Dr. Annaleeza Caputi, ND
Episode Summary
How can you optimize fertility before trying to conceive, and what actually matters when it comes to ovulation, PCOS, prenatal vitamins, egg quality, sperm health and lifestyle?
In this episode of Girls Gone Wellness, Jeanette and Victoria are joined by Dr. Annaleeza Caputi, ND, a naturopathic doctor with a clinical focus in fertility and women's health, for an evidence-focused conversation about fertility optimization, preconception care, menstrual-cycle health, ovulation, polycystic ovary syndrome (PCOS), endometriosis, fibroids, birth control, age-related fertility, prenatal vitamins and male fertility. Dr. Caputi explains why fertility care can begin well before someone is actively trying to become pregnant and why reproductive health provides useful information about overall hormonal and metabolic health.
The conversation begins with menstrual-cycle literacy. Does having a regular period mean you are definitely ovulating? Can you still ovulate with irregular cycles? Dr. Caputi explains that menstrual bleeding does not automatically confirm ovulation and discusses different ways to estimate or confirm ovulation, including basal body temperature (BBT), luteinizing hormone (LH) ovulation predictor kits, cervical mucus and progesterone blood testing approximately seven days after ovulation. She also explains why fertility apps may incorrectly predict the fertile window and why LH strips can be particularly difficult to interpret in people with PCOS.
Diet and lifestyle are another major focus. Dr. Caputi discusses how caloric restriction, under-eating, excessive exercise, inadequate dietary fat and chronic stress may interfere with ovulation in some people. The episode emphasizes adequate calories, protein, fibre and healthy fats, alongside a Mediterranean-style dietary pattern, fruits, vegetables, nuts, seeds, olive oil and regular movement.
The episode also examines fertility in people with PCOS, uterine fibroids and endometriosis. Dr. Caputi discusses insulin resistance, androgen levels, irregular ovulation and pregnancy risks associated with PCOS, as well as why the location and type of a fibroid matters when considering fertility. She also discusses the need to weigh the potential benefits and risks of surgical interventions for fibroids and endometriosis.
Jeanette, Victoria and Dr. Caputi then address one of the biggest fertility myths online: whether oral contraceptive birth control damages future fertility. Dr. Caputi explains that after stopping hormonal birth control, the important question is often what the person's natural menstrual cycle and underlying hormonal condition look like once the medication is removed.
Other major topics include fertility after age 35, pregnancy during perimenopause, egg-quality supplements and prenatal vitamins. Dr. Caputi discusses choline, iron, vitamin D, folic acid, methylfolate and the commonly discussed MTHFR gene, emphasizing the importance of looking at meaningful pregnancy outcomes rather than assuming a supplement improves fertility simply because it affects a theoretical biological mechanism.
Male fertility is also treated as half of the fertility equation. The episode covers sperm count, motility and morphology, along with alcohol, smoking, cannabis, vaping, heat exposure, diet and other lifestyle factors that may affect sperm health.
Finally, Dr. Caputi discusses metabolic testing that may be considered during preconception care, including hemoglobin A1c (HbA1c), fasting glucose, fasting insulin, lipid testing, thyroid markers, vitamin D, iron status and hormonal testing when indicated. The episode closes with a practical discussion of endocrine-disrupting chemicals and why small, manageable exposure reductions may be more useful than creating additional anxiety around trying to eliminate every possible environmental exposure.
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How early should you start preparing for pregnancy?
Dr. Annaleeza Caputi recommends thinking about preconception health approximately six to 12 months before trying to conceive when possible. This provides time to understand the menstrual cycle, identify potential hormonal or metabolic concerns, review nutrition and lifestyle, and address issues before pregnancy becomes an immediate goal.
Does having a regular period mean you are fertile?
No. A regular menstrual cycle does not guarantee that ovulation is occurring or that there are no fertility obstacles. Dr. Caputi explains that a person can experience bleeding on a predictable schedule and still have an anovulatory cycle, which is why understanding ovulation is an important part of fertility assessment.
Can you still ovulate if your periods are irregular?
Yes. Irregular menstrual cycles do not automatically mean that ovulation never happens. The challenge is that ovulation may be less predictable, making it harder to identify the fertile window and appropriately time intercourse.
How can you tell if you are ovulating?
Ovulation can be estimated or assessed using basal body temperature, luteinizing hormone (LH) ovulation predictor kits and cervical mucus, while a properly timed progesterone blood test can help confirm that ovulation occurred. Dr. Caputi discusses checking progesterone approximately seven days after suspected ovulation.
Does a positive ovulation test mean you are ovulating that day?
Not necessarily. Ovulation predictor kits detect the LH surge, which Dr. Caputi explains generally occurs before ovulation rather than confirming that ovulation has already happened. She discusses the LH surge as a tool for identifying the fertile window and better timing intercourse.
Are ovulation predictor kits accurate if you have PCOS?
They can be more difficult to interpret in people with polycystic ovary syndrome (PCOS). Dr. Caputi explains that some people with PCOS have elevated or repeated LH activity throughout the cycle, which may result in positive ovulation tests that do not necessarily correspond with successful ovulation.
Can dieting, under-eating or excessive exercise affect ovulation?
Yes, inadequate energy intake and excessive exercise can interfere with normal menstrual and ovulatory function in some people. The episode discusses caloric adequacy, protein, fibre and healthy fats as important components of supporting reproductive health, particularly in people with irregular or absent periods.
How does PCOS affect fertility?
PCOS can affect fertility primarily by making ovulation irregular or unpredictable. Dr. Caputi also discusses insulin resistance, elevated androgens and metabolic health as important considerations, as well as the increased risk of pregnancy complications such as gestational diabetes and preeclampsia in people with PCOS.
Do fibroids always cause infertility?
