Frozen autologous and donor oocytes are associated with differences in clinical and neonatal outcomes compared with fresh oocytes: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System Analysis

Objective

To study the clinical and neonatal outcomes of embryos derived from frozen oocytes relative to fresh oocytes in both autologous and donor oocyte cycles after fresh embryo transfer (ET).

Design

This is a retrospective cohort study using the Society for Assisted Reproductive Technology Clinic Outcome Reporting System database between 2014 and 2015.

Setting

The Society for Assisted Reproductive Technology Clinic Outcome Reporting System database was used to identify autologous and donor oocyte cycles that resulted in a fresh ET during 2014 and 2015.

Patients

There were 154,706 total cycles identified that used embryos derived from fresh or frozen oocytes and resulted in a fresh ET, including 139,734 autologous oocyte cycles and 14,972 donor oocyte cycles.

Interventions

Generalized linear regression models were used to compare the clinical and neonatal outcomes of frozen oocytes relative to fresh oocytes. Models were adjusted for maternal age, body mass index, smoking status, parity, infertility diagnosis, number of embryos transferred, and preimplantation genetic testing. An additional sensitivity analysis was performed to examine singleton pregnancies separately.

Main Outcome Measures

The live birth (LB) rate was the primary outcome. Secondary outcomes include pregnancy and birthweight outcomes.

Results

Differences in clinical and neonatal outcomes between fresh and frozen-thawed oocytes after fresh ET were observed. Specifically, our study found a higher incidence of high-birthweight infants after the use of frozen oocytes relative to fresh oocytes in both autologous oocytes (12.5% [frozen] vs. 4.5% [fresh], adjusted risk ratio [aRR] 2.67, 95% confidence interval [CI] 1.65-4.3) and donor oocyte cycles (6.2% [frozen] vs. 4.6% [fresh], aRR 1.42, 95% CI 1.1-1.83). This finding remained true when the analysis was restricted to singleton gestations only for both groups: autologous (17.3% [frozen] vs. 7.1% [fresh], aRR 2.77, 95% CI 1.74-4.42) and donor oocytes (9.4% [frozen] vs. 7.8% [fresh], aRR 1.38, 95% CI 1.07-1.77). Additionally, we observed a decrease in LB (aRR 0.81, 95% CI 0.77-0.85); clinical pregnancy (aRR 0.83, 95% CI 0.8-0.87); and an increase in biochemical pregnancy loss (aRR 1.22, 95% CI 1.05-1.43) after the use of frozen oocytes in donors, but not autologous cycles.

Conclusions

Our findings of an increased incidence of high-birthweight infants after the transfer of embryos derived from frozen oocytes in both autologous and donor oocyte cycles raise questions about oocyte vitrification and deserve further study. Additionally, the finding of a decreased likelihood of LB with frozen-donor oocytes compared with fresh donor oocytes is an important finding, especially because more patients are seeking to use frozen oocytes in their donor egg cycles. Future research should be directed toward these findings to optimize the use of frozen oocytes in clinical practice.

Similar pregnancy outcomes from fresh and frozen donor oocytes transferred to gestational carriers: a SART database analysis isolating the effects of oocyte vitrification

PURPOSE

This work aimed to study clinical and neonatal outcomes of embryos derived from frozen compared to fresh donor oocytes in gestational carrier cycles.

METHODS

This is a retrospective cohort study using the Society for Assisted Reproductive Technology Clinic Outcome Reporting System database between 2014 and 2015, comprising of 1284 fresh transfer cycles to gestational carrier recipients of embryos resulting from fresh (n = 1119) and vitrified/thawed (n = 165) donor oocytes. Models were adjusted for gestational carrier age, preimplantation genetic testing (PGT-A), number of embryos transferred, multiple gestation, and fetal heart reduction. As our models were part of a larger analysis, intended parent BMI, smoking status, and parity were also adjusted for, but did not influence outcomes in this analysis.

RESULTS

There was no significant difference in probability of live birth rates when comparing embryos derived from fresh and frozen donor oocytes in gestational carrier cycles. There were also no significant differences in biochemical pregnancy losses or clinical miscarriage. There were no significant differences noted in low birthweight or high birthweight infants derived from fresh versus frozen donor oocyte after transfer into a gestational carrier.

