14. FERTILITY & PREGNANCY Flashcards
This module covers: • Female and male fertility. • Fertility investigations — orthodox • Fertility investigations — functional. • Assisted reproductive technologies (ART). • Natural fertility. • Pregnancy. • Preparing for birth. • Postpartum care.
When are fertility investigations started for those over 36?
After 6 months of unprotected intercourse
What is the prevalence of difficulty conceiving in UK?
One in seven couples
What proportion of fertility issues can be attributed to men?
4 out of 10
What is needed for successful conception?
- Healthy, non-damaged oocyte.
- Adequate sperm (motility, DNA integrity, count, morphology).
- Sufficient transport of sperm and egg to fallopian tubes for fertilisation.
- Successful implantation in the uterus lining.
- Normal embryo development.
Which female structural abnormalities can impair fertility?
- Cervical stenosis: Narrow / closed cervix.
- Uterine septum: Poor environment for embryo to implant due to poor vascular supply of blood (and hence nutrients).
- Uterine polyps and fibroids: May disrupt implantation. Usually due to oestrogen dominance.
- Fallopian tube / obstruction: Pelvic inflammation, STDs (e.g., chlamydia), endometriosis (scar tissue that can obstruct the fallopian tubes), abdominal / pelvic surgeries, ectopic pregnancy.
- Ovarian cysts: Can cause infection and scars of fallopian tubes.
Why does Polycystic Ovarian Syndrome impair fertility?
Elevated androgens, anovulation, irregular cycles, ↓ uterine lining development, implantation issues.
What are the effects of hyper or hypothyroidism on fertility?
- Irregular cycles
- ovulatory disorders
- miscarriage
- pre-term birth
- pre-eclampsia
What can cause Amenorrhoea and impair fertility?
Hypothalamic dysfunction, pituitary tumours, excess exercise, undereating, low BMI, high stress (ACTH / cortisol).
How can obesity/insulin resistance impact fertility?
- Lack of ovulation
- Increased androgen levels
What is premature ovarian failure and what can cause it?
Rare condition characterised by loss of ovarian function aged <40
Can have a genetic cause or be caused by chemotherapy / radiotherapy or SLE.
When does oestrogen peak in the menstrual cycle and what are two main functions?
First half of cycle
* Creates proliferative endometrium.
* Important for ovulation
When does progestrogen peak in the menstrual cycle and what are two main functions?
Second half of cycle
* Maintains secretory endometrium.
* Important for implantation and the survival of the embryo.
What are the main oestrogen and progesterone hormone production and storage sites?
Both are produced in ovaries, adrenals, placenta.
Stored in the adipose (fat) tissue.
List 8 signs and symptoms of oestrogen dominance
- Fibroids and uterine polyps
- Endometriosis
- PCOS
- Heavy bleeding and clotting
- Fibrocystic breasts
- Tender and swollen breasts
- PMS and irritability
- Headaches
- Shorter menstrual cycles (esp. luteal phase)
- Poor memory
- Brain fog
- Hypothyroidism
- Hair loss
- Insomnia
- Fatigue
- Mood swings
- Gallbladder disease
- Swelling and bloating
- Miscarriages
List 8 symptoms and signs of progesterone dominance
- Breast tenderness
- Water retention
- Bloating
- Shortness of breath
- Dizziness
- Drowsiness / lack of concentration
- Sense of physical instability
- Long luteal phase
- Discomfort / pain in legs
- Decreased libido
- Anxiety / panic attacks
- Weight gain
- Insomnia
- Light periods
Outline six strategies to optimise oestrogen / progesterone ratio?
- Reduce stress — regular healthy meals, optimise sleep, ↓ over-exercising, address emotional stressors.
-
Optimise liver function — to detoxify excess oestrogen.
Avoid endocrine disruptors (e.g., home / personal products). - Avoid alcohol — ↑ oestrogen levels by promoting the induction of aromatases and by impairing hepatic oestrogen metabolism.
- Reduce body weight if obese — oestrogen is stored and produced in fat cells.
- Optimise digestion and elimination —to excrete excess oestrogen.
Which herb can be considered when aiming to optimise oestrogen / progesterone ratio?
Vitex Agnus Castus (Chaste tree)
How do the following medications impact fertility?
1. NSAIDs
2. chemotherapy
3. antipsychotic medicines
4. corticosteroids
5. antihistamines
- NSAIDs: Long-term use or ↑ dosage) — inhibit ovulation and lower progesterone levels.
- chemotherapy: damage / depletion of oocytes.
- antipsychotic medicines: increase prolactin levels, leading to anovulation and amenorrhoea.
- corticosteroids: suppress immune function, affect gut microbiome, elevate blood pressure and blood sugar levels.
- antihistamines: dry the mucous membranes.
What effects do tobacco and recreational drugs such as marijuana have on fertility?
Shown to correlate with poorer quality oocytes
Outline five types of environmental factors that can negatively impact female fertility.
Excessive radiation: (mobile phones, x-rays and radiotherapy, frequent flying) — damages oocytes.
Environmental toxins: (e.g., mercury, lead, phthalates, solvents) — associated with infertility and miscarriage.
Chronic alcohol consumption: leads to diminished ovarian reserve and ovulatory dysfunction
Caffeine: increases cortisol production, slows COMT (can lead to oestrogen dominance).
Xenoestrogens, pesticides and endocrine disruptors: plastics, cans, detergents, candles, flame retardants, cosmetics.
What is HLA?
Human leukocyte antigens
Outline two immunological factors that can affect pregnancy outcome.
Tissue type compatibility — if mother’s immune system responds negatively to paternal HLA proteins, this can affect implantation / pregnancy outcome.
Autoimmunity — immune system rejects the embryo.
High uterine NK cells — can trigger ↑ TNF-alpha, cytokines (early pregnancy loss). High BPA exposure linked to NK cell activity.
