When should we start preparing to conceive?

Start about 3 to 6 months before you want to begin trying. Eggs take roughly 90 days to mature and sperm take about 72 to 90 days to build, so the habits of the previous season are written into the cells at conception. 3 months is enough for supplements, training, and the stop list to work; 6 months adds room to fix anything the labs find, like low ferritin or a thyroid that needs adjusting.

How much choline do I need before and during pregnancy?

The target is about 450 to 550 mg of choline a day, from food and supplement combined, ideally starting before conception because the fetal brain and spinal cord form in the earliest weeks. Egg yolks are the best food source at roughly 150 mg each, and many popular prenatals contain little or no choline, so check the label and cover the gap deliberately.

When should we start preparing to conceive?

Start about 3 to 6 months before you want to begin trying. Eggs take roughly 90 days to mature and sperm take about 72 to 90 days to build, so the habits of the previous season are written into the cells at conception. 3 months is enough for supplements, training, and the stop list to work; 6 months adds room to fix anything the labs find, like low ferritin or a thyroid that needs adjusting.

How much choline do I need before and during pregnancy?

The target is about 450 to 550 mg of choline a day, from food and supplement combined, ideally starting before conception because the fetal brain and spinal cord form in the earliest weeks. Egg yolks are the best food source at roughly 150 mg each, and many popular prenatals contain little or no choline, so check the label and cover the gap deliberately.

Preconception Planning in Philadelphia: The 90-Day Runway

TL;DR30-second take

Yes, Fishtown Medicine builds preconception plans, for both partners, and the ideal runway is about 90 days because that is roughly how long an egg takes to mature and a sperm takes to be built. The plan has 5 parts: labs first (thyroid with a TSH goal under 2.5, fasting insulin, ferritin, vitamin D, B12, and methylation status); the nutrients most prenatals miss, led by choline at 450 to 550 mg a day; CoQ10 as ubiquinol for egg and sperm quality, most relevant over 35; strength training 2 to 3 days a week plus zone 2 cardiovascular conditioning, because pregnancy is a months-long metabolic and cardiovascular event worth training for; and the stop list, from alcohol to hot tubs to medications that quietly work against fertility. Dr. Ash partners with your OB or midwife rather than replacing them.

TL;DR: The egg that ovulates this month started maturing about 90 days ago, and the sperm that meets it took about the same time to build. That means the healthiest possible conception is planned a season in advance, by both partners. The plan is not complicated: run the right labs, close the nutrient gaps most prenatals miss (choline above all), add CoQ10 when age or labs argue for it, build strength and cardiovascular conditioning while training is still easy to start, and clear the stop list. This is the runway we build at Fishtown Medicine, in partnership with your OB or midwife.

Most preconception advice begins and ends with "take a prenatal and stop drinking." Both are correct, and they are maybe a fifth of what the evidence supports. The couples who feel best through pregnancy, and recover fastest after it, tend to be the ones who treated the months before conception as preparation rather than waiting.

The biology sets the schedule. A follicle spends roughly 90 days maturing before it releases an egg, and spermatogenesis runs about 72 to 90 days from start to finished sperm. The choices either partner makes today are written into the cells that will meet 3 months from now. That is not pressure; it is opportunity, because it means almost everything below has time to work.

What labs should we run before trying?

Labs come first because they tell us which parts of the plan matter for you, and the panel goes past "you're healthy, good luck." The core set we run at Fishtown Medicine:

Thyroid, read tightly. The lab's reference range for TSH runs to about 4.0, but for conception we want it under 2.5, with free T4 and TPO antibodies checked, because a struggling thyroid raises miscarriage risk and drags energy through pregnancy. Our fertility optimization guide covers why the standard range is too loose here.
Insulin and glucose. Fasting insulin under 7, plus A1C. Quiet insulin resistance degrades egg quality, complicates implantation, and sets up gestational diabetes later. This is also where training earns its place, which is coming below.
Ferritin above 50. Pregnancy consumes iron aggressively. Starting low means spending 9 months behind.
Vitamin D at 50 to 70 ng/mL, checked rather than guessed, because Philadelphia winters almost guarantee a gap.
B12, homocysteine, and methylation status, which decide whether methylated folate beats standard folic acid for you.
For the partner: a semen analysis when anything in the history suggests it, and the same metabolic labs, because sperm are built by the same body systems.

