Embryonic health: new insights, mHealth and personalised patient care

Maternal lifestyle and nutritional habits are associated with oocyte quality and ICSI clinical outcomes

RESEARCH QUESTION

Do maternal lifestyle factors influence the incidence of oocyte dimorphisms and outcomes of intracytoplasmic sperm injection (ICSI) cycles?

DESIGN

A total of 752 female patients undergoing an ICSI cycle at a private university-affiliated IVF centre from January 2015 to December 2019 were included in this historical cohort study. Before starting ovarian stimulation, participants completed a questionnaire on cigarette smoking habits, consumption of alcoholic beverages, refined sugar, artificial sweeteners, soft drinks, fruits, legumes and vegetables, milk and dairy, and meat, as well as exercise frequency over the past 6 months. Oocyte morphology was evaluated before ICSI. The influence of maternal lifestyle factors on the incidence of oocyte dimorphisms and ICSI outcomes was evaluated by multivariate general linear models and generalized linear models, adjusted for potential confounders. The main outcome measures were the incidence of oocyte dimorphisms per cycle and clinical outcomes.

RESULTS

Lifestyle factors and nutritional habits such as cigarette smoking, and the consumption of alcohol, refined sugar and artificial sweeteners, were positively associated with incidence of several oocyte dimorphisms and negatively associated with the response to ovarian stimulation and embryo development. Negative relationships were also observed between these habits and clinical outcomes, apart from miscarriage rate, in which positive relationships were observed. Significant negative dose-dependent relationships between these habits and implantation rates were noted (P < 0.001). Alcoholic beverage consumption also showed inverse dose-dependent relationships with clinical pregnancy and live birth rates. Live birth rate was also negatively associated with cigarette smoking, in a dose-dependent manner.

CONCLUSIONS

Poor maternal habits were associated with reduced oocyte quality and ICSI outcomes in this study. Many of these associations were shown to be dose-dependent.

Evaluation of embryonic posture using four-dimensional ultrasound and virtual reality

Aim

To assess the possibility of embryonic posture evaluation (=feasibility, reproducibility, variation) at rest at 9 weeks' (+0–6 days) gestational age (GA) using four‐dimensional ultrasound and virtual reality (VR) techniques. Moreover, it is hypothesized that embryonic posture shows variation at the same time point in an uneventful pregnancy.

Methods

In this explorative prospective cohort study, 23 pregnant women were recruited from the Rotterdam periconceptional cohort. A transvaginal four‐dimensional ultrasound examination of 30 min per pregnancy was performed between 9 and 10 weeks' GA. The acquired datasets were offline evaluated longitudinally (i.e. per frame) using VR techniques.

Results

The ultrasound data of 16 (70%) out of 23 pregnancies were eligible for evaluation. At rest the analysis of the embryonic posture was feasible and showed a strong (>80%) intraobserver and interobserver reproducibility for most body parts. The majority of the body parts were in similar anatomic positions at rest. However, variations in anatomic positions (e.g. 6% rotated head, 9% laterally bent spine), within and between embryos, were seen at 9 weeks' GA.

Conclusion

In this unique study, we showed for the first time that embryonic posture measurements at rest can be performed in a reliable way using state‐of‐the‐art four‐dimensional ultrasound and VR techniques. Already early in prenatal life there are differences regarding posture within and between embryos.

Reducing growth and developmental problems in children: Development of an innovative postnatal risk assessment

Introduction

Globally, awareness of the relevance of both medical and non-medical risk factors influencing growth and development of children has been increasing. The aim of our study was to develop an innovative postnatal risk assessment to be used by the Preventive Child Healthcare (PCHC) to identify at an early stage children at risk for growth (catch-up growth, overweight and obesity) and developmental problems (such as motor, cognitive, psychosocial and language/ speech problems).

Methods

We used the first four steps of the Intervention Mapping process. Step 1: Review of the literature and focus group discussions. Step 2: Identification of program objectives on how to develop and implement a risk assessment in PCHC daily practice. Step 3: Application of the ASE model to initiate behavioral change in the target group. Step 4: Development of the postnatal R4U and a program plan for the implementation in PCHC organizations.

Results

Subsequently in 2015, the 41 item postnatal R4U (the postnatal Rotterdam Reproduction Risk Reduction checklist) was developed according to steps one until four of the Intervention Mapping process and was implemented in four PCHC organizations.

Conclusions

It was feasible to design and implement a postnatal risk assessment identifying both medical and non-medical risks for growth and developmental problems, using the Intervention Mapping process.

First trimester physiological development of the fetal foot position using three-dimensional ultrasound in virtual reality

Aim

In anatomic studies of the embryo, it has been established that during the development of the lower limb, several changes in foot position can be observed defined as a temporary ‘physiological clubfoot’. The aim of this study was to develop and test a measurement tool for objective documentation of the first trimester foot position in vivo and made an attempt to create a chart for first trimester foot position.