CONCLUSIONS

The analysis of fresh and frozen donor oocytes in gestational carrier cycles provides the opportunity to assess for a possible effect of vitrification on the oocyte by controlling for differences in the uterine environment. We observed no significant differences in live birth, pregnancy loss, low birthweight or high birthweight infants when comparing fresh and frozen donor oocytes in gestational carrier cycles.

Prospectively assessed perceived stress associated with early pregnancy losses among women with history of pregnancy loss

STUDY QUESTION

What is the association between perceived stress during peri-conception and early pregnancy and pregnancy loss among women who have experienced a prior pregnancy loss?

SUMMARY ANSWER

Daily perceived stress above the median is associated with over a 2-fold risk of early pregnancy loss among women who have experienced a prior loss.

WHAT IS KNOWN ALREADY?

Women who have experienced a pregnancy loss may be more vulnerable to stress while trying to become pregnant again. While prior research has indicated a link between psychological stress and clinically confirmed miscarriages, research is lacking among a pre-conceptional cohort followed prospectively for the effects of perceived stress during early critical windows of pregnancy establishment on risk of both hCG-detected pregnancy losses and confirmed losses, while considering important time-varying confounders.

STUDY DESIGN, SIZE, DURATION

Secondary data analysis of the EAGeR trial (2007-2011) among women with an hCG-detected pregnancy (n = 797 women).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women from four US clinical centers enrolled pre-conceptionally and were followed ≤6 cycles while attempting pregnancy and, as applicable, throughout pregnancy. Perceived stress was captured via daily diaries and end-of-month questionnaires. Main outcome measures include hCG-detected and clinically recognized pregnancy losses.

MAIN RESULTS AND THE ROLE OF CHANCE

Among women who had an hCG-confirmed pregnancy, 188 pregnancies (23.6%) ended in loss. Women with high (>50th percentile) versus low (≤50th percentile) peri-implantation or early pregnancy weekly perceived stress had an elevated risk of experiencing any pregnancy loss (hazard ratio (HR): 1.69, 95% CI: 1.13, 2.54) or clinical loss (HR: 1.58, 95% CI: 0.96, 2.60), with higher risks observed for women experiencing an hCG-detected loss (HR: 2.16, 95% CI: 1.04, 4.46). Models accounted for women's age, BMI, employment, marital status, income, education, race, parity, prior losses, exercise and time-varying nausea/vomiting, caffeine, alcohol and smoking.

LIMITATIONS, REASONS FOR CAUTION

We were limited in our ability to clearly identify the mechanisms of stress on pregnancy loss due to our sole reliance on self-reported perceived stress, and the lack of biomarkers of different pathways of stress.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides new insight on early pregnancy perceived stress and risk of pregnancy loss, most notably hCG-detected losses, among women with a history of a prior loss. Our study is an improvement over past studies in its ability to account for time-varying early pregnancy symptoms, such as nausea/vomiting, and lifestyle factors, such as caffeine, alcohol and smoking, which are also risk factors for psychological stress and pregnancy loss.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland (Contract numbers: HHSN267200603423, HHSN267200603424, HHSN267200603426, HHSN275201300023I). Additionally, K.C.S. was supported by the National Institute on Aging of the National Institutes of Health under Award Number K01AG058781. The authors have no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

#NCT00467363.

The association of parity and breastfeeding with anti-Müllerian hormone levels at two time points

OBJECTIVE

To evaluate the association between parity and breastfeeding and anti-Müllerian hormone levels (AMH) and change in AMH levels over time. Furthermore, we examined whether AMH levels mediate the relation of parity and breastfeeding with age at menopause.

STUDY DESIGN

Observational, prospective cohort study.

MAIN OUTCOME MEASURES

AMH levels were assessed in a subset of premenopausal participants in the Nurses' Health Study II, including 1619 women who provided a blood sample in 1996-1999 and an additional 800 women who provided a second premenopausal sample in 2010-2012.

RESULTS

In multivariable linear regression models adjusted for parity, body mass index, smoking, and other factors, mean log AMH levels in 1996-1999 were 39% higher in women reporting ≥25 months of total breastfeeding vs. <1 month (P for trend = 0.009). Parity was not associated with AMH levels after adjustment for breastfeeding. Neither parity nor breastfeeding was associated with decline in AMH levels over 11 to 15 years. Breastfeeding duration was positively associated with age at menopause (P for trend = 0.01), with evidence that the association was mediated via AMH.

