Omega-3 fatty acid supplementation and fecundability

STUDY QUESTION

Is self-reported use of omega-3 fatty acid supplements associated with fecundability, the probability of natural conception, in a given menstrual cycle?

SUMMARY ANSWER

Prospectively recorded omega-3 supplement use was associated with an increased probability of conceiving.

WHAT IS KNOWN ALREADY

In infertile women, omega-3 fatty acid intake has been associated with increased probability of pregnancy following IVF. In natural fertility, studies are conflicting, and no study of natural fertility has evaluated omega-3 fatty acid supplementation and fecundity.

STUDY DESIGN, SIZE, DURATION

Secondary data analysis of 900 women contributing 2510 cycles in Time to Conceive (TTC), a prospective, time to pregnancy cohort study from 2008 to December 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged 30-44 years, trying to conceive <3 months, without history of infertility were followed using standardized pregnancy testing. While attempting to conceive, women daily recorded menstrual cycle events and supplement and medication intake using the Cerner Multum Drug Database. Supplements and vitamins containing omega-3 were identified. Omega-3 use, defined as use in at least 20% of days in a given menstrual cycle, in each pregnancy attempt cycle was determined. A discrete-time Cox proportional hazards model was used to calculate the fecundability ratio.

MAIN RESULTS AND THE ROLE OF CHANCE

Women taking omega-3 supplementation were more likely to be younger, thinner, nulligravid, white and to take vitamin D, prenatal and multivitamins compared to women not taking omega-3s. After adjusting for age, obesity, race, previous pregnancy, vitamin D and prenatal and multivitamin use, women taking omega-3 supplements had 1.51 (95% CI 1.12, 2.04) times the probability of conceiving compared to women not taking omega-3s.

LIMITATIONS, REASONS FOR CAUTION

Our study was not a randomized controlled trial. The women who used omega-3 supplements may represent a more health-conscious population. We sought to address this by adjusting for multiple factors in our model. Additionally, the omega-3 fatty acid supplements that TTC participants used included multiple types and brands with varying dosages of omega-3 fatty acids. Women reported the type of supplement they were taking but not the concentration of omega-3s in that supplement. It is therefore not possible to compare dosing or a dose-response relationship in our study.

WIDER IMPLICATIONS OF THE FINDINGS

Omega-3 supplementation may present a feasible and inexpensive modifiable factor to improve fertility. Randomized controlled trials are needed to further investigate the benefits of omega-3 supplementation for women trying to conceive naturally.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by the Division of Reproductive Endocrinology and Infertility at the University of North Carolina at Chapel Hill, the NIH/NICHD (R21 HD060229-01 and R01 HD067683-01), and in part by the Intramural Research Program of the National Institute of Environmental Health Sciences (Z01ES103333). The authors declare that there is no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Sperm morphology from the actual inseminated sample does not predict clinical pregnancy following intrauterine insemination

Objective

To determine the effect of sperm morphology from the specific sample used for intrauterine insemination (IUI) on clinical pregnancy rates (CPR).

Design

Prospective cohort study.

Setting

Academic fertility clinic.

Patients

Couples undergoing IUI July 2016-January 2017.

Interventions

Morphology slides were prepared from the semen sample produced for IUI.

Main Outcome Measures

CPR was measured by detection of cardiac activity. Multiple logistic regression modeling was performed to determine the association of sperm morphology with CPR, controlling for age, antimüllerian hormone level, and post-wash total motile sperm count.

Results

Semen analyses, including Kruger strict criteria for morphology from the actual sample inseminated, were reviewed for 155 couples, comprising 234 total treatment cycles. The percent normal morphology significantly differed between the preliminary semen analysis and the IUI sample (-2.0% +3.7% (95% CI -2.55, -1.53). Of the total 234 treatment cycles, 8.6% resulted in clinical pregnancy. When categorized by strict morphology >4%, <4%, and <1%, the CPR was 6.6%, 9.8%, and 10.9%, respectively. In couples with otherwise normal semen parameters (isolated teratospermia), CPR by >4%, <4%, and <1% normal forms was 7.2%, 9.8%, and 11.1%, respectively. There was no significant association between the percent normal morphology and CPR in multivariate analysis.

Conclusions

This study evaluating the morphology of the actual inseminated sample did not find differences in CPR following IUI among couples with normal and abnormal sperm morphology, including severe teratospermia. Abnormal sperm morphology should not exclude couples from attempting IUI.

Evidence of profound ovarian suppression on combined hormonal contraception resulting in dramatically different ovarian reserve testing and oocyte retrieval outcomes: case report and review of the literature

Objective

To describe a case report and demonstrate that degree of ovarian suppression with continuous combined hormonal contraception (CHC) may be more profound than previously described and may present similarly as decreased ovarian reserve.

Design

Case report and review of the literature.