Anti-sperm antibodies (ASAs) — sometimes, a woman’s immune system will produce ASAs which destroy sperm, leading to fertilisation difficulties or miscarriage. ASAs can also be found in the ejaculate.
Antiphospholipid syndrome — autoimmune disorder which causes increased risk of blood clotting and ↑ miscarriage and stillbirth risk.
Thyroid antibodies — Leading to autoimmune thyroiditis and ↑ miscarriage and pre-term labour risk.
Ovarian antibodies (antibodies to various cellular components of the ovary) — affects egg and embryo development, ↓ fertilisation and pregnancy rates, implantation failure.
How can blood clotting defects impact fertility?
Increased risk of early / late term loss, maternal embolism / stroke, placental blood flow restriction
What is the semen volume of a normal sperm sample?
1.5 ml or more
Normal sperm concentration?
15 million+ per ml
Normal total sperm count per ejaculate?
39 million or more
Minimum motility percentage of a normal sperm sample?
40% or more
Live spermatozoa percentage of a normal sperm sample?
58% or more
Normal sperm morphology percentage?
4% or more
Outline three structural defects that can negatively impact male fertility
Congenital defect of testes or ejaculatory tract.
Undescended testes ― ↓ sperm count and quality due to heat.
Testicular cancer ― caused by the disease or treatment that damages sperm and causes changes in testosterone levels.
Surgery or injury to testes such as testicular torsion, being kicked; bicycle injury.
Ischaemic damage to the testes e.g., sickle cell anaemia.
Infections (STIs and post-pubertal mumps) cause permanent damage to the testes, vas deferens or epididymis. Impacts transport of semen to ejaculatory ducts.
How can testicular cancer affect male fertility?
Damages sperm and causes changes in testosterone levels.
What is hypogonadism?
↓ gonad function due to tumour, illegal drugs, Klinefelter syndrome
How does obesity affect testosterone?
In obesity there is increased peripheral conversion of testosterone to oestrogen (aromatisation) and decreased luteinising hormone.
What is the effect of Cushing syndrome on sperm count?
Increased cortisol results in low sperm count
What genetic condition causes hypogonadism in males?
Klinefelter syndrome
How does Diabetes mellitus effect male fertility?
neuropathy, neurogenic impotence, and retrograde ejaculation (= semen in bladder).
How does haemochromatosis effect male fertility?
Systemic inflammation and iron deposits in pituitary and gonads can lead to hypogonadism and androgen deficiency.
Scrotal varicocele consequence
The blocked / enlarged veins cause increased scrotal temperature and reduced sperm production.
How can acute and chronic illnesses impact male fertility?
Associated with a suppression of gonadotropin release, possibly through an increase in dopamine and opiate levels and an increase in cortisol production.
Which medications and/or drugs can reduce sperm count?
- Sulfasalazine
- anabolic steroids
- chemotherapy
- alcohol, cigarettes, caffeine, marijuana
What environmental factors can damage sperm?
Pesticides, heavy metals, toxins
How do mobile phones affect sperm?
Interfere with spermatogenesis
How does heat exposure negatively impact sperm production?
It compromises sperm production (hot baths, cycling, tight underwear, mobile phone in pocket).
What are examples of chemical toxins harmful to sperm?
BPA, phthalates
Which lifestyle factors contribute to excessive oxidation that can cause DNA fragmentation and reduced sperm morphology?
Poor diet, smoking, alcohol, obesity
What type of lubricants are spermatotoxic?
KY Jelly, saliva
Outline how periodontal disease in the mother can impact fertility.
It can lengthen the time to conceive by approx. 2 months:
Can prevent ovulation — increases inflammatory markers (IL-1). IL-1 inhibits GnRH production.
Metabolic waste products from oral bacteria and inflammatory markers can cross the placenta and affect the foetus.
Fusobacterium nucleatum has been isolated from the amniotic fluid and placenta of women delivering prematurely.
TRUE OR FALSE:
Causal links exist between oral infections and male infertility
TRUE
What is the improvement percentage in spermatic parameters when oral infections are treated?
20% improvement
What is the role of the seminal microbiome (SMB)?
The SMB is thought to aid conception, support health of the offspring and modulate immune responses.
How does the the seminal microbiome (SMB) differ from the vaginal microbiome (VMB)?
The SMB is more diverse but has lower bacterial concentrations than the vagina. This diversity is thought to help expose and train the VMB and immune system to aid pregnancy and conception.
What bacteria should dominate the seminal microbiome (SMB)?
Lactobacillus
How does sex during IVF increase implantation?
Sex during IVF increases implantation by 23%; the semen (with the SMB) prompts the cervix to release immune signalling molecules such as regulatory T-cells.
What can negatively impact the seminal microbiome (SMB)?
The SMB is negatively impacted by:
* antibiotics
* antifungals
* STIs
* prostatitis
* lubricants
* smoking
* alcohol
* obesity
* poor penile hygiene practices.
Which bacterial overgrowth can be a frequent cause of male infertility?
Ureaplasma urealyticum
Low quality semen is associated with which bacteria?
E.coli, prevotella, chlamydia, gonorrhoea, bacteroidetes and firmicutes
Which bacterial species is dominant in a healthy fertile vaginal microbiome?
Lactobacilli dominance
What environment do lactobacilli create?
Lactobacilli create an acidic, inhospitable environment which prevents the overgrowth of potential pathogens.
Which microbe species is linked to higher IVF implantation rates?
Lactobacillus crispatus
Which bacteria are associated with an increased chance of miscarriage when coupled with low lactobacilli species and a higher pH?
ureaplasma, gardnerella
Name three bacteria negatively associated with fertility.
Mycoplasma, ureaplasma, chlamydia trachomatis
What can negatively impact the vaginal microbiota?
STIs, alcohol, smoking, poor vaginal or oral hygiene, increased blood glucose levels, copper IUD coil, a low vitamin A, D, C and E status
What is a fuel source for lactobacilli in the vaginal microbiome?
Cervical fluid which is rich in glycogen
How can you positively impact vaginal microbiota?
