in many prenatals are in their inactive forms. While they can be converted to the active form, it can be difficult for some people. Moreover, active B vitamins are often better absorbed and therefore better utilized by the body.

Look for these ingredients:

• Vitamin B2 – choose riboflavin-5-phosphate
• Vitamin B6 – choose pyridoxal-5-phosphate
• Folic acid – choose methylfolate (more below)
• Vitamin B12 – choose methylcobalamin

Folate vs. Folic Acid

As you probably know, one of the most important vitamins to take during preconception is folate. This important B vitamin is needed for neural tube defects. In addition, studies have shown that taking folate in the preconception period may increase chances of becoming pregnant and hopefully result in a live birth.

Methylfolate is the active form of folic acid, and while it does the same thing as folic acid, the active form may be better absorbed and used. When choosing a prenatal, look for about 600 mcg in folate levels, although in some cases such as a neural tube defect in a prior pregnancy, a higher dose of folate is required.

Iron

During pregnancy some people will stop taking their prenatal because it causes nausea and/or vomiting, constipation, and stomach pain. This isn’t great because as seen above a prenatal (especially the folate) is important during early embryonic development.

The form of iron in prenatals is typically the reason why people stop taking them – usually it’s in the ferrous sulphate form which is poorly absorbed. Look for iron glycinate instead which is easier on the digestive system. Iron is also better absorbed with vitamin C – another common ingredient in your prenatal.

Iron is really important in pregnancy as blood volume increases during the second and third trimester, thus leading to a decrease in iron. A deficiency results in low energy, cold hands and feet, hair loss, and restless leg syndrome.

Oxide vs. Citrate

When taking a look at the ingredients list, look for citrate forms of vitamins and minerals if possible. Most ingredients are found in the oxide form, but this form isn’t always absorbed well.

Dosage

Because there are tons of prenatal multivitamins on the market, the dosage of vitamins and minerals vary greatly. At the end of the day, they all provide the amount that you need throughout preconception and pregnancy.

However in professional brands you may see a larger amount of B vitamins, important because these are needed for energy (you will be/are growing a baby!), developing brain and nervous system of your baby.

Some brands contain more vitamin B6, which is a first line treatment for nausea and vomiting in pregnancy. Taking too much vitamin B6 is possible, so be aware of the following symptoms: change in sensations to fingers and toes, rashes, walking, reflexes, nervousness, insomnia, feeling ‘wired.’ Before adding more vitamin B6 to your first trimester supplements, speak to your doctor. Or even consider other first line treatments like ginger or acupuncture.

Additional Ingredients

A simple multivitamin with only vitamins and minerals will do the trick. Some brands, particularly those inexpensive formulas found at the pharmacy contain additives. These may not matter to you, but they may have negative effects on the body. A common endocrine disruptor, BHT is found in some brands. Moreover unnecessary colours are also found in some prenatals like: FD&C Red #40 Aluminum Lake, FD&C Blue #1 Aluminum Lake, FD&C Yellow #6 Aluminum Lake, D&C Red #27 Aluminum Lake, FD&C Blue #2 Aluminum Lake.

Some prenatals found at health food stores contain proprietary herbal blends. While a good thought, these are also unnecessary because it doesn’t outline how much of a particular herb you’re getting.

Probiotics may also be found in prenatal vitamins, which can be unnecessary. They may be added in to promote gut health and prevent group B strep (a bacteria tested for in the 3rd trimester). But the strains often aren’t protective or used to help prevent GBS in pregnancy. In which case, you may want to consider taking a separate probiotic supplement in the second or third trimester depending on your history of vaginal/urinary tract infections or a previous positive GBS test.

Final Thoughts

As you can probably see, there’s a lot more involved in choosing a prenatal than picking the lowest-price option. However, if that’s all you can manage at this point that’s okay because it will have all the recommended dosages of what you need.

If you can opt for a professional brand which has better absorbed forms of ingredients and limits any unnecessary ones, that would be a great option. Typically these would be a 2 or 3 capsules per day product, which isn’t as convenient as a 1 capsule per day, but you can likely take all 3 capsules at once.