No. The fertility impact of uterine fibroids depends partly on their type and location. Dr. Caputi explains that some fibroids may have little apparent effect on fertility, while others may warrant a more detailed discussion about treatment, surgery and the individual's pregnancy goals.
Does hormonal birth control damage future fertility?
Dr. Caputi does not characterize oral contraceptive birth control as inherently damaging to fertility. Instead, she emphasizes evaluating what the person's natural menstrual cycle does after stopping birth control and whether an underlying condition such as PCOS or endometriosis was being managed while they were taking it.
What should you do if your period does not return after stopping birth control?
Dr. Caputi discusses seeking medical assessment when menstruation has been absent for several months rather than simply continuing to wait indefinitely. Evaluation may include investigating the endometrium, considering imaging, reviewing hormonal and metabolic factors, and working with a medical provider to determine whether additional treatment is appropriate.
Can you get pregnant after age 35?
Yes. Fertility and ovarian reserve decline with age, but pregnancy after age 35 is still possible. Dr. Caputi discusses how age changes risk assessment and fertility planning without meaning that pregnancy is impossible or that assisted reproductive technology is automatically required.
Can you get pregnant during perimenopause?
Yes. Perimenopause does not mean ovulation has completely stopped. Because cycles become less predictable, ovulation can be harder to anticipate, meaning pregnancy remains possible until menopause has been reached.
Do egg-quality supplements actually improve pregnancy rates?
The episode emphasizes that improving a laboratory marker or theoretical mechanism is not the same as demonstrating better pregnancy or live-birth outcomes. Dr. Caputi is cautious about supplements marketed specifically for “egg quality” and recommends looking at whether research shows meaningful clinical fertility outcomes rather than relying only on antioxidant or mitochondrial theories.
When should you start taking a prenatal vitamin?
Dr. Caputi discusses starting a prenatal vitamin during the preconception period, including when someone plans to try to conceive within the coming months. She looks for nutrients such as choline, folate or folic acid, iron and vitamin D, while individual needs may vary.
Is methylfolate better than folic acid during pregnancy?
Dr. Caputi explains that she does not view methylated folate as universally superior to folic acid based on the pregnancy outcomes discussed in the episode. She specifically challenges the idea that a prenatal is ineffective simply because it contains folic acid rather than methylfolate.
Does the MTHFR gene mean you cannot take folic acid?
The episode does not support treating folic acid as ineffective solely because someone is concerned about MTHFR genetic variants. Dr. Caputi discusses different vitamin forms and methylation but emphasizes that the clinically important question is whether an intervention improves maternal and fetal outcomes.
How does male lifestyle affect fertility and sperm quality?
Male lifestyle matters because sperm contributes half of the genetic material required for conception. Dr. Caputi discusses sperm count, motility and morphology and explains that smoking, alcohol, cannabis, vaping, heat exposure and other lifestyle factors may influence sperm health.
What diet is recommended when trying to conceive?
Dr. Caputi generally focuses on a Mediterranean-style dietary pattern because it emphasizes dietary adequacy rather than restriction. She discusses adequate protein and fibre, healthy fats from foods such as nuts, seeds, avocado and extra-virgin olive oil, along with fruits, vegetables, dark leafy greens and berries.
What blood tests may be useful before trying to get pregnant?
Testing should be individualized, but Dr. Caputi discusses hemoglobin A1c (HbA1c), fasting glucose, fasting insulin, a lipid panel, vitamin D, thyroid testing, iron status and hormonal testing when clinically indicated. Much of the preconception work she describes focuses on metabolic health because of its close relationship with hormones, ovulation and pregnancy outcomes.
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This transcript has been edited for clarity and readability while preserving the substance of the conversation.
Victoria
Welcome to Girls Gone Wellness, Dr. Caputi.
Dr. Annaleeza Caputi
Thank you so much for having me. I'm so excited to be here.
Victoria
We are so thrilled to have you here today, and we're excited to chat about a topic that we could probably go on for days about: optimizing fertility.
I want to leave a caveat right away for our listeners that this isn't just for people who are thinking about getting pregnant right now, ASAP.
It's also a conversation for anyone who wants to get pregnant in the future. We could also argue that it's beneficial for people who simply want to learn more about their own body, their cycle and how to tune into that.
Dr. Annaleeza Caputi
Absolutely. I agree 100%.
I think this is a topic where, no matter what stage you're at in life, fertility is just one piece of the puzzle.
Even just becoming curious about your own reproductive and hormonal health—this is the right place to be.
Jeanette
Amazing.
We'd love for you to take a moment to introduce yourself and let our listeners know how you got into naturopathic medicine and then specifically fertility and women's health.
Dr. Annaleeza Caputi
I think my story is probably similar to most of ours.
I always knew I wanted to be in healthcare. I knew I wanted to be some sort of patient-facing primary-care person.
In my undergrad, I studied neuroscience, psychology and physiology, so I've always been really amazed by the human body.
My journey into naturopathic medicine actually started as a patient.
I had my own health concerns and sought out a naturopathic doctor on the wise advice of my mother—being forced to go, actually.
I remember sitting in the patient chair and having this epiphany moment, as corny as that sounds, where I wanted to be on the other side of that table.
I felt so heard, educated and empowered, and I knew that was the kind of impact I wanted to have on people's lives.
At the time, I was already accepted into advanced-care nursing at the University of Toronto.
I knew nothing about naturopathic medicine. I didn't know anything about the schooling.
Fast-forward two weeks later, I had my interview and did a complete career change in half a month.
And here we are.
Jeanette
Wow. That's amazing.
Like you mentioned, I think a lot of us have similar stories.
I actually did my undergrad in neuroscience too, and that's kind of how I found the connection between the gut and the brain and came across naturopathic medicine.
Vic also has a similar story of sitting on the other side and having that epiphany moment.
