Lifestyle and in vitro fertilization: what do patients believe?

Does a public online IVF prediction tool help set patient expectations? A mixed methods evaluation study

STUDY QUESTION

Does a public online IVF success prediction calculator based on real-world data help set patient expectations?

SUMMARY ANSWER

The YourIVFSuccess Estimator aided consumer expectations of IVF success: one quarter (24%) of participants were unsure of their estimated IVF success before using the tool; one half changed their prediction of success after using the tool and one quarter (26%) had their expectations of IVF success confirmed.

WHAT IS KNOWN ALREADY

Several web-based IVF prediction tools exist worldwide but have not been evaluated for their impact on patient expectations, nor for patient perceptions of usefulness and trustworthiness.

STUDY DESIGN, SIZE, DURATION

This is a pre-post evaluation of a convenience sample of 780 online users of the Australian YourIVFSuccess Estimatorhttps://yourivfsuccess.com.au/ between 1 July and 31 November 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were eligible if they were over 18 years of age, Australian residents, and considering IVF for themselves or their partner. Participants filled in online surveys before and after using the YourIVFSuccess Estimator.

MAIN RESULTS AND THE ROLE OF CHANCE

The response rate of participants who completed both surveys and the YourIVFSuccess Estimator was 56% (n = 439). The YourIVFSuccess Estimator aided consumer expectations of IVF success: one quarter (24%) of participants were unsure of their estimated IVF success before using the tool; one half changed their prediction of success after using the tool (20% increased, 30% decreased), bringing their predictions in line with the YourIVFSuccess Estimator, and one quarter (26%) had their IVF success expectations confirmed. One in five participants claimed they would change the timing of IVF treatment. The majority of participants found the tool to be at least moderately trustworthy (91%), applicable (82%), and helpful (80%), and would recommend it to others (60%). The main reasons given for the positive responses were that the tool is independent (government funded, academic) and based on real-world data. Those who did not find it applicable or helpful were more likely to have had a worse-than-expected prediction, or to have experienced non-medical infertility (e.g. single women, LGBTQIA+), noting that at the time of evaluation the Estimator did not accommodate these patient groups.

LIMITATIONS, REASONS FOR CAUTION

Those who dropped out between the pre- and post-surveys tended to have a lower education status or have been born outside of Australia or New Zealand, therefore there may be issues with generalizability.

WIDER IMPLICATIONS OF THE FINDINGS

With consumers demanding increasing levels of transparency and participation in decisions around their medical care, public-facing IVF predictor tools based on real-world data are useful for aligning expectations about IVF success rates. Given differences in patient characteristics and IVF practices internationally, national data sources should be used to inform country-specific IVF prediction tools.

STUDY FUNDING/COMPETING INTEREST(S)

The YourIVFSuccess website and evaluation of the YourIVFSuccess Estimator are supported by the Medical Research Future Fund (MRFF) Emerging Priorities and Consumer Driven Research initiative: EPCD000007. BKB, ND, and OF have no conflicts to declare. DM holds a clinical role at Virtus Health. His role did not influence the analysis plan or interpretation of results in this study. GMC is an employee of the UNSW Sydney, and Director of the UNSW NPESU. UNSW receives research funding on behalf of Prof Chambers from the MRFF to develop and manage the Your IVF Success website. Grant ID: MRFF Emerging Priorities and Consumer Driven Research initiative: EPCD000007.

TRIAL REGISTRATION NUMBER

N/A.

Food & Fertility Study: study protocol for a Danish multicentre prospective cohort study investigating the association between food intake and semen quality, pregnancy and birth outcomes in infertile women and men

INTRODUCTION

Worldwide infertility is highly prevalent, and lifestyle factors, such as food intake, could have an essential role in the success of a fertility treatment. The literature is not consistent and adequate for recommendations to the increasing number of women and men of reproductive age who ask for lifestyle guidance. Therefore, the aims of the Food & Fertility Study will be to investigate the possible association between food intake and semen quality in men, and pregnancy and live birth rates in women undergoing intrauterine insemination or assisted reproductive technology treatment.