Reducing infections, improving blood glucose levels, improving oestrogen levels, and supporting lactobacilli growth with pre and probiotics.
How does moderate exercise affect fertility?
Improves circulation and insulin resistance which increases the likelihood of conception.
Why does intensive exercise have a deleterious effect on female fertility?
Raises cortisol production which decreases progesterone.
Excessive secretion of endorphins interferes with the normal production of FSH and LH, in turn inducing ovulatory disorders and luteal phase dysfunction, which accounts for lack of embryo implantation and first-trimester miscarriages.
What condition in males is associated with excessive exercise?
Oligospermia
What hormones are inhibited by stress?
The release of cortisol, adrenaline and noradrenaline can inhibit the release of GnRH (responsible for the release of the sex hormones LH and FSH)
What hormone production is prioritized under stress?
Cortisol
What hormones are reduced due to stress?
Progesterone
How does stress influence sex hormones?
Downregulation of LH and FSH
What happens to oocyte numbers and quality with age?
Diminish
What is the risk of chromosomal abnormalities for ages 40+?
1:60
What is MTHFR?
An important folate-metabolising enzyme that is crucial for reproductive function.
How does the C677T polymorphism effect female fertility?
Reduced MTHFR activity leading to impaired folate metabolism and elevated homocysteine (leading to poor egg maturity and egg quality, increased oestrogen).
Risks associated with MTHFR polymorphisms?
Adverse pregnancy outcomes including neural tube defects, pre-eclampsia (high blood pressure and fluid retention) and gestational hypertension
C677T polymorphism effect on male fertility?
Reduced fertility, DNA hypomethylation and changes in sperm maturation
What are key methylating nutrients to optimise for fertility?
Folate, B12, B2, B6, methionine
Folate food sources
Dark green leafy vegetables, asparagus, avocado, Brussel sprouts, legumes, poultry
Foods to avoid for folate
Folic acid fortified foods
Vitamin B12 food sources
Chlorella, nutritional yeast, nori, kombu, fish, organic eggs, meat, liver
Other than with food, what recommendations can you give optimise Vitamin B12 levels?
- A methylated B12 supplement / a B complex.
- Support HCl / pancreatic enzyme levels.
Key food sources of Vitamin B6?
Whole grains, green vegetables, sunflower seeds, pistachios, liver, turkey, fish
Vitamin B2 is an essential component of which coenzyme?
FAD
What is FAD a cofactor for?
MTHFR enzyme
Key food sources of Vitamin B2?
Mushrooms, spinach, organic soybeans, beet greens, organic tempeh, almonds, avocados, liver, venison, eggs
Key food sources of Methionine?
Brazil nuts, sunflower seeds, beans, whole grains, beef, eggs, chicken, turkey, fish
Purpose of Ultrasound scans in fertility investigations?
Rule out structural abnormalities
When in the menstrual cycle is oestrogen tested?
Day 1–5
When in the cycle is progesterone evaluated?
Day 21
In orthodox fertility investigations, what marker is used to check thyroid function?
TSH only
How can elevated blood sugar levels affect fertility?
Ovulation / cycle length
What does AMH stand for?
Anti-Mullerian hormone
What is the purpose of AMH testing?
Marker of ovarian reserve
What could raised AMH indicate?
Polycystic ovaries
How is AFC (antral follicle count) performed?
Via ultrasound scan
What aspects are checked in a sperm sample?
Motility, morphology, volume
What other infections are tested in orthodox fertility investigations?
STIs, UTIs
What analysis identifies toxic metals in the body?
Hair/urine mineral analysis
Which genetic variations can lead to disturbed oestrogen balance and increases the risk of premature ovarian insufficiency?
COMT and COMT Val / Met
What can raised homocysteine levels indicate?
Methylation issues
Why would an adrenal stress profile be a consideration in functional fertility investigations?
Can highlight a need for support due to the suppressive effects of cortisol on fertility.
What do RBC minerals tests measure?
Tests intracellular levels of minerals (zinc, magnesium) instead of blood levels.
Which functional female fertility investigations could be recommended?
- Oxidative markers (e.g. Genova Oxidative Stress test or DUTCH): Blood sample (e.g., Genova) evaluates the oxidative stress status and antioxidant reserve. The oxidative stress marker ‘8-OHdG’ is measured via panels such as DUTCH (urine).
- Immune investigations: NK cells, HLA, antiphospholipid antibodies.
- Vaginal ecology: Evaluate the VMB - look for evidence of BV etc.
- Comprehensive hormone panels: Genova Rhythm Plus (saliva ― female): Comprehensive salivary assessment of oestrogen, progesterone and testosterone that spans a full 28 days. Also tests cortisol, DHEA, melatonin and testosterone.
- DUTCH test: Comprehensive assessment of sex and adrenal hormones + their metabolites. Includes 8-OHdG.
Which male functional fertility investigations could be recommended?
- Serum or urine analysis of amino acids (male): Amino acids can affect sperm count (carnitine / arginine). E.g., Genova amino acid panels.
- DNA Fragmentation (sperm) ― TDL: Measures the DNA of the sperm liable to fragmentation, with the potential to impair / damage normal embryonic development.
Outline three assisted reproductive technologies commonly employed.
- In vitro fertilisation (IVF): Stimulation of ovaries, egg retrieval, fertilised in vitro with sperm, fertilised embryos transferred into uterus.
- Intracytoplasmic sperm injection (ICSI): Sperm is injected into egg in vitro (if fertility issue is due to sperm abnormalities).
- Intrauterine insemination (IUI): Sperm is placed inside uterus around ovulation to facilitate fertilisation.
What is cryopreservation in assisted reproductive technologies?
Freezing sperm, oocyte, or embryo
Outline three key risks of IVF
- Multiple births — if more than one embryo is transferred into uterus.
- Premature delivery and low birth weight ― ↑ risk with IVF.