Methods

We developed a virtual orthopedic protractor for measuring foot positioning using three‐dimensional virtual reality visualization. Three‐dimensional ultrasound volumes of 112 pregnancies of women examined during the first trimester were studied in a BARCO I‐Space. The frontal angle (plantar flexion) and the lateral angle (adduction) between the leg and foot were measured from 8 until 13 weeks gestational age.

Results

We observed that the frontal angle steadily decreases, whereas the lateral angle first increases, resulting in transient physiological clubfeet position at 10‐ to 11‐week gestation, followed by a decrease to a normal foot position.

Conclusion

A transient clubfoot position is present during the normal development of the lower limbs, and it has been measured in vivo for the first time. This study emphasizes that a diagnosis of congenital clubfoot should not be made in the first trimester of pregnancy.

The impact of maternal lifestyle factors on periconception outcomes: a systematic review of observational studies

The main risk factors for important reproductive health issues such as subfertility and perinatal mortality largely originate in the periconception period. To evaluate associations between modifiable maternal lifestyle factors and periconception outcomes, a systematic search was conducted for relevant studies published from 1990 to February 2017 on Embase, Medline, Web of Science, Cochrane database, PubMed and Google Scholar. The initial search identified 6166 articles, of which 49 studies were eligible for inclusion. Fecundity (the capacity to have a live birth) showed significant inverse associations with smoking, alcohol use and poor diet. Studies regarding time to pregnancy showed a decline in fecundity ratios (the monthly conception rate among exposed relative to unexposed couples) with increasing body mass index (BMI). Furthermore, risk of first-trimester miscarriage was found to be increased in smokers, alcohol and caffeine consumers, and with increasing BMI. Vitamin supplement use showed a decrease in this risk. This review demonstrates that maternal modifiable lifestyle factors affect periconception outcomes. If couples planning a pregnancy are more aware and supported to adopt healthy lifestyles during the periconceptional 'window of opportunity', short-term reproductive health as well as health in later life and even of future generations can be further improved.

Early first trimester maternal 'high fish and olive oil and low meat' dietary pattern is associated with accelerated human embryonic development

BACKGROUND/OBJECTIVES

Maternal dietary patterns were associated with embryonic growth and congenital anomalies. We aim to evaluate associations between early first trimester maternal dietary patterns and embryonic morphological development among pregnancies with non-malformed outcome.

SUBJECTS/METHODS

A total of 228 strictly dated, singleton pregnancies without congenital malformations were enrolled in a periconceptional hospital-based cohort. Principal component analysis was performed to extract early first trimester maternal dietary patterns from food frequency questionnaires. Serial transvaginal three-dimensional ultrasound (3D US) scans were performed between 6⁺⁰ and 10⁺² gestational weeks and internal and external morphological criteria were used to define Carnegie stages in a virtual reality system. Associations between dietary patterns and Carnegie stages were investigated using linear mixed models.

RESULTS

A total of 726 3D US scans were included (median: three scans per pregnancy). The 'high fish and olive oil and low meat' dietary pattern was associated with accelerated embryonic development in the study population (β = 0.12 (95%CI: 0.00; 0.24), p < 0.05). Weak adherence to this dietary pattern delayed embryonic development by 2.1 days (95%CI: 1.6; 2.6) compared to strong adherence. The 'high vegetables, fruit and grain' dietary pattern accelerated embryonic development in the strictly dated spontaneous pregnancy subgroup without adjustment for energy intake.

CONCLUSIONS

Early first trimester maternal dietary patterns impacts human embryonic morphological development among pregnancies without congenital malformations. The clinical meaning of delayed embryonic development needs further investigation.

Periconceptional maternal 'high fish and olive oil, low meat' dietary pattern is associated with increased embryonic growth: The Rotterdam Periconceptional Cohort (Predict) Study

OBJECTIVE

To investigate the association between periconceptional maternal dietary pattern and first-trimester embryonic growth.

METHODS

This was a prospective cohort study of 228 women with a singleton ongoing pregnancy, of which 135 were strictly dated spontaneous pregnancies and 93 were pregnancies achieved after in-vitro fertilization or intracytoplasmatic sperm injection (IVF/ICSI). All women underwent serial transvaginal three-dimensional ultrasound (3D-US) examinations from 6 + 0 to 13 + 0 weeks' gestation. Crown-rump length (CRL) and embryonic volume (EV) measurements were performed using a virtual reality system. Information on periconceptional maternal dietary intake was collected via food frequency questionnaires. Principal component analysis was performed to identify dietary patterns. Associations between dietary patterns and CRL and EV trajectories were investigated using linear mixed models adjusted for potential confounders.

RESULTS

A median of five (range, one to seven) 3D-US scans per pregnancy were performed. Of 1162 datasets, quality was sufficient to perform CRL measurements in 991 (85.3%) and EV measurements in 899 (77.4%). A dietary pattern comprising high intake of fish and olive oil and a very low intake of meat was identified as beneficial for embryonic growth. In strictly dated spontaneous pregnancies, strong adherence to the 'high fish and olive oil, low meat' dietary pattern was associated with a 1.9 mm (95% CI, 0.1-3.63 mm) increase in CRL (+14.6%) at 7 weeks and a 3.4 mm (95% CI, 0.2-7.81 mm) increase (+6.9%) at 11 weeks, whereas EV increased by 0.06 cm³ (95% CI, 0.01-0.13 cm³ ) (+20.4%) at 7 weeks and 1.43 cm³ (95% CI, 0.99-1.87 cm³ ) (+14.4%) at 11 weeks. No significant association was observed in the total study population or in the IVF/ICSI subgroup.