If you have any questions about the right prenatal supplement for you, or any questions in general about vitamins and minerals during your pregnancy, reach out to a Naturopathic Doctor. We can help you figure out what would be the best supplements for you to take during your pregnancy.

References

Kominiarek, M. and Rajan, P. (2016). Nutrition Recommendations in Pregnancy and Lactation. Medical Clinics of North America, 100(6), pp.1199-1215.

Sebastiani, G., Herranz Barbero, A., Borrás-Novell, C., Alsina Casanova, M., Aldecoa-Bilbao, V., Andreu-Fernández, V., Pascual Tutusaus, M., Ferrero Martínez, S., Gómez Roig, M. and García-Algar, O. (2019). The Effects of Vegetarian and Vegan Diet during Pregnancy on the Health of Mothers and Offspring. Nutrients, 11(3), p.557.

Endometriosis is a condition where endometrial tissue grows outside of the uterus – commonly on the ovaries and rectum, but even as far as the lungs, brain, or sciatic nerve. This tissue often produces an inflammatory response resulting in symptoms like pain.

Back in the 20s, researchers believed that endometrial lesions regressed during pregnancy – and so doctors would sometimes tell their patients that pregnancy could be “curative” because the person was no longer ovulating or menstruating. However a decrease in symptoms isn’t the case for everyone. Studies show that people with endometriosis can still be affected by this condition.

Pain and Lesions

Only a few studies have evaluated pregnancy and endometriosis-related pain. While some lesions can regress, others can remain stable or increase. The only beneficial effect of endometriosis in pregnancy is that amenorrhea (no periods) decreases the risk of new lesion formation.

One study by Alberico noted an improvement of endometriosis-related pain symptoms, where after 2 years about 63% of women experienced an improvement in pain symptoms and an improvement in quality of life. That said, in this same study, 84% of women still experienced pain-related symptoms after pregnancy.

Pregnancy Loss

People with endometriosis had a greater risk of pregnancy loss – specifically miscarriage before 20 weeks and ectopic pregnancy. The risk of miscarriage was highest in women younger than 35 and was their first pregnancy. The risk of ectopic pregnancy was stronger for pregnancies in women without a history of infertility.

Gestational Diabetes

In the review by Farland, women with endometriosis had a 35% greater risk of gestational diabetes in pregnancy. This risk was highest in women younger than 35, no history of infertility, and in second or later pregnancies.

Gestational diabetes is the onset of carbohydrate intolerance in pregnancy, which is typically diagnosed after the 24th week of pregnancy. It affects 3-25% of pregnancies.

If gestational diabetes was not controlled, it may put pregnant people at risk for abnormal fetal growth, hypertensive disorders of pregnancy, difficult labor and vaginal delivery, and increased risk of cesarean section. Risks for the baby include low blood sugar, increased bilirubin, and possibly delayed lung maturity. Moreover, they’re also at risk for adult onset of metabolic disorders, diabetes, hypertension, obesity, cardiovascular disease, and shorter lifespan.

Hypertensive Disorders

The same review by Farland, women with endometriosis had a 30% greater risk of hypertensive disorders of pregnancy. The risk was highest in second or later pregnancies.

Hypertensive disorders of pregnancy are present in about 15% of pregnancies and include pre-existing high blood pressure, gestational hypertension, and preeclampsia.

Hypertension is defined as a diastolic rate above 90mmHg (based on 2 measurements), while severe hypertension is a blood pressure over 160/110 mmHg. Pre-existing high blood pressure occurs prior to pregnancy or before 20 weeks pregnant, while gestational hypertension is usually diagnosed at or after 20 weeks pregnant.

Preeclampsia is defined as the presence of one or more symptoms at or after 20 weeks of pregnancy with the involvement of other body systems. The main symptoms include: hypertension (greater than 140/90 mmHg taken at least twice, 4 hours apart) and protein in the urine. Other symptoms include visual complaints, headache, vomiting, and abdominal pain.

