The Impact of Preconceptional Multiple-Micronutrient Supplementation on Female Fertility

The Role of Nutrient Supplements in Female Infertility: An Umbrella Review and Hierarchical Evidence Synthesis

BACKGROUND AND OBJECTIVES

Nutrient supplements are commonly used to improve fertility outcomes by women with infertility trying to conceive spontaneously or utilising medically assisted reproduction (MAR). However, despite their widespread use and perceived safety, there is a lack of clear guidance on the efficacy and safety of these supplements for female infertility. The aim of this umbrella review was to identify the best available and most recent evidence on the efficacy and safety of nutrient supplements for female infertility to provide evidence-based guidance for clinicians and reproductive couples.

METHODS

Five electronic databases were searched for umbrella reviews, meta-analyses, and systematic reviews of randomised controlled trials on nutrient supplements for female infertility, published from August 2017 to January 2024. The primary outcomes were live birth, and clinical and biochemical pregnancy rates. Secondary outcomes were adverse effects including miscarriage and ectopic or multiple pregnancy. Quality assessment was performed using the A MeaSurement Tool to Assess systematic Reviews Version 2.0 (AMSTAR 2), and the certainty of evidence for outcomes were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, where possible.

RESULTS

Four meta-analyses were included. Multiple micronutrients and antioxidants increased live birth rates in women utilising MAR and/or trying to conceive spontaneously compared to placebo, standard or no treatment (odds ratio (OR) 2.59 and 1.81 respectively) with very low certainty evidence. L-carnitine, coQ10, melatonin, myo-inositol, NAC and vitamin D increased clinical pregnancy rates in women with PCOS and/or undergoing MAR compared to placebo, standard or no treatment (odds ratio (OR) 11.14, 2.49, 1.66, relative risk (RR) 1.52, OR 2.15, and 1.49 respectively) with very low certainty evidence. Vitamin D did not increase biochemical pregnancy rates in women utilising MAR with very low certainty evidence. NAC, vitamin D, and pooled antioxidants had no effect on miscarriage rates or multiple pregnancy rates in women trying to conceive spontaneously or utilising MAR, with low to very low certainty evidence. Pooled antioxidants had no effect on ectopic pregnancy rates in women trying to conceive spontaneously or utilising MAR, with low certainty evidence.

CONCLUSIONS

The available evidence is insufficient to recommend nutrient supplementation to improve female infertility in women trying to conceive naturally and those utilising MAR. However, there is currently no indication that these nutrients pose any risk of significant harm.

REGISTRATION

PROSPERO (CRD42022365966) 20 October 2022.

Supplementation practices among pregnant women and those trying to conceive: a population-representative survey in Vancouver, Canada

Dietary supplements including vitamins, minerals, and natural health products are commonly consumed by those aiming to optimize fertility and pregnancy outcomes. The aim of this survey was to describe supplementation practices among individuals who were pregnant or trying to conceive in Vancouver, Canada. An online survey was conducted among 500 individuals who were pregnant (n = 250) or trying to conceive (n = 250). Participants met a substantial proportion of vitamin and mineral recommendations through supplements alone. Exceptions included calcium, magnesium, and choline, with median (interquartile range (IQR)) supplementation doses reported by those who were pregnant and trying to conceive, respectively, of: 250 (200 and 250 mg) and 250 (200 and 250 mg), 50 (50 and 75 mg) and 50 (50 and 90 mg), and 53 (10 and 150 mg) and 55 (10 and 100 mg), as compared to perinatal recommendations of 1000 mg/day (calcium), 350 mg/day (magnesium), and 450 mg/day (choline). Conversely, median (IQR) doses of folate reported by those who were pregnant and trying to conceive, respectively, were: 1000 (780 and 1000 µg) and 1000 (800 and 1000 µg), with ∼70% overall (337/471) reporting doses ≥1000 µg (the tolerable upper intake level). Most participants (451/500; 90%) reported supplementation with a prenatal multivitamin; of these, 83% reported that supplementation occurred daily. Overall, as diet was not considered, we cannot ascertain whether recommendations for calcium, magnesium, and choline were met through the combination of supplements and foods; however, we believe that additional supplementation with choline may be required to meet recommendations in pregnancy. Excessive folate supplementation has been previously identified as a concern throughout North America; here, we provide further evidence for excessively high doses consumed via supplements.

