Effectiveness of a mobile preconception lifestyle programme in couples undergoing in vitro fertilisation (IVF): the protocol for the PreLiFe randomised controlled trial (PreLiFe-RCT)

Effectiveness of a blended mobile-based lifestyle intervention in women with glucose intolerance after a recent history of gestational diabetes (MELINDA): a 1-year, prospective, multicentre, randomised controlled trial

Background

Women with glucose intolerance after gestational diabetes mellitus (GDM) are at high risk to develop type 2 diabetes. Traditional lifestyle interventions in early postpartum have limited impact. We investigated the efficacy of a blended mobile-based lifestyle intervention in women with glucose intolerance after a recent history of GDM.

Methods

Prospective, double-arm, non-masked, multicentre randomised controlled trial (RCT) in which women with glucose intolerance, diagnosed 6-16 weeks after a GDM-complicated pregnancy, were assigned 1:1 to a one-year blended-care, telephone- and mobile-based lifestyle program (intervention) or usual care (control). Primary endpoint was the proportion of women able to achieve their weight goal (≥5% weight loss if prepregnancy BMI ≥ 25 kg/m2 or return to prepregnancy weight if prepregnancy BMI < 25 kg/m2) in the intention-to-treat sample. Key secondary outcomes were frequency of glucose intolerance, diabetes and metabolic syndrome, and lifestyle-related outcomes assessed with self-administered questionnaires. The study was registered in ClinicalTrials.gov (NCT03559621).

Findings

Between April 10th 2019 and May 13th 2022, 240 participants were assigned to the intervention (n = 121) or control group (n = 119), of which 167 (n = 82 in intervention and n = 85 in control group) completed the study. Primary outcome was achieved by 46.3% (56) of intervention participants compared to 43.3% (52) in the control group [odds ratio (OR) 1.13, 95% confidence interval (CI) 0.63-2.03, p = 0.680; risk ratio 1.07, 95% CI (0.78-1.48)]. Women in the intervention group developed significantly less often metabolic syndrome compared to the control group [7.3% (6) vs. 16.5% (14), OR 0.40, CI (0.22-0.72), p = 0.002], reported less sedentary behaviour and higher motivation for continuing healthy behaviours. In the intervention group, 84.1% (69) attended at least eight telephone sessions and 70.7% (58) used the app at least once weekly.

Interpretation

A blended, mobile-based lifestyle intervention was not effective in achieving weight goals, but reduced the risk to develop metabolic syndrome.

Funding

Research fund of University Hospitals Leuven, Novo Nordisk, Sanofi, AstraZeneca, Boehringer-Ingelheim, Lilly.

A blended preconception lifestyle programme for couples undergoing IVF: lessons learned from a multicentre randomized controlled trial

STUDY QUESTION

What is the effect of a blended preconception lifestyle programme on reproductive and lifestyle outcomes of couples going through their first 12 months of IVF as compared to an attention control condition?

SUMMARY ANSWER

This randomized controlled trial (RCT) was stopped prematurely because of the coronavirus disease 2019 (Covid-19) pandemic but the available data did not suggest that a blended preconception lifestyle programme could meaningfully affect time to ongoing pregnancy or other reproductive and lifestyle outcomes.

WHAT IS KNOWN ALREADY

Increasing evidence shows associations between a healthy lifestyle and IVF success rates. Lifestyle programmes provided through a mobile phone application have yet to be evaluated by RCTs in couples undergoing IVF.

STUDY DESIGN SIZE DURATION

A multicentre RCT (1:1) was carried out. The RCT started in January 2019 and was prematurely stopped because of the Covid-19 pandemic, leading to a reduced sample size (211 couples initiating IVF) and change in primary outcome (cumulative ongoing pregnancy to time to ongoing pregnancy).