- Ovarian hyperstimulation syndrome — swollen and painful ovaries due to injected fertility drugs such as hCG.
- Egg retrieval procedure complications — aspirating needle use could cause bleeding, infection or damage to the bowel, bladder or a blood vessel. Also risks with anaesthesia.
- Ectopic pregnancy — 2–5% of women who use IVF.
- Cancer — egg growth stimulation drugs are linked with the development of a specific type of ovarian tumour.
In traditional cultures, what was the purpose of the fertility diet for newlyweds?
The diet was designed to provide optimal balance and nutrition to mother, father and baby. It takes around 100 days for an egg to prepare for ovulation, and 72–76 days for man’s sperm to mature.
How long should preconception preparation start before conception?
At least 3 months
What is the timeframe recommended for fertility diet?
6 to 12 months
When should a fertility detox be undertaken?
At least 12 months prior to conception
What enzyme is involved in oestrogen metabolism?
COMT
Briefly outline 8 steps of the protocol to enhance natural fertility
1. AVOID processed food, caffeine, alcohol, dairy and unnecessary medications
2. INCLUDE broad whole foods in a nourishing diet with antioxidants, phytonutrients, plant protein and good fats
3. OPTIMISE body composition: Aim for a BMI of 20-25 and a body fat percentage of 20–25%
4. REDUCE stress: Work-life balance, relaxation and self-care
5. MINIMISE toxin exposure: use non-toxic home and body products; reduce mobile and wifi exposure
6. OPTIMISE sleep: 8 hours of uninterrupted sleep per night.
7. WORK on mindset: This plays a critical role in a fertility journey – Visualisation, affirmations, journalling, gratitude.
8. EXPLORE holistic therapies: Acupuncture, homeopathy, herbal medicine, Arvigo Maya abdominal massage, Reflexology.
As a first step what should be AVOIDED to promote natural fertility?
- Processed food ― sugar, fizzy drinks, refined carbs, trans fats, microwaved food, ready meals, artificial sweeteners, table salt, GM foods. These all promote oxidative damage.
- Caffeine (coffee, tea, chocolate) ― increases cortisol production, slows COMT (oestrogen dominance), associated with early miscarriage and ↑ time to conception.
- Alcohol ― impacts ovulation; ↓ sperm motility and count.
- Non-organic pasteurised / homogenised / low fat dairy.
- Unnecessary medications.
What does caffeine increase that negatively affects fertility?
Cortisol production
What impact does alcohol have on fertility?
Decreases ovulation
Which type of dairy should be avoided for fertility?
Non-organic pasteurised / homogenised / low fat dairy
What type of diet should be consumed to promote natural fertility?
Broad, whole foods, nourishing diet that is:
* suited to your client’s constitution
* Based on local, seasonal foods
* prepared to maintain optimum amounts of nutrients and prevent formation of damaging compounds associated with high-heat cooking and heating of oils
* Focused on quality of food rather than calories
What types of foods should form the basis of a diet to promote natural fertility?
- Antioxidant rich foods ― i.e., high in vit C, E, carotenoids, selenium etc., to reduce oxidative stress and improve sperm quality.
- Phytonutrient-rich foods ― (eat the rainbow) prioritising dark green leafy vegetables and crucifers (also for liver detoxification: I3C stimulates CYP1A1). Consume 1–2 cups with each meal daily.
- Beans and legumes ― rich in fibre, aid bowel transit and toxin elimination, balance blood sugar (crucial for hormonal health). Excellent sources of zinc, folate and amino acids to support detoxification. Contain phytoestrogens thatmodulate oestrogen and disrupt aromatase. Consume 3 x week.
Outline what types of protein are to be included in a natural fertility diet
- Mostly plant protein with some high-quality animal protein:
- Organic eggs — contain cholesterol needed for steroid hormone production. Choline for neural development.
- Wild caught fish and seafood — seafood is high in zinc which is required for ovarian hormone production, spermatogenesis, GI tight junction support and superoxide dismutase production. ‘SMASH’ fish to optimise DHA levels. NHS recommend no more than two portions per week due to potential of mercury — supplementation required.
- Organic liver — high in vitamin A, B vitamins, iron, copper, choline. Consume 2 x month.
Outline the types of fats that are to be included in a natural fertility diet
Consume high quality fats:
* Monounsaturated fats (e.g., olives) ― improve insulin sensitivity and secretion, reduces inflammation and hence assist fertility.
* Daily omega-3 fatty acids (oily fish, flaxseeds etc.) ― support cell membranes and supply energy (particularly in oocytes).
* Nuts (walnuts, macadamia nuts, almonds).
* Moderate use of coconut oil and organic butter (if tolerated).
List five foods traditionally used to boost fertility
Fish, eggs, walnuts, maca root, fresh figs, and especially saffron
What effect does saffron have on fertility?
Boosts libido and supports the nervous system. Crocetin in saffron is believed to enhance nitric oxide synthase activity in the vascular endothelium (eNOS).
What body fat percentage should be aimed for?
20–25%
What risks does obesity pose during pregnancy?
Birth defects, gestational diabetes
What types of exercise can be recommended to support fertility?
Aim for moderate exercise: Avoid running, spinning, HIIT, CrossFit and aim for yoga, pilates, walking and swimming.
How can stress be reduced?
Reorganise work and life, avoid stress-causing people, go for walks, take time off
How can exposure to environmental toxins be minimised?
Use non-toxic body and cleaning products, avoid excess mobile/WiFi exposure
What is recommended for optimizing sleep?
8 hours of uninterrupted sleep
Mindset activities beneficial for fertility include?
Visualisation, affirmations, journalling, gratitude
Which holistic therapies support the body’s homeostatic mechanisms?
Acupuncture, homeopathy, herbal medicine
Benefits of Arvigo Maya abdominal massage?
Increases blood flow to reproductive organs, improves digestion and nutrient absorption, relieves stress
What can reflexology help with in fertility?
Relieves stress, regulates menstrual cycle
How can castor oil packs support fertility?