Insights into disability and psycho-social care of patients with inflammatory bowel disease

In recent years, the concept of disability has increasingly garnered attention as a crucial long-term target of inflammatory bowel disease (IBD) management. The treatment paradigm has changed dramatically from full control of the disease (clinical and endoscopic remission) toward physical and emotional well-being with the goal of preventing disability and normalizing quality of life. However, in certain cases, despite achieving good disease control, patients may still experience symptoms associated with disability, and reduced emotional wellness. These symptoms can significantly impact various biopsychosocial factors, including interpersonal relationships, educational or work-related activities, body image, and sexual functioning. Nevertheless, they often remain overlooked in the context of IBD care. In this narrative review, we aim to shed light on the burden of certain disability-related symptoms such as bowel urgency, sexual dysfunction, impaired fertility and fatigue, emphasizing the importance of acknowledging and validating them in a clinical setting. There is a demanding need for comprehensive care for IBD patients, with IBD clinicians being mindful of the psychosocial challenges faced by their patients. Providing timely and appropriate management of these challenges alongside IBD treatment is key to achieving holistic remission and enhancing the overall quality of life while reducing disability.

Appraisal of Minerals, Fasting Blood Glucose, and Lipid Parameters in Obese and Nonobese Premenopausal Women

Introduction Menopause is an important milestone in the lives of women. Despite it being a natural phenomenon, menopause brings a lot of changes in a woman's life, which significantly affects their health and well-being. Menopause involves the cessation of hormone production necessary for menstrual cycles and fertility of females. The absence of these hormones may disturb the homeostasis of minerals, blood glucose, and lipid parameters and predispose women to several health conditions affecting different organs. Obesity has been identified as one of the several conditions that influence the health of women. Therefore, assessing women's health before menopause may improve understanding of their well-being and predict problems during and after menopause. The present study evaluated the activities of calcium, magnesium, phosphorous, fasting blood glucose (FBG), and lipid parameters in obese and nonobese premenopausal women. Methods The present study included 90 obese and 110 nonobese premenopausal women attending the General Medicine and Obstetrics and Gynaecology Departments of Gandhi Medical College and Hospital (GMC&H), Secunderabad, Telangana, India. The body mass index (BMI) was measured in all the study participants to put them under obese and nonobese categories. Blood samples were collected from all the study participants for the estimation of the activities of minerals like calcium, magnesium, phosphorous, FBG, and lipid parameters including total cholesterol (TC), triglycerides (TG), very low-density lipoproteins (VLDL), low-density lipoproteins (LDL), and high-density lipoproteins (HDL). Results The results demonstrated a significant difference in the activities of lipid parameters (TC-obese (158.90 ± 20.20 mg/dl) versus nonobese (148.7 ± 18.6 mg/dl), p < 0.05; TG-obese (143.1 ± 58.2 mg/dl) versus nonobese (118.40 ± 55.80 mg/dl), p < 0.01; VLDL-obese (28.30 ± 11.50 mg/dl) versus nonobese (23.30 ± 11 mg/dl), p < 0.05; LDL-obese (92 ± 30.30 mg/dl) versus nonobese (73.90 ± 26.10 mg/dl), p < 0.01; HDL-obese (61.60 ± 12.50) versus nonobese (65.30 ± 11.25 mg/dl), p < 0.01), FBG (obese (106.80 ± 32.20 mg/dl) versus nonobese (88.50 ± 42.60 mg/dl); p < 0.01)), and magnesium (obese (1.79 ± 0.36 mg/dl) versus nonobese (2.42 ± 0.67 mg/dl); p < 0.01)). However, the activities of calcium (obese (9 ± 0.54 mg/dl) vs. nonobese (8.9 ± 0.58); p > 0.05)) and phosphorous (obese (3.84 ± 0.53 mg/dl) versus nonobese (3.75 ± 0.46 mg/dl); p > 0.05)) was found to be similar in obese and nonobese premenopausal women.  Conclusions The results suggest that obese premenopausal women revealed lowered activities of magnesium that can predispose them to chronic diseases like cardiovascular diseases. In addition, obese women showed higher activities of FBG that predisposes them to type 2 diabetes mellitus (T2DM). There was significant variation in the lipid parameters among obese and nonobese women. However, serum calcium and phosphorous were similar in obese and nonobese premenopausal women.

The Effects of Thiamine Supplementation on General Health and Infertility Treatment Outcomes in Women with Polycystic Ovary Syndrome: A Triple-Blinded Randomized Placebo-Controlled Clinical Trial

BACKGROUND

The aim of this study was to evaluate the effects of thiamine (vitamin B1) on general health and infertility treatment outcomes in women with polycystic ovary syndrome (PCOS).