CONCLUSIONS

Our results suggest that breastfeeding is associated with higher AMH levels and later onset of menopause, and support the hypothesis that observed relations of parity with AMH levels and menopause timing may be largely attributable to breastfeeding.

Maternal caffeine intake and DNA methylation in newborn cord blood

BACKGROUND

Epigenetic mechanisms may underlie associations between maternal caffeine consumption and adverse childhood metabolic outcomes. However, limited studies have examined neonate DNA methylation (DNAm) patterns in the context of preconception or prenatal exposure to caffeine metabolites.

OBJECTIVES

We examined preconception and pregnancy caffeine exposure with DNAm alterations in neonate cord blood (n = 378).

METHODS

In a secondary analysis of the Effects of Aspirin in Gestation and Reproduction Trial (EAGeR), we measured maternal caffeine, paraxanthine, and theobromine concentrations from stored serum collected preconception (on average 2 months before pregnancy) and at 8 weeks of gestation. In parallel, self-reported caffeinated beverage intake was captured via administration of questionnaires and daily diaries. We profiled DNAm from the cord blood buffy coat of singletons using the MethylationEPIC BeadChip. We assessed associations of maternal caffeine exposure and methylation β values using multivariable robust linear regression. A false discovery rate (FDR) correction was applied using the Benjamini-Hochberg method.

RESULTS

In preconception, the majority of women reported consuming 1 or fewer servings/day of caffeine on average, and caffeine and paraxanthine metabolite levels were 88 and 36 µmol/L, respectively. Preconception serum caffeine metabolites were not associated with individual cytosine-guanine (CpG) sites (FDR >5%), though pregnancy theobromine was associated with DNAm at cg09460369 near RAB2A (β = 0.028; SE = 0.005; FDR P = 0.012). Preconception self-reported caffeinated beverage intake compared to no intake was associated with DNAm at cg09002832 near GLIS3 (β = -0.013; SE = 0.002; FDR P = 0.036). No associations with self-reported intake during pregnancy were found.

CONCLUSIONS

Few effects of maternal caffeine exposure on neonate methylation differences in leukocytes were identified in this population with relatively low caffeine consumption.

Markers of vitamin D metabolism and premenstrual symptoms in healthy women with regular cycles

STUDY QUESTION

Are insufficient 25-hydroxyvitamin D (25(OH)D) concentrations, and other markers of vitamin D metabolism, associated with premenstrual symptoms in healthy women with regular menstrual cycles?

SUMMARY ANSWER

25(OH)D insufficiency was associated with specific physical premenstrual symptoms, while no associations were observed with psychological symptoms or with other markers of vitamin D metabolism.

WHAT IS KNOWN ALREADY

Prior studies evaluating vitamin D and premenstrual symptoms have yielded mixed results, and it is unknown whether 25(OH)D insufficiency and other markers of vitamin D metabolism are associated with premenstrual symptoms.

STUDY DESIGN, SIZE, DURATION

We used two cohorts of women with regular menstrual cycles; 1191 women aged 18-40 years in EAGeR (cross-sectional analysis of a prospective cohort within a randomized trial) and 76 women aged 18-44 years in BioCycle (prospective cohort). In EAGeR, premenstrual symptoms over the previous year were assessed at baseline, whereas in BioCycle, symptoms were assessed prospectively at multiple points over two menstrual cycles with symptoms queried over the previous week. In both cohorts, symptomatology was assessed via questionnaire regarding presence and severity of 14 physical and psychological symptoms the week before and after menses. Both studies measured 25(OH)D in serum. We also evaluated the association of additional markers of vitamin D metabolism and calcium homeostasis, including intact parathyroid hormone (iPTH), calcium (Ca), fibroblast growth factor 23 (FGF23), and 1,25 dihydroxyvitamin D (1,25(OH)2D) with premenstrual symptoms in the BioCycle cohort.

PARTICIPANTS/MATERIALS, SETTING, METHODS

One cohort of women actively seeking pregnancy (Effects of Aspirin in Gestation and Reproduction (EAGeR)) and one cohort not seeking pregnancy (BioCycle) were evaluated. Log-binomial regression was used to estimate risk ratios (RR) and 95% CIs for associations between insufficient 25(OH)D (<30 ng/ml) and individual premenstrual symptoms, adjusting for age, BMI, race, smoking, income, physical activity, and season of blood draw.

