Is folate or folic acid better for fertility and pregnancy? Clearing the controversy.Dec 05, 2022
If you've spent any time looking into prenatal supplements, you've run into the folate vs folic acid controversy.
No one is debating the importance of this nutrient for fertility and preventing neural tube defects (a birth defect in baby's spinal cord). Folate deficiency in women preconception, increases the risk of having a baby with a neural tube defect by 50-70%.
It’s a big deal. And it requires planning ahead – prevention of these birth defects requires getting enough folate in the months prior to pregnancy.
However, there is large disagreement about which form - folate or folic acid - that you should take preconception when trying to conceive (TTC) and during pregnancy. It’s a public health tug of war between the less-costly, well-studied synthetic folic acid vs the more bioavailable / absorbable and naturally occurring, but less studied, folate.
This blog will clear the controversy, so you can feel confident you're taking the best supplement for fertility and a healthy pregnancy. I'll start by covering everything you need to know about why folate is so important, when and how much you should take, and then we'll dive into the best form.
TL;DR I recommend taking a prenatal supplement with folate, not folic acid, for best absorption without any healthy risks to you or to baby to be. Two of my favorite prenatal supplements are FullWell* and Needed*.
Is folic acid the same as folate?
In short, no. This is not an issue of semantics, tomatos vs tomatohs.
Folate, a.k.a. vitamin B-9, is a blanket term for the many molecular forms this nutrient takes. The naturally occurring form found in whole foods is 5-methyltetrahydrofolate or 5-MTHF. For simplicity, I say ‘folate’ to describe 5-MTHF.
Folic acid, on the other hand, refers to the synthetic, human-made molecule found in most supplements and fortified foods.
Why is folate so important for pregnancy?
Folate is such a big deal because it is needed for the synthesis of DNA and RNA, which in turn enables cell division during fetal development.
As you can imagine, if folate is in short supply and cells cannot divide and proliferate as they should, serious issues arise. The most widely known consequences include babies born with spina bifida and other neural tube defects (NTDs).
Does folate make you more fertile?
Yes, folate is critical for optimal female fertility.
Folate is a component of healthy follicular fluid, the fluid that nourishes the developing eggs in your ovaries. It also acts as an antioxidant, protecting the DNA and genetic makeup inside your eggs from oxidative damage.
In sum, folate helps improve egg quality and embryo quality, to help improve chances of conception and then help prevent miscarriage.
When should you start taking folate?
The time to start taking folate is pre-conception / before you're pregnant.
That neural tube forms in the first 4 weeks of gestation. That's before most people miss a period and even realize they're pregnant. This means you need to have enough folate in your reserves BEFORE sperm meets egg, before the neural tube is forming, for your best chances of preventing NTDs.
Many leading health organizations, such as ACOG, recommend you start taking folate at least one month before TTC. Note emphasis on "at least".
Back in the 90's, the FDA mandated folic acid fortification of all wheat-based products in the U.S., based on the belief that all women of reproductive age should be getting more.
How long should you take folate before getting pregnant?
In my opinion as a fertility dietitian, if you're reading this blog, then it's time to start taking folate. You can't "overdo" it because folate is water soluble, and any excess beyond what your body can use, you'll pee out.
As soon as you're even thinking about trying, or at least as soon as you stop using birth control, it's time to take folate.
Is folate only important first trimester?
No. You need folate throughout your pregnancy, first, second and third trimesters (and postpartum!) As explained above, folate is essential to DNA and RNA synthesis. That fetus is a collections of rapidly dividing cells - meaning rapid-fire DNA synthesis.
Folate vs folic acid for preventing neural tube defects
Now, to dive into the meat of the topic. We covered how important folate is for preventing NTDs, and for optimal female fertility. But, why not take folic acid? Is it the same difference?
Not so fast.
Remember that FDA mandate for folic acid fortification? While the U.S. did see an estimated 19-32% decrease in NTDs, unfortunately, this intervention has not proven to be the panacea many had anticipated.
National data in the U.S. estimates that decades later, nearly 20% of U.S. women in our reproductive years are still not getting enough folate.
This is because the synthetic folic acid form of the nutrient is not absorbable by all people.
Is folate or folic acid more absorbable?
Folate is much more bioavailable / absorbable than folic acid.
Folic acid is not in the metabolically active form, meaning your body needs to break it down into 5-MTHF before its usable.
