Human Reproduction Update Advance Access originally published online on February 11, 2005
Human Reproduction Update 2005 11(2):180-204; doi:10.1093/humupd/dmh059
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Female and male lifestyle habits and IVF: what is known and unknown
Department of Family and Preventive Medicine, University of California, San Diego, 9500 Gilman Drive, Dept. 0607, La Jolla, CA 92093–0607, USA
Email:hklonoffcohen{at}ucsd.edu
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Abstract |
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 TOP Abstract IntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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There is no greater tribute to the importance and efficacy of IVF than the fact that >1x106 babies have been born to infertile couples since its clinical introduction in 1978. Despite enormous advances regarding the technical aspects of the IVF procedure, the parents’ contribution has virtually been ignored when considering aspects that influence success rates. This systematic review focuses on the effects of female and male lifestyle habits (specifically: smoking, alcohol and caffeine use, and psychological stress) on the reproductive endpoints of IVF (i.e. oocyte aspiration, fertilization, embryo transfer, achievement of a pregnancy, live birth delivery, and perinatal outcomes, e.g. low birthweight, multiple gestations). What is currently known in the field of lifestyle habits and IVF? There is compelling evidence that smoking has a negative influence on IVF outcomes, whereas for stress, the evidence is suggestive but insufficient due to the heterogeneity of studies. The evidence for the effects of alcohol and caffeine on IVF is inadequate, and therefore unknown, due to the scarcity of studies.
Key words: alcohol / caffeine / IVF / smoking / stress
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Introduction |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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A woman is born with all the oocytes she will ever have, with estimates varying from 400 000 to 2 x 106 (Edwards and Brody, 1995
). Of these, only 
400 will be subject to ovulation during an average female's reproductive life. Contrary to this, with 1% of the supply of sperm created within a man each day, the entire stock of some billions of sperm can be replaced in <4 months (Edwards and Brody, 1995). When conditions are optimal, the maximum chance of a clinically recognized pregnancy occurring in a menstrual cycle is 30–40% (Macklon et al., 2002).
There are 5.0 to 6.3 x 106 women in the USA who are infertile, and by 2025, this will increase to 5.4 to 7.76 x 106 (Grainger and Tjaden, 2000). Among these, there is a subgroup of infertile couples who have exhausted all forms of conventional therapy for infertility and require assisted reproductive techniques such as IVF. Assisted reproductive treatment has been life-transforming for couples with longstanding female factor or male factor infertility. As assisted reproduction's perceived safety and success rates grow, so does its demand (Schultz and Williams, 2002).
IVF is used in the treatment of various forms of infertility including endometriosis, ovulatory dysfunction, pelvic adhesions, cervical factor, tubal disease, luteal defects, immunological causes, male factor, and unexplained infertility. It involves the collection of ripe oocytes from the woman's body in order to achieve fertilization outside of the body, followed by transfer into the woman's womb. A couple's chance of success with IVF is linked to the IVF clinic, causes of infertility, and a woman's age.
The universal experience of IVF success rates indicates that the live birth delivery rate/retrieval in North America is 30% (National Center, 2003). In the USA, assisted reproductive techniques accounted for 1 out of every 150 children born in 1999 (National Center, 2001; Schultz and Williams, 2002) and since 1978, 1 x 106 children have been born as a result of assisted reproductive treatment (Schultz and Williams, 2002).
Although major advances have occurred in the field of assisted reproductive techniques during the past 25 years, researchers and clinicians are still grappling to identify additional factors other than female age, number of embryos transferred, quality of sperm, and response to hormonal stimulation (Craft and Brinsden, 1989), which negatively and positively affect success rates of IVF/gamete intra-Fallopian transfer (GIFT) (particularly healthy live birth deliveries).
The American Society for Reproductive Medicine currently has guidelines to limit the number of embryos implanted. However, there are no recommendations from reproductive endocrinologists regarding the modification of lifestyle habits, which could possibly affect assisted reproductive treatment success rates.
This paper is a systematic review of the short- and long-term effects of male and female smoking, alcohol and caffeine use, and psychological stress on the endpoints of IVF [i.e. oocyte aspiration, fertilization, embryo transfer, spontaneous abortion, achievement of a pregnancy, live birth delivery, and perinatal outcomes (e.g. decreased infant gestational age, low birthweight, increased multiple gestations)].
