The Preconception Blueprint: What Women Need to Know Before Trying to Conceive

Submitted by Eleen Shahmoradian SRN, Dr. Stefanie Ann Varela, PhD, FNP-C, WHNP-BC, MSN-Edu

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The Preconception Blueprint: What Women Need to Know Before Trying to Conceive

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Abstract

The journey of motherhood begins long before pregnancy is confirmed, with preconception health playing a pivotal role in both maternal and fetal well-being. The preconception period is technically defined as the three months prior to conception, because that is typically the amount of time it takes for a fertile couple to conceive (Stephenson et al.). This paper explores the essential components of preconception planning including nutritional considerations, lifestyle modifications, environmental factors, and psychological readiness. Nutritional health is critical, as deficiencies in the body can negatively affect fertility and fetal development. Certain lifestyle choices such as being physically active and refraining from smoking plays a large part in enhancing reproductive health. In addition, environmental toxins and pollutants must be assessed to minimize risks during conception and pregnancy. Furthermore, psychological readiness is vital for coping with the challenges of pregnancy and parenting. All in all, a comprehensive understanding of preconception health can empower women to make informed decisions and enhance their journey through pregnancy.

Understanding Reproductive Health

The female reproductive system is a complex system of organs that function in the reproduction of new offspring. This intricate network of organs produces gametes, regulates sex hormones, and maintains fertilized eggs as they develop into mature fetuses ready for delivery. A woman's reproductive years are the time between menarche, or the first menstrual cycle, to menopause, the cessation of the menstrual cycle for twelve consecutive months. During this large time frame, the recurrent expulsion of ova from the ovary occurs, with the potential for fertilization by male gametes or sperm. This expulsion of ova is a normal part of the menstrual cycle. The internal and external genitalia both work to facilitate fertilization from the joining of the ova and sperm. This leads to the process of gestation. Typically within nine months, the gestation can produce one or more fetuses that are termed infants when born. A woman's reproductive timeline is complex. When a woman is born, she is born with all of the oocytes she will ever have. Only 400-500 of these oocytes become ovulated. As the number of oocytes decline, a woman's menstrual cycle shortens, fertility worsens, and menstrual irregularity begins shortly before menopause. Women under the age of thirty have an estimated 71% chance of conceiving, while it may only be 41% after the age of thirty-six (Rosner et al.).

The Menstrual Cycle

The menstrual cycle is a natural part of the female reproductive system that repeats monthly from menarche to menopause, allowing fertilization and pregnancy. A healthy cycle varies in length between 21 days and 37 days, the average being 28 days. The menstrual cycle consists of phases which are characterized by predictable fluctuations of ovarian hormones estradiol and progesterone. The follicular phase consists of the maturation of ovarian follicles containing oocytes. It begins with the onset of menses and lasts through the day of ovulation. While progesterone levels remain consistently low, estradiol rises gradually through the mid-follicular phase and spikes dramatically just before ovulation. The luteal phase is defined as the day after ovulation through the day before menses. This phase transforms the remains of the dominant follicle into the corpus luteum. The corpus luteum produces estradiol and progesterone. As a result, the corpus luteum forms with gradually rising levels of these two hormones. In the middle of the luteal phase, progesterone peaks and estradiol has its second peak. If the oocyte does not become fertilized, the corpus luteum breaks down, causing rapid perimenstrual withdrawal of estradiol and progesterone which causes menstruation. The corpus luteum has apredictable lifespan, making the luteal phase a more consistent length compared to the follicular phase (Rosner et al.).

Common Reproductive Issues

Women may experience a variety of reproductive health issues that can contribute to infertility. Polycystic Ovarian Syndrome (PCOS) is one of the most common of these health issues. In women with PCOS, the ovaries may become enlarged with cysts formed on the outer edges. Suffering from PCOS is associated with the manifestation of various symptoms including menstrual dysfunction and androgen excess, which significantly hinder the quality of life.
Women dealing with PCOS may be at increased risk for obesity, insulin resistance, type II diabetes mellitus, cardiovascular disease, cancer, psychological disorders and infertility (El Hayek et al.). The exact cause of PCOS is unknown; however, it is thought to be related to a combination of inherited and environmental factors (Singh et al.). Endometriosis is another chronic condition affecting women of reproductive age. It is characterized by the development of endometrial-like tissue outside the uterine cavity (Chauhan et al.). Women who deal with endometriosis often suffer from persistent pelvic discomfort and infertility. Aside from risk factors such as a family history of the disease, heavy menses, and uterine abnormalities, the theory of retrograde menstruation is a widely recognized explanation of endometriosis. According to this idea, endometriosis develops when sloughed endometrial cells and debris after menstruation travel retrogradely down the fallopian tubes and into the pelvic cavity (Chauhan et al.). Given the profound impact that conditions such as PCOS and Endometriosis can have on fertility, it is crucial for women to seek early diagnosis and treatment when experiencing symptoms. Addressing these issues can optimize the chances of conception and ensure a healthier path to pregnancy.

