No, we do not do IVF. We are an internal medicine practice, not a fertility clinic (REI, reproductive endocrinology and infertility). We work upstream of IVF. Optimizing your health often helps couples conceive naturally. If you do need IVF, we make sure your body is in the best metabolic state for transfer.

When should I start fertility optimization?

You should start fertility optimization ideally three to six months before stopping contraception. It takes about 90 days for an egg to fully mature, and roughly the same window for sperm. Changes you make today shape the egg or sperm available three months from now.

I am over 35. Is it too late to optimize?

It is not too late to optimize fertility after 35. While egg quantity declines with age, mitochondrial function and egg quality can be supported through metabolic and lifestyle work. Many of our patients in their late 30s and early 40s conceive naturally with the right preparation.

What does TSH have to do with fertility?

TSH (thyroid-stimulating hormone) is the brain's signal to the thyroid. A TSH above 2.5 mIU/L is associated with lower conception rates and higher miscarriage risk. We aim for TSH under 2.5 before conception, which often requires medication or nutrient adjustment.

Why does iron matter before pregnancy?

Iron matters before pregnancy because pregnancy itself depletes iron rapidly. Low ferritin (stored iron) is linked to fatigue, hair loss, and poor thyroid function. We target ferritin above 50 ng/mL going into pregnancy so you have a reserve.

What is the role of vitamin D in fertility?

Vitamin D plays a real role in fertility because it acts as a pre-hormone for many tissues, including the ovaries, uterus, and placenta. Most adults in Philadelphia, especially in winter, run low. We target a blood level of 50 to 70 ng/mL.

Should I take folic acid or methylated folate?

You should take folic acid or methylated folate based on your methylation labs. Many people convert folic acid efficiently. Some, often those with MTHFR gene variants, do better on methylated folate (5-MTHF). We test homocysteine and decide together.

How does insulin resistance affect egg quality?

Insulin resistance affects egg quality by raising oxidative stress in the ovary, disrupting hormone signals, and changing the maturation environment of the egg. Treating insulin resistance with diet, movement, and sometimes metformin or inositol often improves cycles and ovulation.

What is the "cortisol steal" in fertility?

The "cortisol steal" is the idea that chronic stress shifts adrenal hormone production toward cortisol and away from progesterone, the hormone that helps maintain early pregnancy. While the metaphor is simplified, the practical reality is that high stress often correlates with lower progesterone and disrupted cycles.

Why is methylation status important before pregnancy?

Methylation status is important before pregnancy because methyl groups support DNA repair, neurotransmitter balance, and homocysteine clearance. Variants in MTHFR, the gene that helps activate folate, can affect how well you process folic acid. Methylated folate (5-MTHF) bypasses that step.

How long does it take for an egg to mature?

An egg takes about 90 days to fully mature, a process called folliculogenesis. The metabolic environment during those three months shapes egg quality. That is why pre-conception optimization is most useful when started at least 3 to 6 months before trying.

What lab results suggest possible PCOS?

Lab results that suggest possible PCOS (polycystic ovary syndrome) include high free testosterone, low SHBG, raised LH-to-FSH ratio, and signs of insulin resistance like high fasting insulin and HOMA-IR. We pair labs with cycle history and ultrasound when needed. See our [PCOS guide](/hormones/pcos).

How do environmental toxins affect fertility?

Environmental toxins, including some plastics (BPA, phthalates) and heavy metals, can disrupt hormone signaling. The exposure matters more than headlines suggest. We focus on the highest-yield reductions: filtered water, glass storage, and avoiding heated plastic in food.

Why does Fishtown Medicine emphasize pre-conception male fertility?

Fishtown Medicine emphasizes pre-conception male fertility because half the equation is the sperm. Sperm health responds to sleep, alcohol, heat exposure, weight, and supplements like CoQ10 and zinc within about three months. We screen and optimize partners together.

What is the role of CoQ10 in egg and sperm quality?

CoQ10 (coenzyme Q10) is a mitochondrial nutrient that supports the energy-producing machinery in eggs and sperm. Trials suggest possible benefits for both egg and sperm quality, especially in people over 35. We use ubiquinol form, 100 to 300 mg per day, when appropriate.