PARTICIPANTS/MATERIALS SETTING METHODS

Heterosexual couples initiating IVF in five fertility clinics were randomized between an attention control arm and an intervention arm for 12 months. The attention control arm received treatment information by mobile phone in addition to standard care. The intervention arm received the blended preconception lifestyle (PreLiFe)-programme in addition to standard care. The PreLiFe-programme included a mobile application, offering tailored advice and skills training on diet, physical activity and mindfulness, in combination with motivational interviewing over the telephone. The primary outcome was 'time to ongoing pregnancy'. Secondary reproductive outcomes included the Core Outcome Measures for Infertility Trials and IVF discontinuation. Changes in the following secondary lifestyle outcomes over 3 and 6 months were studied in both partners: diet quality, fruit intake, vegetable intake, total moderate to vigorous physical activity, sedentary behaviour, emotional distress, quality of life, BMI, and waist circumference. Finally, in the intervention arm, acceptability of the programme was evaluated and actual use of the mobile application part of the programme was tracked. Analysis was according to intention to treat.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 211 couples were randomized (105 control arm, 106 intervention arm). The hazard ratio of the intervention for time to ongoing pregnancy was 0.94 (95% CI 0.63 to 1.4). Little to no effect on other reproductive or lifestyle outcomes was identified. Although acceptability of the programme was good (6/10), considerable proportions of men (38%) and 9% of women did not actively use all the modules of the mobile application (diet, physical activity, or mindfulness).

LIMITATIONS REASONS FOR CAUTION

The findings of this RCT should be considered exploratory, as the Covid-19 pandemic limited its power and the actual use of the mobile application was low.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first multicentre RCT evaluating the effect of a blended preconception lifestyle programme for women and their partners undergoing IVF on both reproductive and lifestyle outcomes. This exploratory RCT highlights the need for further studies into optimal intervention characteristics and actual use of preconception lifestyle programmes, as well as RCTs evaluating effectiveness.

STUDY FUNDING/COMPETING INTERESTS

Supported by the Research foundation Flanders (Belgium) (FWO-TBM; reference: T005417N). No competing interests to declare.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03790449.

TRIAL REGISTRATION DATE

31 December 2018.

DATE OF FIRST PATIENT’S ENROLMENT

2 January 2019.

Belgian Fertility Clinic Staff Value Healthy Lifestyle Promotion but Lack Access to a Structured Lifestyle Modification Programme: An Observational Study

OBJECTIVES

Guidelines advise promoting a healthy lifestyle among patients with fertility problems as the lifestyle of women and men proved to be associated with their fertility. Australian fertility nurses were shown to lack access to structured lifestyle modification programmes, although they value healthy lifestyle promotion. This study aimed to examine whether gynaecologists also value promoting a healthy lifestyle and whether structured lifestyle modification programmes are available in Belgian fertility clinics.

DESIGN

An observational study was conducted among health care professionals (HCPs) working in Belgian fertility clinics.

PARTICIPANTS/MATERIALS, SETTING, METHODS

An Australian questionnaire on attitudes and practices related to promoting a healthy lifestyle among patients with fertility problems was reciprocally back-to-back translated and three open-ended questions were added. All HCPs of Belgian fertility clinics, including gynaecologists, fertility nurses/midwives, psychologists, and embryologists, were invited by e-mail to complete the questionnaire online. Responses to closed and open-ended questions were analysed with, respectively, descriptive statistics and qualitative thematic analysis. Finally, differences in perspectives between different groups of HCPs were explored.

RESULTS

A total of 50 fertility nurses/midwives, 42 gynaecologists, and 19 other HCPs completed the survey (n = 111). Regarding attitudes, all respondents valued informing patients about the impact of lifestyle on fertility. The vast majority of HCPs (n = 96; 86%) stated that fertility clinics have the responsibility to address unhealthy lifestyles prior to offering fertility treatment. Fertility nurses/midwives were significantly more likely than gynaecologists to state that fertility clinics have this responsibility (p = 0.040). Regarding practices, the patient's lifestyle was most commonly discussed by the gynaecologist (n = 107; 96%) during the first appointment (n = 105; 95%). The lifestyle factors that were being addressed, according to the vast majority of respondents, were smoking, weight, age, alcohol, and recreational drugs. Only three HCPs (from three different clinics) stated that their clinic offered a structured lifestyle modification programme. HCPs explained that they lacked the resources and expertise for offering a structured lifestyle modification programme.

