Women, Fertility Treatments, and Lifestyle Choices
Study Question: What are the lifestyle choices and dietary aspects of women about to undergo fertility treatment in New Zealand?
Summary Answer: A considerable proportion of women about to undergo fertility treatment make poor lifestyle choices, including the consumption of alcohol and caffeine.
What Is Known Already: Women undergoing fertility treatment are highly motivated to achieve pregnancy, but there are relatively few published data on their lifestyle, lifestyle changes or dietary aspects.
Study Design, Size, Duration: This was a cross-sectional study of 250 women aged 20–43 years, taking place between March 2010 and August 2011.
Participants/Materials, Setting, Methods: Women about to undergo IVF or ICSI treatment in two large fertility clinics in Auckland and Hamilton, New Zealand. Lifestyle and dietary intake questionnaires were individually administered once to each participant 35 days (SD = 22) prior to fertility treatment initiation. Outcome measures included incidence of smoking, consumption of alcohol and caffeinated beverages, BMI, detailed intake of dietary supplements and fertility treatment success. Consumption of certain nutrient supplements was compared with the general female New Zealand population.
Main Results and the Role of Chance: There were high rates of alcohol (50.8%) and caffeine (86.8%) consumption. Most women (82.8%) reported at least one lifestyle change in preparation for fertility treatment, but less than half of women who consumed alcohol regularly reduced their intake and 60% did not change consumption of caffeinated beverages. Similarly, the majority of women did not change their exercise levels (64.4%) or BMI (83.6%) ahead of fertility treatment. Coffee intake appeared unrelated to treatment outcome, but women who consumed caffeinated herbal tea (36.4% of the study population consumed green tea) had lower odds of becoming pregnant (odds ratio, OR 0.52; P = 0.041 versus those not consuming caffeinated herbal tea). Women who abstained from drinking or reduced alcohol intake had twice the odds of becoming pregnant than those who maintained their drinking habits prior to fertility treatment (OR 2.27; P = 0.049). While 93.2% of women took a folic acid supplement, 16.8% had an inadequate intake compared with the current New Zealand prenatal recommendation of 800 mcg/day. Women who held a university degree or higher qualification had twice the odds of becoming pregnant as women with lower levels of education (OR 2.08; P = 0.017), though this finding appeared to be unrelated to lifestyle or dietary habits.
Limitations, Reasons for Caution: The study involved self-reported behaviours that might have been misrepresented by respondents. In addition, our questionnaires covered the period following the first clinical assessment but ~5 weeks prior to fertility treatment initiation, so that we cannot ascertain whether dietary intakes and lifestyle choices persisted over the course of treatment itself.
Wider Implications of the Findings: Many women about to undergo fertility treatment make poor lifestyle choices that may negatively affect their chances of becoming pregnant. These findings may be more widely applicable to other women attempting to become pregnant. Specific advice for women regarding healthy lifestyle choices while undergoing fertility treatment is warranted.
Study Funding/Competing Interest(S): A.A.G. received financial support from Abbott Nutrition Research & Development Asia-Pacific Center; J.C.P. is a shareholder of Fertility Associates; the other authors have no financial or non-financial conflicts of interest to disclose.
Poor nutrition and lifestyle choices hold implications for general health, as well as potential effects on fertility. Importantly, most lifestyle and nutritional choices are modifiable behaviours. There is strong evidence that lifestyle has an effect on fertility, for both males and females (Homan et al., 2007). Older female age (Lim and Tsakok, 1997; Nasseri and Grifo, 1998; Larsen and Yan, 2000; Baird et al., 2005), smoking (Baird and Wilcox, 1985; Feichtinger et al., 1997; Augood et al., 1998; Hull et al., 2000; Hassan and Killick, 2004; Waylen et al., 2009), excessive body weight (Wang et al., 2000; Nichols et al., 2003; Hassan and Killick, 2004; Anderson et al., 2010) and heavy alcohol use (Olsen et al., 1997; Anderson et al., 2010) have a detrimental effect on fertility and on the outcomes of fertility treatment. It is thought that light-to-moderate alcohol use, caffeine consumption, exercise, stress and pollutants may also negatively impact on fertility, but the evidence is currently inconclusive (Homan et al., 2007).
Obesity reduces fecundity in both males and females (Hassan and Killick, 2004; Lim et al., 2007). In males, overweight and obesity are associated with reduced ejaculate volume, sperm concentration and total sperm count (Eisenberg et al., 2014). Among women, high BMI increases the risk of infertility, lengthens time taken to conceive and raises the risk of miscarriage and pregnancy complications (Norman et al., 2008). Fertility treatment appears less successful in overweight and obese women, with decreased rates of pregnancy and live birth (Wang et al., 2000; Nichols et al., 2003; Fedorcsák et al., 2004; Maheshwari et al., 2007; Anderson et al., 2010); however, these findings are not always consistent (Lashen et al., 1999; Wittemer et al., 2000). Underweight women (BMI < 20 kg/m) have similarly been shown to have decreased fecundability and pregnancy rates (Zaadstra et al., 1993; Wang et al., 2000; Nichols et al., 2003), as well as increased risks of premature birth, low birthweight and intrauterine growth retardation (Neggers and Goldenberg, 2003).
