What folate dose should women take before conception and is it different for everyone?

The standard dose is 0.4 mg (400 µg) of folate daily, beginning at least 1 month before conception and continuing until 12 weeks of gestation — this reduces the risk of neural tube defects by approximately 70%. The higher dose of 5 mg daily is indicated for women with type 1 or 2 diabetes, BMI ≥30, a prior pregnancy affected by a neural tube defect, current use of anti-epileptic medication, use of methotrexate within the past 3 months, or malabsorption syndromes including inflammatory bowel disease and coeliac disease. Most Australian pregnancy multivitamins (e.g., Elevit, Blackmores Pregnancy Gold) contain folate at appropriate doses.

What is Mackenzie's Mission and what does the PBS carrier screening panel cover?

Mackenzie's Mission was an Australian research programme demonstrating that routine reproductive genetic carrier screening is feasible and acceptable across the population. Its findings directly informed the PBS listing of a three-condition carrier screening panel — cystic fibrosis (CFTR), fragile X syndrome (FMR1), and spinal muscular atrophy (SMN1) — from 1 November 2023. The test is ordered via MBS Item 73420 using a buccal swab or blood sample. Pre-test counselling is essential: explain what carrier status means, the implications of both partners being carriers (25% risk of affected child for autosomal recessive conditions), and the available reproductive options including PGT-M via IVF, prenatal diagnosis, donor gametes, or proceeding without testing.

After how long should a GP initiate infertility workup?

Infertility workup is indicated after 12 months of regular unprotected intercourse in women under 35, or after 6 months in women aged 35 years or older. Earlier workup is appropriate when a known cause exists: oligomenorrhoea or anovulation, prior pelvic inflammatory disease or pelvic surgery, endometriosis, testicular or scrotal abnormality, or prior chemotherapy or radiotherapy. The GP initiates the core workup — mid-luteal progesterone, AMH, Day 2–3 FSH/LH/E2, TSH, prolactin, pelvic ultrasound, and two semen analyses to WHO 2021 6th edition criteria — before referral to a fertility specialist.

Which medications should be stopped or changed before trying to conceive?

Several medications carry significant teratogenic risk and should be substituted or ceased well before conception. Methotrexate — stop at least 3 months before conception (both partners). Isotretinoin — stop at least 1 month before conception for women. Warfarin — switch to low-molecular-weight heparin under specialist guidance. ACE inhibitors and ARBs — switch to pregnancy-safe antihypertensives (labetalol, methyldopa, nifedipine). Statins — cease (limited safety data). Valproate — review with neurology urgently due to neural tube defect, facial dysmorphism, and neurodevelopmental risks (approximately 10% major malformation rate, IQ approximately 9 points lower). A comprehensive medication review should be part of every pre-conception consultation.

What is the normal semen analysis reference range under WHO 2021 criteria?

The WHO Laboratory Manual for Human Semen (6th edition, 2021) updated the lower reference limits: volume ≥1.4 mL, concentration ≥16 million per mL, total count ≥39 million per ejaculate, total motility ≥42%, progressive motility ≥30%, normal morphology (strict Kruger criteria) ≥4%, and vitality ≥54%. Two analyses at least 3 weeks apart are required to characterise a result, as semen parameters vary considerably between samples. Order via MBS Items 73450–73464. Abnormal results on two occasions warrant urological or fertility specialist referral, with consideration of FSH, LH, testosterone, prolactin, karyotype, and Y-chromosome microdeletion testing in severe oligozoospermia or azoospermia.

Pre-conception care and infertility

Pre-conception care and infertility: the Australian general practice framework

By Dr HB Lo, FACRRM Reviewed 23 June 2026 9 min read

The 3–6 months before conception are the highest-impact preventive medicine window. Core elements: folate 0.4 mg daily (5 mg if high-risk — diabetes, BMI >30, prior neural tube defect, anti-epileptic drugs, methotrexate), iodine 150 µg daily, rubella and varicella immunity with vaccination ≥4 weeks before trying, teratogenic medication substitution, and full alcohol cessation.

Infertility is no conception after 12 months of regular unprotected intercourse (6 months if aged ≥35). The GP initiates workup — mid-luteal progesterone, AMH, Day 2–3 FSH/LH/E2, TSH, prolactin, semen analysis to WHO 2021 criteria — before referral to a fertility specialist.