LIMITATIONS

Response rates were limited, but the responding Belgian gynaecologists and fertility nurses/midwives confirmed the findings of the previous study in Australian fertility nurses.

CONCLUSIONS

HCPs working in Belgian fertility clinics value healthy lifestyle promotion but lack access to structured lifestyle modification programmes to implement in their daily clinical practice. Future studies should focus on developing and evaluating structured lifestyle modification programmes for patients with fertility problems.

A Mixed-Method Approach to Develop and Validate an Integrated Food Literacy Tool for Personalized Food Literacy Guidance

Background

Food literacy refers to all practicalities associated with healthy eating. Current food literacy tools are limited in practical use in clinical practice. Therefore, an integrated food literacy tool (IFLT) to assess food literacy and to personalize food literacy guidance was developed and validated.

Methods

Following an iterative process, a food literacy framework was developed and food literacy goals were defined. A corresponding food literacy screener (FLS) to assess food literacy was developed along with an algorithm to provide personalized food literacy guidance based on the food literacy assessment. Content validation of the FLS was assessed by a panel of experts, measuring item and scale content validity index (I/S-CVI) and by the target population in semi structured interviews with 15 adults of reproductive age. Subsequently, an online cross-sectional survey was conducted among 114 adults of reproductive age to evaluate the validity of the FLS. Construct validity was examined against both the validated healthy eating and weight self-efficacy scale and against a food frequency questionnaire assessing healthy eating self-efficacy (HESE) and diet quality, respectively. Reliability was assessed with a two-week test-retest. Pearson correlation tests were conducted.

Results

An IFLT consisting of a FLS and corresponding algorithm to personalize food literacy guidance by prioritizing food literacy goals was developed. The IFLT includes 24 food literacy goals, addressed by 17 FLS items. Every item received a weighting factor based on theory and expert opinion to prioritize food literacy goals according to personal needs. Content validity revealed that the FLS was rated relevant by experts (S-CVI = 0.93) and well-understood by the target population. The FLS has a good construct validity as it was positively correlated with diet quality (r = 0.536, p &lt; 0.001) and with HESE (r = 0.685, p &lt; 0.001). It also showed a good test-retest reliability (r = 0.721, p &lt; 0.001).

Conclusion

The newly developed IFLT is a practically applicable, context specific theory-and expert-based dual purpose tool to assess food literacy and to personalize food literacy guidance by prioritizing individuals' food literacy goals to their needs.

Systematic development of a mobile preconception lifestyle programme for couples undergoing IVF: the PreLiFe-programme

STUDY QUESTION

Can we develop a preconception lifestyle programme for couples undergoing IVF that is in line with their needs.

SUMMARY ANSWER

A mobile preconception lifestyle programme was systematically developed based on expert opinion, literature and needs of IVF-patients.

WHAT IS KNOWN ALREADY

A healthy lifestyle prior to conception is not only beneficial for the general health of couples, but evidence on its importance for their reproductive health and the health of their children is also emerging. So far, the vast majority of fertility clinics do not offer a lifestyle programme for couples undergoing IVF. Therefore, the present study aimed to develop a lifestyle programme for IVF-couples.

STUDY DESIGN, SIZE, DURATION

The development of the PreLiFe-programme was guided by the steps of the Medical Research Council (MRC) framework for developing complex interventions, a systematic approach for developing theory- and evidence-based health promotion interventions.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

First, the evidence base on lifestyle programmes for IVF-couples was reviewed. Second, several iterations between an expert panel, the literature, and quantitative and qualitative data from IVF-patients identified the content, the format, behaviour change techniques and theory of the programme. Third, the PreLiFe-programme was produced and the expected process and outcomes of a randomized controlled trial assessing it were modelled. Finally, user tests among experts and patients and pilot tests among patients were conducted.