Which nutrients do most prenatal plans miss?

The prenatal aisle is where good intentions go to get diluted, and the full teardown lives in our prenatal supplement guide. The short version for the preconception window:

Choline is the headline gap. It is essential for fetal brain and spinal cord development, the target is about 450 to 550 mg a day between food and supplement, and many popular prenatals contain little or none. Eggs are the food answer (a yolk carries about 150 mg), and a supplement covers the rest. Starting before conception matters because the neural tube forms in the first weeks, often before a positive test.
Folate, in the right form. 400 to 800 mcg daily starting at least a month before trying. If your methylation labs argue for it, methylated folate (5-MTHF) instead of synthetic folic acid.
Iodine and omega-3 DHA, both common gaps in an American diet and both cheap to fix.
Iron, dosed to your ferritin, not to a label.

A prenatal with an NSF or USP seal, a meaningful choline dose, and methylated B vitamins covers most of this. The point of the labs is to personalize the rest instead of stacking pills on faith.

Should we take CoQ10?

CoQ10 is the supplement with the best case in the preconception window, and it still deserves honest framing. Eggs and sperm are among the most energy-hungry cells in the body, each one running on mitochondria that age with the rest of us. Trials suggest CoQ10 can improve sperm count, motility, and morphology, and may protect egg quality from oxidative stress, with the signal strongest for people over 35. That is "suggest," not "prove," and we say so plainly.

When it fits, we use the ubiquinol form at 200 to 600 mg daily, split with meals that contain fat, for both partners, ideally through the full 90-day runway. The CoQ10 clinical guide covers forms, dosing, and who should skip it.

Why does strength training belong in a preconception plan?

Because muscle is the largest insulin-sensitive tissue you own, and insulin sensitivity is fertility infrastructure. Every pound of trained muscle gives glucose somewhere to go, which steadies blood sugar, calms the hormonal environment eggs mature in, and measurably lowers the risk of gestational diabetes later. Strength also carries the mechanical load of pregnancy: a trained back, core, and hips handle the third trimester and the recovery after delivery in a way an untrained body has to improvise.

The preconception window is also simply the right time to start. Obstetric guidance supports continuing established exercise through a healthy pregnancy, and it is far easier to continue a practice than to begin one mid-pregnancy. The prescription is unheroic: 2 to 3 days a week of compound movements (squat or leg press, hinge, press, row), weights that feel like effort by the last few repetitions, progressed gradually. If you have never lifted, a few sessions with a good coach now pays off for the next 2 years.

This applies to both partners. The metabolic health that builds a good egg builds good sperm on the same timeline.

Why does cardiovascular conditioning matter before pregnancy?

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Pregnancy is a months-long cardiovascular event, and it helps to train for it like one. Blood volume expands by roughly 40 to 50%, cardiac output climbs, and by the third trimester the heart is doing more work at rest than it did before conception on a brisk walk. A body with an aerobic base handles that ramp with room to spare; a deconditioned one feels it as breathlessness, fatigue, and a harder labor and recovery.

The base is built the boring way: mostly zone 2, meaning 150 minutes or more a week of work at a pace where you can still speak in sentences - brisk walking with hills, easy cycling, swimming, the Schuylkill River Trail counts. Add stairs or short pickups once the base exists. None of this requires a gym membership or a race bib, and every week of it before conception is capacity you will spend gladly later.

What belongs on the stop list?

