Fertility, PCOS, preconception care
Preconception care has more myths than any other area of reproductive medicine
Quick answer
Female evidence base: folic acid or L-methylfolate 400 mcg/day three months before conception, iodine 150–250 mcg/day in deficient regions, correcting vitamin D to 30–50 ng/mL, controlling hypothyroidism and diabetes. PCOS: myo-inositol 4 g + D-chiro-inositol 100 mg (40:1 ratio) improved ovulation in Cochrane 2022, metformin in insulin resistance. Male fertility: omega-3, CoQ10 200–600 mg/day, zinc, selenium gave a modest improvement in semen parameters in Cochrane 2019. Mega-antioxidant blends without rationale do not help.
Some recommendations (folic acid three months before conception, vitamin D status, no alcohol or smoking) are RCT-backed and in ACOG, ESHRE and ASRM guidance. Others (maca, antioxidant stacks, hormesis blends) come in pretty bottles and do not survive RCTs. The selection splits drugs and supplements into three scenarios: female preconception, PCOS therapy, male fertility.
Female preconception
Supplements with an evidence base for preconception care. All are from ACOG Committee Opinion 762, NICE Antenatal Care 2021 and ESHRE Preconception Guidelines.
PCOS: therapy and supplements
Drugs and supplements in polycystic ovary syndrome. Evidence varies: metformin and inositols are RCT-confirmed, the rest comes with caveats.
Male fertility
Supplements that showed improvements in semen parameters in meta-analyses. Evidence is moderate, the effect is modest but measurable.
Drugs related to fertility
Metformin, clomiphene, letrozole, gonadotropins, progesterone and estradiol form the backbone of drug therapy in reproductive medicine. Every card lists indications, regimens and contraindications.
Frequently asked
How many months before conception should folic acid be started?
Three months minimum, ideally 4–6 months. Dose 400 mcg/day for most women, 800–1000 mcg in BMI over 30, T1D/T2D, epilepsy on valproate, previous pregnancy with a neural tube defect. Form: folic acid or L-methylfolate (5-MTHF); in MTHFR variant carriers the methylated form is absorbed better, but clinical outcomes are comparable per Cochrane 2015.
Inositol in PCOS – does it actually work?
Yes, in the right form and dose. The combination myo-inositol 4 g + D-chiro-inositol 100 mg (40:1, the plasma physiological ratio) improved ovulation and reduced insulin resistance in Cochrane 2022 and the ESHRE Guideline 2023. Course at least 3–6 months. Isolated high-dose D-chiro-inositol worsens oocyte quality and is not recommended.
Does CoQ10 help men with poor semen analysis?
Moderately. A Cochrane 2019 meta-analysis (3 RCTs, 297 men) showed that CoQ10 200–600 mg/day for 3–6 months raised sperm concentration and motility by 15–25% on average. The effect on pregnancy rate is poorly estimated. Use is justified in idiopathic male infertility after ruling out varicocele, genetic causes and infections.
Which fertility supplements lack an evidence base?
Maca (Lepidium meyenii), DHEA in women under 35 without a POI diagnosis, bovine or placental blends, homeopathic preparations, essential oils marketed for “cycle harmonization” or “ovary detox”, antioxidant blends without rationale in couples with a normal semen analysis. They come in expensive packaging, but the RCT effect does not exceed placebo.
How Evigrade helps in fertility
Most preconception resources either sell supplement stacks or stop at “take folic acid”. Evigrade shows the evidence tier (A/B/C/D/F) for each supplement, excluded scenarios (e.g. maca without confirmation in men under 40), and drug interactions – important for PCOS patients on metformin or hypothyroidism on L-thyroxine.
Primary sources
ESHRE PCOS International Evidence-Based Guideline 2023, ASRM Practice Committee Opinions (preconception care, optimizing natural fertility), ACOG Committee Opinion 762 (folic acid), NICE Antenatal Care 2021, Cochrane Reviews on myo-inositol/CoQ10 and fertility, AEMPS, EMA SmPC. Every card has a full list of references.