MAIN RESULTS AND THE ROLE OF CHANCE

25(OH)D insufficiency was associated with increased risk of breast fullness/tenderness (EAGeR RR 1.27, 95% CI 1.03, 1.55; BioCycle RR 1.37, 95% CI 0.56, 3.32) and generalized aches and pains (EAGeR RR 1.33, 95% CI 1.01, 1.78; BioCycle 1.36, 95% CI 0.41, 4.45), though results were imprecise in the BioCycle study. No associations were observed between insufficient 25(OH)D and psychological symptoms in either cohort. In BioCycle, iPTH, Ca, FGF23, and 1,25(OH) 2D were not associated with any premenstrual symptoms.

LIMITATIONS, REASONS FOR CAUTION

Results from the EAGeR study were limited by the study design, which assessed both 25(OH)D at baseline and individual premenstrual symptoms over the past year at the baseline. As such, reverse causality is a potential concern. Though premenstrual symptoms were assessed prospectively in the BioCycle cohort, the power was limited due to small sample size. However, results were fairly consistent across both studies.

WIDER IMPLICATIONS OF THE FINDINGS

Serum 25(OH)D may be associated with risk and severity of specific physical premenstrual symptoms.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland (Contract nos. HHSN267200603423, HHSN267200603424, and HHSN267200603426). JG.R. and D.L.K. have been funded by the NIH Medical Research Scholars Program, a public-private partnership jointly supported by the NIH and generous contributions to the Foundation for the NIH by the Doris Duke Charitable Foundation (Grant #2014194), the American Association for Dental Research, the Colgate Palmolive Company, Genentech, and other private donors. For a complete list, visit the foundation website at http://www.fnih.org. The authors have no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT00467363.

Maternal Caffeine Intake and DNA Methylation in Newborn Cord Blood

Objectives

Prior research has suggested that epigenetic mechanisms may underly associations between maternal caffeine intake and adverse childhood metabolic outcomes. We examined preconception and early pregnancy maternal caffeine exposure with DNA methylation (DNAm) patterns in the cord blood of 378 neonates.

Methods

DNAm was profiled by the Infinium MethylationEPIC BeadChip in women enrolled in the EAGeR Trial. Maternal serum was collected 1–2 cycles preconception and at 8 weeks gestation as was self-reported caffeinated beverage intake through standardized questionnaires or daily diaries. Serum caffeine, paraxanthine, and theobromine were measured by liquid chromatography mass spectrometry. We performed multivariable robust linear regression to assess associations between maternal caffeine and methylation β-values and Ingenuity Pathway Analysis to evaluate biologic implications.

Results

Preconceptionally, 65%, 21% and 7% reported any soda, coffee or tea intake, respectively with the majority consuming on average ≤ 1 serving/day. Preconception self-reported intake compared to no intake was associated with DNAm at cg09002832 near GLIS3 (false discovery rate [FDR] p = 0.036). No associations with self-reported intake were found during pregnancy. Preconception serum markers were not associated with individual CpG sites (FDR &gt; 5%), though pregnancy theobromine (tertile 2 vs 1) was associated with DNAm at cg09460369 near RAB2A (FDR p = 0.012). Overlapping pathways for the top 100 CpG sites identified in the preconception intake and pregnancy theobromine analyses elucidated cell cycle and lipid metabolism processes.

Conclusions

Few differences in DNAm were identified in association with maternal caffeine intake in this low consumption population. DNAm changes from preconception caffeine or pregnancy theobromine exposure may be linked to signaling networks involving lipid metabolism, but further research among women with higher caffeine and theobromine exposure is warranted.

Funding Sources

Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD.