It's interesting that a lot of people have that moment in our profession. It's really special.
Dr. Annaleeza Caputi
My interest in women's health and hormones really stemmed from having a fascination with endocrinology and how the hormones in our body work and feed back on each other.
But fertility fell into my lap more from a personal experience.
When my husband and I decided to grow our family, this was the kind of care I was seeking.
I was able to identify, from both a patient and practitioner perspective, all of the gaps we currently have in the medical-care system for people seeking this kind of support.
I became a patient myself.
I didn't necessarily need fertility support, but there were aspects of my hormonal health that weren't ideal for wanting to conceive at that moment.
Then that obviously transferred into becoming pregnant and now being postpartum.
I've identified all these gaps and areas where I could better support patients.
Now, being eight months postpartum, my practice has really transitioned into focusing in this area, which I'm really happy about.
It just kind of fell into my lap.
Victoria
Absolutely.
I think being a patient in a particular area can make you a better doctor in that area.
If I'm going to see a doctor for any health concern, I'd rather them understand some of that experience themselves, which we see all the time in naturopathic medicine.
Don't love that we have to go through the challenges as patients, but we learn from them, and it can become really helpful to our future patients.
I want to start by talking about what I mentioned in our intro: why does fertility matter even if we don't have immediate plans to have kids?
Dr. Annaleeza Caputi
Fertility isn't just about conceiving.
Everything I talk about in an initial fertility consult still involves taking a thorough, comprehensive health history and going through all of those aspects of hormonal health.
We need to care about those things regardless of whether you want to conceive.
But especially if you do plan on conceiving, I would argue that we should start having those conversations around six to 12 months in advance.
If we identify issues or obstacles along the way, we can be preventative and deal with them before you want to start conceiving rather than being reactive in the moment.
That can add a lot of stress and anxiety around conception, which doesn't help either.
This is especially relevant when patients already know they have certain common hormonal conditions and they've heard things online that fear-monger about how those conditions may affect conception or fertility outcomes.
Having those conversations even before fertility becomes a current goal is really important.
Victoria
I like that you said preventative rather than reactive.
I feel like a lot of people wait until the last minute and then almost come to us as a last resort.
We can still help, of course, but sometimes there are things we could have started a year earlier.
Do you see that?
Dr. Annaleeza Caputi
I do.
I feel like it's changing a little bit, which is nice.
I definitely see patients who have been trying for a year without success or who've experienced one or several miscarriages and feel lost as to why that's happening.
But recently, I feel like people are becoming more curious about their health outside of their immediate fertility goals.
We're seeing them a little earlier.
Then, when conceiving becomes one of their main health goals, we've already done a lot of the heavy lifting, which is really awesome.
I'm hoping it continues to move in that direction.
Nonetheless, even if you've been trying or you're just starting to try and want support, it's never too late.
I want to reiterate that.
Jeanette
We've always heard that your period and hormonal system can be thought of almost like another vital sign.
If that's optimized, it can tell us something about what's happening elsewhere because everything is connected hormonally.
A big issue is that there's a general lack of education around our cycles.
I barely remember what I was taught about my period growing up.
Then we get into adulthood, and some women think they have a normal period but don't know what's normal or whether they're fertile.
Can you debunk this?
Does having a normal period mean you're fertile, and do irregular periods mean you're not?
Dr. Annaleeza Caputi
That's a fantastic question.
This could be an episode in itself.
Menstrual-cycle literacy is lacking in every regard.
Myth number one is assuming that if you're menstruating, you're not going to have any fertility obstacles.
That's definitely not true.
In terms of what a “regular” cycle means, it depends on what's diagnostically regular but also what's consistent for you.
Anything ranging from roughly 25 to 35 days can fall within a normal range, but the key is what's consistent for you.
It's normal for cycles to vary a few days in either direction.
It's when we start consistently deviating by around seven or more days that we're raising our eyebrows and wondering whether something is going on.
Myth number two is saying, “I have a regular cycle, so I assume I'm ovulating and there are no issues.”
You can have a regular cycle every 28 days, still have a period and still not be ovulating.
That's a really big piece of the puzzle that many of my patients aren't aware of.
This is often where our fertility conversation starts.
Then myth number three is that if you have irregular cycles, you're not ovulating.
That's also not necessarily true.
It's simply harder to predict and identify when ovulation is happening.
That's where we may need to support the patient with underlying hormonal issues or help them become more educated on how we determine whether ovulation is actually occurring.
Jeanette
Do you find that patients come in already knowing when they're ovulating because they've done tests or used ovulation kits?
Or do many people have no idea whether it's happening?
Dr. Annaleeza Caputi
I definitely get a mix of both.
I have patients who—through no fault of their own—are completely unfamiliar with what ovulation even means.
Then I have patients who've exhausted every resource and are trying to self-research and self-educate on how to use all these tools, and they may even be misusing them.
There are different ways to predict ovulation and confirm whether ovulation happened.
There's a lot of discussion online about basal body temperature tracking and fertility awareness.
The idea is to use a very specific thermometer consistently every morning upon waking and track minute changes in temperature.
After ovulation, progesterone rises and has a thermogenic effect on the body.
The problem is that there's a lot of room for error.
If you're not measuring every day at the same time or the way you're taking the measurement changes, that can affect your interpretation.
I wouldn't personally call it completely reliable, and I especially wouldn't rely on that alone as a contraceptive method.
Then there are ovulation predictor kits.
These can be more useful, but I find this is where patients sometimes aren't using them properly simply because nobody has instructed them.
Depending on the length of your cycle, you start collecting a urine sample and using the strips to measure luteinizing hormone, or LH.
LH is released from the brain and helps trigger ovulation.
The problem is that when someone gets a positive test, they often assume they're ovulating that day.