MATERIALS AND METHODS

The study is a triple-blinded, randomized, placebo-controlled clinical trial performed on 64 infertile women with PCOS referred to Sarem Hospital in Tehran, Iran. The primary outcomes of the study were general health and infertility treatment outcomes. Eligible women were randomly assigned to the vitamin B1 group (n=32, vitamin B1 tablet at a dose of 300 mg/day for 4 weeks) or the placebo group (n=32, placebo tablet daily for 4 weeks). A general health questionnaire was completed before and after the intervention by both groups, and treatment success was evaluated at the end of the study. Data were analyzed using SPSS software ver.16 P<0.05 was considered statistically significant.

RESULTS

The mean age of participants in the vitamin B1 (VB1) group was 30.4 ± 3.27 years and in the placebo (Pl) group was 29.1 ± 2.66 years with the mean duration of marriage 12.7 ± 3.01 and 13.2 ± 2.97 years respectively. Our results showed that there were significant differences between the two groups in overall score (P<0.001) and scores for all domains of the general health questionnaire including somatic symptoms (P<0.001), anxiety and insomnia (P<0.001), social dysfunction (P=0.028), and severe depression (P<0.001) after the intervention. Four weeks consumption of vitamin B1 also resulted in higher numbers of positive pregnancy tests (P=0.006), although the number of fetuses was not significantly different between the two groups after the intervention.

CONCLUSION

The results of the current study support a possible favourable effect of vitamin B1 on improving general health, infertility treatment outcome, and retrieved follicle count without changing the number of fetuses in women with polycystic ovary syndrome (registration number: IRCT201510266917N3).

Expert consensus on the role of supplementation in obstetrics and gynecology using modified delphi method

PURPOSE

To reach a consensus among obstetrics and gynecology experts on the effects of micronutrient supplementation on fertility and pregnancy to aid clinicians in decision-making and create a unified approach to managing micronutrient deficiencies in women, by performing a modified Delphi study.

METHODS

A three-round modified Delphi process was conducted among a Delphi panel of 38 Egyptian experts to define recommendations regarding the role of supplementation on fertility and pregnancy in women of reproductive age. A literature review was performed and supporting evidence was graded to help guide the recommendations based on available evidence.

RESULTS

A total of 62 statements were developed for discussion and voting. Out of the 62 statements, 60 statements reached expert consensus. Statements were divided into two domains. The first domain discussed the role of supplementation in fertility: optimizing natural fertility, polycystic ovary syndrome (PCOS), in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), unexplained infertility, and endometriosis, whereas the second domain was concerned with the role of supplementation in pregnancy during the prenatal, antenatal, and postnatal periods.

CONCLUSION

In this work, a modified Delphi methodology was implemented to reach a consensus on the use of micronutrient supplementation in women of reproductive age. These recommendations can help clinicians in their practice, guide future research, and identify gaps in the market for the pharmaceutical industry. This clinical guidance can be extrapolated to similar communities.

Female infertility and diet, is there a role for a personalized nutritional approach in assisted reproductive technologies? A Narrative Review

Female infertility is a major public health concern and a global challenge. It is a disorder of the reproductive system, defined as the inability to achieve a clinical pregnancy. Nutrition and other environmental factors are found to impact reproductive health in women as well as the outcome of assisted reproductive technologies (ART). Dietary factors, such as polyunsaturated fatty acids (PUFA), fiber as well as the intake of Mediterranean diet appear to exert beneficial effects on female reproductive outcomes. The exact mechanisms associating diet to female fertility are yet to be identified, although genomic, epigenomic, and microbial pathways may be implicated. This review aims to summarize the current knowledge on the impact of dietary components on female reproduction and ART outcomes, and to discuss the relevant interplay of diet with genome, epigenome and microbial composition.

Vitamin Supplementation in Pre-Pregnancy and Pregnancy among Women-Effects and Influencing Factors in Romania

Introduction: The aim of the study was to identify the consumption of vitamin and folic acid supplements before and during pregnancy in a group of post-partum women (Romanian, Hungarian, and Roma) from Mureș County, Romania, and the influence of socio-economic and behavioral factors on the consumption of vitamins. Materials and Methods: This cross-sectional questionnaire-based study included 1278 post-partum women (during the three days of hospitalization for birth), average age 29.5, registered for giving birth in the three hospitals in Mureș County, 2015−2016. Results: In our sample, 69.58% of the interviewed women did not use any vitamin and folic acid supplements before pregnancy, while 30.70% did not use vitamin supplements during pregnancy. The lack of vitamin supplementation during pregnancy was associated with the low birth weight (<2500 g) of newborns (OR = 2.4, 95% CI [1.6−3.8]) and birth at under 36 weeks of gestation (OR = 0.5, 95% CI [0.2−0.8]). Conclusion: The use of vitamin supplements, including folic acid, continues to be deficient among Romanian women before getting pregnant, as well as during their pregnancy. We observed a lack of vitamin supplementation for pregnant women even if they were influenced by risk factors. This highlights the importance of promoting the benefits of vitamin supplementation equally among all subjects.