Preparing for the Journey to Conception

Nutrition and Weight

A woman who is healthy at the time of conception is more likely to have a successful pregnancy with a healthy child to follow (Stephenson, et. al). Weight plays a large role in the preconception period as pregnancy has high metabolic demands. Most metabolic processes, including basal metabolic rate, protein usage and storage, triglyceride synthesis, and hemodynamic changes, become altered during pregnancy to provide a sufficient supply of glucose and protein to mothers and fetuses. Obesity decreases fertility during the preconception period. It also increases the risk of adverse pregnancy outcomes including gestational diabetes, pre-eclampsia, caesarean section, postpartum weight retention. Ultimately, obesity increases the long-term health risks for both the mother and offspring (Lim et al.). Regular physical activity during the preconception period may prevent gestational diabetes and lead to improved fecundability. Studies show that women who are overweight or obese have lower levels of vitamin D and calcium, which are linked to fetal growth, maternal depressive moods, and maternal and fetal bone formation requirements. A healthy, balanced diet during the preconception period is important to prevent teratogenesis and gestational diabetes and to generate normal fetal programming of the adrenal-pituitary-hypothalamic axis during gestation (Cha et al.). There is no set diet to follow during the preconception period that is associated with optimal pregnancy and fetal outcomes. However, certain studies that have assessed dietary exposures found that increased adherence to the Mediterranean diet displayed the most consistent association with improved clinical pregnancy rates (Alesi et al.). Reducing trans fatty acids, saturated fatty acids, fast foods, and sugar-sweetened beverages were associated with improvements in live birth and clinical pregnancy rates (Alesi et al.).

Vitamins

It has been studied that 2-3 months before and after conception is a critical period for improving gamete function and early placental development. Folic acid supplementation during this time leads to a reduced risk of pre-eclampsia, miscarriage, low birthweight, small for gestational age birth, neonatal death, and autism in children (Stephenson et al.). A minimum of 4-6 weeks of supplementation is required to reach adequate concentrations before neurulation
begins three weeks after conception. Additionally, folic acid during the preconception period can reduce the risk for neural tube defects by as much as 70%. In a study done on over 1.5 million women in China, folic acid supplementation three months before pregnancy was associated with lower risk of low birthweight, miscarriage, stillbirth, and neonatal mortality compared to women who did not take folic acid prior to pregnancy (Stephenson et al.). For similar reasons as folic acid, iron supplementation during the preconception period may also lead to better maternal and fetal health outcomes. In experimental rodent models, restriction of iron from the beginning of gestation can lead to a 40-50% decrease in brain iron 10 days following birth (Stephenson et al.). Zinc deficiency, too, may compromise fetal and placental growth and neural tube closure. A study done in the UK found that many women of reproductive age do not meet the recommended nutrient intake for key minerals. It was found that 77% of women aged 18-25 years old had iodine intakes below the recommended intake, and 96% of women of reproductive age had insufficient folate and iron intake (Stephenson et al.). In many countries, including Canada, Chile, and the US, a decline in neural tube defects has been seen following mandatory folic acid fortification of food products such as wheat flour and cereals (Stephenson et al.).

Substance Use

Smoking affects several aspects of the female reproductive system and ultimately, female fertility. Smoking deteriorates the organs important to the conception process including the ovary, oviduct, and uterus. It has also been shown to decrease the efficacy of assisted reproductive technologies (ART). Cigarette smoke contains 4000 substances belonging to a variety of chemical classes including polycyclic aromatic hydrocarbons, heavy metals, and alkaloids, which are all compounds displaying reproductive toxicity (de Angelis et al.). In order for a fertilized egg to properly attach to the lining of the uterus, there must be a precise interaction between a receptive endometrium and a competent blastocyst. There must also be a properly timed remodeling of the endometrium prior to embryo arrival within the uterus. This preparation that the endometrium must go through may be affected by an estrogen-deficient environment, or poor corpus luteum development. The result of this is low endometrial receptivity and implantation failure. Trophoblast gene expression also has a significant role in the interaction with the endometrial lining. The trophoblast cells are the cells that form the outer layer of the developing embryo and later become the placenta. A damaged trophoblast may not succeed in implantation. Endometrial receptivity and trophoblast gene expression have shown to be impacted by smoking, and it has been found to delay implantation (de Angelis et al.).