That's not necessarily the case.
The LH surge generally happens before ovulation, so the test is more useful for identifying the fertile window and helping optimize the timing of intercourse.
Then there are physiological signs such as cervical mucus.
People talk about the egg-white-type colour and stretchy consistency.
But this isn't completely reliable either because not seeing it doesn't automatically mean you're not ovulating.
Last but not least, you can take a progesterone blood test approximately seven days after ovulation.
That can help confirm whether ovulation occurred and give us additional information about that ovulatory cycle.
Victoria
There's so much confusion around ovulation.
People don't even necessarily think about ovulation as the main part of the cycle.
They think, “My period is here. That's the important thing.”
But really, ovulation is incredibly important.
So many people also assume they ovulate on day 14, and that's not necessarily the case.
It's hard because we were never properly taught this information.
Dr. Annaleeza Caputi
Absolutely.
I think ovulation is the main event—not even just from a fertility standpoint.
When patients say, “I have PMS,” technically PMS is linked to what happens after ovulation.
Even debunking that is a lot.
To your point about assuming ovulation happens on day 14, one obstacle I'm seeing more in practice is that we're getting really good at tracking periods, which is awesome because we have the technology.
But we're not necessarily tracking the other signs of ovulation.
We're depending on an app to tell us when our fertile window is.
We're not robots.
Our hormones fluctuate every month.
Sometimes you might ovulate a little earlier or a little later.
This can cause confusion because patients will have intercourse during the fertile window their app gives them and not become pregnant, but we may simply have mistimed intercourse because physiologically they didn't ovulate when the app predicted they would.
That's really important.
Then in someone with polycystic ovary syndrome, or PCOS, I often wouldn't rely on ovulation predictor strips the same way because some people with PCOS have elevated LH or repeated LH surges throughout the cycle.
Their body can repeatedly be trying to ovulate without successfully doing so.
That can give you false-positive tests and make it look like you're ovulating frequently when you're not.
There's a lot of misinformation.
Victoria
There are also so many things that can affect ovulation from one cycle to another.
You could have a cycle where you didn't ovulate and then the next month you do.
What lifestyle factors can disturb ovulation?
Dr. Annaleeza Caputi
A really big area is caloric restriction and over-exercising.
I'd probably say caloric restriction more commonly.
That's why, not only in fertility consults but in regular consults, talking about adequate calories, enough protein, fibre and healthy fats is so important.
It's not only important for general health. It's important for optimizing ovulation and fertility.
I see this commonly in patients with irregular periods or absent periods.
Their body is in a state of caloric restriction, dieting or over-exercising.
The body may literally not have the resources to menstruate or ovulate properly.
This is something I always screen for, including potential eating disorders.
I don't think we spend enough time talking about this, but it's more common than we realize.
Victoria
It's scary because so many of us are constantly in a state of wanting to be in a smaller body, wanting to diet and wanting to over-exercise.
Dr. Annaleeza Caputi
Absolutely.
Another lifestyle factor is stress.
We live in such a hustle culture right now.
People ask, “Why weren't these issues happening 100 years ago?”
The world we live in, fortunately or unfortunately, is not the same.
Our bodies aren't endlessly resilient to stress.
Something has to give, and sometimes that's ovulation.
Another part of the diet conversation is the fear around fats.
People assume fat is negative because the word has such a negative connotation.
We need to educate people about the difference between healthy fats and fats we may want less of.
We need healthy dietary fats.
Cholesterol is part of the foundation from which steroid hormones are produced.
If we're heavily restricting dietary fat and not eating enough, we're not supporting that hormonal system appropriately.
We need to give much more credit to what we're feeding ourselves.
Jeanette
I read something years ago that always stuck with me.
If you're not feeding your body enough, your body doesn't think it's safe, so it isn't going to prioritize ovulation or pregnancy.
That always stuck with me.
Dr. Annaleeza Caputi
Absolutely.
We naturally spend so much time in that fight-or-flight state, and our bodies compensate in ways that can be hard for us to understand.
It's almost taboo to blame stress.
It's not that stress causes everything, but there are mechanisms by which stress can influence health.
We can't ignore that as part of the patient-support system.
Jeanette
I'd like to move on to PCOS.
PCOS, fibroids and endometriosis are all health concerns that many women deal with.
Do these conditions have a detrimental impact on fertility for everyone?
Should people with these conditions start working with their practitioner earlier when it comes to preconception care?
Dr. Annaleeza Caputi
This is something I see all the time.
Sometimes we're diagnosing these conditions, and sometimes the patient already has the diagnosis and fertility eventually becomes a goal.
With PCOS, because of the nature of having irregular or absent cycles, higher androgens or insulin resistance, the main fertility concern is often unpredictability around ovulation.
That makes it harder to use our typical tools to predict ovulation, so we may need to become a little more strategic.
We also need to address the metabolic component of PCOS.
That includes insulin resistance and things such as elevated cholesterol.
This matters not only for conception but also because people with PCOS can be at higher risk for certain complications during pregnancy, including gestational diabetes and preeclampsia.
It's not only about becoming pregnant. It's also about having a healthy pregnancy.
Fibroids are another really interesting one that I'm seeing more often in practice.
Fibroids are extremely common, and many people are asymptomatic, so they may not even know they have them unless they're discovered incidentally while investigating something else.
There's a lot of fear and misinformation because patients assume fibroids will automatically negatively affect fertility.
But when we look at fertility, it depends on the type and location of fibroid.
That's where having an informed discussion with your primary-care provider is important.
For example, subserosal fibroids don't appear to have the same fertility impact as some other locations, so removal solely for fertility reasons may not necessarily be recommended.
With some intramural fibroids, there may be circumstances where removal is considered.
But on the flip side, any surgical procedure can also potentially affect fertility.