The Joint Role of Iodine Status and Thyroid Function on Risk for Preeclampsia in Finnish Women: a Population-Based Nested Case-Control Study

Preeclampsia, a pregnancy disorder that includes hypertension and proteinuria, is a major cause of maternal and fetal morbidity and mortality. Some studies, but not all, have found that women with preeclampsia have significantly lower iodine levels than healthy pregnant women. Resolving this issue is important because iodine deficiency in pregnancy is common in the USA and parts of Europe including Finland. We conducted a nested case-control study to determine whether the risk for preeclampsia is associated with iodine status. We measured serum iodine, thyroglobulin (Tg), and thyroid stimulating hormone (TSH) at 10-14 weeks gestational age in 204 women with preeclampsia and 246 unaffected controls selected from all births in Finland. We found no significant difference in iodine (case mean = 26.04 ng/mL, control mean = 27.88 ng/mL, p = 0.995), Tg (case mean = 31.11 ng/mL, control mean = 29.61 ng/mL, p = 0.996), and TSH (case mean = 1.30 mIU/L, control mean = 1.24 mIU/L, p = 0.896) levels between cases and controls. There was no significant relationship between preeclampsia risk and iodine, Tg, or TSH after adjustment for known risk factors. These results are reassuring given the high prevalence of iodine deficiency in pregnancy.

Urinary Phytoestrogens and Relationship to Menstrual Cycle Length and Variability Among Healthy, Eumenorrheic Women

Context

Phytoestrogens may influence fecundability, although biological mechanisms remain elusive. Since it is hypothesized that phytoestrogens may act through influencing hormone levels, we investigated associations between phytoestrogens and menstrual cycle length, a proxy for the hormonal milieu, in healthy women attempting pregnancy.

Design

A population-based prospective cohort of 326 women ages 18 to 40 with self-reported cycles of 21 to 42 days were followed until pregnancy or for 12 months of attempting pregnancy.

Methods

Urinary genistein, daidzein, O-desmethylangolensin, equol, enterodiol, and enterolactone were measured upon enrollment. Cycle length was determined from fertility monitors and daily journals. Linear mixed models assessed associations with continuous cycle length and were weighted by the inverse number of observed cycles. Logistic regression models assessed menstrual regularity (standard deviation > 75th vs ≤ 75th percentile). Models were adjusted for age, body mass index, race, creatinine, exercise, supplements, lipids, lead, cadmium, cotinine, parity, alcohol, and other phytoestrogens.

Results

Individual phytoestrogens were not associated with cycle length, although total phytoestrogens were associated with shorter cycles (-0.042 days; 95% confidence interval [CI], -0.080 to -0.003, per 10% increase). Each 1 nmol/L increase in enterolactone (odds ratio [OR] 0.88; 95% CI, 0.79-0.97) and total lignans (OR 0.85; 95% CI, 0.76-0.95) was associated with reduced irregularity, and each 1 nmol/L increase in genistein with irregularity (OR 1.19; 95% CI, 1.02-1.38).

Conclusion

Phytoestrogens were not meaningfully associated with cycle length but may be associated with menstrual regularity, among women with self-reported regular cycles. These results highlight differences between isoflavones and lignans and are reassuring for women attempting pregnancy.

Preconception Marijuana Use and Pregnancy Outcomes (P18-033-19)

Objectives

Marijuana is the most widely used and fastest growing drug in the United States, with legislation currently broadening legalization for both medical and recreational use. However, there are limited data evaluating associations with fecundity and adverse pregnancy outcomes. A few studies evaluating self-reported use suggest marijuana may not be harmful for pregnancy, yet there is a concern for underreporting due to stigma as marijuana is not universally legalized. Our aim was to examine the association between preconception marijuana use, using both self-reported and urinary levels of tetrahydrocannabinol (THC), and fecundability, live birth, and pregnancy loss.

Methods

Women aged 18–40 years old (n = 1212) enrolled in the EAGeR trial were screened for urinary THC at up to 2 time points during preconception using a homogenous enzyme immunoassay from Randox Laboratories, and asked at baseline to report any marijuana use during the past year. Women were followed for up to 6 months while attempting pregnancy. Cox proportional hazard regression was used to calculate fecundability odds ratios (FOR), and log-binomial regression to estimate risk ratios (RR) for live birth and pregnancy loss adjusting for age, race, BMI, education, smoking, alcohol, and detectable levels of opioids.

Results

33 (2.7%) women screened positive for THC during the preconception period, of which 14 also self-reported use during the past year. 62 women (5.1%) either screened positive or self-reported use. Women who screened positive for preconception THC had reduced fecundability (FOR 0.50; 95% CI 0.25, 1.00), as well as women who self-reported marijuana use (FOR 0.54; 95% CI 0.31, 0.94), or who were positive using either urinary or self-report (FOR 0.53, 95% CI 0.33, 0.86). No associations were observed between marijuana use and live birth (RR 0.71; 95% CI 0.41, 1.22) and pregnancy loss (RR 0.78; 95% CI 0.28, 2.18).