Setting

Private practice in vitro fertilization center.

Patient(s)

A 36-year-old single gravida 0 presenting for oocyte cryopreservation on CHC.

Intervention(s)

Discontinuation of vaginal ring combined hormonal contraceptive for 6 months.

Main Outcome Measure(s)

Antral follicle count, antimüllerian hormone, day 3 follicle-stimulating hormone, total oocytes, and mature oocytes retrieved before and after discontinuation of CHC.

Result(s)

After a 6-month break from CHC, our patient’s antimüllerian hormone level increased from undetectable levels to 3.45 ng/mL, day 3 follicle-stimulating hormone level decreased from 14.9 IU/mL–6.17 IU/mL, and antral follicle count improved from 0–28. In addition, the number of oocytes retrieved after a 4-month CHC break and 6-month break increased from 8 to 29, respectively.

Conclusion(s)

In patients on long-term combined continuous hormonal contraception, profound ovarian suppression can result in a clinical picture of diminished ovarian reserve and extremely poor response to high-dose stimulation, which may be reversed by more time off from suppression.

Serum omega-3 and omega-6 fatty acid concentrations and natural fertility

STUDY QUESTION

Are serum omega-3 and omega-6 essential fatty acid concentrations associated with the probability of conceiving?

SUMMARY ANSWER

There is no strong association between serum concentrations of omega-3 and omega-6 fatty acids and the probability of conceiving naturally.

WHAT IS KNOWN ALREADY

Omega-3 and omega-6 fatty acid serum concentrations have been shown to play an important role in reproduction in animal models, while conflicting results have been reported in human studies of infertile women. It is unknown to what extent omega fatty acid serum concentrations impact natural fertility.

STUDY DESIGN, SIZE, DURATION

A nested, case-control study was conducted consisting of 200 participants [fertile: conceived within 3 cycles of attempt (n = 50), subfertile: conceived within 4 and 12 cycles of attempt (n = 100) and infertile: did not conceive within 12 cycles of attempt (n = 50)] randomly selected from the Time to Conceive cohort, a prospective time-to-pregnancy study (2008 to 2015).

PARTICIPANTS/MATERIALS, SETTING, METHODS

In the Time to Conceive study, women aged 30-44 years who were trying to conceive for <3 months and had no history of infertility were recruited and followed until the end of their pregnancy or ~1 year of pregnancy attempt. For this study, serum collected early in the woman's pregnancy attempt was analysed for anti-Müllerian hormone (AMH) and omega-3 and omega-6 fatty acid concentrations by liquid chromatography-mass spectrometry. The primary outcome was a positive home pregnancy test. The secondary outcomes were miscarriage and serum AMH level. A discrete-time Cox proportional hazards model was used to estimate the fecundability ratio. The odds ratios for miscarriage were calculated using logistic regression. The association between serum omega fatty acid concentrations and AMH level (natural log transformed) was analysed using Pearson's Correlation.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 200 women provided 1321 cycles for analysis.Mean omega-3, omega-6 and omega-6:omega-3 ratios did not significantly differ between the fertile, subfertile and infertile groups. There were no associations (all fecundability ratios ~1.0) between pregnancy and individual omega-3 fatty acid concentrations, including alpha-linolenic acid, eicosapentaenoic acid and docosahexaenoic acid, or omega-6 fatty acids, including linoleic acid (LA), dihommo-gamma linolenic acid and arachidonic acid. There was no significant association between any individual omega fatty acid serum concentration and the age-adjusted odds of miscarriage. No association was found between any serum omega fatty acid concentration and AMH.

LIMITATIONS, REASONS FOR CAUTION

This study is limited by the sample size. Omega-3 and omega-6 fatty acid concentrations were derived from serum provided at a single timepoint in the first cycle of enrollment. Serum concentrations may therefore not be representative of all critical timepoints in the menstrual cycle or throughout their attempts to conceive. Additionally, women enrolled in this study were 30 years of age and older, and therefore the findings may not apply to younger women.

WIDER IMPLICATIONS OF THE FINDINGS

These data would suggest that omega-3 and omega-6 serum levels are not associated with natural fertility or risk of miscarriage. However, due to the above-mentioned limitations, future investigation is still needed to determine whether omega-3 fatty acid supplementation may benefit women planning to conceive naturally.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Division of Reproductive Endocrinology and Infertility at the University of North Carolina at Chapel Hill, by the NIH/NICHD (R21 HD060229-01 and R01 HD067683-01) and, in part, by the Intramural Research Program of the National Institute of Environmental Health Sciences (Z01ES103333). Dr. Jukic received vitamin D supplements for a research study from Theralogix, Inc. The authors have no other conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Psychosocial Aspects of Fertility and Assisted Reproductive Technology

Psychosocial aspects of fertility, infertility, and assisted reproductive technology (ART) can significantly impact patients' sense of self-identity and personal agency, mental well-being, sexual and marital relationships, reproductive efficiency, compliance with treatment, and pregnancy outcomes. Research is needed to understand how stress, anxiety, depression, mood disorders, and psychotropic medications impact fertility and infertility treatment. The psychosocial implications of ART on our society include a shift toward older maternal age at conception, the complexities of third-party reproduction, and consideration for the psychological and socioeconomic barriers to receiving care. Clinicians must understand, screen for, and identify couples struggling with the psychological and social aspects of fertility and ART.