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Materials and methods |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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An intensive computerized search of the published literature was conducted on a total of eight databases (inclusive dates), specifically, PubMED (MEDLINE) (1953 to October 2004), Biosis previews (1969 to October 2004), Web of Science (1975 to October 2004), PsycINFO (1840 to October 2004), LexisNexis Academic (1981 to October 2004), Expanded Academic ASAP (1980 to October 2004), Sociological abstracts (1963 to October 2004), and Ovid Medline (1966 to October 2004). Retrieved articles were reviewed for content and their references were used to identify other relevant articles.
All languages were reviewed in the abstracts for the following key words: smoking, stress, caffeine, alcohol, in vitro fertilization, IVF, assisted reproductive technologies, and ART. The endpoints consisted of oocyte aspiration, fertilization, embryo transfer, achievement of a pregnancy, live birth delivery, and perinatal outcomes (e.g. birthweight, gestational age, multiple gestations).
Criteria for inclusion consisted of human studies, retrospective and case–control studies, and prospective studies, with detailed methods and statistical analysis sections. General exclusion criteria consisted of case reports, meeting abstracts, expert opinions, newspaper articles, magazines, and comments, all of which had insufficient information or no details on the lifestyle habit and/or IVF endpoints, which prohibited careful estimation of the accuracy and reproducibility of the study. Articles written in German, Chinese and Czech were excluded.
Intervention studies were considered premature and beyond the scope of this review. The objective was to determine whether a lifestyle habit had an impact on the biological/reproductive endpoints of IVF (i.e. success rates), not to determine the effectiveness of counselling, social support groups or cognitive behaviour treatments on IVF.
Among the studies identified, those not involving IVF (e.g. general infertility, animal studies, GIFT, and ICSI) were discarded. Frozen embryos and oocyte donation studies were omitted because of the inability to determine the effect of lifestyle habits on IVF outcomes.
In order to generate the strategy for assessing manuscripts, a PubMed search was conducted on ‘criteria for reviewing literature’ and ‘criteria for reviewing literature in reproductive medicine’, as well as an examination of all ‘review’ papers from Human Reproduction Update dating from 2000 to October 2004. All of the studies evaluated and approved for this manuscript were based on specific criteria adapted from Sackett et al. (1991), Peipert and Bracken (1997), Pelinck et al. (2002) and Tarlatzis et al. (2003).
The criteria consisted of: (i) an appropriate study design, (ii) description of the selection and characteristics of subjects and comparison group with a sample size of >25, (iii) the existence of standardized IVF outcome measures, (iv) the use of standardized instruments and/or laboratory samples to verify lifestyle habits, and (v) the existence of multivariate analysis. For each lifestyle habit, all studies were compared and contrasted using these five criteria.
Two other independent reviewers selected and reviewed the publications to be included in accordance with the above-mentioned criteria. If there was discordance, a discussion resolved the issue, leading to a uniform decision.
It was speculated that differences in study results could arise from seven sources: different hypotheses, different types (and sources) of patients, different methods (e.g. study design, different rigor and sample size), different ways of verifying exposures (e.g. lifestyle histories), different reproductive outcomes, different statistical methods, and different conclusions (supported by the data).
The hypothesis, study sample, study design, characteristics of the lifestyle habit, measurement for each lifestyle (e.g. instrument, laboratory samples), IVF outcomes, results, and conclusions are presented in Tables I–IV. The final association between a lifestyle habit and IVF was based on the Institute of Medicine criteria (i.e. evidence sufficient, evidence suggestive but insufficient, evidence inadequate, and evidence suggestive of no association) (Field and Lohr, 1990).
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Smoking and IVF |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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Female and male smoking and natural reproduction
Tobacco smoke contains several hundred substances including nicotine, carbon monoxide and mutagens (e.g. radioactive polonine, benzo[a]pyrene, naphthalene and methylnaphthalene) (Stillman et al., 1986).
There is strong evidence that smoking negatively impacts virtually all facets of fertility (Bolumar et al., 1996; Buck et al., 1997; Feichtinger et al., 1997; Augood et al., 1998), including follicle development/ovulation, oocyte retrieval from the ovary and its transport down the Fallopian tubes, and fertilization and early embryo development. Studies have illustrated that when a pregnant woman smokes, the future fertility of the fetus (male or female) is also put in jeopardy (Sharpe and Franks, 2002).