MAIN RESULTS AND ROLE OF CHANCE

The finally developed PreLiFe-programme is a mobile application to be used autonomously by both partners of IVF-couples during the first year of IVF, in combination with motivational interviewing over the telephone every three months (i.e. blended care). The PreLiFe-programme provides advice and skills training on physical activity, diet and mindfulness based stress reduction and is in part tailored based on monitoring and tracking the lifestyle of patients. Based on the literature the expert panel considers it plausible that all three components contribute to IVF-success rates. The PreLiFe-programme is likely to be acceptable to patients as it meets the need of patients for lifestyle advice and treatment information.

LIMITATIONS, REASON FOR CAUTION

The pilot in IVF-couples had a 3-month duration. The feasibility of the PreLiFe-programme in other infertile populations and/or upon longer use is yet to be examined. Whether the PreLiFe-programme effectively improves lifestyle and IVF-success rates is currently being examined in a trial randomizing heterosexual couples starting IVF to the PreLiFe-programme or an attention-control group for 12 months.

WIDER IMPLICATIONS OF THE FINDINGS

If the PreLiFe-programme improves lifestyle and the chance of IVF-success, it will be a powerful tool and provide guidance for implementing lifestyle programmes in fertility clinics.

STUDY FUNDING/COMPETING INTEREST(S)

Funded by the Research Foundation Flanders (FWO-TBM (Applied Biomedical Research with a Primary Social finality); reference: T005417N). The authors have no conflict of interest to report.

TRIAL REGISTRATION NUMBER

NCT03790449.

Investigating partner involvement in pregnancy and identifying barriers and facilitators to participating as a couple in a digital healthy eating and physical activity intervention

BACKGROUND

Maternal obesity and excessive gestational weight gain are associated with adverse maternal and foetal health outcomes. Interventions targeting dietary and physical activity behaviours during pregnancy have typically been directed at women only. A digital intervention targeting couples could encourage expectant parents to support each other in improving energy balance (dietary and physical activity) behaviours.

AIMS

This study aimed to investigate the role partners play in pregnant women's energy balance behaviours, and to identify barriers and facilitators to participating as a couple in a digital intervention to encourage healthy eating and physical activity in pregnancy.

METHODS

A qualitative design combined online focus groups and telephone interviews. Three focus groups were held with men (n = 15) and one mini focus group (n = 3) and 12 telephone interviews were conducted with women. Participants were either in the last trimester of pregnancy or had a baby under 18 months old. Most were from more deprived population groups where prevalence of maternal obesity is higher. Data were analysed thematically. Barriers and facilitators to participating as a couple in a digital intervention were mapped to the COM-B model and the Theoretical Domains Framework.

RESULTS

Four main themes were identified; partner involvement and support; partner understanding of good energy balance behaviours; couple concordance of energy balance behaviours; partner influence on her energy balance behaviours. Most facilitators to participating in a digital intervention as a couple fell within the Reflective Motivation domain of COM-B. Men were motivated by the desire to be supportive partners and good role models. Women were motivated by their belief that partner involvement would improve their success in achieving goals and enhance couple-bonding. Other facilitators included concordance in dietary behaviours (Physical Opportunity), healthcare practitioner recommendation, perceptions of pregnancy as 'ours' (Social Opportunity) and feeling supported and involved (Automatic Motivation). Barriers were rarely mentioned but included potential for partner conflict, perceptions of pregnancy as 'hers' and economic constraints.

CONCLUSIONS

An opportunity exists to harness partner support to improve maternal energy balance behaviours. Barriers and facilitators to participating in a digital intervention as a couple indicate its potential to benefit emotional and relationship wellbeing in addition to physical health.

Influence of social determinants on fertility: a critical review

PURPOSE OF REVIEW

Intrinsic factors, such as age, weight and lifestyle habits, together with extrinsic factors, such as socioeconomic level, must be considered when it comes to reproductive healthcare. Over the last few years, studies that attempt to respond to the participation and interaction of these factors in subfertility have been published; however, some questions remain unanswered.