Conclusions

Women who screened positive for THC during preconception, or self-reported use during the past year had reduced fecundability, though no associations were observed with live birth or pregnancy loss. Further investigations are needed to determine what duration and dose of marijuana may negatively impact fecundability.

Funding Sources

Intramural Research Program, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Preconception Vitamin D Status and Offspring Sex Ratio Among Women with Prior Pregnancy Loss (OR17-05-19)

Objectives

Experimental data indicate that maternal exposure to factors known to alter inflammatory milieu may be specifically harmful to the conception or survival of male fetuses. Indeed, in a recent clinical trial, preconception administration of low dose aspirin versus placebo restored the skewed sex ratio at birth among women with elevated inflammation, providing direct evidence of this phenomenon in humans. However, it is unknown whether other factors associated with inflammation, such as vitamin D status, are associated with offspring sex ratio at birth. Our objective was thus to evaluate the association of preconception serum 25-hydroxyvitamin D levels [25(OH)D] and male live birth among 1228 reproductive-age women with a history of 1–2 prior losses who were enrolled in the Effects of Aspirin in Gestation and Reproduction trial between 2007–2011.

Methods

We estimated RRs and 95% CIs for male live birth according to 25(OH)D sufficiency (≥75 vs. <75 nmol/L) using generalized estimating equations of log-binomial regression with robust standard errors.

Results

Among the 1086 women who completed follow-up, the proportion of live-born males was 24% (n = 136) and 30% (n = 156) in the 25(OH)D insufficient and sufficient groups, respectively. After adjustment for age, race/ethnicity, and other factors, women in the 25(OH)D sufficient group were 23% (95% CI: 1.01, 1.49) more likely to have a live-born male infant compared to the insufficient group. Associations were stronger among women with elevated versus low levels of high sensitivity C-reactive protein (>1.95 ng/mL: RR: 1.41; 95% CI: 0.99, 2.00 versus ≤1.95 ng/mL RR: 1.11; 95% CI: 0.88, 1.41), a marker of systemic low-grade inflammation.

Conclusions

Preconception vitamin D status was associated with male live birth, particularly among women with low-grade inflammation. These data suggest that maternal vitamin D sufficiency may mitigate maternal inflammation that would otherwise be detrimental to male fetal survival.

Funding Sources

Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD.

Food Intake and Blood Levels of Mercury, Lead, and Cadmium Among Healthy Reproductive Aged Women (P18-024-19)

Objectives

Exposure to toxic metals mostly occurs via contaminated food intake. Though toxic metals adversely affect reproductive health, common food sources among reproductive aged women are less understood. We addressed this gap among healthy premenopausal women, residing in western New York, 2005–2007.

Methods

Women enrolled in the BioCycle Study (n = 249, mean age 27.4 years and body mass index [BMI] 24.1 kg/m2) completed a baseline food frequency questionnaire and provided blood samples to measure levels of mercury (Hg), lead (Pb), and cadmium (Cd). We used linear regression to examine associations between food intake and log-transformed toxic metals, adjusted for age, BMI, race, smoking, physical activity, and intakes of total energy, protein, fat, and fiber. Models were adjusted for false discovery rate.

Results

Total fish intake ≥ 1 serving per day was associated with 54.7% (95% confidence interval [CI] 36.1, 75.9) higher Hg levels, compared to <1 serving. Specific fish intakes (i.e., canned tuna, fried fish, shellfish, white fish, and dark fish) were also associated with higher Hg levels. Though total meat intakes were not associated with Hg, intakes of lunch meat (28.1%), beef, pork, and lamb (21.0%), and chicken and turkey (43.5%) were associated with higher Hg levels, compared to no intake. Intakes of specific vegetables, including red pepper (17.4%), green beans (20.1%), summer (24.7%) and winter squash (19.3%), and garlic (18.5%) were associated with higher Hg. Total fruit intake ≥ 1 serving per day was also positively associated with Hg (18.7%, 95% CI 4.8, 34.5), compared to <1 serving, particularly with bananas (21.6%, >0 versus no intake). Compared to no intake, green pepper (11.8%) and cauliflower (9.9%) were positively associated with Pb, whereas apples were inversely associated with Pb (−14.6%). No associations were found between food intakes and Cd in our data.