There is also evidence that smoking induces DNA damage in sperm (Rubes et al., 1998; Zenzes et al., 1999). According to Sharpe and Franks (2002), ‘men's smoking can be associated with minor reductions in sperm count/morphology, but this is inconsistent and not usually associated with altered fertility’ (Hughes and Brennan, 1996; Vine, 1996), although effects have been reported with IVF outcome (Joesbury et al., 1998). Currently, it is generally accepted that smoking cessation should be an integral part of infertility treatment (Sharpe and Franks, 2002).
Female and male smoking and IVF
A total of 82 abstracts were retrieved from the eight databases, and 59 abstracts were excluded based on eligibility criteria (e.g. meeting abstracts, comments, review articles, newspapers, magazines, animal studies, GIFT, ICSI, infertility, interovarian differences, hyperandrogenism, and delayed conception as endpoints, semen quality as an endpoint, did not address primary question). This resulted in 23 articles being reviewed, with a further one article being excluded because it was in German. A total of 22 articles were included for the final review.
Appropriate study design
Six retrospective studies (Pattinson et al., 1991; Maximovich and Beyler, 1995; Van Voorhis et al., 1996; El-Nemr et al., 1998; Joesbury et al., 1998; Weigert et al., 1999), 10 prospective studies (Trapp et al., 1986; Harrison et al., 1990; Elenbogen et al., 1991; Hughes et al., 1992; Rosevear et al., 1992, Hughes et al., 1994; Sterzik et al., 1996; Crha et al., 2001; Klonoff-Cohen et al., 2001a), two meta-analyses (Feichtinger et al., 1997; Augood et al., 1998) and one systematic review (Hughes and Brennan, 1996) have investigated the effect of smoking on the biological and reproductive endpoints of IVF and GIFT (Table I).
Sample size and method of selection and description of subjects and comparison group
The size of the study sample (not including meta-analyses) varied from 41 patients (Elenbogen et al., 1991) to 650 patients (Harrison et al., 1990). The source of patients was derived entirely from infertility clinics, and all studies had groups of smokers and non-smokers. One race was represented in every study, except one, which contained Whites, Asians, African-Americans, and Hispanics (Klonoff-Cohen et al., 2001b).
Existence of standardized IVF outcomes
Maternal smoking resulted in decreased fertilization rates [Elenbogen et al., 1991; Rosevear et al., 1992; Zenzes and Reed, 1997; Weigert et al., 1999 (in clomiphene citrate/hMG-stimulated women); El-Nemr et al., 1998; Crha et al., 2001; Zitzmann et al., 2003], decreased numbers of oocytes (Harrison et al., 1990; El-Nemr et al., 1998; Weigert et al., 1999; Crha et al., 2001; Klonoff-Cohen et al., 2001; Zitzmann et al., 2003), decreased embryos (Van Voorhis et al., 1996), decreased embryo transfer rates (Klonoff-Cohen et al., 2001), decreased pregnancy rates (Harrison et al., 1990; Pattinson et al., 1991; Feichtinger et al., 1997; Augood et al., 1998; Klonoff-Cohen et al., 2001), increased miscarriage rates (Harrison et al., 1990; Pattinson et al., 1991; Maximovich and Beyler 1995; Hughes and Brennan 1996), and lower live birth delivery rates (Pattinson et al., 1991; Klonoff-Cohen et al., 2001) (Figure 1 and Table I).
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In contrast, several studies determined that there was no effect of smoking on fertilization rates [Trapp et al., 1986
; Harrison et al., 1990; Pattinson et al., 1991; Hughes et al., 1992, 1994; Sterzik et al., 1996; Zenzes and Reed, 1997 (in the younger group); Weigert et al., 1999], implantation rates (Harrison et al., 1990; Pattinson et al., 1991), and pregnancy rates (Hughes et al., 1992, 1994; Maximovich and Beyler, 1995; Hughes and Brennan, 1996; Sterzik et al., 1996; El-Nemr et al., 1998; Weigert et al., 1999). Only one study considered multiple endpoints of IVF, including live birth delivery and neonatal characteristics (low birth, multiple gestations) (Klonoff-Cohen et al., 2001).