If left untreated, preeclampsia can lead to neurologic complications, such as seizures (eclampsia) and strokes, kidney injury, and the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.

Preterm Birth

The review by Farland demonstrated that women with endometriosis had a 16% greater risk of preterm birth, specifically in second or later pregnancies. Preterm birth was defined as birth less than 37 weeks of gestation.

Low Birth Weight

Lastly, the review by Farland demonstrated that women with endometriosis had a 16% greater risk of low birth weight. Low birth weight was defined as birth weight less than 5.5 lbs (in a single pregnancy).

Final Thoughts

Overall, while new lesions are unlikely to develop during pregnancy, there’s limited knowledge about the impact of existing lesions and related symptoms during pregnancy or in the postpartum.

Furthermore, because there are some adverse pregnancy outcomes in people with endometriosis, it may be warranted to think about conditions like gestational diabetes and hypertension prior to the second trimester. Perhaps thinking about prevention may be worthwhile in the first trimester. Also, since pregnancy loss has been shown to be an adverse event in the first trimester, it may be worthwhile to talk to your healthcare provider prior to pregnancy to see if there’s anything that can be done to prevent this. However, miscarriage is more common than we think, and sometimes can be unavoidable.

At the end of the day, if you have endometriosis, don’t buy into the hype that you should become pregnant to decrease symptoms, and this isn’t the best advice. Choosing to expand your family should be done because you want to become a parent, not to improve your endometriosis symptoms.

If you have endometriosis and are looking to become pregnant or manage this condition during pregnancy, consider booking an appointment with a Naturopathic Doctor to complement obstetric or midwifery care.

References

Alberico, D., Somigliana, E., Bracco, B., Dhouha, D., Roberto, A., & Mosconi, P. et al. (2018). Potential benefits of pregnancy on endometriosis symptoms. European Journal Of Obstetrics & Gynecology And Reproductive Biology, 230, 182-187. https://doi.org/10.1016/j.ejogrb.2018.08.576

Denney, J., & Quinn, K. (2018). Gestational Diabetes. Obstetrics And Gynecology Clinics Of North America, 45(2), 299-314. https://doi.org/10.1016/j.ogc.2018.01.003

Farland, L., Prescott, J., Sasamoto, N., Tobias, D., Gaskins, A., & Stuart, J. et al. (2019). Endometriosis and Risk of Adverse Pregnancy Outcomes. Obstetrics & Gynecology, 134(3), 527-536. https://doi.org/10.1097/aog.0000000000003410

Leeners, B., & Farquhar, C. (2019). Benefits of pregnancy on endometriosis: can we dispel the myths?. Fertility And Sterility, 112(2), 226-227. https://doi.org/10.1016/j.fertnstert.2019.06.002

Leeners, B., Damaso, F., Ochsenbein-Kölble, N., & Farquhar, C. (2018). The effect of pregnancy on endometriosis—facts or fiction?. Human Reproduction Update, 24(3), 290-299. https://doi.org/10.1093/humupd/dmy004

Leone Roberti Maggiore, U., Ferrero, S., Mangili, G., Bergamini, A., Inversetti, A., & Giorgione, V. et al. (2015). A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes. Human Reproduction Update, 22(1), 70-103. https://doi.org/10.1093/humupd/dmv045

Shah, S., & Gupta, A. (2019). Hypertensive Disorders of Pregnancy. Cardiology Clinics, 37(3), 345-354. https://doi.org/10.1016/j.ccl.2019.04.008

If you’re approaching your mid 30s and are starting to think about kids, you may want to consider getting some of your hormones tested. You might be thinking, “My periods are like clockwork, isn’t that good enough?” Maybe – but having regular periods doesn’t truly give us a glimpse of your hormones.

As we age, our hormones begin to change, and it can take longer to become pregnant. Normally it’s recommended that people under 35 seek care (ie. go to a fertility clinic) if they’ve been trying for about 12 months without a live birth. If you’re over 35, then it’s recommended that you seek care if you’ve been trying for 6 months without a live birth.