METHODS AND ANALYSIS

The Food & Fertility Study is a multicentre prospective cohort study which plans to enrol a total of 4000 women and men between 2022 and 2024. Data collection will take place in four fertility clinics through a web-based Food Frequency Questionnaire. Data on sperm quality and pregnancy and live birth rates will be obtained from medical records and national registers.

ETHICS AND DISSEMINATION

The study is registered with and approved by the Danish Data Protection Agency, the North Denmark Region (j.nr: 2019-055298). Further, a Statement of Work and a Master Collaboration Agreement have been submitted and approved by the regional legal departments (AGR-2019-731-9667). Dissemination of the results will be through national and international conferences, in scientific environments, in the form of lectures to the broader public, and by peer-reviewed publications in international scientific journals.

TRIAL REGISTRATION NUMBER

NCT05454046.

Adherence to the Mediterranean diet and the risk of unexpected poor response to ovarian stimulation in IVF cycles

RESEARCH QUESTION

Can preconception adherence to a Mediterranean diet influence the rate of poor response to ovarian stimulation in IVF cycles?

DESIGN

The impact of dietary habits on the success of IVF is controversial. Inconsistencies may be explained by confounders associated with the use of pregnancy as an outcome as well as by a reductionist view of diet that focuses on single components rather than on food patterns. This cross-sectional study analysed adherence to a Mediterranean diet in women with unexpected poor response to ovarian stimulation. Main inclusion criteria were: age 18-39 years, normal weight, preserved ovarian reserve and starting dose of gonadotrophins of 150-225 IU/day. Adherence to the Mediterranean diet was assessed through a Mediterranean diet score (MDS). Unexpected poor ovarian response was defined as the retrieval of ≤3 suitable oocytes.

RESULTS

A total of 296 women were included, of whom 47 (15.9%) showed an unexpected poor response. A clear dose-related association with tertiles of MDS was not observed in the univariate analysis. However, in the multivariate analysis, the risk of unexpected poor response was significantly lower for women in the second tertile of MDS compared with the first tertile (adjusted odds ratio [OR] 0.29, 95% confidence interval [CI] 0.11-0.76) and for women in the second and third tertiles, grouped together, compared with the first tertile (adjusted OR 0.34, 95% CI 0.14-0.82).

CONCLUSIONS

Low adherence to a Mediterranean diet could be a risk factor for unexpected poor ovarian response.

University students' fertility awareness and its influencing factors: a systematic review

INTRODUCTION

In recent years, a growing number of researchers have begun to study fertility awareness (FA). Evidence suggests that college students in their reproductive years have a common understanding of fertility, risk factors for infertility, and assisted reproductive technologies. Therefore, this systematic review summarizes these studies and explores the factors affecting college students' fertility awareness.

METHODS

A systematic literature search of databases (PUBMED/MEDLINE, Cochrane, Web of Science, Embase, and EBSCO) was conducted from inception to September 2022. Studies that assessed the levels of fertility awareness and factors influencing college students were considered for the review. The qualities of the included studies were evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. This systematic review is reported according to the preferred reporting items for systematic review (PRISMA) guidelines.

RESULTS

Twenty-one articles met the eligibility criteria and were included. The preliminary results showed that participants reported low to moderate FA. Female medical students demonstrated higher levels of fertility awareness. The association between age, years of education, and FA was insufficient.

CONCLUSION

The results of the current study suggest that increased FA interventions are warranted, especially for the male, non-medical student population. Governments and educational institutions should strengthen education programs for young students on reproductive health to help them raise awareness about childbirth, and society should provide family support for young people.

Health Related Behaviors and Life Satisfaction in Patients Undergoing Infertility Treatment

The aim of the study was to evaluate the level of life satisfaction and health behaviors presented by patients with diagnosed infertility. This cross-sectional study included 456 patients (235 women and 221 men) from infertile couples in southeastern Poland from June 2019 to February 2020. Participants completed a questionnaire on sociodemographic characteristics, the Health Behaviors Inventory (HBI), and the Satisfaction with Life Scale (SWLS). The average score of severity of health behaviors for the study group was 82.96 points. Satisfaction with life at a higher level was declared by 57.6% of respondents, at an average level was declared by 31.4%, and at a lower level was declared by 11%. The SWLS score for the entire study group was 24.11 points (6.82 points on the sten scale). Respondents who achieved a higher rate of life satisfaction also had a higher level of severity of health behaviors (p < 0.0001). There were no significant differences between male and female SWLS scores, although the women had significantly higher rates of severity of health behaviors than men. The level of health behavior is positively related to life satisfaction in infertile patients. Medical personnel should conduct health education on a healthy lifestyle that promotes the improvement of reproductive health.