Use of standardized instruments and/or laboratory samples to verify lifestyle habits
Methodological limitations for obtaining smoking history may have contributed to the contradictory findings. Smoking history was ascertained by questionnaire (Trapp et al., 1986; Elenbogen et al., 1991; Hughes, 1994; Weigert et al., 1999; Klonoff-Cohen et al., 2001a), follicular fluid cotinine concentrations (Rosevear et al., 1992; Hughes et al., 1994; Zenzes et al., 1996; Zenzes and Reed, 1997) or both (Crha et al., 2001). The definition of smoking history in these studies was insufficient, failing to differentiate the amount, frequency, type (e.g. cigarettes, cigars, and pipes), and timing of smoking. Some classified smokers as current or former smokers (Augood et al., 1998; Sterzik et al., 1996) or as active, passive and non-smokers (Zenzes et al., 1996; Zenzes and Reed, 1997), whereas others used only two categories, smokers and non-smokers (Elenbogen et al., 1991; Hughes et al., 1992). The number of cigarettes was quantified per day (with number of years not specified) (Pattinson et al., 1991; Hughes et al., 1996; El-Nemr et al., 1998; Klonoff-Cohen et al., 2001a), as well as packs/day (Trapp et al., 1986; Maximovich and Beyler, 1995), and pack-years (Van Voorhis et al., 1996). Zitzmann et al. (2003) quantified smoking as cigarettes/day for 
2 years, while Klonoff-Cohen et al. (2001a) ascertained number of cigarettes or cigars smoked per week during the subject's lifetime, as well as 1 year, 1 week, 1 day prior to and during the IVF procedure (Table I).
Smoking was only classified once at study entry (Harrison et al., 1990; Maximovich and Beyler, 1995; El-Nemr et al., 1998; Joesbury et al., 1998; Zitzmann et al., 2003) or after IVF treatment (Van Voorhis et al., 1996) and not throughout the procedure, when habits could change markedly, resulting in misclassification of smokers and quitters. One additional study administered questionnaires twice (Hughes et al., 1994), while Klonoff-Cohen et al. (2001a) administered questionnaires at three different time-points, specifically, at the initial clinic visit, during embryo transfer for women and sperm collection for the men, and after pregnancy outcome.
Furthermore, the contribution of the male partner's smoking history, although included in four studies (Hughes and Brennan, 1996; Joesbury et al., 1998; Klonoff-Cohen et al., 2001a; Zitzmann et al., 2003), was entirely omitted in the majority of studies (Trapp et al., 1986; Weiss and Eckert, 1989; Harrison et al., 1990; Elenbogen et al., 1991; Rosevear et al., 1992; Sterzik et al., 1996; Weigert et al., 1999; Crha et al., 2001).
Existence of multivariate analyses
Potential confounders such as age, race, education, type of assisted reproduction procedure, parity, type of infertility, and number of IVF attempts, estradiol levels, endometrial thickness, and sperm parameters were not usually adjusted for in any of the studies, apart from four (Hughes et al., 1994; Joesbury et al., 1998; Klonoff-Cohen et al., 2001a; Zitzmann et al., 2003), and only one study (Klonoff-Cohen et al., 2001a) adjusted for other lifestyle habits (e.g. marijuana and recreational drug use, and alcohol consumption) (Table I).
Body of evidence for effect of smoking on IVF
In summary, despite the variations between studies, there was compelling evidence that smoking had a negative influence on IVF outcome (Harrison et al., 1990; Elenbogen et al., 1991; Pattinson et al., 1991; Rosevear et al., 1992; Van Voorhis et al., 1996; Maximovich and Beyler, 1995; Feichtinger et al., 1997; Augood et al., 1998; El-Nemr et al., 1998; Joesbury et al., 1998; Crha et al., 2001; Klonoff-Cohen et al., 2001a; Zitzmann et al., 2003).
Mechanism
It has been noted that the zona pellucida of oocytes and embryos of active and passive smokers were significantly thicker than those of non-smokers, and did not become thinner after 48 h in culture (Shiloh et al., 2004). Smoking may be one of the factors that interfere with fertility (Shiloh et al., 2004).