Curcumin Supplementation and Endometrial Lining: Examining the Role and Pathophysiology of Use During Frozen-Thawed Embryo Transfer

Curcumin is a commonly used herbal supplement purported for its antioxidant, anti-inflammatory, and antineoplastic properties. The effects of curcumin supplementation on endometrial lining have been proposed; however, endometrial preparation in the case of frozen-thawed embryo transfer (FET) has not been established. This case series references two scenarios where turmeric was ingested by the patient, and endometrial thickness was subsequently reduced disrupting the FET cycle. Throughout this case series, curcumin's possible interactions with the uterine lining are summarized. Additionally, these cases highlight the importance of physicians’ awareness of taking a full history of any herbal remedies or supplements in addition to prescription or over-the-counter medications taken when undergoing treatment for controlled FET cycles or in-vitro fertilization (IVF). To our knowledge, no studies to date have investigated this relationship.

Female Fertility and the Nutritional Approach: The Most Essential Aspects

Infertility is an increasing problem that affects couples attempting pregnancy. A growing body of evidence points to a link between diet and female fertility. In fact, data show that a diet high in trans fats, refined carbohydrates, and added sugars can negatively affect fertility. Conversely, a diet based on the Mediterranean dietary patterns, i.e., rich in dietary fiber, omega-3 (ɷ-3) fatty acids, plant-based protein, and vitamins and minerals, has a positive impact on female fertility. An unhealthy diet can disrupt microbiota composition, and it is worth investigating whether the composition of the gut microbiota correlates with the frequency of infertility. There is a lack of evidence to exclude gluten from the diet of every woman trying to become pregnant in the absence of celiac disease. Furthermore, there are no data concerning adverse effects of alcohol on female fertility, and caffeine consumption in the recommended amounts also does not seem to affect fertility. On the other hand, phytoestrogens presumably have a positive influence on female fertility. Nevertheless, there are many unanswered questions with regard to supplementation in order to enhance fertility. It has been established that women of childbearing age should supplement folic acid. Moreover, most people experience vitamin D and iodine deficiency; thus, it is vital to control their blood concentrations and consider supplementation if necessary. Therefore, since diet and lifestyle seem to be significant factors influencing fertility, it is valid to expand knowledge in this area.

Dietary Approaches to Women's Sexual and Reproductive Health

Over the course of the reproductive life span, it is common for women to experience one or more of the most common gynecologic conditions, including sexual dysfunction, polycystic ovary syndrome, fibroids, endometriosis, and infertility. Although current management guidelines often turn to the established pharmaceutical approaches for each of these diagnoses, the scientific literature also supports an evidence-based approach rooted in the paradigm of food as medicine. Achieving healthy dietary patterns is a core goal of lifestyle medicine, and a plant-forward approach akin to the Mediterranean diet holds great promise for improving many chronic gynecologic diseases. Furthermore, creating an optimal preconception environment from a nutritional standpoint may facilitate epigenetic signaling, thus improving the health of future generations. This state-of-the-art review explores the literature connecting diet with sexual and reproductive health in premenopausal women.

Effects of Periconceptional Multivitamin Supplementation on Folate and Homocysteine Levels Depending on Genetic Variants of Methyltetrahydrofolate Reductase in Infertile Japanese Women

Methylenetetrahydrofolate reductase (MTHFR) has various polymorphisms, and the effects of periconceptional folic acid supplementation for decreasing neural tube defects (NTDs) risk differ depending on the genotypes. This study analyzed the effectiveness of multivitamin supplementation on folate insufficiency and hyperhomocysteinemia, depending on MTHFR polymorphisms. Of 205 women, 72 (35.1%), 100 (48.8%) and 33 (16.1%) had MTHFR CC, CT and TT, respectively. Serum folate and homocysteine levels in women with homozygous mutant TT were significantly lower and higher, respectively, than those in women with CC and CT. In 54 women (26.3% of all women) with a risk of NTDs, multivitamin supplementation containing folic acid and vitamin D for one month increased folate level (5.8 ± 0.9 to 19.2 ± 4.0 ng/mL, p < 0.0001) and decreased the homocysteine level (8.2 ± 3.1 to 5.8 ± 0.8 nmol/mL, p < 0.0001) to minimize the risk of NTDs in all women, regardless of MTHFR genotype. Regardless of MTHFR genotype, multivitamin supplements could control folate and homocysteine levels. Tests for folate and homocysteine levels and optimal multivitamin supplementation in women with risk of NTDs one month or more before pregnancy should be recommended to women who are planning a pregnancy.