The subtractions matter as much as the additions, and 90 days is enough time for most of them to pay off:

Alcohol, for both partners. It measurably degrades sperm parameters and egg quality, and there is no established safe dose once you may be pregnant.
Smoking and vaping, the single strongest lifestyle lever for fertility in either partner.
Heat on the testes: hot tubs, saunas, and laptops parked on laps suppress sperm production for the full 90-day cycle that follows.
A medication review, done properly. Finasteride, testosterone therapy (which suppresses sperm production, sometimes profoundly - our male fertility guide covers preserving fertility on TRT), retinoids, and several common prescriptions deserve a planned exit or a swap, not a panicked one after a positive test.
Ultra-processed load, traded for the protein, eggs, fish, legumes, and produce that carry the nutrients above in their food form.

How does Fishtown Medicine run the preconception plan?

As one plan for 2 people with one physician reading all of it. The labs go in on day one for both partners, the results get read together with no timer, and the plan that comes out covers the nutrients, the training, the stop list, and the timeline, personalized to what the numbers found. When something needs a specialist, a reproductive endocrinologist, a urologist for a semen-analysis finding, we reach out on your behalf and fold the answer back into the plan.

And the boundary is worth stating plainly: we are the architects of the soil, not your OB. Pap smears, pelvic exams, and pregnancy care itself belong with your OB or midwife, and we coordinate with them rather than replacing them. What we own is the metabolic, hormonal, and conditioning groundwork that makes their job, and your pregnancy, easier.

Key Takeaways

The runway is 90 days, for both partners. Eggs and sperm maturing today carry today's habits into conception a season from now.
Labs first: TSH under 2.5 with antibodies, fasting insulin under 7, ferritin above 50, vitamin D 50 to 70, B12 and methylation status, and a semen analysis when history calls for it.
Choline is the gap most prenatals miss: 450 to 550 mg a day, started before conception. CoQ10 (ubiquinol, 200 to 600 mg) earns its place for many, most clearly over 35.
Train for it: strength 2 to 3 days a week builds the insulin sensitivity fertility runs on, and zone 2 cardio builds the base a 40 to 50% blood-volume expansion will draw against.
Subtract deliberately: alcohol, smoking, testicular heat, and a planned medication review beat a panicked one after a positive test.

Scientific References

Gaskins AJ, Chavarro JE. "Diet and Fertility: A Review." American Journal of Obstetrics and Gynecology. 2018;218(4):379-389.
Caudill MA, Strupp BJ, Muscalu L, Nevins JEH, Canfield RL. "Maternal Choline Supplementation During the Third Trimester of Pregnancy Improves Infant Information Processing Speed: A Randomized, Double-Blind, Controlled Feeding Study." FASEB Journal. 2018;32(4):2172-2180.
Wallace TC, Blusztajn JK, Caudill MA, et al. "Choline: The Underconsumed and Underappreciated Essential Nutrient." Nutrition Today. 2018;53(6):240-253.
Ben-Meir A, Burstein E, Borrego-Alvarez A, et al. "Coenzyme Q10 Restores Oocyte Mitochondrial Function and Fertility During Reproductive Aging." Aging Cell. 2015;14(5):887-895.
Salas-Huetos A, Bulló M, Salas-Salvadó J. "Dietary Patterns, Foods and Nutrients in Male Fertility Parameters and Fecundability: A Systematic Review of Observational Studies." Human Reproduction Update. 2017;23(4):371-389.
American College of Obstetricians and Gynecologists. "Physical Activity and Exercise During Pregnancy and the Postpartum Period: Committee Opinion No. 804." Obstetrics & Gynecology. 2020;135(4):e178-e188.

Fertility Optimization & Pre-Conception Health - the lab-by-lab workup this plan is built on
The Prenatal Supplement Trap - how to vet a prenatal, and the choline gap in detail
CoQ10 Clinical Guide - forms, dosing, and who benefits
Male Fertility on TRT - preserving fertility when testosterone therapy is part of the picture
Postpartum Care in Philadelphia - the other end of this runway, planned the same way

Fishtown Medicine | Playbooks

2418 E York St, Philadelphia, PA 19125(267) 360-7927 hello@fishtownmedicine.comHSA/FSA Eligible

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Frequently Asked Questions

Common Questions

Yes, preconception planning is one of the practice's core uses: a 90-day (or longer) runway built for both partners, covering labs, nutrition, targeted supplements like choline and CoQ10, strength and cardiovascular training, and a medication and lifestyle stop list. Dr. Ash runs the workup, reads the results with you with no timer, and partners with your OB or midwife rather than replacing them. Start the intake and note where you are in the process.