- Stimulates lymphatic, circulation and liver function.
- Supports ovarian, fallopian, uterine health.
- Promotes blood flow to reproductive organs.
- Aids detoxification (if placed on the liver).
How often should castor oil packs be used?
3–4 times a week
When should castor oil packs be avoided?
- During the luteal phase
- When trying to conceive
Male fertility: Why would you recommend the following and what is the daily supplementary dosage:
Selenium
Zinc
CoQ10
Fish oil
- Selenium = 100mcg. Selenium improves sperm motility and is key for their structural stability. GPO protects sperm against ROS.
- Zinc = 15-45mg. Zinc exerts an antioxidant effects specific to the reproductive system (protects sperm from ROS). Zinc is required for spermatogenesis and sperm motility. It is also needed for thyroid function.
- CoQ10 = 200mg. A key antioxidant and nutrient for the electron transport chain - increases sperm concentration and motility.
- Fish oil containing at least 900mg of DHA. Omega-3 FAs are required to ensure cell membrane fluidity — needed for the acrosome reaction. DHA appears to be most important.
Why are sperm susceptible to oxidation?
High unsaturated FA contents
Why would you recommend the following for male fertility?
* L-carnitine
* N-acetyl-cysteine
* B-complex with Folate, B2, B6, B12
- L-carnitine is highly concentrated in the epididymis and plays a crucial role in sperm metabolism and maturation. Carnitine functions as an energy substrate for sperm, assisting their motility. It also functions as an antioxidant working well with CoQ10.
- NAC supports glutathione production. Glutathione is the primary antioxidant system utilised in spermatozoa.
- B-complex provides methylation support (as needed). Also avoid folic acid fortified foods and caffeine.
Role of Vitamin A in fertility
Vitamin A is an antioxidant critical for cell division and differentiation (pertinent for embryo development).
How much cod liver oil can be recommended for fertility support and when should it not be taken?
1 tsp / day. Stop cod liver oil when pregnancy has been confirmed
- Why would you recommend the following for female fertility and at which supplementary dosages?
- CoQ10
- Myo-inositol
- Arginine
- L-carnitine
- Alpha lipoic acid
- Vitamin C and E
- Folate
- Vitamin B3
- CoQ10 is important for oocyte development. Improves ovarian response to IVF / ICSI treatment. 200mg/day.
- Myo-inositol: Promotes ovarian function, enhances oocyte quality, encourages regular cycles. A 2017 study showed it increased pregnancy rates in IVF & ICSI. 2000 mg/day for 26 weeks.
- Arginine: As a precursor to nitric oxide, arginine is required for angiogenesis, fertility and hormone secretion. Supports cell division and embryo development. 1000–2000 mg/day
- L-carnitine: Increases endometrial thickness, useful for implantation issues in ICSI and frozen embryo transfers. Enhances oocyte ATP production. 500–1000 mg daily (in case of IVF - take until embryo transfer).
- ALA: Antioxidant, has immunomodulatory effect, aids in chelation of heavy metals, aids insulin sensitivity. Caution: May lower thyroid hormone or improve blood sugar levels. 300 mg of R-alpha lipoic acid or 600 mg normal ALA / day.
- Vit C & E: Improves oocyte quality, protects against ovarian decline. Caution: Avoid vitamin E if taking aspirin. 500 mg vit. C daily; 200 IU vit. E daily.
- Folate is required for RNA and DNA synthesis. It is important for neural tube development. Females with an MTHFR polymorphism should take methyl-folate. Increased need if expecting twins, MTHFR or obese (↑ BMI = ↑ risk of birth defects).
- Vit B3: A deficiency in NAD can cause recurrent miscarriages and birth defects (Dr Dunwoodie). 100 mg daily (best taken as part of a B complex).
Discuss Vitex agnus castus as a herb for fertility, including mode of action and dosage
- Vitex Agnus Castus regulates the cycle in women with irregular periods and general imbalance.
- Regulates prolactin levels (binds to dopamine D2 receptors, lowering prolactin pituitary secretion), enhancing corpus luteum development and corrects luteal phase progesterone deficiency.
- Normalises shortened luteal phases.
- Effective in restoring the menstrual cycle after years of taking the contraceptive pill.
- Dosage: 15–20 drops first thing in the morning OR 1 tsp dried berries decocted 1–2 daily. (Can take up to 3–6 months to see an effect).
What are the benefits of Ashwagandha for fertility?
- Ashwaganda is a great fertility herb for females and males. Builds energy, stamina and libido.
- In males it increases DHEA, LH and testosterone and improves semen / sperm quality.
- Improves anxiety
- Anti-inflammatory
Caution for Ashwagandha?
Not for use in pregnancy
Name the herb:
Ayurvedic female fertility tonic. Nourishing and calming, promotes hormonal balance. Good for a low sperm count.
Shatavari
Caution for Shatavari root?
Avoid in oestrogen-receptor cancer
How long can sperm live in favourable circumstances?
About 3 days
How does pinpointing ovulation maximise chances of conception?
- As oestrogen increases in the lead up to ovulation, women produce fertile-quality cervical fluid that provides a medium to protect the sperm from the acidic pH of the vagina.
- Whilst sperm can live up to three days, an egg normally only survives up to 48 hours after ovulation.
- It is recommended to have regular intercourse 5 days prior to ovulation, and 3 days after. Depending on the length of a cycle, you can judge possible ovulation times.
What do ovulation strips measure?
LH in urine
When is the best time to start testing with ovulation strips?
Cycle day 9
What is a potential issue with relying solely on ovulation tests?
When relying solely on these tests, ovulation can be missed due to all efforts being concentrated on a few days a month.
When does cervical mucus secretion reach its maximum?
24–48 hours before ovulation
What are the characteristics of cervical mucus at its maximum?
Thin, watery, alkaline, elastic and looks like egg white
Which factors can alter cervical mucus secretion?