Smoking significantly reduces the chances of success from assisted reproductive technologies, including IVF. A meta-analysis of 21 studies concluded that there are lower odds of live birth and clinical pregnancy per cycle, as well as increased odds of miscarriage and ectopic pregnancy in smokers (Waylen et al., 2009). Smoking also increases both maternal and foetal health risks, such as the risk of miscarriage, premature labour, foetal growth restriction, low birthweight and sudden infant death syndrome (DiFranza and Lew, 1995; Castles et al., 1999; Cnattingius, 2004; Anderson et al., 2010).
A heavy alcohol intake decreases fertility in males and females, with more than eight alcoholic drinks per week linked with decreased fecundity in a large European-based multicentre study (Olsen et al., 1997; Anderson et al., 2010). Alcohol consumption during pregnancy also negatively affects maternal and foetal health and can have lifelong consequences for offspring in the form of foetal alcohol syndrome and foetal alcohol spectrum disorders (Windham et al., 1992, 1995; Parazzini et al., 2003; Mukherjee et al., 2005).
The dietary intake of women during the periconceptional period can also have profound and lasting effects on the health of their children. Under-nutrition and over-nutrition around the time of conception have both been shown to increase the risk of obesity, cardiovascular and metabolic disorders in the offspring (Gluckman et al., 2008; McMillen et al., 2008). Folic acid supplementation of 400 mcg/day prior to and during the first trimester of pregnancy has been shown to reduce neural tube defects by up to 70% (Wald et al., 1991; Rush, 1994). Despite this, rates of folic acid use by women planning a pregnancy or pregnant women are often low (Wild et al., 1997; Rogers and Emmett, 1998; Forster et al., 2009; Inskip et al., 2009; Pinto et al., 2009).
Animal studies have shown that maternal caffeine consumption has a range of long-term adverse effects in the offspring, including impaired glucose homeostasis (Sun et al., 2014), neuromotor development (Souza et al., 2015) and reproductive organ development (Dorostghoal et al., 2012). In humans, epidemiological studies have shown that increased caffeine consumption during pregnancy is associated with impaired foetal growth (Klebanoff et al., 2002; Bakker et al., 2010). Further, a recent prospective study showed that in utero exposure to caffeine was associated with increased risk of childhood obesity (Li et al., 2015).
Regular moderate exercise in pregnancy confers the same maternal benefits as for non-pregnant women (Artal and O'Toole, 2003), which may include weight control and improvement of cardiovascular and metabolic risk factors. There may also be a combined effect of poor lifestyle choices on fertility and neonatal health, where health risks are greater in the presence of several factors compared with the sum of the individual risk increases (ESHRE Task Force on Ethics and Law et al., 2010).
Women undergoing fertility treatment are an ideal study cohort when researching the dietary intake and lifestyle habits of women planning a pregnancy. These women are undergoing frequent intensive medical intervention, and their motivation to achieve pregnancy is very high. However, there are relatively few published data on the lifestyle, lifestyle changes or dietary intake of women undergoing fertility treatment.
A prospective study of 118 women undergoing IVF treatment showed that despite lifestyle changes being advocated by clinic medical staff, many women still made poor lifestyle choices (Domar et al., 2012). During their IVF cycle, 49% of the women consumed alcohol, 77% drank caffeinated beverages and 2% smoked (Domar et al., 2012). Similarly, a 2010 study of 436 women undergoing their first ICSI cycle found that 32% of women had more than one coffee daily, 18% had at least one caffeinated soft drink per day and that alcohol was consumed more than five times per week by 5% of study participants (Ferreira et al., 2010). A prospective controlled study of pregnant women from an ICSI cycle found that only 38% of subjects had taken folic acid prior to pregnancy and only 62% took iodine supplements at any stage during their pregnancy (Ludwig et al., 2006).
While there is evidence to show that lifestyle factors have a detrimental effect on fertility, there are limited data examining the effects of lifestyle changes on fertility treatment outcome (Rooney and Domar, 2014). In this study, we aimed to evaluate the lifestyle choices and dietary aspects of women about to undergo fertility treatment in New Zealand. We hypothesized that women undergoing fertility treatment would be already following a healthy lifestyle in preparation for a planned pregnancy. We also hypothesized that these women would follow clinic recommendations and would be interested in making further lifestyle improvements prior to treatment.