Female dietary patterns and outcomes of in vitro fertilization (IVF): a systematic literature review

Background

Infertility affects up to 15% of couples. In vitro fertilization (IVF) treatment has modest success rates and some factors associated with infertility and poor treatment outcomes are not modifiable. Several studies have assessed the association between female dietary patterns, a modifiable factor, and IVF outcomes with conflicting results. We performed a systematic literature review to identify female dietary patterns associated with IVF outcomes, evaluate the body of evidence for potential sources of heterogeneity and methodological challenges, and offer suggestions to minimize heterogeneity and bias in future studies.

Methods

We performed systematic literature searches in EMBASE, PubMed, CINAHL, and Cochrane Central Register of Controlled Trials for studies with a publication date up to March 2020. We excluded studies limited to women who were overweight or diagnosed with PCOS. We included studies that evaluated the outcome of pregnancy or live birth. We conducted an initial bias assessment using the SIGN 50 Methodology Checklist 3.

Results

We reviewed 3280 titles and/or titles and abstracts. Seven prospective cohort studies investigating nine dietary patterns fit the inclusion criteria. Higher adherence to the Mediterranean diet, a ‘profertility’ diet, or a Dutch ‘preconception’ diet was associated with pregnancy or live birth after IVF treatment in at least one study. However, causation cannot be assumed. Studies were potentially hindered by methodological challenges (misclassification of the exposure, left truncation, and lack of comprehensive control for confounding) with an associated risk of bias. Studies of the Mediterranean diet were highly heterogenous in findings, study population, and methods. Remaining dietary patterns have only been examined in single and relatively small studies.

Conclusions

Future studies with rigorous and more uniform methodologies are needed to assess the association between female dietary patterns and IVF outcomes. At the clinical level, findings from this review do not support recommending any single dietary pattern for the purpose of improving pregnancy or live birth rates in women undergoing IVF treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-021-00757-7.

Can Nutrition Help in the Treatment of Infertility?

Infertility is defined as the inability to conceive after 12 months of unprotected intercourse or six months for women aged 35 years or older. The physical, emotional, psychological, and financial statuses of infertile couples are tremendously affected especially after undergoing diagnostic and/or curative treatments. Human fertility is influenced by multiple factors including female or male, and modifiable or non-modifiable factors. There is growing evidence that nutri-tion may play an important role in adjusting fertility-related outcomes in both men and women. The objective of our study was to summarize the latest data on nutritional factors (specific food groups, nutrients, and nutritional supplements) that have an impact on female or male sexual and reproductive function. PubMed and Google Scholar platforms were used to collect appropriate articles for the review using several combinations of keywords (infertility, diet, dietary supplements, antioxidants, and beverages). Adherence to a healthy dietary pattern favoring fish, poultry, whole grains, fruits, vegetables, and healthy fats, was related to better fertility in both genders. Despite the multifactorial etiology of sexual infertility, nutrition may affect the sexual/reproductive function in both women and men.

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.

The effect of psychological distress on IVF outcomes: Reality or speculations?

Introduction

Infertility is a problem that affects millions of people worldwide. The aim of this study was to assess the effect of stress, depression and anxiety on the IVF outcomes in Kazakhstan.

Methods

The prospective cohort study was performed using questionnaires to assess psychological distress in 304 infertile female in three different cities in Kazakhstan.

Results

The average age of participants was 33.7 years with infertility duration of 5.9 years. Regarding stress, depression and anxiety we found that more than 80% of all respondents had CES-D score higher than 16, indicating that they are at risk of developing clinical depression. On average, FPI subscales’ scores, global stress score and anxiety scale (STAI-S and STAI-T) scores were statistically significantly higher among not pregnant women than pregnant women. Similarly, in simple logistic regression analysis all FPI subscales scores, global stress scale score and anxiety scales’ scores were negatively associated with clinical pregnancy.