Pre-conception care is one of the highest-impact preventive medicine interventions available in Australian general practice. Up to 50% of Australian pregnancies are unplanned — which means the window to optimise fetal development environments before conception is frequently missed. The Your Fertility national programme and RANZCOG pre-pregnancy counselling guidance both recommend the “One Key Question” — “Would you like to become pregnant in the next year?” — at every consultation with reproductive-age people. This single question opens the conversation that makes the 3–6 month pre-conception window actionable.

A. Core clinical — the AU general-practice framework

A.1 Who needs a pre-conception consultation

Any person planning pregnancy in the next 12 months benefits from a pre-conception consultation — not just those with known medical complexity. The RACGP recommends routine pregnancy intention screening at every reproductive-age consultation using the One Key Question.

A.2 Folate and iodine — the foundation

Folate:

Standard dose: 0.4 mg (400 µg) daily, starting at least 1 month before conception and continuing until 12 weeks of gestation. This dose reduces neural tube defect (NTD) risk by approximately 70% (MRC Vitamin Study Group evidence).
High-dose: 5 mg daily for women with type 1 or type 2 diabetes, BMI ≥30, a prior pregnancy affected by NTD, current anti-epileptic medication (especially valproate, carbamazepine, phenytoin), methotrexate use within the past 3 months, or malabsorption (IBD, coeliac disease, bariatric surgery).
Most Australian pregnancy multivitamins (Elevit, Blackmores Pregnancy Gold) contain folate at appropriate doses. Folate 5 mg tablets are available on general schedule prescription and over-the-counter.

Iodine:

NHMRC recommends 150 µg of iodine daily throughout pre-conception, pregnancy, and lactation. Iodine deficiency impairs neurocognitive development — the pre-conception window is when to establish adequate intake.
Note: women with pre-existing thyroid disease should seek specialist advice before supplementing, as iodine requirements may differ.

A.3 Vaccinations before pregnancy

Rubella IgG — titres <10 IU/mL: administer MMR (live vaccine) at least 4 weeks before attempting conception. Avoid pregnancy within 4 weeks.
Varicella IgG — negative with no clear history of chickenpox: administer varicella vaccine (live) at least 4 weeks before conception.
dTpa — every pregnancy at 20–32 weeks for newborn protection; pre-conception update if >10 years since last dose.
Influenza — annual; safe at any trimester.
COVID-19 — per current ATAGI recommendations; safe pre-conception and in pregnancy.
Hepatitis B — vaccinate if non-immune; check anti-HBs after completion.
HPV Gardasil 9 — catch-up to age 26 if not previously vaccinated.

Record all vaccinations in the Australian Immunisation Register (AIR).

A.4 Teratogenic medication review

Comprehensively review all medications — prescription, over-the-counter, complementary — and substitute or cease teratogens before conception:

Medication	Action
Valproate	Review urgently with neurology — switch to lamotrigine or levetiracetam if possible; folate 5 mg; TGA Pregnancy Prevention Programme documentation if continuing
Methotrexate	Cease ≥3 months before conception (both partners)
Isotretinoin	Cease ≥1 month before conception; strict contraception required during use
ACE inhibitors/ARBs	Switch to labetalol, methyldopa, or nifedipine pre-conception
Statins	Cease; limited safety data
Warfarin	Switch to LMWH with haematology/cardiology guidance
Mycophenolate, leflunomide	Cease ≥3 months before conception

Medications safe to continue: most SSRIs (sertraline preferred in first trimester; avoid paroxetine), ICS for asthma (budesonide preferred), levothyroxine (increase dose by ~25–30% once pregnant), hydroxychloroquine (continue in lupus), mesalazine (continue in IBD).