We always have to do that risk-benefit analysis.
The same type of individualized discussion applies to endometriosis.
Laparoscopy has historically been considered the gold standard for diagnosis, but surgical procedures themselves also come with considerations for fertility.
These are conditions we commonly support patients with, but they require deeper conversations about options and what makes sense for the person's goals.
Victoria
Even from a fibroid standpoint, most people don't know any of this.
We barely learned about the options for patients who are trying to get pregnant, how different types of fibroids affect fertility or when surgery might be appropriate.
I didn't even know subserosal fibroids weren't necessarily a major factor for fertility.
Dr. Annaleeza Caputi
Exactly.
Most people are asymptomatic, so they wouldn't necessarily know.
And if they are symptomatic, that's another set of issues.
A lot of what we do is education.
Then that empowers the person to make the decision that's best for them.
Victoria
I want to talk about the oral birth control pill.
There's so much misinformation around birth control.
Jeanette and I have talked about how naturopathic doctors often see the outliers—the patients who believe they developed a problem from the pill or struggled after stopping it.
That doesn't necessarily mean everybody who uses birth control and then stops it is going to have fertility or hormonal issues.
Does the birth control pill negatively affect fertility?
Dr. Annaleeza Caputi
This is a great question.
I want to preface this by saying that, as an integrative medical practitioner, I fully support birth-control use.
I think it's a great contraceptive method when pregnancy isn't wanted, and it can provide significant symptomatic support for certain hormonal concerns.
When it comes to fertility, I think this conversation is less about the birth-control pill itself and more about learning what your menstrual cycle does naturally.
When you're taking the birth-control pill, the purpose of those exogenous hormones includes preventing ovulation, which contributes to its contraceptive effect.
When you stop the pill, it can take some time for the body and menstrual cycle to adjust.
That's going to vary between individuals.
Some people get their previous cycle back right away.
For others, it takes longer.
There are also a lot of other factors involved, including the diet and lifestyle factors we already discussed.
When someone comes to me on birth control and wants to conceive, I often suggest that we consider coming off it several months before the planned conception period—assuming that person is comfortable with the possibility of becoming pregnant at any point—so we can see what their natural cycle is doing, identify ovulation and time intercourse appropriately.
The bigger question is often why you were using birth control in the first place.
If you have PCOS and you were put on the pill, it may be keeping your bleeding pattern regular enough that you're not going months without a withdrawal bleed, and it may improve symptoms related to elevated androgens such as acne or unwanted hair growth.
When you then want to conceive, you come off the pill and now we have to see what your PCOS and natural cycle are doing and whether we can predict ovulation.
It's indirectly about birth control and more about what was happening before and underneath it.
Victoria
So if a patient has PCOS or endometriosis, goes on birth control and experiences symptom relief—which is great—when they come off, the birth control didn't necessarily eliminate the underlying condition.
We may still need to deal with that issue.
Dr. Annaleeza Caputi
One hundred percent.
We would support that patient regardless.
With PCOS, for example, if insulin resistance is part of that person's picture, the birth-control pill isn't necessarily addressing that metabolic component.
We can have a lot of impact there while they're still on birth control.
Then, when they come off, maybe their symptoms don't come back with such a vengeance, and we may have better supported their overall health heading into preconception.
It's a much deeper conversation than simply “on birth control” or “not on birth control.”
Jeanette
You mentioned that you like patients to come off about six months before.
What if someone didn't have a PCOS or endometriosis diagnosis beforehand, stops the pill and six months later still hasn't had a period?
How would you approach that?
Dr. Annaleeza Caputi
My immediate concern is that they've gone more than three months without a period.
At that point, we want proper medical assessment.
Depending on the situation, imaging such as ultrasound may be appropriate to evaluate the endometrium.
With certain hormonal conditions, going long periods without menstruation can allow the uterine lining to continue thickening, which can increase concern about endometrial hyperplasia.
So my immediate response would often involve referring them back to their family doctor or gynecologic provider to determine whether imaging or a progesterone challenge to initiate a withdrawal bleed is appropriate.
Then I would also look at the evidence-based lifestyle and integrative pieces that might help the menstrual cycle re-regulate, depending on why the cycle is absent.
Jeanette
I'm glad you touched on that.
Women now are having babies later in life for a lot of different reasons.
I'd love for you to talk about age and fertility.
We hear the term “geriatric pregnancy,” which always makes me laugh a little bit.
We know age comes with some increased risks, so let's talk about that.
Dr. Annaleeza Caputi
The evidence is fairly clear that ovarian reserve declines with age.
You're born with your ovarian reserve, and over time that number naturally decreases.
Age 35 is the number that gets talked about a lot.
I hate the term “geriatric pregnancy” because that does not make women feel good at all.
Women can absolutely become pregnant after age 35.
But yes, fertility declines with age, and maternal and fetal risks increase.
That changes how we support the patient.
Our lens becomes a little broader around certain health considerations than it might be with someone younger.
The problem online is when this turns into the assumption that pregnancy is impossible or that assisted reproductive technology is automatically your only option.
It also completely ignores the other half of what is required to conceive: sperm.
And it makes women feel inferior, as though they've waited too long, failed themselves and can no longer achieve that goal.
That's not true.
There is also a lot of talk online about egg quality.
Yes, egg quality changes with age.
There may be things we can do around overall health, diet and lifestyle, but we need to be very careful about claims that supplements can reverse age-related egg-quality changes.
Victoria
On the topic of age, there's also a myth that once you reach perimenopause, you can't get pregnant.
Can you debunk that?
Dr. Annaleeza Caputi
Please.
I have this conversation with all of my patients over age 40, even if they aren't in perimenopause yet, because it's such a huge misconception.
It goes back to that idea that if I don't have a regular period, I can't conceive.
That is not true.