- Hormonal changes
- medications (OCP, clomiphene citrate)
- surgical procedures
- infections
- hypoestrogenism
- radiation therapy
- Smoking
How does cigarette smoking affect cervical mucus?
Decreases production
What simple method can be used to help monitor fertile days?
Cervical mucus monitoring
What can be recommended when cervical mucus is scanty?
- Increase fluid intake
- Take evening primrose oil (prior to ovulation only)
- Use a fertility friendly lubricant that does not affect the pH during intercourse (e.g., organic jojoba oil).
What does BBT stand for?
Basal Body Temperature
When does BBT drop?
Just before ovulation
What causes BBT to rise after ovulation?
Extra progesterone
How much does BBT typically rise after ovulation?
0.5° C
When should BBT be measured?
Every morning upon waking before moving about
What is necessary before taking a BBT reading?
4 hours unbroken sleep
What can affect the accuracy of BBT readings?
Interrupted sleep
How does alcohol consumption affect BBT readings?
Can increase temperature and invalidate readings
What is the normal cervical position throughout the cycle and how does it feel?
Low, firm (feels like the tip of your nose), closed
How does the cervix change as ovulation approaches?
Higher, softer (feels like your lips), open
What is a crucial hygiene step before checking cervical position?
Wash your hands
Outline the three stages of foetal growth
- Blastogenesis stage (2 weeks): Fertilised ovum divides and implants itself in the uterus.
- Embryonic stage: Principal organs / membranes develop. Drugs, alcohol, nutrient deficiency can cause problems in development.
- Foetal stage (third month til term): The most rapid period of growth. Pregnancy is often divided into trimesters (13 week periods).
TRUE OR FALSE:
Cramping pains with bleeding is common in the first trimester and not a cause for concern.
FALSE
Whilst cramping (like menstrual cramps) is common due to the embryo implanting in the uterus, as well as the uterus growing, painful cramping associated with any vaginal bleeding may be a sign of ectopic pregnancy, threatened abortion, or missed abortion.
List 5 common pregnancy symptoms
Nausea
vomiting
heartburn
increase in abdominal girth
changes in bowel habits
increased urinary frequency
vaginal discharge
palpitations
ankle swelling
fatigue
shortness of breath.
What increases energy and nutritional needs during pregnancy?
Healthy balanced diet
What are the risks of undernutrition during pregnancy?
Epigenetic increase in the risk of diabetes mellitus and cardiovascular disease.
What can excess unbalanced food choices in pregnancy lead to?
Higher birth weight
Increased risk of obesity, cancer and asthma later in life
How can maternal high-fat diets effect offspring?
Epigenetic DNA modifications passed on to future generations.
Can postpartum dietary changes reverse original fetal insult?
It may not reverse the original insult
What foods should be avoided during pregnancy and why?
- Paté, soft and blue cheeses — listeria risk (miscarriage, stillbirth, pre-term labour, illness, new born deaths).
- Raw eggs — salmonella risk (infection of amniotic fluid leading to miscarriage)
- Raw fish — parasite risk. Smoking fish removes parasites.
- Green or sprouting potatoes — contain alpha-solanine and alpha-chaconine, which have been linked to neural tube defects.
- Undercooked meat — salmonella, parasite risk.
- Soft ice cream and ‘squirty’ fresh cream from dispensers.
Why is adequate intake of pure filtered water important during pregnancy?
Accommodates blood volume to replenish the amniotic fluid
What are some pregnancy-related problems that proper hydration can help reduce?
Morning sickness, pre-eclampsia, constipation
TRUE OR FALSE:
Herbs are a natural and safe alternative that can be recommended for ailments during pregnancy and lactation
FALSE
Most herbs should be avoided during pregnancy and lactation without specialist supervision. Nutrition and homeopathy are safer options for common pregnancy ailments.
Which herbal teas are safe in small doses during pregnancy?
Ginger, peppermint, chamomile
Which herbs should be avoided due to stimulating the uterus?
Emmenagogue herbs (e.g. parsley, rosemary, basil, yarrow, pennyroyal, angelica, mug-wort, wormwood, black cohosh. Their stimulation of the uterus can cause spontaneous abortions.
What is a safe herb for colds and flu during pregnancy?
Elderberry
What is red raspberry leaf tea used for in pregnancy and when?
Red raspberry leaf tea is a uterine tonic which can be used in the last month of pregnancy to encourage parturition.
What causes toxoplasmosis?
Protozoan parasite
How can toxoplasmosis affect unborn babies?
Miscarriage, stillbirth, brain and organ damage
What should be avoided to reduce the risk of toxoplasmosis?
- Unwashed produce
- Raw / undercooked meat
- Cured meats such as salami
- Unpasteurised goat’s milk or goat’s cheese
- Contact with soil or faeces that might contain toxoplasmosis (e.g. cat litter trays).
What do NICE guidelines recommend about prescription medicines during pregnancy?
- Use as little as possible
- Limited to circumstances in which the benefit outweighs the risk
What are the risks associated with antibiotics during pregnancy?
Miscarriage and teratogenesis
What can antidepressants cause during pregnancy?
Congenital defects
What impact can smoking have on pregnancy and the infant?
- Premature delivery
- Low birth weight
- Increased chance of infant being overweight
- Cleft lip/palate
- Childhood cancer
- SIDS
Role of protein in pregnancy?
Supports placental and maternal tissue growth
Consequences of restricted protein intake during pregnancy?
Dyslipidaemia, obesity, hypertension, hyperinsulinemia in offspring.
Examples of good protein sources during pregnancy?
Beans
lentils
quinoa
wild fish
organic eggs
Additional protein needed per day during pregnancy?
6–10 g
Daily calcium requirement in pregnancy?
1000 mg
Why is adequate maternal calcium so important during pregnancy?
Calcium is needed for the ossification of the foetal skeleton, teeth and neural development as well as protection of maternal bones.
What condition is associate with low maternal calcium?
Pre-eclampsia
Examples of good calcium food sources?