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Stress and IVF |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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Infertility is often described as the most stressful event in the lives of most couples (Freeman et al., 1985
). The IVF procedure is stressful because of daily hormone injections, blood samples, laparoscopic surgery, and the possibility of pregnancy failure; however, the most traumatic aspects are waiting to see if fertilization was successful, undergoing oocyte retrieval (Demyttenaere et al., 1991) and embryo transfer (Johnston et al., 1987; Siebel and Levine, 1987; Baram et al., 1988; Callan and Hennessey, 1988; Demyttenaere et al., 1991; Connolly et al., 1993), and not achieving a pregnancy after a prolonged treatment (Baram et al., 1988; Connolly et al., 1993). A total of 344 abstracts was retrieved from the eight databases, and 302 abstracts were excluded based on eligibility criteria (e.g. meeting abstracts, book chapters, dissertation abstracts, review articles, animal studies, GIFT and infertility as endpoints, oxidative, sperm, and heat stress, psychoendocrinology, interventions and intervention counselling, support groups, ethical issues, and did not address primary question). This resulted in 48 articles being reviewed, with a further three articles being excluded because they were written in German, Chinese and Czech, and two articles being excluded because the sample sizes were <25. A total of 43 articles was included for the final review.
Appropriate study design
There was a total of four retrospective studies (Mahlstedt et al., 1987; Leiblum et al., 1987; Beutel et al., 1999; Csemiczky et al., 2000; Hammarberg et al., 2001), 24 prospective studies (Johnston et al., 1987; Harrison et al., 1987; Reading et al., 1989; Newton et al., 1990; Demyttenaere et al., 1991, 1992, 1994, 1998; Merari et al., 1992; Boivin and Takefman, 1995; Harlow et al., 1996; Facchinetti et al., 1997; Stoleru et al., 1997; Boivin et al., 1998; Milad et al., 1998; Yong et al., 2000; Gallinelli et al., 2001; Klonoff-Cohen et al., 2001b; Smeenk et al., 2001; Verhaak et al., 2001; Hsu and Kuo, 2002; Hjelmstedt et al., 2003; Lovely et al., 2003), and 15 cross-sectional studies (Freeman et al., 1985; Callan et al., 1988; Callan and Hennessey, 1988; Chan et al., 1989; Collins et al., 1992; Baluch et al., 1993; Van Balen et al., 1996; Bringhenti et al., 1997; Mori et al., 1997; Sanders and Bruce, 1999; Kee et al., 2000; Tarabusi et al., 2000; Lee et al., 2001; Merari et al., 2002; Phromyothi and Virutamasen, 2003) on stress and IVF (Table II).
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Sample size and method of selection and description of subjects and comparison group
The sample size ranged from a total of 37 patients (Reading et al., 1989; Yong et al., 2000) to 500 subjects (Harrison et al., 1987). All studies recruited women attending IVF clinics at university-affiliated or private clinics. A total of seven studies used fertile women as the comparison group (Baluch et al., 1993; Harlow et al., 1996; Van Balen et al., 1996; Bringhenti et al., 1997; Csemiczky et al., 2000; Kee et al., 2000; Hjelmstedt et al., 2003), while the remainder had no control group (Table II).
Existence of standardized IVF outcomes
The majority of studies on stress and IVF explored one or two IVF outcomes, and the majority concentrated on achieving a pregnancy (Demyttenaere et al., 1992, 1994, 1998; Merari et al., 1992, 2002;, Boivin and Takefman, 1995; Harlow et al., 1996; Facchinetti et al., 1997; Boivin et al., 1998; Milad et al., 1998; Sanders et al., 1999; Csemiczky et al., 2000; Kee et al., 2000; Tarabusi et al., 2000; Yong et al., 2000; Smeenk et al., 2001; Verhaak et al., 2001; Hjelmstedt et al., 2003; Lovely et al., 2003). The remaining studies investigated the effects of stress on the number of oocytes aspirated (Demyttenaere et al., 1991; Merari et al., 1992; Boivin et al., 1998), fertilization (Harrison et al., 1987; Johnston et al., 1987; Smeenk et al., 2001; Stoleru et al., 1997; Boivin et al., 1998), embryo transfer (Johnston et al., 1987; Demyttenaere et al., 1991; Merari et al., 1992; Boivin and Takefman, 1995; Boivin et al., 1998; Yong et al., 2000), implantation rates (Gallinelli et al., 2001), spontaneous abortion rates (Demyttenaere et al., 1991), and number of positive pregnancy outcomes (Milad et al., 1998). One other study (Klonoff-Cohen et al., 2001b) examined the effect of stress on six IVF outcomes, including the number of oocytes aspirated, fertilization, embryo transfer, achievement of a pregnancy, spontaneous abortion, and live birth delivery, as well as neonatal characteristics (e.g. low birthweight, gestational age, and multiple gestations) (Table II).