In perimenopause, your cycles start becoming less predictable, and ovulation may not happen as consistently.
But that makes it harder to predict when you're ovulating—it doesn't mean you're never ovulating.
If you don't have a contraceptive plan in place, pregnancy is still possible.
This has happened to women in my practice.
So I have that conversation about contraception and still being diligent about cycle tracking as much as possible.
It's totally possible that you're ovulating. We just can't predict and time it the way we could previously.
You can get pregnant during perimenopause.
Jeanette
Let's talk about egg quality.
We hear a lot about fertility supplements specifically marketed to improve egg quality or decrease inflammation.
But these supplements don't always have evidence showing improved pregnancy outcomes, which is ultimately what we're looking for.
How do you navigate supplements during preconception, and how do you decide which ones are worth taking?
Dr. Annaleeza Caputi
This is where I really hone in on the evidence.
Exactly like you said, Jeanette: what are the actual pregnancy and clinical outcomes?
That's what matters.
This is where theory doesn't always translate into real-world outcomes.
With “egg-quality supplements,” theoretically, we might think that giving a therapeutic dose of antioxidants reduces reactive oxygen species and oxidative damage and therefore improves egg quality.
But we don't necessarily see that translate into meaningful fertility outcomes in the research.
Age is also one of the biggest non-modifiable factors.
If egg quality is a concern in somebody over 35, I don't know how much leeway we realistically have.
There may not necessarily be a large risk in trying some of these interventions, but I would never guarantee that they will improve meaningful clinical outcomes.
That's an important conversation because the internet often says the opposite and can make women feel like they should be able to reverse any egg-quality issue.
That's not a realistic expectation.
Victoria
That's the problem with just reading the conclusion of a research paper.
You see, “This improves egg quality,” and then suddenly you're $700 deep in supplements, but we haven't addressed the right outcome.
Maybe it affects mitochondria, but what does that actually mean for the patient?
If it doesn't increase the chance of a healthy baby, that's what the patient ultimately cares about.
Dr. Annaleeza Caputi
Exactly.
With fertility and pregnancy, that's what we care about.
Is this thing you're telling me to take going to improve my outcome of having a healthy baby—yes or no?
In a lot of instances, the answer is no.
In some instances, the answer is yes.
I like to focus on the yeses.
Jeanette
Let's talk about prenatal vitamins.
Does every patient go on a prenatal?
How soon do you start one, and what do you look for?
Dr. Annaleeza Caputi
Prenatals are basically like a multivitamin on steroids.
If someone comes to me and wants to conceive within the next six months, I'm generally discussing a prenatal.
But the type of prenatal matters.
The first thing I look for is choline.
Not every prenatal contains much choline.
Choline is a nutrient we want to make sure we're getting during preconception and pregnancy.
You can also get choline from food—eggs are a great source.
Then there's the folic-acid conversation, which is another myth I love to debunk.
There has been a big push toward methylated folate or 5-methyltetrahydrofolate (5-MTHF).
What we see when we look at maternal and fetal outcomes is that I don't think the research supports telling every patient that their prenatal is inadequate simply because it contains folic acid instead of methylfolate.
I used to tell patients to switch prenatals because their folate wasn't methylated.
I've changed that practice because I don't think the evidence supports doing that universally.
I also look at the rest of the formulation, including iron.
Pregnancy significantly increases blood volume, so iron status becomes particularly important.
I look for vitamin D too, although vitamin D is something I may supplement separately based on testing and individual levels.
Then I make sure the rest of the vitamins and minerals are present in forms the patient can tolerate and absorb appropriately.
There's a lot to look for in a prenatal.
But the folic-acid piece is important because there's a lot of messaging online saying that if folate isn't methylated, the prenatal is a waste.
I don't think that's true.
In terms of higher-dose folic acid, that's something we use for specific indications.
For example, higher doses may be considered when there has been a previous pregnancy affected by a neural tube defect.
If that isn't the situation, I don't automatically assume more folic acid is better.
Victoria
I know Karen is going to be in our comment section about folic acid.
Someone will also ask about the MTHFR gene.
Can you touch on that?
Dr. Annaleeza Caputi
Totally.
This isn't only about folic acid.
We can use vitamin B12 as an example too.
There are different forms of vitamins, and some forms are more bioavailable than others.
There's a huge conversation around methylation and genetic variants such as MTHFR.
You could test yourself, or in some cases you could simply use certain methylated forms of nutrients.
For example, I often look for methylcobalamin as a form of vitamin B12.
But when it comes specifically to folic acid and pregnancy outcomes, I don't think the evidence supports saying folic acid won't work because it's not methylated.
We don't need methylfolate in order for folate supplementation to reduce the risk of neural tube defects.
That's my response to Karen.
Victoria
Perfect. I'm going to make that an audio clip for Karen and DM it to her.
Okay, we have to talk about the other half of the equation: males.
Nobody talks about men when it comes to fertility, which is kind of funny.
There's a misconception that when we're talking about things like smoking or drinking alcohol, men only need to worry about secondhand exposure once their partner is pregnant.
They aren't necessarily thinking about how their own lifestyle affects sperm quality.
What do you have to say about that half of the equation?
Dr. Annaleeza Caputi
They're 50% of the equation.
That's why I often encourage couples to do a couples consult.
I look at both counterparts right from the start because lifestyle factors can have a major impact.
Just like we care about the health of the egg, we care about sperm health.
And I don't mean to exclude anybody by gender—I'm referring anatomically to the reproductive components involved.
With sperm, we care about several things.
We care about motility, which is how well the sperm move.
We care about morphology, which refers to their shape.
And we care about sperm count.
There are many lifestyle factors that may affect those measures.
Alcohol consumption is one.
Smoking is another—separate from secondhand smoke exposure.
We also talk about excessive heat exposure.
