Most important take away

Fertility is not just about getting pregnant — it is a fundamental health marker that reflects hormonal, metabolic, and cellular health, and women with infertility have increased rates of metabolic syndrome, cancer, heart attack, stroke, and early death. The 60 days before conception (“trimester zero”) represent the window when egg quality is most susceptible to lifestyle factors, and controlling chronic inflammation through five non-negotiable pillars — sleep, stress management, muscle building, nutrition, and toxin avoidance — can tangibly improve both fertility outcomes and long-term health.

Summary

• Fertility as a health marker: Fertility reflects overall hormonal, metabolic, and cellular health. Infertility is often the first warning sign of chronic inflammation or insulin resistance that can lead to long-term health problems. Every woman should get an AMH test to understand her egg reserve, regardless of whether she currently wants children.
• Hormone replacement and augmentation: The medical field is shifting toward earlier hormone therapy for perimenopausal women rather than waiting until 12 months without a period. Estrogen is cardioprotective, may lower Alzheimer’s risk, and protects bones. Progesterone alone or in combination with estrogen can help during the perimenopausal transition.
• Prior pregnancy and secondary infertility: Women who have had a prior live birth maintain an 18-20% monthly pregnancy probability up to age 37 (versus the typical age-related decline starting at 35). However, secondary infertility is real and should be evaluated after six months of trying. The current system of requiring failure before testing is counterproductive — proactive screening for ovarian reserve, tubal patency, uterine anatomy, and semen analysis should be standard.
• Sleep (7-9 hours, closer to 7.5 for women): Poor sleep doubles the rate of infertility. FSH and LH are released during early morning hours, so insufficient sleep disrupts hormonal signaling. Day-to-day consistency matters as much as duration. Low-dose melatonin (1-3 mg, 30 minutes before bed) can improve egg quality and fertility odds — but avoid common over-the-counter products with 10x that amount.
• Building skeletal muscle: The single best mechanism for reversing insulin resistance and improving hormonal health. Insulin resistance directly impairs ovarian function, egg quality, and embryo development. Resistance training should be prioritized.
• Nutrition for fertility: High fiber from fruits, vegetables, and whole grains; quality protein with an emphasis on increased plant-based protein (each serving of plant protein over animal was associated with better ovulation); healthy fats from nuts, olive oil, fish, and flax (cholesterol is the backbone of steroid hormones — insufficient dietary fat impairs progesterone production); minimize ultra-processed foods and artificial sweeteners. An elimination diet approach can help identify individual inflammatory triggers.
• Supplementation (“trimester zero” essentials): Prenatal vitamin with folic acid, CoQ10 (robust human data for egg quality), omega-3 fatty acids, and vitamin D. For men: L-carnitine, zinc, and selenium. CoQ10 is stopped during pregnancy due to lack of safety data. NAD/NMN may benefit unexplained infertility cases but is not universally recommended.
• Cannabis is highly detrimental: Female cannabis use in the prior year decreases eggs retrieved by 25%, reduces fertilization rates by 28%, and increases miscarriage. Male cannabis use damages sperm DNA fragmentation, leading to higher miscarriage rates in their partners. In the IVF lab, embryos that halt at day three are overwhelmingly associated with undisclosed male cannabis use.
• Nicotine damages fertility: Cigarette smoking is one of the few things that directly depletes the egg reserve and accelerates menopause. Oral nicotine (pouches) likely impacts egg quality and clearly tanks sperm counts. All nicotine should be avoided when trying to conceive.
• NSAIDs block ovulation: Ibuprofen, Advil, Aleve, and similar anti-inflammatories taken around ovulation can prevent the follicle from rupturing and releasing the egg. They are safe only during menstruation. This is widely unknown.
• Cold plunges are not recommended when trying to conceive, as they may dampen the acute inflammatory response required for ovulation and implantation.
• Endocrine disruptors matter: Lavender, tea tree, and evening primrose oils have endocrine-disrupting properties. Scented products contain phthalates. Look for “fragrance free” (not “unscented,” which may mask fragrances with additional chemicals). Thermal receipt paper is a major BPA exposure source. Microplastics accumulate in the ovary and are associated with worse IVF outcomes.
• Birth control considerations: Stop the combination pill at least six months before trying to conceive to learn your cycle and detect ovulation. Remove a progesterone IUD at least six months before conception to allow endometrial rebuilding. A single Depo-Provera shot can suppress ovulation for up to 18 months — avoid it if planning pregnancy within two years. The pill often masks underlying conditions like PCOS that are never properly diagnosed.
• GLP-1 agonists for inflammatory infertility: Low-dose GLP-1s for approximately three months before an IVF cycle are showing promising clinical results for patients with endometriosis or unexplained infertility, even in patients without excess adipose tissue, suggesting direct anti-inflammatory effects beyond weight loss.
• Red light therapy: Early evidence suggests potential benefits for ovulatory patterns (systemic panels) and possibly egg quality (ovarian-directed therapy), though definitive human data is still pending.
• Biotin interferes with lab tests: Supplementation above 300 micrograms (common in hair/skin/nail products at 10-30x this amount) causes false readings on steroid hormone assays including estradiol, progesterone, HCG, TSH, and testosterone. Stop biotin before any hormone panel.
• Advanced paternal age (50+) is associated with increased risk of autism, autosomal dominant mutations, and schizophrenia in offspring, though absolute risk remains low. Sperm banking earlier is advisable.
• All of these recommendations apply equally to perimenopause: The same anti-inflammatory lifestyle practices that support fertility also improve the perimenopausal transition, since menopause removes estrogen’s profound anti-inflammatory benefits.