Conclusions

We found that intakes of certain foods are related to a higher blood level of toxic metals among reproductive aged women with metals level typical of the US population. Given the nutritional values of these food items, further research on food preparations (e.g., washing, packing) to reduce toxic metals exposure is needed.

Funding Sources

Intramural Research Program, DIPHR, NICHD.

Vitamin D and Premenstrual Syndrome in Healthy Women with Regular Cycles (P18-056-19)

Objectives

Vitamin D levels have been associated with premenstrual syndrome (PMS) and symptom severity, but data are mixed. Our aim was to assess the relationship between serum vitamin D and PMS in women with regular menstrual cycles.

Methods

We looked at vitamin D and PMS using two cohorts of healthy women with regular cycles. BioCycle followed 76 women, for up to 2 menstrual cycles prospectively and EAGeR followed 1191 women with 1–2 prior pregnancy losses. 25(OH)D was measured in serum at baseline in both cohorts, with PMS assessed via questionnaire evaluating the presence and severity of 14 psychological and physical menstrual symptoms the week before and after menses. EAGeR assessed symptoms over the past year, and BioCycle assessed symptoms prospectively over the next cycle. We used status and PMS associations adjusting for age, BMI, race, smoking, income, physical activity, and season of blood draw.

Results

54% and 47% of women had sufficient 25(OH)D (≥30 ng/mL) and 33% and 40% exhibited PMS in BioCycle and EAGeR, respectively. Vitamin D status was not associated with risk of PMS in either cohort (BioCycle: D insufficiency was associated with risk of breast fullness/tenderness (RR 1.27, 95% CI 1.03, 1.55) and generalized aches and pains (RR 1.33, 95% CI 1.01, 1.78), compared to women with vitamin D sufficiency. Similar associations were observed in BioCycle though confidence intervals were wide. No associations were observed between vitamin D status and psychological symptoms.

Conclusions

Among women with regular menses, 25(OH)D was not associated with PMS, though it may be associated with individual symptoms. Additional studies are needed to understand these relationships in women with irregular menstrual.

Funding Sources

Intramural Research Program, Division of Population Health Research, NICHD. NIH Medical Research Scholars Program. Doris Duke Charitable Foundation.

Caffeinated Beverage Intake and Serum Caffeine Metabolites and Risk of Pregnancy Loss (OR17-04-19)

Objectives

The association between caffeine and pregnancy loss remains controversial due to limitations of prior studies such as relying on self-reported intake only, exposure measurement after clinical confirmation of pregnancy, and potential time-varying confounding by nausea/vomiting and lifestyle factors, which may be affected by prior caffeine exposure. Thus, our aim was to evaluate associations of preconception and early pregnancy serum caffeine, paraxanthine, and theobromine, self-reported intake of caffeinated beverages, and risk of pregnancy loss among 1228 reproductive-age women attempting pregnancy in the EAGeR trial during 2007–2011.

Methods

We estimated HRs and 95% CIs for any pregnancy loss, hCG loss (prior to ultrasound confirmation), and clinical loss (after ultrasound confirmation) according to caffeinated beverage intake and caffeine biomarkers measured at preconception and the 8th week of gestation using weighted adjusted Cox proportional hazards models.

Results

At preconception, 67%, 28%, and 9% of women reported any intake of caffeinated sodas, coffee, and tea, respectively. Preconception total caffeinated beverage intake of ≥3 vs. 0 cups/day was associated with 85% (95% CI: 1.18, 2.94) higher risk of any pregnancy loss, driven primarily by associations for hCG loss (HR: 2.88 (95% CI: 1.20, 6.91)). Caffeinated soda intake was associated with hCG loss (≥2 vs. <2 cups/day HR: 2.11 (95% CI: 1.14, 3.89)), whereas caffeinated coffee intake was associated with clinical loss (≥2 vs. <2 cups/day HR: 1.27 (95% CI: 1.02, 2.90)). Likewise, any detectable level of serum caffeine (>0.2 vs. ≤0.2 ng/mL) at preconception was strongly associated with hCG loss (HR: 4.51 (95% CI: 1.36, 14.91)). Serum caffeine, paraxanthine, and theobromine measured at the 8th week of gestation were not associated with risk of loss.