A practical example is constantly using a laptop directly on your lap.
We also consider things such as very tight clothing in situations where a lot of heat is being generated.
Sometimes people dismiss these things because they seem small, but fertility is often a combination of many small lifestyle factors.
I talk about smoking, alcohol, diet, caffeine and drug use and how those factors relate not only to general health but potentially to sperm health.
Victoria
Can we group vaping and cannabis use into that conversation too?
Dr. Annaleeza Caputi
Yes, although this is an area where the research is still developing.
Cannabis use, vaping and e-cigarettes are relatively newer compared with the decades of data we have on traditional cigarette smoking.
So some of the concern is extrapolated from smoking research while newer research continues to emerge.
The other important point is how common these exposures are becoming.
As use becomes more widespread and frequent, we need to understand the implications.
Based on what we're seeing so far, I don't think these are things to completely dismiss when we're talking about fertility.
Victoria
What are some diet and lifestyle pieces you typically start with for patients who want to optimize fertility, whether male or female?
Dr. Annaleeza Caputi
From a nutrition standpoint, I focus on more of a Mediterranean-style way of eating.
One reason is that the evidence tends to support this dietary pattern in reproductive and metabolic health.
The other reason is that it's not restrictive.
We clearly see that restrictive eating isn't what we want when supporting fertility.
I prefer a dietary pattern focused on what we're including rather than what we're eliminating.
We focus on adequate protein intake, which will change depending on someone's activity level, body size and individual needs.
We focus on fibre intake to support gut health, bowel movements and blood-sugar regulation.
We focus on healthy fats such as nuts, seeds, avocado and extra-virgin olive oil.
Then fruits and vegetables, particularly dark leafy greens and berries for their antioxidant and nutrient profiles.
The goal is making sure we're getting adequate calories and a well-rounded diet.
In terms of exercise, I encourage movement in general.
The research trends toward regular activity being positive for fertility outcomes.
That could mean walking for one person, strength or resistance training for somebody else, or other forms of exercise.
The exact type isn't necessarily the point.
Then we're definitely talking about stress.
Not just assessing stress or telling someone to meditate, but actually doing lifestyle counselling around what is weighing on them.
What is modifiable?
What isn't modifiable?
What support systems can we put in place to help reduce how heavily this affects the fertility journey?
Victoria
I don't think patients always realize how important the diet, lifestyle and stress pieces are.
Very few healthcare professionals have enough time to sit down and ask what is actually happening with someone's stress.
I love what you said about modifiable and non-modifiable factors.
It's empowering when patients realize that there are areas where they can have an impact.
Dr. Annaleeza Caputi
And with stress management, it's also about building whatever support system that person needs.
Because when pregnancy happens and when children arrive, those support systems still need to be in place.
It's not only about getting pregnant.
It's making sure you have a supportive healthcare team and people around you throughout that entire journey.
That's beyond deep breathing, meditation and grounding.
It's beyond only nervous-system regulation.
People are struggling, and they need real support.
Victoria
How important is the metabolic piece to fertility?
Dr. Annaleeza Caputi
Very important.
From the cholesterol standpoint, cholesterol is involved in steroid-hormone production.
Blood sugar is equally important.
Especially in females who aren't ovulating regularly, we need to make sure insulin resistance isn't playing a role because that can be a significant obstacle.
We also consider things such as high blood pressure and hypertension.
Metabolic issues present before conception can increase risks during pregnancy and postpartum.
So it's not only about treating something so the person can get pregnant.
It's about reducing risk during pregnancy and postpartum too.
That's why metabolic health is just as important as talking about reproductive hormones.
Jeanette
Do you run blood work when patients first come in for this?
Would you run things like HbA1c and a cholesterol panel, or does it depend on the patient?
Dr. Annaleeza Caputi
It's completely individualized, and the list isn't exhaustive.
But I definitely consider things like hemoglobin A1c, or HbA1c, fasting glucose and fasting insulin.
I look at vitamin D.
I look at the lipid panel.
Another big one is the thyroid, especially for the person carrying the pregnancy.
We're particular about thyroid levels when someone is trying to conceive and during pregnancy.
This is particularly important to screen for in patients who've experienced one or multiple miscarriages.
That's something that can sometimes be overlooked.
I also look at iron status because that can change dramatically during pregnancy.
And if necessary, I'll run hormonal testing if there are concerns around the menstrual cycle or ovulation.
But again, it depends on the patient.
You'll notice that much of that list is focused on metabolic health.
That's not a coincidence because of how tightly connected metabolic health is with hormonal health.
Jeanette
I'd like to round out the conversation by talking about the environment, specifically endocrine disruptors.
This conversation can feel hopeless.
You learn about all of these exposures and start thinking, “What do I avoid? What's safe? What's not safe?”
It can become very stressful.
What are endocrine-disrupting chemicals, and how might they relate to preconception and fertility?
Dr. Annaleeza Caputi
This is a hard question to answer.
Endocrine-disrupting chemicals are substances that exist in products we use in everyday life and that may interact with the body's hormonal signalling.
They may mimic hormones, bind to receptors or influence receptor signalling, which theoretically could influence reproductive health.
But we already have so many things people are stressed about when it comes to fertility.
For me, this is the cherry on top.
It's also something that can feel minimally modifiable because we're surrounded by these exposures.
When patients bring this up, I like to pick quick wins.
What are small things we could change without making you feel like you need to completely overhaul every household and personal-care product?
One example is receipt paper.
If you can get an emailed receipt instead of holding a physical receipt, great.
If there's a harsh cleaning or personal-care product that you can easily swap for something else, that's another quick win.
Am I telling patients to download apps and scan every product to calculate their “toxic load”?
No.
I would argue that the stress created by doing that may become more detrimental to the person's fertility journey than obsessing over every individual product.