RECENT FINDINGS

Although there are little modifiable factors for women, it is possible to influence other factors, such as behavioural or cultural factors in order to minimize fertility problems; however, they are often highly influenced by each other.

SUMMARY

Advanced age, obesity, sedentary lifestyle, alcohol, tobacco and other compounds, have a clearly negative effect and may extend time-to-pregnancy, although the responsible mechanisms and the magnitude of the detriment that they produce in the reproductive health are yet to be studied. Economic context and new environmental factors are a current challenge for reproductive health too.

Preconception lifestyle advice for people with infertility

BACKGROUND

Infertility is a prevalent problem that has significant consequences for individuals, families, and the community. Modifiable lifestyle factors may affect the chance of people with infertility having a baby. However, no guideline is available about what preconception advice should be offered. It is important to determine what preconception advice should be given to people with infertility and to evaluate whether this advice helps them make positive behavioural changes to improve their lifestyle and their chances of conceiving.

OBJECTIVES

To assess the safety and effectiveness of preconception lifestyle advice on fertility outcomes and lifestyle behavioural changes for people with infertility.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, CINAHL, trial registers, Google Scholar, and Epistemonikos in January 2021; we checked references and contacted field experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), randomised cross-over studies, and cluster-randomised studies that compared at least one form of preconception lifestyle advice with routine care or attention control for people with infertility.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Primary effectiveness outcomes were live birth and ongoing pregnancy. Primary safety outcomes were adverse events and miscarriage. Secondary outcomes included reported behavioural changes in lifestyle, birth weight, gestational age, clinical pregnancy, time to pregnancy, quality of life, and male factor infertility outcomes. We assessed the overall quality of evidence using GRADE criteria.

MAIN RESULTS

We included in the review seven RCTs involving 2130 participants. Only one RCT included male partners. Three studies compared preconception lifestyle advice on a combination of topics with routine care or attention control. Four studies compared preconception lifestyle advice on one topic (weight, alcohol intake, or smoking) with routine care for women with infertility and specific lifestyle characteristics. The evidence was of low to very low-quality. The main limitations of the included studies were serious risk of bias due to lack of blinding, serious imprecision, and poor reporting of outcome measures. Preconception lifestyle advice on a combination of topics versus routine care or attention control Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.79 to 1.10; 1 RCT, 626 participants), but the quality of evidence was low. No studies reported on adverse events or miscarriage. Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice on a combination of topics affects lifestyle behavioural changes: body mass index (BMI) (mean difference (MD) -1.06 kg/m², 95% CI -2.33 to 0.21; 1 RCT, 180 participants), vegetable intake (MD 12.50 grams/d, 95% CI -8.43 to 33.43; 1 RCT, 264 participants), alcohol abstinence in men (RR 1.08, 95% CI 0.74 to 1.58; 1 RCT, 210 participants), or smoking cessation in men (RR 1.01, 95% CI 0.91 to 1.12; 1 RCT, 212 participants). Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of women with adequate folic acid supplement use (RR 0.98, 95% CI 0.95 to 1.01; 2 RCTs, 850 participants; I² = 4%), alcohol abstinence (RR 1.07, 95% CI 0.99 to 1.17; 1 RCT, 607 participants), and smoking cessation (RR 1.01, 95% CI 0.98 to 1.04; 1 RCT, 606 participants), on low quality evidence. No studies reported on other behavioural changes. Preconception lifestyle advice on weight versus routine care Studies on preconception lifestyle advice on weight were identified only in women with infertility and obesity. Compared to routine care, we are uncertain whether preconception lifestyle advice on weight affects the number of live births (RR 0.94, 95% CI 0.62 to 1.43; 2 RCTs, 707 participants; I² = 68%; very low-quality evidence), adverse events including gestational diabetes (RR 0.78, 95% CI 0.48 to 1.26; 1 RCT, 317 participants; very low-quality evidence), hypertension (RR 1.07, 95% CI 0.66 to 1.75; 1 RCT, 317 participants; very low-quality evidence), or miscarriage (RR 1.50, 95% CI 0.95 to 2.37; 1 RCT, 577 participants; very low-quality evidence). Regarding lifestyle behavioural changes for women with infertility and obesity, preconception lifestyle advice on weight may slightly reduce BMI (MD -1.30 kg/m², 95% CI -1.58 to -1.02; 1 RCT, 574 participants; low-quality evidence). Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice affects the percentage of weight loss, vegetable and fruit intake, alcohol abstinence, or physical activity. No studies reported on other behavioural changes. Preconception lifestyle advice on alcohol intake versus routine care Studies on preconception lifestyle advice on alcohol intake were identified only in at-risk drinking women with infertility. We are uncertain whether preconception lifestyle advice on alcohol intake affects the number of live births (RR 1.15, 95% CI 0.53 to 2.50; 1 RCT, 37 participants; very low-quality evidence) or miscarriages (RR 1.31, 95% CI 0.21 to 8.34; 1 RCT, 37 participants; very low-quality evidence). One study reported on behavioural changes for alcohol consumption but not as defined in the review methods. No studies reported on adverse events or other behavioural changes. Preconception lifestyle advice on smoking versus routine care Studies on preconception lifestyle advice on smoking were identified only in smoking women with infertility. No studies reported on live birth, ongoing pregnancy, adverse events, or miscarriage. One study reported on behavioural changes for smoking but not as defined in the review methods.