A.5 Lifestyle optimisation

Alcohol: NHMRC advises no safe level in pregnancy or while trying to conceive — recommend full abstinence
Smoking: cease; refer to Quitline 13 7848 and discuss nicotine replacement therapy (NRT) — the risk of continued smoking exceeds NRT risk in pregnancy
Cannabis and illicit drugs: cease; harm-reduction referral if required
Caffeine: reduce to <200 mg/day (approximately 2 cups of coffee)
BMI optimisation: BMI 20–30 is associated with optimal conception rates and lowest risk of gestational diabetes, pre-eclampsia, and miscarriage; 5–10% weight loss in BMI >30 frequently restores ovulation in PCOS
Exercise: ≥150 minutes of moderate aerobic activity per week; resistance training improves insulin sensitivity
Diet: Mediterranean-style (vegetables, legumes, wholegrains, fish, olive oil); folate-rich foods; avoid listeria-risk items (soft cheese, pâté, deli meats, pre-cut fruit, unpasteurised dairy); limit mercury-containing fish per FSANZ guidance

A.6 Carrier screening — the PBS panel

Mackenzie’s Mission demonstrated that routine reproductive genetic carrier screening is feasible and widely acceptable across the Australian population. From 1 November 2023, a three-condition panel — cystic fibrosis (CFTR), fragile X syndrome (FMR1), and spinal muscular atrophy (SMN1) — became PBS-funded via MBS Item 73420. Order via buccal swab or blood sample after pre-test counselling.

Pre-test counselling should cover: what it means to be a carrier (generally healthy), what happens if both partners are carriers (25% risk of affected child for autosomal recessive — CF, SMA; X-linked pattern for fragile X), and available reproductive options: PGT-M via IVF, prenatal diagnosis (CVS at 11–14 weeks, amniocentesis at 15–20 weeks), donor gametes, or proceeding without testing.

Both partners being carriers: refer to clinical genetics for counselling and management planning.

B. Infertility workup and evidence

Definitions

Primary infertility: no prior pregnancy
Secondary infertility: prior pregnancy, current difficulty conceiving
Infertility: no conception after 12 months of regular unprotected intercourse (<35 years) or 6 months (≥35 years); earlier if known cause

Female GP workup

Investigation	Notes
Mid-luteal progesterone (Day 21 of a 28-day cycle, or 7 days post-confirmed ovulation)	>25 nmol/L confirms ovulation
Day 2–3 FSH, LH, E2	FSH >10 IU/L suggests reduced ovarian reserve
AMH (any cycle day)	<7 pmol/L = low reserve; >25 pmol/L = PCOS morphology range
TSH, prolactin	Hyperprolactinaemia and thyroid disease are treatable anovulatory causes
Pelvic transvaginal ultrasound	Antral follicle count, uterine anatomy, fibroids, endometrioma, polyps
HSG or HyCoSy (sono-HSG)	Tubal patency; uterine cavity assessment
STI screen (chlamydia, gonorrhoea NAAT)	Tubal damage is a treatable infertility cause

Male GP workup

Two semen analyses at least 3 weeks apart, to WHO 2021 6th edition criteria (lower reference limits: volume ≥1.4 mL, concentration ≥16 million/mL, total motility ≥42%, morphology ≥4%). Order via MBS Items 73450–73464.

Take a history of testicular trauma or torsion, undescended testes, mumps orchitis, varicocele, prior chemotherapy or radiotherapy, anabolic steroid use (suppresses the hypothalamic–pituitary–gonadal axis), and hot bath or sauna habits. Examine testicular volume (orchidometer, normal >15 mL) and palpate for varicocele.

Common causes

Female	Male
Anovulation (PCOS, hyperprolactinaemia, premature ovarian insufficiency)	Idiopathic oligo/asthenoteratozoospermia
Tubal disease (PID, hydrosalpinx)	Varicocele
Endometriosis	Obstructive azoospermia (vasectomy, CFTR-related CBAVD)
Uterine factors (fibroids, polyps, adhesions)	Non-obstructive azoospermia (Klinefelter, Y-chromosome microdeletion)
Age-related diminished ovarian reserve	Hypogonadotropic hypogonadism

Approximately 25% of infertility is classified as unexplained after full workup.

C. ART, PCOS, and treatment overview

PCOS and ovulation induction

PCOS is the leading cause of anovulatory infertility in Australia. First-line: 5–10% weight loss restores spontaneous ovulation in many women with BMI >27 and PCOS. First-line pharmacological ovulation induction: letrozole 2.5–5 mg on Days 2–6 (PBS Authority when initiated by a fertility specialist; superior to clomiphene per the PPCOS II trial — higher live birth rate). Clomiphene remains available on general schedule for anovulatory dysfunction (GP-initiated Authority). Metformin is an adjunct for insulin-resistant PCOS.