It’s been my experience in practise where couples under 35 don’t want to wait out that full year before they begin to seek out help. Measuring basal body temperature, assessing cervical fluid, using ovulation predictor kits, timing sex, and the two week wait can be really stressful – and after a few months of unsuccess, people are ready for answers.

Many people think that fancy tests need to be done to get an assessment about fertility – and that isn’t true. I like looking at blood work because it gives us an idea of what’s going on upstream (aka. in the brain). Whereas urinary metabolites looks at the downstream products. Ideally, we want to see how the pituitary gland is functioning, not the different types of estrogen metabolites (which won’t really tell us anything about what’s going on fertility-wise). Not to mention, fertility clinics aren’t using urine tests to guide their treatments, they’re using serum (aka. blood).

Basic Fertility Assessment

If you’re wanting to get some basic tests done potentially before visiting a fertility clinic, here’s what you should consider. All of these tests can be ordered by Naturopathic Doctors.

FSH (Follicle Stimulating Hormone)

FSH is a hormone that stimulates ovarian follicles to grow and develop. In some women, the pituitary secretes a lot of FSH to encourage the ovary to respond. When this begins to happen, it’s usually due to a decline in ovarian reserve (the total number of gonadotropin-responsive follicles and oocytes within a person’s ovaries at any given time), and we would typically start to suspect this when the FSH is over 10mIU/mL.

FSH should be tested on day 3 of your menstrual cycle.

Estradiol

This is a form of estrogen that is typically measured early on in your cycle in conjunction with FSH and AMH as a means to assess your ovarian reserve.

Estradiol should be tested on day 3 of your menstrual cycle.

AMH (Anti-Mullerian Hormone)

AMH is produced by the granulosa cells surrounding each oocyte in developing ovaries, and serves as a marker of ovarian reserve as it reflects the size of the follicle pool. An AMH greater than 0.8-1.0 ng/mL is suggestive of a normal ovarian reserve.

It’s important to be mindful that AMH does not accurately predict the chance of pregnancy in people who are not infertile. A single test will not predict time to pregnancy – meaning you could have an optimal level, and it can still take a few months to become pregnant.

Moreover, studies have been done in women with low serum AMH, and the monthly ability of pregnancy compared to women with normal AMH levels did not differ. That said, this test is commonly run in women considered to be infertile as it is useful for prediction of the ovarian response to ovulation induction and controlled ovarian hyperstimulation.

Some docs will run this test right away, and some will wait. In people with PCOS, this number may be high. If we find that it’s low, however, sometimes prompted treatment is warranted. There does appear to be a seasonal variability with AMH, where low levels of vitamin D may be one of the reasons for low AMH.

While AMH can be tested anytime during your cycle, it’s best to run it at the same time with FSH and estradiol.

TSH (Thyroid Stimulating Hormone)

An association between thyroid health and fertility exists. Thyroid conditions like hypothyroidism and Hashimotos can contribute to a wide array of fertility issues like no period, recurrent miscarriage and prolonged spotting.

Ideally, getting a WHOLE thyroid panel done would be ideal – this includes, TSH, T3, T4 and thyroid antibodies. But sometimes only TSH should be run. The target for TSH should be between 1-2.

If you think IVF may be part of your family plan, a study has shown that hypothyroid women are less responsive to ovarian stimulation and have a lower rate of embryo transfer.

Thyroid hormones can be tested anytime during your cycle.

What About Egg Quality?

The important thing to remember about these tests is that while they provide some good information, they don’t tell you about egg quality. A reproductive endocrinologist on a podcast I listened to used an example of keeping eggs in the fridge – the longer they’re kept inside, the less fresh they are.

This isn’t to say at 30 your eggs aren’t ‘fresh’, but egg quality starts to play a factor. Luckily, there are some lifestyle modifications you can adopt to help maintain egg quality – I’ll be discussing that in a future post.

References

Obstetrics & Gynecology, 2019. ACOG Committee Opinion No. 773. 133(4), pp.e274-e278.