CONCLUSION

Periconceptional maternal adherence to a high fish and olive oil, low meat dietary pattern is positively associated with embryonic growth in spontaneously conceived pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Periconception mHealth platform for prevention of placental-related outcomes and non-communicable diseases

Most placental-related pregnancy complications originate during the first trimester of pregnancy where gene-environmental interactions play a role. The environmental factors also include parental behaviors that can be positive, such as folic acid supplement use, or negative, e.g. poor lifestyle choices like smoking, and nutritional choices that contribute to obesity or micronutrient deficits. The overlapping risk factors associated with non-communicable disease are poor nutrition, smoking, and obesity. These modifiable factors differ between individuals, populations and high, middle and low income countries, but have in common that they are extremely difficult to change. Parents-to-be however are most motivated to change poor behaviors when they are aware of short-term health benefits of having a healthy baby. Therefore, these couples should be empowered to use evidence-based and personalized effective tools to improve poor behaviors. Moreover, these tools should be implemented to support healthcare professionals in delivering 'nutrition and lifestyle care' in routine patient care. From this background the usability and effectiveness of the mHealth coaching program www.SmarterPregnancy.co.uk (Dutch version www.SlimmerZwanger.nl) is presented as an opportunity to further customize this tool for specific target groups, healthcare professionals and low resource settings with the potential to prevent placental-related and non-communicable disease during the life course.

The Impact of Kidney Development on the Life Course: A Consensus Document for Action

Hypertension and chronic kidney disease (CKD) have a significant impact on global morbidity and mortality. The Low Birth Weight and Nephron Number Working Group has prepared a consensus document aimed to address the relatively neglected issue for the developmental programming of hypertension and CKD. It emerged from a workshop held on April 2, 2016, including eminent internationally recognized experts in the field of obstetrics, neonatology, and nephrology. Through multidisciplinary engagement, the goal of the workshop was to highlight the association between fetal and childhood development and an increased risk of adult diseases, focusing on hypertension and CKD, and to suggest possible practical solutions for the future. The recommendations for action of the consensus workshop are the results of combined clinical experience, shared research expertise, and a review of the literature. They highlight the need to act early to prevent CKD and other related noncommunicable diseases later in life by reducing low birth weight, small for gestational age, prematurity, and low nephron numbers at birth through coordinated interventions. Meeting the current unmet needs would help to define the most cost-effective strategies and to optimize interventions to limit or interrupt the developmental programming cycle of CKD later in life, especially in the poorest part of the world.

Impact of an mHealth Platform for Pregnancy on Nutrition and Lifestyle of the Reproductive Population: A Survey

Background

Poor nutrition and lifestyle behaviors exert detrimental effects on reproduction and health during the life course. Therefore, lifestyle interventions during the periconceptional period can improve fertility, pregnancy outcome, and health of subsequent generations.

Objective

This survey investigates the compliance, usability, and initial effectiveness of the Web-based mHealth platform, Smarter Pregnancy.

Methods

A free subscription to the mHealth platform, Smarter Pregnancy, was provided to couples contemplating pregnancy (n=1275) or already pregnant (n=603). After baseline identification of inadequate nutrition and lifestyle behaviors, a personal online coaching program of 6 months was generated. Using multiple imputation and the generalized estimating equation model with independent correlations, we estimated the changes from inadequate to adequate nutrition and lifestyle behaviors over time. Subgroup analyses were performed for (1) overweight and obese women (body mass index [BMI] ≥25 kg/m²), (2) pregnant women at the start of the program, and (3) couples.

Results

A 64.86% (1218/1878) compliance rate was observed and 54.7% (range 39.2-73.4%) of participants rated the program usability as positive or very positive. Adequate nutrition and lifestyle behaviors at baseline were 21.57% (405/1878) for vegetable intake, 52.61% (988/1878) for fruit intake, 85.44% (1303/1525) for folic acid use, 86.79% (1630/1878) for no tobacco use, and 64.43% (1210/1878) for no alcohol consumption. After 6 months of coaching, these lifestyle behaviors improved by 26.3% (95% CI 23.0-29.9) for vegetable intake, 38.4% (95% CI 34.5-42.5) for fruit intake, 56.3% (95% CI 48.8-63.6) for folic acid use, 35.1% (95% CI 29.1-41.6) for no tobacco use, and 41.9% (95% CI 35.2-48.9) for no alcohol consumption. The program showed the strongest effectiveness for participating couples.

Conclusions

This novel Web-based mHealth platform shows high compliance and usability, and users demonstrate improvements in nutrition and lifestyle behaviors. The next step will be further validation in randomized controlled trials and implementation.