Folate and Fertility
All you need to know about Folate and Folic Acid for fertility and pregnancy

What the folate?

Folate is an essential B vitamin, naturally occuring in food, predominantly in green leafy vegetables. Folic Acid on the other hand is the synthetic forms of Folate. The body needs Folate before conception and during pregnancy to prevent neurological defects, (spina bifida) in the developing foetus. When you’re growing a baby, cells are dividing like rapid fire and by the end of the first trimester your baby’s neural tube has closed. Insufficient Folate during this period is associated with spina bifida and miscarriage. 

This is why it’s important to have optimal levels of Folate prior to conception. To make things a little more confusing is that there are different forms of Folate. So let me explain: the body converts Folate into the ‘active form’ 5-MTHF also known as Levomefolic Acid (or methylated folate). Folic Acid is the synthetic form of Folate commonly found in supplements, food fortification and another synthetic form is Folinic Acid. All of these are converted to 5-MTHF in the body which is what the body uses for the cell division etc. 

So when should you start taking Folic Acid? START before you STOP the pill 

Often we think we’ll take ages to fall pregnant, but for some, it can happen straight off the bat. Did you know that 40% of NZ pregnancies are unplanned? Some don’t even know they’re pregnant until 7 weeks. By which time that neural tube has already closed and so too has the need for Folate. Hence, an adequate intake of Folate prior to conception is really important. Adding more importance to preconception supplementation is research that shows the Pill (OCP) can reduce our absorption of certain nutrients, Folate being one of them, and so too can alcohol.

A supplementation period of 3 months prior to conception and during your first trimester of pregnancy is recommended. This ensures optimal folate stores to prevent NTDs. So, if you’re planning on stopping the pill, supplement with Folic Acid for 3 months before you stop to make sure you’re covered. Preconception nutrition counts! So how much Folic Acid should we take?

Choose your dose

The recommended daily intake of Folate in NZ for women is 0.4mg/day, which increases to 0.6mg/day for pregnant women. However, PHARMAC only fund a supplement of 0.8mg or 5mg. The most common dose prescribed in NZ is the 0.8mg dose. This will provide sufficient amounts of Folic Acid for the prevention of Neural Tube Defects. However, in some cases, you need a much higher dose of FA:

– BMI >30kg/m2

– taking anticonvulsant medication

– have diabetes, 

– have a family history or have a neural tube defect such as spina bifida occulta

– Increased risk of malabsorption i.e., crohns disease 

In these cases, you will require 5mg Folic Acid daily, three months prior to conception and during your first trimester of pregnancy. Remember if you’re taking a multivitamin, this too will contain Folic Acid or another form and will contribute to your total dose. If you’re not sure what dose you should be on, or how much is in your current Multi; check with a Dietitian who specialises in this area, who can give you peace of mind.  

Folic Acid beyond the First Trimester  

So, as we’ve established the purpose of supplementing with Folic Acid is primarily to prevent neural tube defects. The spinal cord closes during the first trimester. After this point, no amount of folic acid will impact the risk for NTDs, because the spinal cord has already been formed. You know the recommended daily intake (RDI) of Folate for pregnancy is 0.6mg/day, which is what you should have for the duration of your pregnancy. BUT, if you’ve needed a higher dose (5mg/day) then once you hit second trimester, you should be dropping your dose back to the RDI. 

What’s the problem with just carrying on with the high dose I hear you say? Well, research published by the Boston Birth Cohort showed women who had very high levels of Folate (>60.3nmol/L) at birth, had babies with 2.5 x increased risk of developing Autism. It’s important to note they also showed adequate Folic Acid intake during pregnancy was associated with a reduction in risk for congenital heart defects and orofacial clefts. 

So it remains essential that you DO supplement with Folic Acid; ensuring you start 3 months prior to conception. But choose the correct dose for your individual risk, and once you hit the second trimester, regardless of your risk, reduce your dose so you’re getting the RDI of 0.6mg/day.

What type of Folic Acid?

Well, you’re probably quite confused about which type to choose. You’re not alone; it is confusing. Basically, in a small number of people they have a gene defect (MTHFR) which makes it hard for them to break down Folate, Folic Acid and Folinic Acid into 5-MTHF. Therefore, 5-MTHF is a good substitute to Folic Acid in those people. But how do you know if you have that defect?

Well, you can get a genetic test, but that’s costly and there isn’t sufficient evidence to suggest that all women should be tested. By far, the evidence to date emphasises choosing your dose based on your medical and family history and supplementing prior to conception are the key factors. Some prenatal supplements have a mixture of the differing types of Folate which can be a good option. The most important thing is to consult with a Dietitian who works in the pregnancy, fertility area. They can customise the right supplement for you, because there is no one size fits all. 

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