How to prepare for pregnancy?

Is there anything I can do to help having a healthy pegnancy? is the question commonly asked by prospective patients. It is important that you and your partner get off to the best possible start for the much wanted pregnancy. There are important links between preconception health and IVF outcomes. Preparing for pregnancy will not only increase your chance of achieving a pregnancy but may also decrease the risk of complications to both mother and fetus and congenital anommalies. Researchers from the University Medical Center in The Netherlands reported that ninety six per cent of women who attended a preconception clinic before undergoing IVF had three or more lifestyle problems and risk factors such as obesity, smoking, recreation drugs and alcohol (Journal of Advanced Nursing, (2012). Increasing numbers of women with often complex medical conditions such as women who had renal transplant or cardiac surgery, women with sickle cell disease and beta thalassaemia are now becoming pregnant or seeking fertility treatment, these women should receive pre-pregnancy counselling, ideally by Multidisciplinary team involving their specialists and obstetric physicians.

Preconception care encompasses health promotion, risk identification and preventative measures to promote the health of the expevctant mother and her child. these include:

Weight and nutrition

It is essential to eat a balanced healthy diet with fresh fruits, green vegetables and plenty of water. A recent study from Harvard School of Public Health, in the US, investigated how differences in 147 women's diets affected IVF and reported that diets high in saturated fats, such as those from butter, fatty meats and cheese, lowered the number of eggs a women produced for IVF. Avoid eating processed food as it contains flavouring and additives. . Diet rich in Omega 3 can significantly decrease natural killer cell activity and suppress the production of TNF alpha cytokines (Frank et al 2001; Gazvani et al 2001). Being overweight or underweight can affect normal ovulation, reduce the chance of getting pregnant, increase pregnancy complications and the risks associated with anesthesia etc. If your body mass index is above 30 you need a supervised weight loss program involving dietary advice and exercise. Obese women take longer to conceive and are at higher risk of miscarriage than ordinary women. If your body mass index is less than 20 then you may also need to go on a sensible eating program to correct it. Restoration of body weight may help resume ovulation and restore fertility.

Changes in lifestyle - What lifestyle changes should you consider when you plan for a pregnancy?

• Give up smoking, if this is difficult cut down as much as possible. Cigarette smoking is harmful to the woman's ovaries (smoking has been linked to premature ovarian aging. Kinney 2007). Women who smoke reduce their chance of successful pregnancy by approximately 40% compared with non-smokers. Smoking reduce implantation and pregnancy rates (Neal et al, 2005,. Human Reproduction). Smoking also adversely affects live birth rates equivalent to increased female age by 10 years (Linsten et al, 2005. Human Reproduction, Salihu et al. Early Hun Dev 2007; Gray et al BMJ 2009). . Furthermore, pregnant smokers are more likely to have low birth rate babies and preterm birth etc. It has also been associated with an increased risk of miscarriage, placenta previa (low lying placenta) and abruption placenta (separation of a normally sited placenta from its attachment into the womb). A recent review of the effect of smoking on IVF outcomes has confirmed that smoking patients have a significantly lower chance of live birth and clinical pregnancy per cycle, and a significantly higher risk of spontaneous miscarriage and ectopic pregnancy than non-smoking patients. (Waylen et al. Hum Reprod Update 2009).
• Reduce or eliminate consumption of alcohol as it may affect ovulation. In addition, there is an increasing body of evidence suggesting harm to the fetus from alcohol consumption during pregnancy including increased rate of miscarriage, growth retardation, prematurity, higher risk of addiction to alcohol and other drugs. and developmental delay. Furthermore, excess alcohol during pregnancy is associated with fetal abnormalities such as 'Fetal Alcohol Syndrome'. The syndrome (FASD) can lead to learning and physical disabilities and behavioural problems and a higher risk of addiction to alcohol and other drugs. It is estimated that around 3.2% of babies born in the UK are estimated to be affected by FASD.BMJ 2019
• Do not use recreational drugs e.g. marijuana, cocaine, etc. or antidepressant drugs. The use of Cannabis by women in the year before IVF treatment is associated with a reduction of the number of eggs collected (Klonoff-Cohen et al, 2006. American Journal of Obstetrics and Gynecology). It is also associated with preterm birth and low birth weight. Heroin is associated with miscarriage, growth restriction and preterm birth.
• Breast self-examination will help to pick up a breast lump. Breast cancer is rare in young women. However, the high levels of hormone estradiol and progesterone produced by the ovarian stimulation drugs could stimulate the growth of a pre-existing cancer. If you find a lump in your breast, your doctor should assess this urgently. He or she will be able to arrange further evaluation and referral to a specialist when necessary.
• Stop or reduce the caffeine intake. Caffeine is present in coffee, tea, coca-cola, chocolate etc. and is associated with an increased risk of fetal growth restriction (Care study group 2008 BMJ), miscarriage and low birth rates (Fernandos 1998 and Cnattingius, 2000). Decaffeinated coffee could aggravate the immune system more than caffeinated variety (Mikuls et al 2003).A recent study from Denmark suggested heavy coffee drinking was as bad as smoking for IVF success rates.
• Avoid cat litter and under cooked meat to reduce the risk of catching toxoplasmosis in pregnancy. Toxoplasmosis may cause brain damage to the fetus.
• Keep your mouth as healthy as possible and, if you have periodontal disease, get this treated before you become pregnant. There is evidence that treating periodontal disease reduce the risk of having a preterm baby.
• If you suffer from chronic medical condition and on regular medications such as high blood pressure, epilepsy, diabetes and asthma etc., check with your doctor if these medications are safe in pregnancy. For example if you are taking ACE drugs such as Ramipril to control high blood pressure, this drug is not safe in pregnancy as it can cause skull abnormalities and renal failure in the fetus. Your doctor may change it to safer drugs such as methyldopa, labetalol or Nifedipine. Preconception counselling for women with chronic medical condition such as heart disease or kidney problem should not be aimed at discouraging women from becoming pregnant rather it should empower them to make informed choices.
• Women who have epilepsy and are taking medication. Valproate in pregnancy is associated with 11% increased risk of birth defects and 30-40% neurodevelopmental disabilities. In the UK, since 2018 valproate has been contraindicated in women of child bearing age., Women who have diabetes should consult their doctor to check their diabetes is under control.