CoQ10 is a reasonable addition for many couples, with honest framing: trials suggest it can improve sperm count, motility, and morphology and may protect egg quality, with the strongest case over age 35, but the evidence is suggestive rather than settled. Fishtown Medicine uses the ubiquinol form at 200 to 600 mg daily with meals for both partners through the runway, and skips it when the picture does not call for it.

Yes, and you should, if you are healthy and the training is established. Strength work improves the insulin sensitivity that egg and sperm quality depend on, lowers gestational diabetes risk, and prepares your body for the load of pregnancy and recovery. Obstetric guidance supports continuing established exercise through a healthy pregnancy, which is one more reason to build the habit before conception rather than after.

The same plan on the same 90-day timeline: labs, alcohol down to zero or near it, no smoking, heat off the testes (hot tubs, saunas, laptops), CoQ10 and zinc when labs or the semen analysis argue for it, and strength plus cardio for the same metabolic reasons. Men on testosterone therapy need a specific plan, because TRT suppresses sperm production; the male fertility guide covers how fertility is preserved or recovered.

Deep-Dive Questions

Insulin resistance degrades fertility years before any glucose number looks alarming, because the ovary listens to insulin directly. Chronically high insulin pushes the ovary toward more androgen production, disrupts the signaling that matures a dominant follicle, and degrades the energy environment the egg develops in, while the same metabolic noise lowers sperm quality on the male side. This is why a fasting insulin under 7 is on the preconception panel even when glucose and A1C look fine, and why muscle, the body's largest glucose sink, is fertility equipment.

Choline and folate work adjacent jobs in the same construction project. Folate's role in neural tube closure is proven to the point of public policy, which is why it is in every prenatal. Choline supplies the methyl groups and membrane phospholipids the developing brain builds with, and higher maternal intake has been linked to better infant processing speed in randomized work, but it was recognized later and never made it into most formulations. The result is a nutrient with an official adequate intake that most pregnant women do not reach and most prenatals do not contain, which is why it gets its own line in this plan.

Pregnancy expands blood volume by roughly 40 to 50%, raises resting heart rate, and increases cardiac output by a third or more, which amounts to a months-long endurance event assigned to whoever shows up for it. An aerobic base built before conception raises stroke volume and mitochondrial capacity, so the pregnant heart meets the demand with reserve instead of strain. In practice that reads as less breathlessness, better energy, easier labor tolerance, and a faster return to baseline afterward. Zone 2 work is the tool because it builds this machinery at an intensity that is safe to continue, with your obstetric clinician's blessing, well into pregnancy.

MTHFR variants slow the enzyme that converts folic acid into the active methylfolate the body uses, and a homocysteine level is the practical readout of whether your conversion is keeping up. For carriers with elevated homocysteine, we use methylated folate (5-MTHF) instead of synthetic folic acid, and recheck. For everyone else the standard forms work, and the variant alone, with normal homocysteine, is not a reason to buy anything special. This is a good example of why the labs come first: the gene matters through its chemistry, and the chemistry is measurable.

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Start your intake

Dr. Ash reads every intake himself, and answers questions personally - usually within a few hours.

TL;DR30-second take

TL;DR: The egg that ovulates this month started maturing about 90 days ago, and the sperm that meets it took about the same time to build. That means the healthiest possible conception is planned a season in advance, by both partners. The plan is not complicated: run the right labs, close the nutrient gaps most prenatals miss (choline above all), add CoQ10 when age or labs argue for it, build strength and cardiovascular conditioning while training is still easy to start, and clear the stop list. This is the runway we build at Fishtown Medicine, in partnership with your OB or midwife.

What labs should we run before trying?