Conclusions

Collectively, these data suggest that caffeine intake prior to pregnancy may increase risk of pregnancy loss, particularly in early gestation.

Funding Sources

Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD.

Child Health: Is It Really Assisted Reproductive Technology that We Need to Be Concerned About?

Concerns remain about the health of children conceived by infertility treatment. Studies to date have predominantly not identified substantial long-term health effects after accounting for plurality, which is reassuring given the increasing numbers of children conceived by infertility treatment worldwide. However, as technological advances in treatment arise, ongoing studies remain critical for monitoring health effects. To study whether the techniques used in infertility treatment cause health differences, however, remains challenging due to identification of an appropriate comparison group, heterogeneous treatment, and confounding by the underlying causes of infertility. In fact, the factors that are associated with underlying infertility, including parental obesity and other specific male and female factors, may be important independent factors to consider. This review will summarize key methodological considerations in studying children conceived by infertility treatment including the evidence of associations between underlying infertility factors and child health.

Menstrual Cycle Characteristics in Adolescence and Early Adulthood Are Associated With Risk of Early Natural Menopause

CONTEXT

Early natural menopause (i.e., before age 45 years) is associated with increased risk of adverse outcomes. Associations of earlier menopause with younger age at menarche and short and/or regular cycle length are suggested, but study findings are inconsistent and few address early menopause risk.

OBJECTIVE

To evaluate the relationship between menstrual cycle characteristics in early life with incident early natural menopause.

DESIGN

The prospective Nurses' Health Study 2 (1989 to 2011).

SETTING AND PARTICIPANTS

Women ages 25 to 42 years and premenopausal in 1989 (N = 108,811).

MAIN OUTCOME MEASURE(S)

Risk of early natural menopause not due to surgery, radiation, or chemotherapy (n = 2794) was evaluated with Cox proportional hazards models. Anti-Müllerian hormone (AMH) levels were considered in a nested case-control sample (n = 820).

RESULTS

In adjusted models, risk was associated with earlier age at menarche (P for trend = 0.05), shorter (P for trend < 0.0001), and more-regular cycles (P for < 0.0001). The hazard ratio (HR) for women with age at menarche ≤9 (vs. 12) years was 1.28 (95% CI, 0.99 to 1.67). Women reporting usual menstrual cycle lengths <25 days at ages 18 to 22 years had substantially higher risk of early menopause (HR, 1.70; 95% CI, 1.47 to 1.96) than women with 26- to 31-day cycles, whereas women with ≥40 day cycles had lower risk (HR, 0.44; 95% CI, 0.34 to 0.58). Women with irregular cycle length had lower risk compared with women with regular cycles (HR, 0.51; 95% CI, 0.43 to 0.60). Associations with AMH concentrations among the nested case-control subset were consistent with these findings.

CONCLUSION

Results from this large prospective study of early menopause suggest an influence of accelerated oocyte depletion on risk and may help clarify the etiology of early menopause.

Dietary Protein Intake and Early Menopause in the Nurses' Health Study II

Early menopause, which is the cessation of ovarian function before age 45 years, affects 5%-10% of Western women and is associated with an increased risk of adverse health outcomes. Literature suggests that high levels of vegetable protein intake may prolong female reproductive function. We evaluated the association of long-term intake of vegetable protein, animal protein, and specific protein-rich foods with incidence of early natural menopause in the Nurses' Health Study II cohort. Women included in analyses (n = 85,682) were premenopausal at baseline (1991) and followed until 2011 for onset of natural menopause. Protein intake was assessed via food frequency questionnaire. In Cox proportional hazard models that were adjusted for age, smoking, body mass index, and other factors, women in the highest quintile of cumulatively averaged vegetable protein intake (median, 6.5% of calories) had a significant 16% lower risk of early menopause compared with women in the lowest quintile (3.9% of calories; 95% confidence interval: 0.73, 0.98; P for trend = 0.02). Intake of specific foods, including pasta, dark bread, and cold cereal, was also associated with lower risk (P < 0.05). Conversely, animal protein intake was unrelated to risk. High consumption of vegetable protein, equivalent to 3-4 servings per day of protein-rich foods, is associated with lower incidence of early menopause in US women.