Conclusion

Rates of stress, anxiety and depression among IVF patients are higher than in general population. If the level of infertility-related stress is higher, IVF success rate is lower. Findings of our study indicate the need for the specific psychological interventions for all infertility women, to improve IVF success rate.

Effectiveness of a therapeutic multiple-lifestyle intervention taking into account the periconceptional environment in the management of infertile couples: study design of a randomized controlled trial - the PEPCI study

BACKGROUND

Infertility is defined as the inability to conceive after 12 months of unprotected intercourse. It affects approximately one in six couples seeking pregnancy in France or western countries. Many lifestyle factors of the couples' pre and peri-conceptional environment (weight, diet, alcohol, tobacco, coffee, drugs, physical activity, stress, sleep…) have been identified as risk factors for infertility in both males and females. The high prevalence rates of unhealthy diets and lifestyles in the reproductive population of industrialized countries are worrisome. Nevertheless, adoption of a healthy lifestyle may improve fertility but lifestyle changes are difficult to achieve and to maintain due notably to behavioral factors.

METHODS

Consequently, we decided to propose an interventional study aimed at improving the quality of life of infertile couples before the start of assisted reproductive technology treatment. It is a randomized controlled multicentre trial. Both members of the couples are involved in an integrated global care program (PEPCI for "Parcours Environnement PériConceptionnel en Infertilité") vs. usual care. This global intervention not only considers diet and/or physical activity but follows a holistic approach, including a multidisciplinary assessment to address complete physical, psychological and social well-being. According to patient needs, this includes interventions on weight, exercise, diet, alcohol and drugs, mental and social health.

DISCUSSION

The main objective of trial is to demonstrate that periconceptional multidisciplinary care has a positive impact on reproductive functions. We will also focus on feasibility, acceptance, compliance and conditions of success of a multifaceted lifestyle intervention.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov, Identifier: NCT02961907 on November 11, 2016.

Association Between the Frequency of Eating Non-home-prepared Meals and Women Infertility in the United States

Objectives

The purpose of this study was to determine whether eating non-home-prepared meals (NHPM), including fast food, ready-to-eat foods, and frozen foods, was associated with self-reported infertility in the United States women.

Methods

Data on diet and infertility from women aged 20-49 years who participated in the 2013-2014 and 2015-2016 National Health and Nutrition Examination Surveys were analyzed (n=2143). Dietary information, including the number and types of NHPM consumed, was obtained from a self-reported questionnaire, and infertility status was analyzed using the following question, “Have you ever attempted to become pregnant over a period of at least a year without becoming pregnant?”

Results

The frequency of NHPM consumption was positively associated with self-reported infertility after adjusting for confounding effects (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.48 to 5.38 of >1 vs. 0 NHPM/d). The odds of infertility were 2-3 times higher in women who consumed fast food than in those who did not consume fast food (OR, 2.73; 95% CI, 1.15 to 6.48 of >1 vs. 0 times/d).

Conclusions

The frequency and types of NHPM may be a factor contributing to infertility. Although our findings require confirmation, they suggest that eating out may be deleterious to women fecundity.

The Uppsala-Stockholm Assisted Reproductive Techniques (UppStART) study

PURPOSE

The Uppsala-Stockholm Assisted Reproductive Techniques (UppStART) study is a prospectively recruited sample of couples undergoing assisted reproduction in Stockholm and Uppsala county in Sweden. The study was initiated to (1) investigate possible changes in the epigenetic profile of infants inferred through the ART procedures and their consequence and (2) to assess the impact of lifestyle and health exposures on treatment outcome.

PARTICIPANTS

Recruitment took place between September 2011 and December 2013, and in vitro fertilisation (IVF) cycles initiated and pregnancies conceived during this time were followed until December 2014. The cohort includes 971 participants (n= 514 women; n= 457 men), and 129 pregnancies were achieved from the first IVF cycle included in the study.