Australian ART context

Approximately 14,500 ART babies are born in Australia annually — approximately 1 in 16 births — per AIHW data. Medicare covers a significant portion of IVF cycle costs (no annual cycle limit since 2010); out-of-pocket cost is approximately AUD 4,000–5,000 per fresh cycle after rebates, and less via public IVF programmes available in Victoria, the ACT, and Western Australia. IVF providers comply with NHMRC ART Guidelines and the Fertility Society of Australia and New Zealand (FSANZ) accreditation.

PBS Authority covers clomiphene (GP-initiated Streamlined Authority for anovulatory dysfunction), and through fertility specialists: letrozole, FSH preparations (Gonal-F, Puregon, Menopur), GnRH agonists and antagonists, and progesterone pessaries (Crinone, Utrogestan) for ART luteal support.

D. Australian operations

MBS items for pre-conception and infertility

MBS Item	Description
36 / 44	Level C/D GP consultations — initial pre-conception or infertility workup
73420	Reproductive genetic carrier screening (3-condition PBS panel from 1 Nov 2023)
73450–73464	Semen analysis
73531 / 73533	AMH (limited eligibility — fertility assessment)
13290–13297	Assisted reproductive technology (specialist-initiated)
16500	First antenatal visit (once viable intrauterine pregnancy confirmed)
715	Aboriginal and Torres Strait Islander Health Assessment — integrate pre-conception
2715 / 2717	Mental Health Treatment Plan and review — pre-conception mental health support
10954	Allied health — dietitian (under GPCCMP)

Referral pathways

Refer to a fertility specialist (RANZCOG CREI — Certificate in Reproductive Endocrinology and Infertility, or fertility clinic) when:

Female ≥35 years at 6 months trying
Female <35 years at 12 months trying
Anovulation confirmed (progesterone consistently low), suspected tubal disease, severe endometriosis, or diminished ovarian reserve
Abnormal semen analysis on two occasions
Same-sex couples, single person by choice, or donor gamete needs
Recurrent miscarriage (≥2 consecutive losses — refer earlier for workup)
Genetic carrier screen showing both partners as carriers

Public fertility services: Royal Women’s Hospital (Vic), Canberra Fertility Centre (ACT), FertilityWA (WA). Private clinics include Monash IVF, Genea, IVF Australia, City Fertility, Newlife IVF — out-of-pocket approximately AUD 4,000–5,000 per fresh cycle after Medicare rebates.

E. Special populations

Aboriginal and Torres Strait Islander couples: Culturally safe pre-conception care via ACCHOs integrates Item 715 health assessment; address tobacco use (single highest modifiable risk for fetal outcomes), alcohol cessation, and social determinants. Birthing on Country programmes provide culturally safe birth settings. Rates of STI-related tubal infertility are higher — STI screening and treatment are important.

LGBTQI+ family-building: Donor sperm, reciprocal IVF, surrogacy (altruistic only — state-specific legislation), and co-parenting arrangements. Same-sex couples are eligible for ART under most state laws. Inclusive language and non-assumptive consultations are standard. Donor identifiability rules differ by state — identifiable donors are required in New South Wales, Victoria, and Western Australia.

Older parents (≥35 years): Counsel regarding declining fertility (ovarian reserve diminishes from mid-30s), increasing aneuploidy risk, rising miscarriage rates, and higher obstetric risk. Offer earlier referral to a fertility specialist at 6 months trying, rather than waiting 12 months.

Refugee and migrant women: Vaccination catch-up (rubella, varicella, hepatitis B), haemoglobinopathy screening (FBC and Hb electrophoresis for Mediterranean, South-East Asian, African, Middle Eastern ancestry — beta-thalassaemia trait, sickle cell trait), and trauma-informed care are priorities.

Chronic kidney disease, organ transplant, prior cancer: Multidisciplinary pre-conception planning with relevant specialists. Fertility preservation (oocyte or embryo cryopreservation) should be offered before gonadotoxic chemotherapy or radiotherapy.

