Historically, obstetricians have been hesitant to advise non-exercisers to become active and many have recommended that women tame the vigor of their exercise regimens with pregnancy. It is assumed that these cautions are attributed to the lack of evidence regarding safety of exercise in pregnancy.

Recently a study was undertaken to evaluate fetal well-being in women with otherwise healthy pregnancies (low-risk). Women studied included those who exercised < 60 minutes weekly, > 60 minutes weekly and those who described themselves as “highly active” exercising > 4 days weekly.  These three categories of women were then subjected to aerobic exercise and their aerobic capacity was monitored as well as was the fetal response in utero. Although there was transient increase in fetal heart rates mirroring the increases in the maternal heart rate with exercise; no immediate or long term adverse effects were noted.

Healthy mothers make healthy children. The benefits of exercise extend to the mother and fetus alike. Women, in conjunction with approval from their obstetricians, should be comfortable following established guidelines.

Many hypotheses have been proposed for acupuncture’s mechanism and nearly all of these have been prefaced with the word “may”.  Acupuncture may modulate ovarian blood flow, may increase uterine blood flow, may inhibit uterine irritability, may reduce anxiety and may modulate immune function.  A study of 34 IVF patients receiving multiple acupuncture treatments showed higher levels of cortisol and prolactin in intermittent cycle days as compared to non-acupuncture patients.  Acupuncture patients in this small study also had a higher clinical pregnancy rate (51% vs 37%) but no definitive association with increased cortisol and pregnancy could be made.  More recent evaluations pooled results of multiple acupuncture studies in a “meta-analysis”.  A Chinese study of over 5000 pooled patients (Fertil Steril March 2012 97(3):599-611) concluded that acupuncture improves live birth rate in IVF patients.  A similar meta-analysis in London of 2500 women ( BJOG 115(10):1203-13) showed no difference in pregnancy rates when using acupuncture.  A Chicago study of 168 patients randomized to acupuncture (Fertil Steril 95(2):583-7) also showed no statistically significant difference in pregnancy rates.

So, 10 years after the initial acupuncture study, where do we stand?  The general consensus is that it may help and it does not seem to hurt.  No large study showed detrimental effects of acupuncture.  There is a patient consensus that acupuncture reduced their anxiety associated with the IVF process and that alone may be cause to pursue its use.

Evidence has accumulated for the role of Vitamin D in maintaining glucose homeostatsis –effectively, reducing the tendencies toward diabetes.  In a relatively recent study of women both deficient and repleted in Vitamin D, those women with lower circulating blood levels were 2-fold more likely to be diagnosed with Gestational Diabetes Mellitus (diabetes in pregnancy).

It also has been proposed that adequate Vitamin D levels during pregnancy may afford protection against the risk of Type I Diabetes in early childhood.  In a large population study performed in Norway representing over 29,000 women, it was reported that women deficient in Vitamin D in pregnancy had a higher tendency toward diabetes in their offspring.  Women with adequate Vitamin D were 2-fold less likely to have a child with diabetes then their Vitamin D-deficient counterparts. (Sorensen et. Al.  Diabetes 2012. Jan; 61(1):175-8.)

Maintaining adequate Vitamin D levels will not abolish childhood diabetes, but it may lower its frequency.

Simplistically, to maintain your weight, approximately 15 calories per pound are required if you lead a very active life style. In older women who are active, 13 calories per pound is all that is needed, and for those who are relatively inactive, only 10 calories per pound are necessary to maintain current weight.

To lose weight, you should subtract 500 calories from your maintenance caloric level, while to gain weight, you would need to add 500 calories.  Therefore, if your maintenance caloric needs are 2,000 calories per day, you should consume no more than 1500 calories each day to lose approximately one pound per week.  If you are very inactive, have a difficult time losing weight, or are obese (Obese=BMI > 30,  which for a 5 foot 5 inch tall women would be a weight over 180 pounds), then you should consume no more than 9 calories per pound which would be no more than 1680 calories for a 5 foot 5 inch tall woman who was 180 pounds.

No diet works for everyone. Each plan must be tailored to suit the individual. A diet should not be thought as short term but rather as a healthy lifestyle choice.  Select lower glycemic index carbohydrates like whole grains, fruits, vegetables and legumes instead of rice, potatoes, white bread, and sweets.

Prepare balanced meals.  Select healthy unsaturated fats and eliminate saturated and trans fats. Include omega 3 fats found in fatty fish like salmon, canola oil, leafy green vegetables, and walnuts.  Beware, however, of very low fat diets, as these may lead to food cravings. Don’t  go overboard on fats as one tablespoon of olive oil contains 120 calories.

Aerobic exercise is an important  component of maintaining a healthy life style. Three to four 20-30 minute brisk walks every week is sufficient especially if combined with resistance training using light weights and more repetition.

Make small changes one at a time. Get adequate sleep and practice stress management. Vitamin and mineral supplements are also worthwhile and should include a standard multivitamin with at least 400 mcg of Folic Acid. Additional daily supplements of Vitamin D, 2000 IU together with 1500 mg of Calcium (equivalent to 2 Extra Strength Tums tablets) has been shown to enhance egg and embryo quality especially in women with ovulation dysfunction and endometriosis. B complex should be taken if you have PCOS and are taking Metformin.  Approximately 1-2 grams of mega 3 fatty acids should be taken if you are not eating fatty fish at least 3 times per week.

Weight management can be frustrating.  However, you can empower yourself to be healthier and thereby improve your chances for a successful pregnancy. This can be done using common sense by making a few healthy lifestyle choices.