A total of 19 studies indicated no specific IVF endpoints, other than treatment-related (Leiblum et al., 1987; Chan et al., 1989; Baluch et al., 1993; Bringhenti et al., 1997; Mori et al., 1997; Beutel et al., 1999; Lee et al., 2001), IVF treatment outcomes (Reading et al., 1989; Van Balen et al., 1996; Phromyothi and Virutamasen, 2003), continued or stopped IVF (Callan et al., 1988), number of attempts (Callan and Hennessey, 1988), pre- and post-IVF (Newton et al., 1990), and nothing stated in the articles (Freeman et al., 1985; Mahlstedt et al., 1987; Collins et al., 1992; Kee et al., 2000; Hammarberg et al., 2001; Hsu and Kuo, 2002) (Table II).
Use of standardized instruments and/or laboratory samples to verify lifestyle habits
The most common stress instrument utilized in the literature on stress and IVF was Spielberger State-Trait Anxiety Inventory (STAI). To date, 15 international studies and four studies in the USA have utilized the STAI to examine the effects of anxiety on oocyte retrieval and embryo transfer (Johnston et al., 1987; Demyttenaere et al., 1991; Merari et al., 1992; Boivin and Takefman, 1995; Merari et al., 2002), achievement of implantation (Gallinelli et al., 2001), fertilization (Johnston et al., 1987; Stoleru et al., 1997; Smeenk et al., 2001), pregnancy (Chan et al., 1989; Demyttenaere et al., 1992, 1994; Merari et al., 1992, 2002; Boivin and Takefman, 1995; Harlow et al., 1996; Facchinetti et al., 1997; Milad et al., 1998; Sanders and Bruce, 1999; Csemiczky et al., 2000; Kee et al., 2000; Smeenk et al., 2001; Verhaak et al., 2001; Hjelmstedt et al., 2003; Lovely et al., 2003), spontaneous abortions (Demyttenaere et al., 1992), and adverse outcomes (Milad et al., 1998) with IVF (Figure 1 and Table II).
Contradictory results were reported among studies examining state anxiety and IVF. Anxiety apparently increased during both oocyte retrieval and embryo transfer (Demyttenaere et al., 1991) in one study, yet decreased during embryo transfer day and rose again on pregnancy test day in another study (Merari et al., 1992). Women undergoing IVF had significantly higher state anxiety than those not undergoing treatment (Harlow et al., 1996), whereas another study found that anxiety did not influence the chance of pregnancy (Harlow et al., 1996; Milad et al., 1998) or miscarriage rates (up to <20 weeks) (Milad et al., 1998).
The other 27 studies investigated depression [11 international (Chan et al., 1989; Demyttenaere et al., 1991, 1992, 1994, 1998; Beutel et al., 1995; Bringhenti et al., 1997; Kee et al., 2000; Smeenk et al., 2001; Verhaak et al., 2001; Hsu and Kuo, 2002), four in the USA (Leiblum et al., 1987; Reading et al., 1989; Merari et al., 1992, 2002)], marital status [six international (Newton et al., 1990; Boivin and Takefman, 1995; Bringhenti et al., 1997; Hammarberg et al., 2001; Verhaak et al., 2001; Hjelmstedt et al., 2003), one in the USA (Leiblum et al., 1987)], coping styles [nine international (Callan et al., 1988; Callan and Hennessey, 1988; Demyttenaere et al., 1991, 1992, 1994, 1998; Stoleru et al., 1997; Lee et al., 2001; Hsu and Kuo, 2002), three in the USA (Freeman et al., 1985; Reading et al., 1989; Klonoff-Cohen et al., 2001] (Table II).