How does sleep apnea affect fertility?

Sleep apnea, a condition where breathing stops repeatedly during sleep, disrupts hormones, raises insulin resistance, and lowers oxygen at night. In men, it can lower testosterone. In women, it correlates with cycle irregularity. Treating apnea improves the broader hormonal environment.

What does "metabolic flexibility" mean for fertility?

Metabolic flexibility means your body can switch easily between burning fat and burning carbohydrates. Better flexibility lowers blood sugar swings, lowers insulin resistance, and supports a calmer hormonal environment. Strength training plus zone 2 cardio is one of the strongest builders.

How do thyroid antibodies affect fertility?

Thyroid antibodies, especially TPO antibodies, can raise miscarriage risk even when TSH looks normal. We watch antibody levels and may treat earlier with thyroid hormone in women with high antibodies and a borderline TSH, especially when trying to conceive.

Should I freeze my eggs in my early 30s?

Egg freezing in your early 30s is a personal decision based on age, partner status, ovarian reserve markers like AMH (anti-Müllerian hormone), and life timeline. We can run AMH and antral follicle counts and refer to a reproductive endocrinology specialist when freezing makes sense.

Why does Fishtown Medicine partner with midwives like Magpie Midwifery?

Fishtown Medicine partners with midwives like Magpie Midwifery because shared care produces better outcomes. We handle pre-conception, primary care, hormones, and postpartum recovery. Midwives lead the pregnancy and birth. The two roles complement each other naturally.

No. We are an advanced internal medicine practice, not a fertility clinic (REI). We work upstream of IVF. By optimizing your health, we often help couples conceive naturally. If you do need IVF, our goal is to ensure your body is in the best possible metabolic state for a successful transfer.

When should I start this process?

Ideally three to six months before you stop contraception. It takes about 90 days for an egg to fully mature (folliculogenesis), so the metabolic changes you make today affect the egg you ovulate three months from now.

I am over 35, is it too late?

It is not too late to improve your health. While egg quantity declines with age, we can support mitochondrial function and egg quality through metabolic and lifestyle work.

TL;DR · 30-second take

Fertility optimization is pre-conception care that targets thyroid function, insulin sensitivity, vitamin D, iron, and folate before you start trying. We test deeply, set optimal-range targets like TSH under 2.5 mIU/L and ferritin above 50 ng/mL, and address nutrient gaps so the body is genuinely ready, not just 'not preventing.'

Fertility Is a Vital Sign: The "Soil Before Seed" Approach

TL;DR: The traditional medical model asks you to "try for a year" before investigating. In our experience, that is a missed opportunity. At Fishtown Medicine, we focus on pre-conception optimization, which is finding and correcting metabolic, thyroid, and nutrient issues before you try to conceive.

We see a specific pattern in our practice here in Philly. Whether you are building a career in Center City or running a business in Northern Liberties, you are used to planning, optimizing, and executing on big goals. When it comes to fertility, the healthcare system asks you to do the opposite: "Just relax and let it happen." If nothing happens after 6 or 12 months, you are often funneled straight into the high-intervention IVF (in vitro fertilization) pipeline. I believe there is a missing step in the middle: optimization. Fertility is not just about conception. It is a key sign of your overall metabolic health.

Why don't we wait the standard 12 months?

We do not wait the standard 12 months because that timeline assumes the only options are "wait" or "aggressive intervention." In our experience, the barriers are often quiet physiological signals that can be detected and corrected much earlier. Waiting is not a strategy. Gathering data and optimizing your physiology is.

My Perspective: Soil Before Seed

Guidance from the Clinic: "We use the analogy of soil and seed. You would not plant a prize-winning rose in dry, depleted soil and hope for the best. You would feed the soil first. A healthy pregnancy needs a metabolically resilient system. That foundation helps you conceive and helps shape the metabolic programming of your baby."

What does the optimization checklist look like?