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births. Evidence was insufficient to allow conclusions on the effects of preconception lifestyle advice on adverse events and miscarriage and on safety, as no studies were found that looked at these outcomes, or the studies were of very low quality. This review does not provide clear guidance for clinical practice in this area. However, it does highlight the need for high-quality RCTs to investigate preconception lifestyle advice on a combination of topics and to assess relevant effectiveness and safety outcomes in men and women with infertility.

Research-supported mobile applications and internet-based technologies to mediate the psychological effects of infertility: a review

Infertility is a chronic condition commonly accompanied by psychological and emotional distress. A significant contributor to the discontinuation of infertility treatment is the psychological burden of treatment. Many individuals experiencing infertility report high levels of depression and anxiety. Unfortunately, barriers to traditional individual and couples counselling include stigmatization, finances, trepidation, challenges of travel and uncertainty. New technology, such as mobile applications and internet-based programmes, may be a feasible option for reducing the emotional distress of infertility diagnoses and treatments. This review focuses on current and developing technologies designed to decrease emotional distress in individuals with infertility.

Mobile-Based Lifestyle Intervention in Women with Glucose Intolerance after Gestational Diabetes Mellitus (MELINDA), A Multicenter Randomized Controlled Trial: Methodology and Design

The aims of the 'Mobile-based lifestyle intervention in women with glucose intolerance after gestational diabetes mellitus (GDM)' study (MELINDA) are: (1) to evaluate the prevalence and risk factors of glucose intolerance after a recent history of GDM; and (2) to evaluate the efficacy and feasibility of a telephone- and mobile-based lifestyle intervention in women with glucose intolerance after GDM. This is a Belgian multicenter randomized controlled trial (RCT) in seven hospitals with the aim of recruiting 236 women. Women in the intervention group will receive a blended program, based on one face-to-face education session and further follow-up through a mobile application and monthly telephone advice. Women in the control group will receive follow-up as in normal routine with referral to primary care. Participants will receive an oral glucose tolerance test (OGTT) one year after baseline. Primary endpoint is the frequency of weight goal achievement (≥5% weight loss if pre-pregnancy BMI ≥ 25 Kg/m2 or return to pre-gravid weight if BMI < 25 Kg/m2). At each visit blood samples are collected, anthropometric measurements are obtained, and self-administered questionnaires are completed. Recruitment began in May 2019.