Eight studies measured stress hormones in conjunction with psychological scales (Demyttenaere et al., 1991, 1992, 1994; Harlow et al., 1996; Merari et al., 1992; Milad et al., 1998; Csemiczky et al., 2000; Lovely et al., 2003), whereas one study did not employ any psychological scales (Harrison et al., 1987). A total of two studies (Klonoff-Cohen et al., 2001b; Lee et al., 2001) used the Perceived Stress Scale; however, only one study administered it before and after hormone use (Klonoff-Cohen et al., 2001b). Furthermore, five studies employed the Bipolar Profile of Mood Status (POMS) (Leiblum et al., 1987; Reading et al., 1989; Sanders et al., 1999; Klonoff-Cohen et al., 2001b; Hsu and Kuo, 2002), and three utilized the Infertility Reaction Scale (Collins et al., 1992; Klonoff-Cohen et al., 2001b; Hjelmstedt et al., 2003). Finally, the Network Resource Scale, the Positive Negative Affect Scale (PANAS), and Expected Likelihood of Achieving a Pregnancy Scale were used in only one study in conjunction with five other scales (Klonoff-Cohen et al., 2001b) (Table II).
Existence of multivariate analyses
A total of 13 studies employed multivariate analyses and adjusted for potential confounders (Callan et al., 1988; Newton et al., 1990; Collins et al., 1992; Boivin and Takefman, 1995; Facchinetti et al., 1997; Bringhenti et al., 1997; Stoleru et al., 1997; Boivin et al., 1998; Sanders et al., 1999; Klonoff-Cohen et al., 2001b; Hsu and Kuo, 2002; Merari et al., 2002; Hjelmstedt et al., 2003) (Table II). Only two studies adjusted for other lifestyle habits, specifically smoking, alcohol, and caffeine (Sanders et al., 1999; Klonoff-Cohen et al., 2001b), and the latter study also adjusted for recreational drugs.
Limitations of studies investigating stress and IVF
Potential limitations of studies evaluating the effect of stress on IVF include: (i) not taking more than one psychological or psychosocial measure into account (Harrison et al., 1987; Mahlstedt et al., 1987; Baluch et al., 1993; Yong et al., 2000), (ii) not examining IVF endpoints beyond pregnancy, specifically live birth deliveries and neonatal outcomes (Freeman et al., 1985; Harrison et al., 1987; Johnston et al., 1987; Leiblum et al., 1987; Mahlstedt et al., 1987; Callan et al., 1988; Callan and Hennessey, 1988; Chan et al., 1989; Reading et al., 1989; Newton et al., 1990; Demyttenaere et al., 1991, 1992, 1994; Collins et al., 1992; Baluch et al., 1993; Boivin and Takefman, 1995; Harlow et al., 1996; Van Balen et al., 1996; Bringhenti et al., 1997; Facchinetti et al., 1997; Mori et al., 1997; Stoleru et al., 1997; Boivin et al., 1998; Milad et al., 1998; Beutel et al., 1999; Sanders et al., 1999; Csemiczky et al., 2000; Kee et al., 2000; Tarabusi et al., 2000; Yong et al., 2000; Gallinelli et al., 2001; Hammarberg et al., 2001; Lee et al., 2001; Smeenk et al., 2001; Verhaak et al., 2001; Hsu and Kuo, 2002; Merari et al., 2002; Hjelmstedt et al., 2003; Lovely et al., 2003; Phromyothi and Virutamasen, 2003), apart from one study (Klonoff-Cohen et al., 2001b), (iii) not differentiating procedural stress versus lifetime stress in results, apart from seven studies (Johnston et al., 1987; Newton et al., 1990; Harlow et al., 1996; Stoleru et al., 1997; Yong et al., 2000; Klonoff-Cohen et al., 2001b; Verhaak et al., 2001), (iv) having small sample sizes (n=40) (Demyttenaere et al., 1991, 1992; Boivin and Takefman, 1995; Gallinelli et al., 2001), high drop-out rates, and retrospective or cross-sectional designs that measure stress at one time-point (Freeman et al., 1985; Callan et al., 1988; Callan and Hennessey, 1988; Chan et al., 1989; Collins et al., 1992; Baluch et al., 1993; Van Balen et al., 1996; Bringhenti et al., 1997; Mori et al., 1997; Sanders et al., 1999; Kee et al., 2000; Tarabusi et al., 2000; Lee et al., 2001; Merari et al., 2002; Phromyothi and Virutamasen, 2003), (v) recruiting only one race, except for one study (Klonoff-Cohen et al., 2001b), and (vi) not considering the independent effect of male stress on IVF outcomes aside from three studies (Harrison et al., 1987, Tarabusi et al., 2000; Klonoff-Cohen et al., 2001b).