Screening by your doctor or clinic

• Check if you are immune to Rubella (German measles) as Rubella puts babies at risk of blindness, deafness, mental retardation and heart defect. Women who are susceptible to rubella should be offered rubella vaccination before they become pregnant.The vaccine is injected into the muscle of the upper arm. Women should avoid conception for at least 1 month following vaccination.
• Check if you are immune to chickenpox. Nine out of ten pregnant women (90%) in the UK are immune to chickenpox. If you are not immune; have the vaccine. The chickenpox vaccination is effective in making nine out of ten women (90%) immune. The vaccination cannot be given in pregnancy and you should avoid getting pregnant for 3 months after the injection Primary infection with herpes varicella zoster virus (VZV), in pregnancy may cause maternal mortality or serious complications such as inflammation of the lungs (pneumonia) and inflammation of the brain (encephalitis). It may also cause fetal varicella syndrome. If you are pregnant and you are not immune, avoid contact with any person who has chickenpox or shingles and to immediately inform healthcare workers of a potential exposure(FVS).
• Check if your cervical smear (PAP test) is in date.
• Check if you have a high blood pressure.
• Check if you are anemic.
• Check if you are diabetic (indicated by sugar in the urine).
• Check If you have got kidney disease (indicated by protein in the urine).
• Check if you have got genital infection (many genito-urinary infection are asymptomatic).
• Patients who are concerned about their fertility and who are known to have chronic viral infections such as hepatitis B, hepatitis C or HIV should be referred to centres that have appropriate expertise and facilities to provide safe risk-reduction investigation and treatment
• Check your dental health.
• Testing for HIV, hepatitis B or hepatitis C if appropriate to minimize the viral load and reduce the risk of transmission to the fetus.
• Request certain tests to check for genetic diseases, if there is a history of genetic disorders or for certain ethnicity group, Sickle cell, thalassemia and cystic fibrosis;.

Occupation

Some occupations may reduce male and female fertility such as bakers, drivers, welders, radiotherapists, agricultural workers and woodworkers. The exposure to heat, X-rays, chemical pesticides, solvents, mercury, phthalates etc. may all contribute to infertility.

Folic acid

It is advisable that woman who are contemplating pregnancy should take folic acid (Vitamin B9), one tablet a day (400 mcg) till the 12th week of pregnancy. This will decrease the risk of neural tube defects such as spina bifida (a hole in the spine) and anencephaly (absent brain) and hydrochephaly (water in the brain). This dose should be increased to 4 mg daily in women who have previously had a baby with a neural tube defect.

Researchers from Norway have founded a link between periconceptional folic acid supplements in women and a lower risk of autistic disorders in their young children 0.1% compared to 0.2% in women who took none (BMJ 2013).

If you are not very keen to take folic acid tablets you need to eat food which is rich in folic acid such as spinach, green beans, fortified cornflakes and oranges.

Batool and colleagues from USA reported that daily iron use before pregnancy improved outcomes and birth weight.(BMJ, 2013)

Advice for men

• Wear loose fitting boxer shorts and trousers. There is an association between elevated scrotal temperature and reduced semen quality.
• Avoid hot baths and take showers instead. Higher temperatures are known to affect sperm production and the testicles hang down from the body in men to cool them. Finish study (2013) demonstrated the effect of sauna on men sperm. In the study, men in their 30s with normal sperm counts spent 15 minutes in a sauna two times a week for three months, after which they stopped visiting the sauna. The sauna sessions lowered the men's sperm counts, and they remained below normal for three months after the men stopped visiting the sauna, compared with the levels at the study's start. After six months, however, sperm counts returned to normal.
• Cut down smoking and alcohol drinking or stop altogether. Men who smoke heavily or drink too much appear to have lower sperm motility and a higher proportion of abnormal sperm and impair the fertilising capacity of the sperm by reducing mitochondrial activity and increase DNA damage (Fertility and Sterility, 2007, Reprod Biomed Online, 2009).
• have a good healthy diet; men consuming omega-3 fatty acids were found to have sperm with a more normal structure and higher concentration (count) than men who consume junk food diets with high levels of saturated fats.
• If overweight they should loose weight. Men who have a BMI of 30 or over are likely to have reduced fertility possibly due to DNA damage, decrease libido and erectile dysfunction.
• They should avoid exposure to chemicals and radiations etc.
• Sperm DNA damage caused by oxidative stress may be the cause of male infertility in 30% to 80%. Recent evidence suggests that antioxidant supplementation in subfertile males, including carnitines, vitamin C, vitamin E, selenium, zinc and coenzyme Q10, improves semen quality and live birth rates in couples undergoing fertility treatment.
• Men who are taking Valproate and who are planning a family should consider alternative drug. A study showed around 5 in 100 children born to fathers treated with valproate in the three months before conception subsequently had a neurodevelopmental disorders compared to 3 children whose fathers were taking alternative antiepilepsy drugs such as lamotrigine or levetiracetam.