The optimization checklist looks like a deep dive into thyroid function, insulin sensitivity, and key nutrient stores. We are looking for function, not only the absence of disease.

1. Thyroid: The Goldilocks Zone

The standard reference range for TSH (thyroid-stimulating hormone) is roughly 0.4 to 4.0 mIU/L. For conception, we consider this range too wide. Current data suggests that a TSH below 2.5 mIU/L is associated with better conception rates and lower miscarriage risk. We look at free T3, free T4, and TPO antibodies (a marker of Hashimoto's thyroiditis, an autoimmune thyroid condition) to make sure your thyroid can support the metabolic demands of pregnancy.

2. Insulin and Metabolic Health

Insulin resistance is a common and often quiet barrier to egg quality and implantation.

We target a fasting insulin under 7 µIU/mL.
We assess metabolic flexibility so blood sugar stays stable, which lowers later risks like gestational diabetes.

3. Common Nutrient Deficiencies

It is rare to see a patient who is not depleted in at least one important area, especially if they have a history of hormonal birth control use, which can deplete several B vitamins.

Vitamin D: A pre-hormone important for fertility. In Philadelphia winters, we almost never see optimal levels without supplementation. We aim for 50 to 70 ng/mL.
Ferritin (stored iron): Pregnancy demands iron. If ferritin is low before you start, you spend the pregnancy playing catch-up. Low iron also drags down thyroid function. We target ferritin above 50 ng/mL.
Folate and methylation: We check homocysteine and methylation status to decide whether you do better on methylated folate (5-MTHF) than on synthetic folic acid.

How does stress affect fertility?

Stress affects fertility because chronic stress shifts your body toward survival, not reproduction. "Just relax" is the most frustrating advice a patient can hear because it ignores physiology. Telling someone to relax does not actually relax their nervous system. When the body is under chronic stress (work, commute, metabolic inflammation, undereating), resources shift away from progesterone production, the hormone that helps hold a pregnancy. This pattern is sometimes called the "cortisol steal." We do not just say "relax." We figure out where the stress is coming from. Is it sleep loss? Undereating? Work overload? Then we build a strategy to lower the load.

Actionable Steps in Philly

Optimize the soil before the seed.

Run a deep panel 3 to 6 months before trying: full thyroid (TSH, free T3, free T4, TPO antibodies), fasting insulin, vitamin D, ferritin, B12, folate, homocysteine, and key sex hormones.
Aim for TSH under 2.5 mIU/L. Standard "in range" is not the goal here.
Replete iron, vitamin D, and folate first. Use methylated folate if methylation labs suggest it.
Lower stress load with sleep above seven hours, daily walks, and protein-forward meals.
Check your partner. Male fertility deserves an equal workup. See Male Fertility on TRT and HCG.

Key Takeaways

Be proactive: You can optimize fertility months or years before you try to conceive.
Check the thyroid: "Lab normal" is not always "pregnancy optimal." We aim for TSH under 2.5 mIU/L.
You have agency: There are dozens of levers we can pull, from lipid management to insulin sensitivity, that improve egg quality.

Related Articles:

Dr. Ash is a board-certified internal medicine physician at Fishtown Medicine in Philadelphia. He approaches fertility from a whole-body, metabolic lens.

Scientific References

Alexander EK, et al. "2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum." Thyroid. 2017;27(3):315-389.
Pilz S, et al. "The Role of Vitamin D in Fertility and during Pregnancy and Lactation: A Review of Clinical Data." International Journal of Environmental Research and Public Health. 2018;15(10):2241.
Chang EM, et al. "Insulin resistance in polycystic ovary syndrome." Human Reproduction Update. 2013;19(5):532-545.
Gaskins AJ, Chavarro JE. "Diet and fertility: a review." American Journal of Obstetrics and Gynecology. 2018;218(4):379-389.

Medical Disclaimer: This resource provides clinical context for educational purposes. In the world of Precision Medicine, there is no "one size fits all", the right plan must be matched to your unique lab work, physiology, and goals. Consult Dr. Ash to determine if this approach is right for you, especially if you have chronic health conditions or are taking prescription medications.

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