Kale, okra, green beans, sesame seeds, figs, red kidney beans, sardines
Daily magnesium requirement during pregnancy and lactation?
360–400 mg
Effects of magnesium deficiency during pregnancy?
Risk of pre-eclampsia, foetal growth retardation, pre-term labour, metabolic dysregulation and SIDS
List 6 good food sources of magnesium
Almonds
Pumpkin seeds
Spinach
Barley
Brewer’s yeast
Cashew nuts
Kelp
Legumes
Eggs
Why is there increased need for iron during pregnancy?
To meet the growth demands of the foetus and placenta and to support increased material production of erythrocytes. Essential for oxygen transport.
List 4 good food sources of iron
Spinach, quinoa, legumes, pumpkin seeds, clams, beef
What are the key functions of Vitamin A during pregnancy?
Foetal growth, vision, hearing, immune functions
What amount of pre-formed Vitamin A is considered teratogenic?
Excess of 10,000 IU
Why is optimal Vitamin A status before conception important and how much is needed per day
Vitamin A is required for foetal growth, development of vision, hearing, immune and respiratory functions.
It controls neurogenesis in the embryo and control of neural plasticity.
> 5000 IU/day
What is BCO1 and why is it important?
Beta-Carotene Oxygenase 1 converts beta carotene to retinol and reduced activity (due to genetic polymorphisms) can cause Vitamin A deficiency.
Why is beta carotene to be recommended rather that pre-formed Vitamin A and which foods are rich in beta carotene?
Pre-formed vitamin A in excess of 10,000 IU has teratogenic effects so source from beta-carotene in pregnancy.
Food sources: apricots, barley, carrots, green leafy vegetables, kohlrabi, spinach, sweet potatoes.
What percentage of people have reduced BCO1 activity?
Approximately 50%
What is the importance of vitamin D during pregnancy?
Calcium homeostasis, cell differentiation and immune function
How can inadequate perinatal vitamin D affect children?
Inadequate Vitamin D levels during perinatal life can:
* Affect a child’s bone health, brain development
* Increase the risk of heart disease, Type 1 diabetes, insulin resistance, dental issues and reduced muscle mass.
What is the daily vitamin D requirement in pregnancy?
2000 IU
What risk can low vitamin D increase for the mother during pregnancy?
Pre-eclampsia
Sources of vitamin D?
Sunlight exposure, mushrooms, egg yolk, wild-caught oily fish
Why is adequate levels of EPA and DHA important during pregnancy?
Adequate levels of EPA and DHA are especially important for neurodevelopment and are associated with:
* Healthy birth weight.
* Increased gestational length.
* Healthier BMI.
* Improved infant visual performance
* Lowered allergic response.
* Better mental processing.
Benefits of maternal fish oil supplementation
Reduced food allergy, IgE associated eczema / asthma risk.
Recommended fish intake during pregnancy
SMASH fish 2 x weekly
Fish oil supplement dosage during pregnancy
200–300 mg DHA + EPA
Why should fish oil supplementation be reduced four weeks before due date?
Due to anticoagulant effect
How is the newborn gut first colonised?
Microbes from the mother as the baby move through the birth canal
What influences the neonate’s microbiome?
Birth method (vaginal birth vs. caesarean) as well as perinatal care (e.g. breastfeeding)
What can excessive pre-pregnancy weight or excessive weight gain during pregnancy lead to?
Gut flora changes (↑ bacteriodes, ↑ E.coli, ↓ bifido) which can predispose the child to obesity
What is the effect of Lactobacillus rhamnosus GG supplementation during pregnancy?
Moderates weight gain, reduces eczema development in the infant in later life.
Which probiotics could have a protective effect against allergy development in infants?
Lactobacillus rhamnosus GG and Bifidobacterium lactis
List four ways to encourage optimal neonatal gut flora?
- Natural childbirth and breastfeeding.
- Avoidance of antibiotic use.
- Pets in the home.
- Avoidance of hyperclean environment (‘hygiene hypothesis’).
- Outdoor activities — let children play outside and eat dirt!
What exercise is recommended for the first trimester?
Brisk walking or low-impact classes
What are suitable exercises for the second and third trimesters?
Pregnancy yoga, gentle walking, aqua-natal
What should be encouraged alongside exercise?
Rest, relaxation, optimal sleep
What should be avoided during pregnancy?
Endocrine disruptors and toxins
What is morning sickness characterized by?
Nausea, vomiting, food aversions, a metallic taste in the mouth, hunger even when nauseous, and relief from nausea by eating.
When is morning sickness most common?
Week 5 to 2nd trimester
What hormone levels rise during the first trimester contributing to morning sickness?
hCG
List four factors that can contribute to morning sickness
- Rising hCG levels in first trimester (higher in women with twins or with hyperemesis gravidarum (severe / prolonged vomiting).
- High oestrogen (oestradiol).
- Enhanced sense of smell.
- Poor nutritional status and poor blood sugar control.
Acupressure point for morning sickness?
P6 on wrist
Vitamin B6 dosage for morning sickness?
25mg, three times a day
Homeopathic options for morning sickness?
Sepia 30C, Nux vomica 30C
Dietary advice for morning sickness?
Stay hydrated, smaller, frequent meals including protein and carbohydrates, ginger / ginger tea
Recommended beverage for morning sickness?
Ginger tea
What is pre-eclampsia?
Pregnancy-induced hypertension associated with protein in urine and oedema.
At what stage of pregnancy does pre-eclampsia typically affect women?
Around 20 weeks
What are key risk factors for pre-eclampsia?
Advanced age, first pregnancy, twin pregnancy, family history, hypertension, chronic autoimmune disease, BMI >35.
What are common symptoms of pre-eclampsia?
Water retention, severe headaches, vision problems, pain below ribs.
What is the orthodox treatment for pre-eclampsia?
Give birth at 37-38 weeks
What complications can arise from pre-eclampsia?