Chapter Summaries

Fertility as a Health Marker

Dr. Crawford explains that fertility reflects hormonal, metabolic, and cellular health. Infertility correlates with higher rates of metabolic syndrome, cancer, cardiovascular events, and early death — not because infertility causes these directly, but because it signals underlying chronic inflammation or insulin resistance. Women should think of fertility as a vital sign regardless of reproductive goals.

Hormone Replacement and Perimenopause

The medical field is moving toward earlier hormone therapy rather than waiting for the strict 12-month-without-a-period definition of menopause. Estrogen replacement is cardioprotective, may reduce Alzheimer’s risk, and supports bone health. Dr. Crawford advocates for women to have agency over their hormonal health and not be dismissed during the 5-10 year perimenopausal transition.

Prior Pregnancy and Secondary Infertility

Data from the Time to Conceive study shows that women with a prior live birth maintain higher monthly pregnancy rates (18-20%) up to age 37. However, secondary infertility is real and often emotionally isolating. The current medical model of requiring 12 months of failure before investigation is outdated — proactive testing should be the norm, especially since 72% of natural conceptions occur in the first six months.

Pregnancy Loss and Evaluation

After two pregnancy losses, a full evaluation is warranted (blood tests, semen analysis, sperm fragmentation, uterine and tubal evaluation). Dr. Crawford shares her personal experience of four pregnancy losses and being told she needed a third loss before testing would be ordered. Prior pregnancy of any outcome does confirm certain systems are intact (sperm present, at least one functional tube, implantation capability).

Plastics, Microplastics, and Toxin Avoidance

Microplastics accumulate in the ovary and are associated with worse IVF outcomes and longer time to pregnancy. Endocrine-disrupting chemicals in plastics contribute to the overall inflammatory burden. The goal is not all-or-nothing avoidance but reducing daily cumulative exposure through practical choices about water bottles, food containers, and personal care products.

The Five Non-Negotiables: Sleep

Seven to nine hours with circadian consistency. Poor sleep doubles infertility rates and reduces eggs retrieved at IVF. FSH and LH release during early morning hours requires adequate sleep duration. Low-dose melatonin (1-3 mg) can augment the body’s natural production and improve egg quality.

The Five Non-Negotiables: Stress, Muscle, and Insulin Resistance

Chronic stress directly increases insulin resistance. Building skeletal muscle is the most powerful mechanism to reverse insulin resistance and optimize hormonal health. These factors work together — improving one tends to improve the others.

NSAIDs, Cold Plunges, and Acute Inflammation

Acute inflammation is required for ovulation (follicle rupture) and implantation. NSAIDs taken around ovulation can prevent egg release. Cold plunges may similarly dampen necessary acute inflammatory responses. Both should be avoided during the fertile window. Curcumin supplements are also not recommended, though cooking with turmeric is fine.

Supplements for Egg and Sperm Quality

Universal pre-conception supplements: prenatal vitamin with folic acid, CoQ10, omega-3 fatty acids, and vitamin D. For sperm: L-carnitine, zinc, and selenium. NAD/NMN shows promise in animal studies for unexplained infertility but lacks definitive human data. Inositol benefits PCOS patients by decreasing insulin resistance. N-acetylcysteine may help endometriosis and chronic inflammatory disease.

Cannabis, Nicotine, and Alcohol

Cannabis is the most concerning substance Dr. Crawford encounters in clinical practice. It reduces egg retrieval by 25%, fertilization by 28%, and significantly damages sperm DNA integrity. Nicotine directly depletes egg reserves and sperm counts. Alcohol has no safe level for fertility optimization. These are “behavioral toxins” with no place in a fertility-optimized lifestyle.

Birth Control and Fertility Planning

The combination pill should be stopped six months before trying to conceive to allow cycle tracking and detection of underlying conditions like PCOS. The progesterone IUD should be removed six months early to allow endometrial rebuilding. Depo-Provera can suppress ovulation for up to 18 months from a single dose. Intentional termination does not negatively impact future fertility, though any intrauterine procedure carries a small risk of scarring.

Nutrition for Fertility

A fertility diet emphasizes high fiber, whole grains, quality protein with increased plant-based sources, and healthy fats (especially omega-3s and monounsaturated fats). Cholesterol is essential for steroid hormone production — inadequate dietary fat impairs progesterone. Red meat in high quantities is associated with worse IVF outcomes and higher endometriosis staging. An elimination approach can identify personal inflammatory triggers.

Endocrine Disruptors

Lavender, tea tree, and evening primrose oils have endocrine-disrupting properties. Scented products contain phthalates. “Unscented” is not the same as “fragrance free.” Thermal receipt paper is a significant BPA source. Population-level data from the EARTH study confirms that higher endocrine disruptor levels are associated with worse fertility outcomes even with IVF.

GLP-1 Agonists and Emerging Therapies

Low-dose GLP-1 agonists used for three months before IVF cycles show clinical improvement in patients with endometriosis or unexplained infertility, potentially through direct anti-inflammatory effects independent of weight loss. Human growth hormone added during IVF stimulation improves egg maturity and embryo development. Red light therapy and PRP (platelet-rich plasma) are emerging areas with intrauterine PRP showing the most promise for implantation failure. Ovarian PRP remains more speculative.

Biotin and Lab Interference

Biotin supplementation above 300 micrograms (commonly exceeded in hair/skin/nail supplements) causes false readings on steroid hormone assays. Any woman getting hormone panels should discontinue high-dose biotin supplements beforehand.

Paternal Age and Sperm Quality

After age 50, paternal age is associated with increased risk of autism, autosomal dominant mutations, and schizophrenia in offspring. The absolute risk remains small, but banking sperm younger and optimizing lifestyle factors in the 90 days before use is advisable.