Abstract and Introduction
Abstract
Study Question: What are the lifestyle choices and dietary aspects of women about to undergo fertility treatment in New Zealand?
Summary Answer: A considerable proportion of women about to undergo fertility treatment make poor lifestyle choices, including the consumption of alcohol and caffeine.
What Is Known Already: Women undergoing fertility treatment are highly motivated to achieve pregnancy, but there are relatively few published data on their lifestyle, lifestyle changes or dietary aspects.
Study Design, Size, Duration: This was a cross-sectional study of 250 women aged 20–43 years, taking place between March 2010 and August 2011.
Participants/Materials, Setting, Methods: Women about to undergo IVF or ICSI treatment in two large fertility clinics in Auckland and Hamilton, New Zealand. Lifestyle and dietary intake questionnaires were individually administered once to each participant 35 days (SD = 22) prior to fertility treatment initiation. Outcome measures included incidence of smoking, consumption of alcohol and caffeinated beverages, BMI, detailed intake of dietary supplements and fertility treatment success. Consumption of certain nutrient supplements was compared with the general female New Zealand population.
Main Results and the Role of Chance: There were high rates of alcohol (50.8%) and caffeine (86.8%) consumption. Most women (82.8%) reported at least one lifestyle change in preparation for fertility treatment, but less than half of women who consumed alcohol regularly reduced their intake and 60% did not change consumption of caffeinated beverages. Similarly, the majority of women did not change their exercise levels (64.4%) or BMI (83.6%) ahead of fertility treatment. Coffee intake appeared unrelated to treatment outcome, but women who consumed caffeinated herbal tea (36.4% of the study population consumed green tea) had lower odds of becoming pregnant (odds ratio, OR 0.52; P = 0.041 versus those not consuming caffeinated herbal tea). Women who abstained from drinking or reduced alcohol intake had twice the odds of becoming pregnant than those who maintained their drinking habits prior to fertility treatment (OR 2.27; P = 0.049). While 93.2% of women took a folic acid supplement, 16.8% had an inadequate intake compared with the current New Zealand prenatal recommendation of 800 mcg/day. Women who held a university degree or higher qualification had twice the odds of becoming pregnant as women with lower levels of education (OR 2.08; P = 0.017), though this finding appeared to be unrelated to lifestyle or dietary habits.
Limitations, Reasons for Caution: The study involved self-reported behaviours that might have been misrepresented by respondents. In addition, our questionnaires covered the period following the first clinical assessment but ~5 weeks prior to fertility treatment initiation, so that we cannot ascertain whether dietary intakes and lifestyle choices persisted over the course of treatment itself.
Wider Implications of the Findings: Many women about to undergo fertility treatment make poor lifestyle choices that may negatively affect their chances of becoming pregnant. These findings may be more widely applicable to other women attempting to become pregnant. Specific advice for women regarding healthy lifestyle choices while undergoing fertility treatment is warranted.
Study Funding/Competing Interest(S): A.A.G. received financial support from Abbott Nutrition Research & Development Asia-Pacific Center; J.C.P. is a shareholder of Fertility Associates; the other authors have no financial or non-financial conflicts of interest to disclose.
Introduction
Poor nutrition and lifestyle choices hold implications for general health, as well as potential effects on fertility. Importantly, most lifestyle and nutritional choices are modifiable behaviours. There is strong evidence that lifestyle has an effect on fertility, for both males and females (Homan et al., 2007). Older female age (Lim and Tsakok, 1997; Nasseri and Grifo, 1998; Larsen and Yan, 2000; Baird et al., 2005), smoking (Baird and Wilcox, 1985; Feichtinger et al., 1997; Augood et al., 1998; Hull et al., 2000; Hassan and Killick, 2004; Waylen et al., 2009), excessive body weight (Wang et al., 2000; Nichols et al., 2003; Hassan and Killick, 2004; Anderson et al., 2010) and heavy alcohol use (Olsen et al., 1997; Anderson et al., 2010) have a detrimental effect on fertility and on the outcomes of fertility treatment. It is thought that light-to-moderate alcohol use, caffeine consumption, exercise, stress and pollutants may also negatively impact on fertility, but the evidence is currently inconclusive (Homan et al., 2007).
Obesity reduces fecundity in both males and females (Hassan and Killick, 2004; Lim et al., 2007). In males, overweight and obesity are associated with reduced ejaculate volume, sperm concentration and total sperm count (Eisenberg et al., 2014). Among women, high BMI increases the risk of infertility, lengthens time taken to conceive and raises the risk of miscarriage and pregnancy complications (Norman et al., 2008). Fertility treatment appears less successful in overweight and obese women, with decreased rates of pregnancy and live birth (Wang et al., 2000; Nichols et al., 2003; Fedorcsák et al., 2004; Maheshwari et al., 2007; Anderson et al., 2010); however, these findings are not always consistent (Lashen et al., 1999; Wittemer et al., 2000). Underweight women (BMI < 20 kg/m) have similarly been shown to have decreased fecundability and pregnancy rates (Zaadstra et al., 1993; Wang et al., 2000; Nichols et al., 2003), as well as increased risks of premature birth, low birthweight and intrauterine growth retardation (Neggers and Goldenberg, 2003).