Labs come first because they tell us which parts of the plan matter for you, and the panel goes past "you're healthy, good luck." The core set we run at Fishtown Medicine:

Thyroid, read tightly. The lab's reference range for TSH runs to about 4.0, but for conception we want it under 2.5, with free T4 and TPO antibodies checked, because a struggling thyroid raises miscarriage risk and drags energy through pregnancy. Our fertility optimization guide covers why the standard range is too loose here.
Insulin and glucose. Fasting insulin under 7, plus A1C. Quiet insulin resistance degrades egg quality, complicates implantation, and sets up gestational diabetes later. This is also where training earns its place, which is coming below.
Ferritin above 50. Pregnancy consumes iron aggressively. Starting low means spending 9 months behind.
Vitamin D at 50 to 70 ng/mL, checked rather than guessed, because Philadelphia winters almost guarantee a gap.
B12, homocysteine, and methylation status, which decide whether methylated folate beats standard folic acid for you.
For the partner: a semen analysis when anything in the history suggests it, and the same metabolic labs, because sperm are built by the same body systems.

Which nutrients do most prenatal plans miss?

The prenatal aisle is where good intentions go to get diluted, and the full teardown lives in our prenatal supplement guide. The short version for the preconception window:

Choline is the headline gap. It is essential for fetal brain and spinal cord development, the target is about 450 to 550 mg a day between food and supplement, and many popular prenatals contain little or none. Eggs are the food answer (a yolk carries about 150 mg), and a supplement covers the rest. Starting before conception matters because the neural tube forms in the first weeks, often before a positive test.
Folate, in the right form. 400 to 800 mcg daily starting at least a month before trying. If your methylation labs argue for it, methylated folate (5-MTHF) instead of synthetic folic acid.
Iodine and omega-3 DHA, both common gaps in an American diet and both cheap to fix.
Iron, dosed to your ferritin, not to a label.

A prenatal with an NSF or USP seal, a meaningful choline dose, and methylated B vitamins covers most of this. The point of the labs is to personalize the rest instead of stacking pills on faith.

Should we take CoQ10?

Why does strength training belong in a preconception plan?

This applies to both partners. The metabolic health that builds a good egg builds good sperm on the same timeline.

Why does cardiovascular conditioning matter before pregnancy?

Fishtown Medicine

A 90-minute conversation with Dr. Ash. A written plan you can actually follow.

Start your intake

What belongs on the stop list?

The subtractions matter as much as the additions, and 90 days is enough time for most of them to pay off:

Alcohol, for both partners. It measurably degrades sperm parameters and egg quality, and there is no established safe dose once you may be pregnant.
Smoking and vaping, the single strongest lifestyle lever for fertility in either partner.
Heat on the testes: hot tubs, saunas, and laptops parked on laps suppress sperm production for the full 90-day cycle that follows.
A medication review, done properly. Finasteride, testosterone therapy (which suppresses sperm production, sometimes profoundly - our male fertility guide covers preserving fertility on TRT), retinoids, and several common prescriptions deserve a planned exit or a swap, not a panicked one after a positive test.
Ultra-processed load, traded for the protein, eggs, fish, legumes, and produce that carry the nutrients above in their food form.

How does Fishtown Medicine run the preconception plan?

Key Takeaways

The runway is 90 days, for both partners. Eggs and sperm maturing today carry today's habits into conception a season from now.
Labs first: TSH under 2.5 with antibodies, fasting insulin under 7, ferritin above 50, vitamin D 50 to 70, B12 and methylation status, and a semen analysis when history calls for it.
Choline is the gap most prenatals miss: 450 to 550 mg a day, started before conception. CoQ10 (ubiquinol, 200 to 600 mg) earns its place for many, most clearly over 35.
Train for it: strength 2 to 3 days a week builds the insulin sensitivity fertility runs on, and zone 2 cardio builds the base a 40 to 50% blood-volume expansion will draw against.
Subtract deliberately: alcohol, smoking, testicular heat, and a planned medication review beat a panicked one after a positive test.