That might be an unpopular opinion, but that's how my brain works.
Could environmental exposures matter? Potentially, yes.
Is there harm in making easy, reasonable changes? No.
Is it my main focus? No.
Jeanette
I agree 100%.
Vic and I were talking about the same thing with egg quality.
Is doing a complete overhaul realistically going to reduce exposure enough to meaningfully change the outcome?
Sometimes we get too focused on that.
Dr. Annaleeza Caputi
I also don't want to completely ignore the environmental conversation.
There has been research looking at sperm counts over time and reporting substantial declines across populations over the past several decades.
There are likely many potential contributors, including environmental exposures, workplace exposures and the lifestyle factors we've discussed.
I don't want to ignore the environment.
But I also don't want to “stress-monger” and make patients feel like they aren't getting pregnant because they touched a receipt.
Jeanette
I love the word stress-monger.
Victoria
It's so true.
I like what you said about the little wins.
If there's something easy you can reduce, great.
But sometimes you walk outside your apartment in Toronto and think, “What am I even breathing in today?”
There are modifiable and non-modifiable factors.
Take the little wins where you can.
Dr. Annaleeza Caputi
Absolutely.
Victoria
At the end of every episode, we love to do rapid fire.
We'll give you a statement and you say myth, truth or it depends.
You can explain if you want or leave it at that.
First one: having a normal menstrual cycle means you don't have to worry about fertility.
Dr. Annaleeza Caputi
Myth.
Like we talked about before, we still have to make sure ovulation is happening.
There are so many factors involved.
So that's a myth.
Victoria
Lifting your legs after intercourse will help you get pregnant.
Dr. Annaleeza Caputi
Myth.
I don't even have an explanation.
It doesn't change anything.
The sperm are not going to swim any faster.
Jeanette
You hear it all the time, though. It's crazy.
Dr. Annaleeza Caputi
All these old wives' tales at least give us a laugh, but no. That's a myth.
Victoria
For males, abstaining from sex will increase the chance of their partner getting pregnant.
Dr. Annaleeza Caputi
This one is more nuanced.
There has been research looking at abstinence and semen parameters.
A period of abstinence can increase sperm count, which makes sense because there's been more time between ejaculations.
But that doesn't necessarily improve other parameters such as motility or morphology in the same way, and it doesn't automatically mean the couple will become pregnant faster.
So I would say it depends.
Victoria
You should stop drinking and smoking well in advance of trying to get pregnant.
Dr. Annaleeza Caputi
I would say that's a fact.
Based on what we know about alcohol and smoking in relation to sperm quality and fertility and pregnancy outcomes in general, I usually talk to patients who want to conceive within the next several months about limiting alcohol and avoiding smoking.
Victoria
Last one: you can get pregnant any day of your cycle.
Dr. Annaleeza Caputi
Conception is very time-sensitive.
You need to ovulate.
The egg only remains viable for a limited time after ovulation, whereas sperm can survive in the reproductive tract for several days.
So conception is this timing between ovulation and having viable sperm present around that window.
If you're not ovulating, you're not getting pregnant.
Jeanette
Amazing.
We've obviously been myth-busting throughout this whole episode.
If you could pick one fertility myth—either one we've already talked about or something else—that you want to debunk once and for all, what would it be?
Dr. Annaleeza Caputi
I would say the biggest myth is thinking that it's too early to start caring about your fertility.
I've had patient visits where they're talking about conceiving in the next six to 12 months and I suggest a prenatal.
They're like, “Oh, I don't want to get pregnant right now.”
And I'm like, “No, no, no. Taking a prenatal isn't going to make you pregnant.”
It's called a prenatal vitamin.
The things we're recommending to help support fertility are generally also supporting overall health.
The overarching myth is that you need to wait until you're “ready,” whatever that even means.
I would argue that you're never completely ready.
People either wait until they feel ready or suddenly reach the point where they wanted to be pregnant yesterday.
I think you should seek support for your hormonal and fertility health as early as you see fit.
Victoria
I love it.
This was incredibly helpful, even just for Jeanette and me.
We really appreciate you coming on today.
Where can listeners keep up with you, follow your work or book with you?
Dr. Annaleeza Caputi
I practise in Port Credit in Mississauga, and I also practise in Guelph.
I see patients virtually throughout Ontario as well.
You can also find me on Instagram.
I'm active there—slightly less right now because I have eight-month-old twins keeping me very busy.
But that's where I love sharing what I'm up to, what I'm supporting patients with and talking about evidence-based things we can do to support people.
Victoria
Love it.
Thank you so much for being on today.
We'll include all of that information in the show notes for our listeners.
This was great.
Dr. Annaleeza Caputi
Thank you so much. Thanks for having me.
Jeanette
Thank you.
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My hormones and I had a lifelong battle. From acne and painful periods to insulin resistance, I understand what it means to feel frustrated, overwhelmed, confused and hopeless. As a first time mom of twins, I also know how hard it is to navigate the medical system throughout pregnancy and postpartum. My goal is to bridge this gap in healthcare for you in your motherhood journey.
I believe that knowledge is power, and that is why I'm motivated to help you become educated and empowered about your health care and realize that our body and hormones are working for us, not against us. We just need to give our bodies the support and tools in order to do so.
Being a partner in your healthcare journey fuels my fire and is truly an honour that I cherish.
My journey to optimal health completely changed my life, and ever since then I have been committed to making my patients feel the same way and to no longer accept being 'fine' as their normal.
My practice is built on the foundation of comprehensive health assessments to identify the root cause, and curation of treatment plans together. This means that our work is sustainable and in line with your goals and values. We use evidence-based medicine, integrating the most recent treatment guidelines with clinical experience and patient values to carve our path. Every patient will be informed and understand all of their options. I will support you no matter what.