Stress

Maternal stress before conception plays a significant role in influencing both maternal and fetal health outcomes including mental health issues, preterm birth, and low birth weight. Research suggests that psychological stress collected through a woman's life can shape the hypothalamic-pituitary-adrenal (HPA) function and affect pregnancy outcomes. The HPA axis-which regulates the body's stress response-releases the hormone cortisol, which is vital in stress adaptation. During pregnancy, the placenta dysregulates HPA axis regulation, leading to increased cortisol levels, which peak near labor. These changes in cortisol patterns include higher tonic cortisol, a dampened response to acute stress, and a flattened diurnal cortisol slope by late pregnancy. Dysregulated cortisol patterns may contribute to negative maternal mental health outcomes and poor birth outcomes (Rinne et al.). Elevated maternal cortisol can cross the placenta, affecting fetal development. This is because the placenta's enzyme system, (11 -HSD-2), only partially blocks cortisol. This is linked to adverse long-term effects including altered infant temperament and later mental health problems (Rinne et al.). These findings highlight the importance of addressing stress before and during pregnancy to improve maternal and fetal health outcomes.

Endocrine Disruptors

Pesticides, endocrine disruptors, and other chemicals have detrimental effects on the woman's reproductive system. They impede normal hormone activity and dysregulate the function of the endocrine system. It is crucial to consider exposure to these toxins during the preconception period as it can have lasting impacts on fertility. One chemical known to have such effects is BPA, or Bisphenol A. BPA is a chemical compound used in the manufacturing of certain plastics and resins. This chemical can cause chromosomal abnormalities in oocytes as well as recurrent miscarriages (Sharma et al.). Organo-chemicals and pesticides including DDT, DDE, and Methoxychlor also create harmful reproductive repercussions. These chemical compounds cause alterations in hormone levels, decrease fertility, and cause irregular menstrual cycles (Sharma et al.). They have also been studied to decrease libido and increase the risk of fetal loss and miscarriage. Dioxins are persistent environmental pollutants that are formed as a result of combustion processes such as burning fuels. Dioxins have the ability to alter puberty and the start of menarche, as well as lead to the higher risk of developing endometriosis (Sharma et al.). The endocrine disruptor humans come into closest contact with on a daily basis is Phtylates. Phytates are found in perfumes, deodorants, soaps, lotions, and a number of other
self-care, everyday products. These chemicals have been shown to result in earlier menarche, an altered menstrual cycle, and infertility (Sharma et al.). Reducing exposure to these chemicals may optimize reproductive health and limit the risks of developmental disorders, birth defects, and long-term health for both the mother and child.

Practical Steps For Conception

Conception is the broader term that refers to the entire process from the point of fertilization to the moment when the fertilized egg successfully implants in the uterine lining and begins to grow an embryo. This act marks the beginning of pregnancy. Fertilization is the physiologic process where a sperm cell from a male joins with an egg cell from a female to form a fertilized egg, or zygote. This process occurs in the fallopian tube. Here, the sperm penetrates the egg, merging its genetic contents to create a new cell with a complete set of chromosomes. This new cell will then begin dividing and developing into an embryo.

Ovulation is a key event in both the menstrual cycle and within the conception process. During ovulation, a mature egg, or oocyte, is released from the ovaries into the fallopian tube, where it has the potential to be fertilized by male sperm. The exact timing of ovulation can vary, but it typically occurs between 10 and 16 days before the start of the menstrual period. The timing of sexual intercourse in relation to ovulation strongly impacts the chance of conception. One effective method for tracking ovulation and the fertile window is by monitoring a woman's basal body temperature (BBT). BBT has been reported and studied since the early 1900s (Shilaih et al.). It is defined as the core body temperature during the body's resting state, estimated orally, rectally, or vaginally immediately after awakening or prior to any physical activity. The BBT fluctuates in response to hormonal variations across the menstrual cycle. The temperature reaches its lowest point in the fertile window, just prior to ovulation and corresponding to a peak in estrogen. The fertile window, or the time frame where conception can occur, is defined as the five days leading up to ovulation and the day of ovulation. The probability of conception drops significantly after ovulation, which suggests that oocytes can only survive 12-24 hours without fertilization. Therefore, a dip in BBT may indicate imminent ovulation. After ovulation occurs, BBT rises as progesterone levels rise. This shift in temperature is directly influenced by estrogen, progesterone, and testosterone. These reproductive hormones act directly on the warm-sensitive and cold-sensitive neurons of the preoptic anterior hypothalamus (Shilaih et al.). By tracking these physiologic changes, a woman can gain useful insight on their chances for conception, increasing the probability for success.

Conclusion

The preconception period is a crucial window of time that heavily influences the health of both the mother and developing fetus. Preconception health is influenced by a number of factors that, if addressed, can enhance fertility and limit the risk of complications during pregnancy. By gaining awareness and promoting comprehensive preconception care, women can make informed decisions that will positively impact their reproductive journey.

References

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