Each individual’s ability to make this conversion to the bioavailable 5-MTHF varies based on liver function, genetics (particularly the MTHFR gene, see below), alcohol consumption, and gut health (those with impaired absorption due to conditions like Celiac Disease or IBD are at greater risk of folate deficiency).
Folate on the other hand, is 5-MTHF, and thus no conversion is required. It is already perfectly bioavailable.
WTF is MTHFR?
MTHFR is a genetic variations that largely determines your ability to convert folic acid into the bioavailable form, 5-MTHF.
Folic acid supplementation is particularly complicated for those of us with a genetic variation called an MTHFR polymorphism. An estimated 10-25% of women in the U.S. have a variation in both of their MTHFR genes (one from each parent).
The MTHFR gene codes for the enzyme that converts folic acid into 5-MTHF. Boiled down, the MTHFR gene mutation limits your ability to absorb and utilize folic acid.
This can result in unmetabolized folic acid accumulating in your bloodstream, which poses its own health risks, including a 4%, increased risk of having a baby with a NTD.
You read that right; unmetabolized folic acid increases the risk of the neural tube defect that you're hoping to prevent by taking this supplement.
Although this sounds frightening, the solution is relatively simple:
Take a prenatal multi that provides the most bioavailable form of folate, the 5-MTHF (a.k.a. methyl-folate), rather than folic acid. Authors of a 2020 systemic review conclude,
“… risks can be avoided by supplementation with 5-MTHF rather than folic acid. Because 5-MTHF does not require activation, it is immediately available to mother and fetus and does not accumulate in the blood like folic acid does [in some cases]”.
Why the folate vs folic acid controversy?
Why don't all healthcare providers recommend folate instead of folic acid? Good question.
Unfortunately, the majority of the gold-standard research trials used folic acid supplementation to prevent NTDs, rather than folate.
So, even though we know folate supplementation is effective for increasing your blood folate levels, the specific trials linking the nutrient to NTD prevention used folic acid and many medical providers feel that's reason enough to stick with folic acid.
The other drawback to folate is that it's more expensive, resulting in a prenatal multivitamin with a hefty price tag - making needed prenatal supplements more expensive / less accessible and thus posing a health equity issue.
What if I don’t have, or don’t know if I have, the MTHFR variation?
If unsure as to whether or not you have this MTHFR genetic variation (most of us do not know, since this genetic testing is not standard practice), or even if you know you do not, the cautious approach is to choose a prenatal with folate instead of folic acid.
In most cases, genetic testing is not necessary, you can simply choose folate over folic acid.
Unlike folic acid which can pose health risks when unmetabolized, naturally-occurring folate poses no known side effects, if taken in appropriate doses.
Other than the increased cost, there is no risk to choosing folate over folic acid. This is why I recommend all women TTC, looking to improve fertility, take folate as soon as you start trying all the way through your pregnancy.
How much folate should I take before and during pregnancy?
ACOG recommends at least 600 mcg/day of supplemental folate, from pre-conception through at least the first 12-weeks of pregnancy.
I consider those recommendations to be the bare minimum. The FullWell* and Needed* prenatal supplements that I recommend both contain 800 mcg/day, and they're intended to be taken throughout pregnancy and postpartum.
What should I look for on the supplement label?
Naturally-occurring, highly absorbable folate comes in a few different names. Look for any of these on the supplement label:
What about getting folate from food?
Great question. As an advocate for a food-first approach, I can’t overlook the importance of eating food rich in folate, like:
- green leafy vegetables (particularly spinach)
- Brussel’s sprouts
- nuts and
Supplements are intended to be just that, supplemental, not a replacement for whole, real, nourishing foods. That said, as noted above, about 20% of women in the U.S. are not getting enough folate, from food alone.
To be safe, because your fertility and your baby-to-be's health are not the place to take any risks, I recommend eating folate rich foods on the daily and supplementing with folate.
Like so many health issues, there are pros and cons, not rights or wrongs. Ultimately, you get to make an informed decision about what’s best for you, and your babe-to-be.
For more guidance about the best prenatal supplements for fertility, I made you a totally free 3-Step Checklist to the Best Prenatals. Get it here.
Rooting for you,
*This is an affiliate link, meaning you get a discounted price and I receive a very small % of each purchase. Know that I only recommend what I 100% believe to be the best for your fertility and I am so grateful for your support, helping me to provide this information for free to you.
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