Poor foetal growth, eclampsia, stroke, organ problems, liver and blood clotting disorder
What does HELLP stand for?
Haemolysis, elevated liver enzymes, low platelet count
Low serum levels of which nutrients are associated with increased risk of pre-eclampsia?
Calcium, magnesium, zinc, vitamin D, omega-3s
Outline your recommendation for a pregnant client with pre-eclampsia
- Focus on foods rich in Calcium, magnesium, zinc, vitamin D, omega-3s
- Support methylation: elevated homocysteine is associated with abnormal placental vasculature
- Get adequate rest and manage stress.
- Supplementation: 2 g calcium in second and third trimester; 200 mg CoQ10 from week 20; 500–750 magnesium in first & second trimester.
Why should magnesium supplementation be reduced in the third trimester?
It can interfere with contractions
What percentage of pregnant women are affected by gestational diabetes mellitus (GDM)?
2–5%
What are the increased risks associated with gestational diabetes mellitus (GDM)?
Larger birth weight, caesarean birth, neonatal hypoglycaemia
What are the risk factors for gestational diabetes mellitus (GDM)?
Family history of diabetes, obesity, history of large birth weight
Give lifestyle and supplement recommendations for managing gestational diabetes mellitus (GDM)?
Low GI diet, daily exercise (e.g. a walk after meals)
Possible supplementation of 4–8 mcg x kg of chromium picolinate
What causes heartburn in pregnancy?
- Hormonal changes can allow the muscles in the oesophagus to relax more frequently.
- In the third trimester, the enlarging uterus and baby reduces the space for the digestive organs.
Name three possible dietary triggers for heartburn.
Spicy foods, chocolate, caffeine, tomatoes.
What practical lifestyle advice could you offer a pregnant woman to help reduce heartburn?
Avoid eating before bed.
Raise the head of the bed with a wedge-shaped pillow
Sleep on the left side (right side will position the stomach higher than the oesophagus).
What can be taken between meals for heartburn relief?
Alkalising salts or pasteurised apple cider vinegar
What manual therapy can help with heartburn?
Osteopathy to release the diaphragm
Why does constipation occur in late pregnancy?
Enlarging uterus reduces space
Increased progesterone relaxes intestinal muscles
What dietary changes can help relieve constipation?
Increase fluids and fibre. Consume probiotic-rich foods
What should be mixed in water to potentially help constipation?
Ground flaxseeds
During pregnancy, what risks do aloe vera and large amounts of flaxseeds pose?
- Large amounts of flaxseeds can affect hormone levels as they are oestrogenic
- Aloe vera contains anthraquinones, strong purgative substance which can cause uterine contractions - avoid!
Which supplement may help alleviate constipation?
Magnesium citrate
What is a birth plan?
Document of mother’s wishes regarding birth period.
List 8 considerations for a birth plan about which you can help educate clients?
- Birth location: Home, hospital, water
- Different inductions or acceleration of labour.
- Who will be at the labour and their role.
- Pain relief: Birthing pool, TENs machine, gas and air, epidural, pethidine, homeopathy, acupuncture.
- Heart rate monitoring.
- 3rd stage of labour (i.e., placenta delivery).
- Natural vs oxytocin injection.
- Delayed cord clamping (at least 3 mins) babies can get 30% more iron-rich blood, oxygen, erythrocytes, leukocytes and stem cells.
- Mouth swab in case of caesarean birth (to inoculate baby’s gut with mother’s microbes).
- Skin-to-skin contact.
- Who will cut the cord.
- Vitamin K injections, vaccinations.
- Avoiding wiping the vernix caseosa off the baby after birth.
- Not bathing the baby after birth (preferably for 2–3 weeks)
What kind of things should a postpartum plan include?
- Support network
- food preparation
- help with household chores
- lactation consultant
What is perineal massage?
Prepares perineum for childbirth , making it more flexible so it can stretch more easily during labour to help prevent tears or the need for a surgical cut when giving birth.
When can perineal massage be done?
From 34+ weeks of pregnancy
When should perineal massage be avoided?
When there is vaginal herpes, thrush or infection
What herbal tea can be consumed from 36+ weeks to help tone the uterus and improve labour?
Red raspberry leaf tea — 1‒3 cups a day
What is the fourth trimester?
12-week period after birth
What is crucial for parents during the fourth trimester?
Support network
What should mothers do for the first week after birth?
Rest and establish breastfeeding
What is encouraged for integrating the baby into everyday life?
Baby wearing
What causes postpartum affective instability such as rapidly fluctuating mood, tearfulness, irritability and anxiety?
This is due to hormonal changes postpartum. There is a huge drop in progesterone and increase in prolactin (prepares for lactation) and oxytocin (contracts the womb back to its size and stimulates lactation, can also increase anxiety)
When do symptoms of postpartum affective instability peak?
Fourth or fifth day
What homeopathy remedies may be considered postpartum?
sepia 30C or ignatia 30C
What are red flags and cause for referral in postpartum affective instability?
If symptoms persist for longer than two weeks and become more intense, to include:
* Difficulty in bonding with the baby.
* Withdrawing from the family.
* Feeling of hopelessness.
* Excessive crying.
* Severe anxiety.
* Thoughts of harming self or the baby.
What alternative therapies can help postpartum?
Homeopathy, acupuncture, herbalism
What is a common condition (incidence of 4–9%) after giving birth?
Postpartum thyroiditis
What is a likely cause of postpartum thyroiditis?
In most cases it is autoimmune. It is possible that the shift in Th1 cell function, loss of tolerance for foetal antigens and enhanced IgG secretion, which may be triggered by the marked drop in oestrogen and progesterone is contributory.
What can postpartum thyroiditis mimic?
Anaemia, depression
What common postpartum condition should be screened for and could cause depressive symptoms similar to thyroiditis?
Anaemia
What does ‘Mum MOT’ refer to?
Pelvic floor examination, diastasis recti assessment, screening for bladder, bowel or sexual dysfunction.