• Oral thyroid hormone is indicated for women who demonstrate overt hypothyroidism.
• Hypothyroidism is associated with an increased risk of miscarriage and preterm birth.
• Women with subclinical hypothyroidism and thyroid antibodies should be treated as well.
• Women receiving thyroid replacement should increase their dose by  at least 25% when they become pregnant
• Two pills on the weekends should meet the needs for pregnancy.
• (TSH) Serum hormone levels should be monitored every month through 20 weeks then at least once between 26-32 weeks gestation.
• TSH range should be 0.1-2.5 mIU/L for the first trimester increasing to 0.2-3.0mIU/L for the second trimester and 0.3-3.0mIU/L for the last trimester.
• The RDA of Iodine is 250ug daily not to exceed 500ug daily from diet and/or supplements.

Remember, healthy mothers make healthy babies.  Optimizing your chances and affording you the healthiest pregnancy possible favors great outcomes!

Not surprisingly, patients search for both emotional and physical signs to affirm or deny the potential of pregnancy; all while watching the calendar turn at a turtle’s pace.  One becomes hyperaware of weight, the body’s reaction to elevating progesterone and the psychologic stress involved.  The amount of rent-free brain space afforded to becoming pregnancy often is greater than prior to presenting to the fertility center to initiate treatment.

This two-week time between anticipated fertilization and pregnancy test is related to biology.  Once the embryo is created from fertilization of the egg by the sperm, the embryo must develop.  As it develops, the implanting blastocyst (stage of embryo development) becomes more specialized forming both the fetus and the placenta.  This placental tissue much reach a critical mass as it is releasing pregnancy hormone into the maternal circulation.  Pregnancy hormone is hCG (human chorionic gonadotropin).  Patients return to the center on one of the first days that this level can be detected accurately.

We recommend that patients refrain from performing home pregnancy tests as they are not as sensitive as blood levels and can render both false-positive as well as false-negative results; thus, they can provide more angst than affirmation.

Pregnancy hormone, along with progesterone (natural and supplemented) causes very rapid transitions in the women’s body in preparation for providing the most accommodating environment for the pregnancy.   Some women perceive these changes and some do not.

They symptoms can include a perception in ability in changes in respiratory rate – pregnant women tend to breathe more rapidly with more shallow breathes; Bloating and constipation can be an issue – intestinal motility slows so maximal nutrition can be pulled from the gut.   Breast soreness and tenderness is a direct effect from progesterone exposure and it is exceedingly difficult to make it not noticeable.  Having more symptoms does not mean that pregnancy did not occur.  Ironically, many women are more hopeful the more uncomfortable they become.

One of the best ways to get through this time is to keep one occupied.  A calendar with daily projects and activities will help to pass the time.  Women should continue their healthful diets and ways as well continue to take their prenatal vitamins as discussed previously with their health care teams.  Remember, healthy mothers make healthy babies.

Caffeine
Studies have shown that small amounts of caffeine are not necessarily detrimental to conceiving. Caffeine intake of up to one-to two cups of coffee per day has not been shown to decrease fertility. However, caffeine consumption greater than five cups of coffee per day has been associated with decreased fertility up to 50%. Also, consumption of 2-3 cups of coffee per day has been associated with an increased likelihood of miscarriage but does not affect risk of congenital anomalies. In summary, women who consume 1-1.5 cups of coffee per day, before and during pregnancy, should experience no adverse effects on fertility or pregnancy outcome.

Alcohol
Small amounts of alcohol prior to conception, up to 3-4 glasses per week, have also not been shown to decrease a woman’s fertility. Greater than two alcoholic drinks per day has been shown to decrease fertility in women. Certainly, once a woman believes she may be pregnant, she should, without question, abstain from all alcohol intake.

Patients who consume more than the above recommended amount of caffeine or alcohol should decrease their intake. However, it not necessary to bring intake of caffeine and alcohol down to zero.

Diet and Weight
Women who are significantly underweight (BMI<19) and women who are significantly overweight (BMI>35) will experience a 2-4 fold increase in time to conception. However, there is little evidence that specific dietary variations, such as low-fat diets, or vegetarianism, affect fertility. Women attempting to conceive should take 400 micrograms of folic acid. This is to reduce the risk of neural tube defects in the fetus. To calculate your own BMI, go to this link: http://www.nhlbisupport.com/bmi/.

Smoking
Smoking (even small amounts) has substantial negative effects on fertility. Women who smoke cigarettes have a 60% increased risk of infertility, as well as an increased risk of miscarriage. Additionally, women who smoke cigarettes go through menopause an average of 1-4 years earlier compared with women who do not smoke.  Smoking cigarettes appears to cause increased loss of healthy eggs. Smoking marijuana seems to have similar negative effects on fertility.

Men
When it comes to men attempting to conceive, small amounts of alcohol and caffeine use do not appear to adversely effect sperm parameters (density, motility, and abnormalities in morphology). However, cigarette smoking and marijuana use have been shown to decrease all sperm parameters. Severly overwight men also have decreased sperm parameters and decreased fertility.

In Sum
As Aristotle  wrote 2,500 years ago, “Everything in Moderation”: there is no need to be an ascetic while trying to conceive.

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Uterine fibroids are associated with miscarriages and may be a cause of recurrent pregnancy loss.  A recent study from the United Kingdom (Human Reproduction 26:3274;2011) found that the intrauterine cavity was distorted by fibroids in 8.2% of women with a history of recurrent pregnancy loss.  They also found that surgical removal of these intrauterine fibroids increased the chance of their next pregnancy delivering a healthy baby by as much as 50%.  This study exemplifies the importance of a thorough evaluation including intrauterine cavity assessment for women with a history of recurrent pregnancy loss so that intervention can occur to prevent another miscarriage.