A model to predict risk of blood transfusion after gynecologic surgery

BACKGROUND

A model that predicts a patient's risk of receiving a blood transfusion may facilitate selective preoperative testing and more efficient perioperative blood management utilization.

OBJECTIVE

We sought to construct and validate a model that predicts a patient's risk of receiving a blood transfusion after gynecologic surgery.

STUDY DESIGN

In all, 18,319 women who underwent gynecologic surgery at 10 institutions in a single health system by 116 surgeons from January 2010 through June 2014 were analyzed. The data set was split into a model training cohort of 12,219 surgeries performed from January 2010 through December 2012 and a separate validation cohort of 6100 surgeries performed from January 2013 through June 2014. In all, 47 candidate risk factors for transfusion were collected. Multiple logistic models were fit onto the training cohort to predict transfusion within 30 days of surgery. Variables were removed using stepwise backward reduction to find the best parsimonious model. Model discrimination was measured using the concordance index. The model was internally validated using 1000 bootstrapped samples and temporally validated by testing the model's performance in the validation cohort. Calibration and decision curves were plotted to inform clinicians about the accuracy of predicted probabilities and whether the model adds clinical benefit when making decisions.

RESULTS

The transfusion rate in the training cohort was 2% (95% confidence interval, 1.72-2.22). The model had excellent discrimination and calibration during internal validation (bias-corrected concordance index, 0.906; 95% confidence interval, 0.890-0.928) and maintained accuracy during temporal validation using the separate validation cohort (concordance index, 0.915; 95% confidence interval, 0.872-0.954). Calibration curves demonstrated the model was accurate up to 40% then it began to overpredict risk. The model provides superior net benefit when clinical decision thresholds are between 0-50% predicted risk.

CONCLUSION

This model accurately predicts a patient's risk of transfusion after gynecologic surgery facilitating selective preoperative testing and more efficient perioperative blood management utilization.

Supraumbilical primary trocar insertion for laparoscopic access: the relationship between points of entry and retroperitoneal vital vasculature by imaging

OBJECTIVES

Advances in laparoscopy have demonstrated that supraumbilical primary ports can be desirable in complex cases with large masses. This study evaluated distances to vital retroperitoneal vasculature that were encountered with 45- and 90-degree angle entry from the umbilicus and 2 commonly described supraumbilical entry points at 3 and 5 cm cephalad from the umbilicus.

STUDY DESIGN

Retrospective analysis of computed tomography scans of the abdomen and pelvis from 100 randomly selected women who were 18-50 years old with normal anatomy was performed. Three-dimensional models of sagittal sections were generated using IMPAX software. Measurements from the abdominal wall at the umbilicus and 3 and 5 cm cephalad with 45- and 90-degree angles to retroperitoneal structures were performed.

RESULTS

With 90-degree angle entry, the abdominal wall thickness (AWT) was thinnest at the umbilicus; however, the thickness at 3 and 5 cm was similar. AWT increased at all sites with 45-degree angle entry, and the same pattern was observed. AWT and intraperitoneal distance positively correlated with body mass index and supraumbilical entry points. With 90-degree angle entry, the aorta was 1.9 cm (95% confidence interval [CI], 1.4-2.4) and 2.5 cm (95% CI, 2.0-2.9) farther away at 3 and 5 cm cephalad compared with umbilical entry. In one-third of the cases, regardless of port placement, a vascular structure other than the aorta was the most anterior vessel. With 45-degree angle entry at the umbilicus, no vessels were encountered. With 45-degree angle entry at 3 and 5 cm cephalad, the aorta was the most anterior vessel in 1% and 2% of cases, respectively, and was noted to be 1.0 cm (95% CI, 1.0-1.0) and 2.3 cm (95% CI, 1.2-3.3) farther away than with 90-degree angle entry. A vessel other than the aorta was encountered in 4% and 7% of cases at 3 and 5 cm, respectively.

CONCLUSION

According to theoretic modeling, supraumbilical primary port placement can be implemented safely in laparoscopy. With supraumbilical entry, the distance to retroperitoneal vessels was greater than at the umbilicus. Compared with a 90-degree angle, with a 45-degree angle entry, it was uncommon to encounter vasculature, and all measured distances were greater.