When to escalate

Refer or escalate when:

Female ≥35 years with 6 months of trying — fertility specialist
Female <35 years with 12 months of trying — fertility specialist
Abnormal semen analysis (two results) — urologist or fertility specialist
Both partners positive on carrier screening panel — clinical genetics
Recurrent miscarriage (≥2) — fertility specialist; lupus anticoagulant, anticardiolipin, anti-β2 glycoprotein I antibodies, TSH, parental karyotype
PCOS with BMI >35 not responding to lifestyle — bariatric surgery consultation before ART
Pre-existing medical condition requiring multidisciplinary pre-conception planning (cardiac disease, epilepsy on valproate, lupus, organ transplant) — relevant specialty plus obstetric medicine

What this article is and is not

This is general health information derived from RANZCOG pre-pregnancy counselling guidance, eTG, NHMRC, Mackenzie’s Mission research, WHO 2021 semen analysis criteria, and AIHW ART statistics. It is not personal medical advice and does not create a doctor–patient relationship. Pre-conception planning for individual patients — particularly those with complex medical histories, prior pregnancy complications, or infertility — requires clinical assessment and management with appropriate specialist involvement.

For patient resources: Your Fertility, HealthDirect — Fertility and pregnancy planning, FSANZ carrier screening information.

Sources cited

Frequently asked questions

What folate dose should women take before conception and is it different for everyone?

The standard dose is 0.4 mg (400 µg) of folate daily, beginning at least 1 month before conception and continuing until 12 weeks of gestation — this reduces the risk of neural tube defects by approximately 70%. The higher dose of 5 mg daily is indicated for women with type 1 or 2 diabetes, BMI ≥30, a prior pregnancy affected by a neural tube defect, current use of anti-epileptic medication, use of methotrexate within the past 3 months, or malabsorption syndromes including inflammatory bowel disease and coeliac disease. Most Australian pregnancy multivitamins (e.g., Elevit, Blackmores Pregnancy Gold) contain folate at appropriate doses.
What is Mackenzie's Mission and what does the PBS carrier screening panel cover?

Mackenzie's Mission was an Australian research programme demonstrating that routine reproductive genetic carrier screening is feasible and acceptable across the population. Its findings directly informed the PBS listing of a three-condition carrier screening panel — cystic fibrosis (CFTR), fragile X syndrome (FMR1), and spinal muscular atrophy (SMN1) — from 1 November 2023. The test is ordered via MBS Item 73420 using a buccal swab or blood sample. Pre-test counselling is essential: explain what carrier status means, the implications of both partners being carriers (25% risk of affected child for autosomal recessive conditions), and the available reproductive options including PGT-M via IVF, prenatal diagnosis, donor gametes, or proceeding without testing.
After how long should a GP initiate infertility workup?

Infertility workup is indicated after 12 months of regular unprotected intercourse in women under 35, or after 6 months in women aged 35 years or older. Earlier workup is appropriate when a known cause exists: oligomenorrhoea or anovulation, prior pelvic inflammatory disease or pelvic surgery, endometriosis, testicular or scrotal abnormality, or prior chemotherapy or radiotherapy. The GP initiates the core workup — mid-luteal progesterone, AMH, Day 2–3 FSH/LH/E2, TSH, prolactin, pelvic ultrasound, and two semen analyses to WHO 2021 6th edition criteria — before referral to a fertility specialist.
Which medications should be stopped or changed before trying to conceive?

Several medications carry significant teratogenic risk and should be substituted or ceased well before conception. Methotrexate — stop at least 3 months before conception (both partners). Isotretinoin — stop at least 1 month before conception for women. Warfarin — switch to low-molecular-weight heparin under specialist guidance. ACE inhibitors and ARBs — switch to pregnancy-safe antihypertensives (labetalol, methyldopa, nifedipine). Statins — cease (limited safety data). Valproate — review with neurology urgently due to neural tube defect, facial dysmorphism, and neurodevelopmental risks (approximately 10% major malformation rate, IQ approximately 9 points lower). A comprehensive medication review should be part of every pre-conception consultation.
What is the normal semen analysis reference range under WHO 2021 criteria?

The WHO Laboratory Manual for Human Semen (6th edition, 2021) updated the lower reference limits: volume ≥1.4 mL, concentration ≥16 million per mL, total count ≥39 million per ejaculate, total motility ≥42%, progressive motility ≥30%, normal morphology (strict Kruger criteria) ≥4%, and vitality ≥54%. Two analyses at least 3 weeks apart are required to characterise a result, as semen parameters vary considerably between samples. Order via MBS Items 73450–73464. Abnormal results on two occasions warrant urological or fertility specialist referral, with consideration of FSH, LH, testosterone, prolactin, karyotype, and Y-chromosome microdeletion testing in severe oligozoospermia or azoospermia.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.