Smoking significantly reduces the chances of success from assisted reproductive technologies, including IVF. A meta-analysis of 21 studies concluded that there are lower odds of live birth and clinical pregnancy per cycle, as well as increased odds of miscarriage and ectopic pregnancy in smokers (Waylen et al., 2009). Smoking also increases both maternal and foetal health risks, such as the risk of miscarriage, premature labour, foetal growth restriction, low birthweight and sudden infant death syndrome (DiFranza and Lew, 1995; Castles et al., 1999; Cnattingius, 2004; Anderson et al., 2010).
A heavy alcohol intake decreases fertility in males and females, with more than eight alcoholic drinks per week linked with decreased fecundity in a large European-based multicentre study (Olsen et al., 1997; Anderson et al., 2010). Alcohol consumption during pregnancy also negatively affects maternal and foetal health and can have lifelong consequences for offspring in the form of foetal alcohol syndrome and foetal alcohol spectrum disorders (Windham et al., 1992, 1995; Parazzini et al., 2003; Mukherjee et al., 2005).
The dietary intake of women during the periconceptional period can also have profound and lasting effects on the health of their children. Under-nutrition and over-nutrition around the time of conception have both been shown to increase the risk of obesity, cardiovascular and metabolic disorders in the offspring (Gluckman et al., 2008; McMillen et al., 2008). Folic acid supplementation of 400 mcg/day prior to and during the first trimester of pregnancy has been shown to reduce neural tube defects by up to 70% (Wald et al., 1991; Rush, 1994). Despite this, rates of folic acid use by women planning a pregnancy or pregnant women are often low (Wild et al., 1997; Rogers and Emmett, 1998; Forster et al., 2009; Inskip et al., 2009; Pinto et al., 2009).
Animal studies have shown that maternal caffeine consumption has a range of long-term adverse effects in the offspring, including impaired glucose homeostasis (Sun et al., 2014), neuromotor development (Souza et al., 2015) and reproductive organ development (Dorostghoal et al., 2012). In humans, epidemiological studies have shown that increased caffeine consumption during pregnancy is associated with impaired foetal growth (Klebanoff et al., 2002; Bakker et al., 2010). Further, a recent prospective study showed that in utero exposure to caffeine was associated with increased risk of childhood obesity (Li et al., 2015).
Regular moderate exercise in pregnancy confers the same maternal benefits as for non-pregnant women (Artal and O'Toole, 2003), which may include weight control and improvement of cardiovascular and metabolic risk factors. There may also be a combined effect of poor lifestyle choices on fertility and neonatal health, where health risks are greater in the presence of several factors compared with the sum of the individual risk increases (ESHRE Task Force on Ethics and Law et al., 2010).
Women undergoing fertility treatment are an ideal study cohort when researching the dietary intake and lifestyle habits of women planning a pregnancy. These women are undergoing frequent intensive medical intervention, and their motivation to achieve pregnancy is very high. However, there are relatively few published data on the lifestyle, lifestyle changes or dietary intake of women undergoing fertility treatment.
A prospective study of 118 women undergoing IVF treatment showed that despite lifestyle changes being advocated by clinic medical staff, many women still made poor lifestyle choices (Domar et al., 2012). During their IVF cycle, 49% of the women consumed alcohol, 77% drank caffeinated beverages and 2% smoked (Domar et al., 2012). Similarly, a 2010 study of 436 women undergoing their first ICSI cycle found that 32% of women had more than one coffee daily, 18% had at least one caffeinated soft drink per day and that alcohol was consumed more than five times per week by 5% of study participants (Ferreira et al., 2010). A prospective controlled study of pregnant women from an ICSI cycle found that only 38% of subjects had taken folic acid prior to pregnancy and only 62% took iodine supplements at any stage during their pregnancy (Ludwig et al., 2006).
While there is evidence to show that lifestyle factors have a detrimental effect on fertility, there are limited data examining the effects of lifestyle changes on fertility treatment outcome (Rooney and Domar, 2014). In this study, we aimed to evaluate the lifestyle choices and dietary aspects of women about to undergo fertility treatment in New Zealand. We hypothesized that women undergoing fertility treatment would be already following a healthy lifestyle in preparation for a planned pregnancy. We also hypothesized that these women would follow clinic recommendations and would be interested in making further lifestyle improvements prior to treatment.
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