FINDINGS TO DATE

Self-reported demographic, health and lifestyle data were collected from a baseline questionnaire, and to assess changes to lifestyle, a follow-up questionnaire was issued at the time of oocyte retrieval, and at subsequent IVF cycles. Questionnaire data were linked to data extracted from medical records. Biological samples were collected at baseline: blood for extraction of serum, plasma and DNA, morning and evening saliva samples for cortisol measurement and at delivery including samples of maternal blood, placenta and amniotic fluid, and cord blood for epigenetic analysis.

FUTURE PLANS

Through the unique identification number assigned to each Swedish citizen at birth or immigration, UppStART study participants will be linked to the Swedish population-based national and quality registers to provide data from prenatal, obstetrical, neonatal and infant care, and subsequent updates will provide data on childhood health and educational outcomes. Collaboration and use of UppStART data is encouraged, and more information about access can be found at www.ki.se/meb/uppstart.

Investigating the effect of lifestyle risk factors upon number of aspirated and mature oocytes in in vitro fertilization cycles: Interaction with antral follicle count

Introduction

There is evidence demonstrating that certain lifestyle factors have a detrimental effect on fertility. Since such factors often coexist, possible synergistic effects merit further investigation. Thus we aimed to examine the cumulative impact of lifestyle factors on in vitro fertilization (IVF) early reproductive treatment outcomes and their interaction with measures of ovarian reserve.

Materials and methods

By following women who were starting their first fresh IVF cycle in 2 cohorts, the “Lifestyle study cohort” (hypothesis generating cohort, n = 242) and the “UppSTART study” (validation cohort, n = 432) in Sweden, we identified two significant risk factors acting independently, smoking and BMI, and then further assessed their cumulative effects.

Results

Women with both these risk factors had an Incidence Rate Ratio (IRR) of 0.75 [(95% CI 0.61–0.94)] regarding the number of aspirated oocytes compared to women without these risk factors. Concerning the proportion of mature oocytes in relation to the total number of aspirated oocytes, the interaction between BMI and Antral Follicle Count (AFC) was significant (p-value 0.045): the lower the value of AFC, the more harmful the effect of BMI with the outcome.

Conclusions

Data shows that there is an individual as well as a cumulative effect of smoking and BMI on the number of aspirated and mature oocytes in fresh IVF treatment cycles. AFC might modify associations between BMI and the proportion of mature oocytes in relation to the total number of aspirated oocytes. These results highlight the importance of lifestyle factors on IVF early reproductive outcomes and provide additional evidence for the importance of preconception guidance for the optimization of IVF cycle outcome.

Lack of a meaningful association between dietary patterns and in vitro fertilization outcome among Japanese women

PURPOSE

The purpose of this study was to examine whether preconception maternal dietary pattern is associated with in vitro fertilization (IVF) outcome among Japanese women.

METHODS

This prospective study included 140 Japanese women who underwent conventional-IVF/intracytoplasmic sperm injection. The patients' diets during the previous month before egg retrieval were assessed with validated brief-type self-administered diet history questionnaire. Dietary patterns from 33 predefined food groups [energy-adjusted food (g/1000 kcal)] were extracted by factor analysis. The primary outcome measure was clinical pregnancy rate after IVF.

RESULTS

Thirty-six women had confirmed clinical pregnancy. Three dietary patterns were identified: "Vegetable and seafood," "Western," and "Rice and miso soup." The "Vegetables and seafood" dietary pattern (high intakes of green and other vegetables, mushrooms, seasoning, fish, soy products, chicken, and potatoes) was not associated with clinical pregnancy ([odds ratio per one-quartile increase in dietary pattern: 0.94 (95% confidence interval: 0.67-1.32), P = 0.73]. This relationship was unaltered after controlling for potential confounders. Furthermore, no association was seen between the other two dietary patterns and clinical pregnancy.

CONCLUSIONS

The three maternal preconception dietary patterns identified revealed no meaningful association with IVF outcome in Japanese women. Further studies in various populations with different dietary patterns are needed to confirm these findings.

