Folic Acid, Folate & MTHFR Deficiency - everything you need to know

We hear a lot about vitamin B9 (aka folic acid or folate) for fertility and pregnancy, and it’s for a good reason. It's necessary for DNA synthesis, and therefore is considered key for proper egg development and ovarian function, as well as embryo and fetal growth.

In fact, a budding embryo needs higher than usual levels of vitamin B9 before you even know you’re pregnant, and deficiencies are serious enough they can actually result in infertility, miscarriage, or birth defects. Being that B vitamins get depleted with stress and poor diets, many people tend to run low on this critical nutrient.

If we know how important it is, all we've got to do is take a supplement. Problem solved...right?

Well, with this vitamin in particular its not quite that simple. What form, the dosage, how our body metabolizes it, even a common genetic disorder, all play a huge role in the amount of vitamin B9 available. But not to fret! I'm going to break it all down for you here.


Folic Acid, Folate & L-Methylfolate

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Vitamin B9 comes in several different forms, the 3 main ones are folic acid, folate, and L-methylfolate (aka methyl-folate or 5-MTHF.)

Folic Acid is the synthetic form of vitamin B9, folic acid is only manmade. It's found in synthetic vitamins and fortified foods, such as breads, pastas, crackers, and other products made with fortified flour.

Our body can usually process folic acid into folate, but it must be processed by the liver and some people have a harder time converting it to folate than others, especially when taking high doses such as those found in prenatal vitamins.

Folate is the food form, it's plentiful in foods like broccoli, kale, brussel sprouts, chard, legumes, beans, citrus, avocado, nuts and seeds, asparagus, and squash. Folate absorbs directly from the intestines and our body can usually convert it into L-methylfolate, but once again, some people have a harder time with conversion than others.

L-methylfolate is the active form in our body, this is the form that's essential for fertility, healthy embryo growth, and pregnancy. Even if you're taking a ton of folic acid, if very little is ending up as L-methylfolate, then it doesn't do much good.


Signs of Deficiency


While a mild deficiency may not result in any noticeable symptoms for most people, some people may experience:

  • low immunity

  • low energy

  • poor digestion

  • weight loss or loss of appetite

  • canker sores

  • anemia

  • heart palpitations

  • changes to mood

If you are deficient enough prior to conceiving that you notice symptoms, then it may be dangerous to get pregnant before you bring your vitamin B9 levels up, as deficiency is closely linked to neural tube defects.


MTHFR Deficiency

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MTHFR (Methylenetetrahydrofolate reductase) is the enzyme that converts folate to L-methylfolate. Deficiency of this enzyme's activity can have a major effect on fertility and pregnancy.

Everyone has 2 copies of the MTHFR gene. 40% of the population has 1 gene mutation, which can result in 20-40% reduction in enzyme activity. 10% of the population has 2 gene mutations, which can result in 70% reduction of enzyme activity.

If you have been trying to conceive for more than a year, if you've been diagnosed with diminished egg quality, or if you have a history of miscarriages and you have not yet been tested, consider talking to your doctor about testing for MTHFR gene mutations.

Some doctors, such as naturopaths or OBGYNs, may screen for it as part of a fertility workup. It's also included as part of certain genetic testing, such as 23andme. But it’s still not considered a standard test, so not all doctors think to order it, even if you do show signs of deficiency.

If you have no reason to believe you have MTHFR deficiency, then you should still be able to get a significant amount of available L-methylfolate from supplements and diet.


What to take

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If you don't have any MTHFR mutations, then most prenatal vitamins will work fine for you, as long as it has at least 800mcg of folic acid of folate, but I recommend opting for folate for 2 main reasons: many people still don't efficiently convert folic acid to folate, and folate - even at high doses - doesn't really cause side effects. 

Brands such as Garden of Life and MegaFoods contain 800mcg folate.

If you do have MTHFR deficiency, many patients are prescribed Folgard by their doctor, which is a large dose of folic acid (usually 1000-4000mcg.) Depending on the patient that may be sufficient, but it is more work for the liver to process it all.

I recommend my MTHFR deficient patients definitely opt for the folate-containing prenatals, as well as a stand alone supplement of 800mcg folate or 400mcg L-methlyfolate for an extra boost. There are prenatal vitamins that contain L-methylfolate, but the downside of that form of is it may cause headaches, pain, changes to mood, or insomnia, so I don't typically recommend getting high doses of it. If you want to try the 400mcg L-methylfolate as an adjunct to your folate-containing prenatal, start with 100mcg and slowly bring the level up. 

Folate, on the other hand, doesn't typically cause side effects, even at higher doses. Even with reduced MTHFR activity, taking dosages of folate at this level are likely to be sufficient.

You can also supplement your prenatal with 800mcg worth of folate-rich foods, if you'd rather not take one extra pill. That's approximately 4-8 servings, but this requires you to be diligent about making sure you're eating them every day.

Do not attempt to get a higher dose of folic acid or folate by increasing the dosage of your prenatal, if you get too much vitamin A it can be dangerous.

These recommendations are based on It Starts with the Egg by Rebecca Fett. Speak with your doctor prior to taking any vitamins or supplements or making changes to your diet.