Caffeine, alcohol, smoking, and reproductive outcomes among couples undergoing assisted reproductive technology treatments

During the past decade, as the use of assisted reproductive technologies (ART) has continued to increase worldwide, research investigating whether modifiable lifestyle factors, such as alcohol, caffeine, and smoking, may affect ART outcomes has grown. Despite the vast literature, there is still uncertainty regarding the effects of some of these exposures on ART outcomes. The objective of this review is to summarize the epidemiologic literature on intakes of caffeine and alcohol, smoking, and reproductive outcomes among women undergoing ART. Of the five epidemiologic studies on caffeine intake and ART outcomes, only one found a significant negative effect of caffeine intake on live birth following ART. There have been six epidemiologic studies exploring whether alcohol intake is associated with fertility outcomes among women undergoing ART. Three studies assessed current alcohol consumption and observed a negative effect on outcomes such as fertilization, embryo quality, and implantation. When alcohol intake in the year before treatment was assessed, no relationships were observed with clinical outcomes following ART. Finally, numerous epidemiologic studies and a handful of meta-analyses have confirmed that female current smokers have worse ART outcomes compared with nonsmokers. Although former smokers tend to have better ART outcomes than current smokers, very few individual studies have investigated the influence of smoking cessation on ART outcomes. Literature on male smoking, drinking, and caffeine habits in relation to ART outcomes is even sparser and inconsistent, making it difficult to draw strong conclusions on that topic. In summary, there is little evidence supporting a detrimental effect of moderate caffeine intake on ART outcomes. Current consumption of alcohol may have a negative effect on ART outcomes, but at present the evidence is limited. Women who currently smoke cigarettes have been consistently found to have poorer ART outcomes, including reduced live birth rates, but a quantification of the benefits of smoking cessation is lacking.

Preconception care for infertile couples: Nurses' and midwives' roles in promoting better maternal and birth outcomes

INTRODUCTION

Preconception care promotes better maternal outcomes, may assist in preventing birth defects and improves fertility awareness among healthy childbearing couples. Yet, the significance of preconception care for infertile couples is undeveloped area of practice in Europe.

AIMS AND OBJECTIVES

To discuss the importance of nurses and midwives in providing preconception care to infertile couples in the United Kingdom and Spain.

DESIGN

Discursive paper.

METHOD

A comparison of different midwifery and nursing approaches to preconception care for infertile couples in two European countries.

FINDINGS

At present, infertile couples' needs for preconception care are not routinely identified or understood. There is an opportunity for these needs to be considered and identified by nurses at the time of investigation for infertility or when planning pregnancy with assisted conception.

CONCLUSIONS

We argue that, by providing preconception care, nurses and midwives have an opportunity to deliver important advice to infertile couples in both primary care and specialist infertility services.

Diet and fertility: a review

The literature on the relationship between diet and human fertility has greatly expanded over the last decade, resulting in the identification of a few clear patterns. Intake of supplemental folic acid, particularly at doses higher than those recommended for the prevention of neural tube defects, has been consistently related to lower frequency of infertility, lower risk of pregnancy loss, and greater success in infertility treatment. On the other hand and despite promising evidence from animal models, vitamin D does not appear to exert an important role in human fertility in the absence of deficiency. Antioxidant supplementation does not appear to offer any benefits to women undergoing infertility treatment, but it appears to be beneficial when it is the male partner who is supplemented. However, the available evidence does not allow discerning which specific antioxidants, or at which doses, are responsible for this benefit. Long-chain omega-3 fatty acids appear to improve female fertility, although it remains unclear to what extent contamination of shared food sources, such as fish with high levels of environmental toxicants, can dampen this benefit. Lastly, adherence to healthy diets favoring seafood, poultry, whole grains, fruits, and vegetables are related to better fertility in women and better semen quality in men. The cumulative evidence has also piled against popular hypotheses. Dairy and soy, once proposed as reproductive toxicants, have not been consistently related to poor fertility. In fact, soy and soy supplements appear to exert a beneficial effect among women undergoing infertility treatment. Similarly, because data from large, high-quality studies continue to accumulate, the evidence of a potentially deleterious effect of moderate alcohol and caffeine intake on the ability to become pregnant seems less solid than it once did. While a complete picture of the role of nutrition on fertility is far from complete, much progress has been made. The most salient gaps in the current evidence include jointly considering female and male diets and testing the most consistent findings in randomized trials.