Body of evidence for the effect of stress on IVF
The evidence that psychological stress during treatment was associated with negative IVF outcomes is suggestive but insufficient due to the heterogeneity of studies, particularly with reference to stress instruments and IVF endpoints (Harrison et al., 1987; Johnston et al., 1987; Leiblum et al., 1987; Mahlstedt et al., 1987; Callan et al., 1988; Chan et al., 1989; Newton et al., 1990; Demyttenaere et al., 1991, 1992, 1994; Harlow et al., 1996; Van Balen et al., 1996; Boivin et al., 1998; Milad et al., 1998; Kee et al., 2000; Merari et al., 1992, 2002; Yong et al., 2000; Csemiczky et al., 2000; Hammarberg et al., 2001; Lee et al., 2001; Verhaak et al., 2001; Hjelmstedt et al., 2003; Phromyothi and Virutamasen, 2003). In contrast, the emotional impact by IVF was not apparent during IVF treatment (Bringhenti et al., 1997; Lovely et al., 2003).
Mechanism
Psychological stress may diminish success rates, possibly by one of the following mechanisms: hypothalamic dysfunction either by neurotransmitting alterations, catecholamine depletion, or interference with hypothalamic receptors for neurotransmitters. The exact mechanism by which stress interferes with the hypothalamic–pituitary–gonadal axis is not clearly understood (Edelmann, 1990). Progesterone and cortisol, the neuroendocrine measures of stress, may provide potential pathways through which stress could affect IVF outcome (Boivin and Takefman, 1996). Future studies should measure plasma and follicular levels of stress hormones such as prolactin and cortisol to clarify the role of these hormonal mechanisms, and determine the neuroendocrine and physiological pathways that mediate an effect on IVF outcomes (Rubinow and Roca, 1995).
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Alcohol and IVF |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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Female and male alcohol consumption and IVF
Although studies have evaluated the effect of tobacco on IVF, the effects of alcohol consumption have only been indirectly studied as a potential confounder of smoking (Hughes et al., 1992).
A total of 324 abstracts was retrieved from the eight databases, and 323 abstracts were excluded based on eligibility criteria (e.g. meeting abstracts, case reports, comments, no human data, semen/oocyte donors or donations, female fecundity as an endpoint, alcohol in fertile medium, cryopreservation, did not address primary question, did not have any endpoints). This resulted in one article being reviewed.
Only one study has examined female and male alcohol consumption as a primary risk factor for IVF (Klonoff-Cohen et al., 2003). Female alcohol consumption was associated with a decrease in oocyte retrieval (OR 0.87, CI 0.77–0.98, P=0.02), pregnancy (OR 2.86, CI 0.99–8.24, P=0.05), and increased risk of miscarriage (OR 2.2, CI 1.09–4.49, P=0.03) (Figure 1 and Table III).
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Men who drank
1 drink during any time period increased the risk of experiencing spontaneous miscarriages, compared with men who did not drink 1 month before the IVF attempt (OR 2.7, CI 1.00–7.27, P=0.05), or up to 1 week before sperm collection (OR 38.04, CI 3.30–438.56, P=0.01) (Klonoff-Cohen et al., 2003) (Figure 1 and Table III). In addition, for men, one additional can of beer per day decreased the risk of a live birth by 5.49 to 45 times (CI 1.11–27.18, P=0.04), depending on the time of consumption (Klonoff-Cohen et al., 2003) (Figure 1 and Table III). Body of evidence for effect of alcohol on IVF
The findings of this one study require confirmation in future, multiple, prospective studies. The evidence for an association between alcohol and IVF is inadequate and unknown at this time due to the paucity of published articles.
Mechanism
In mice, exposure to alcohol had a similar action on the meiotic spindle apparatus during the estrous cycle before conception, and induced chromosome segregation errors in the ovulated oocyte. The successful fertilization of such oocytes consequently resulted in the production of aneuploid embryos, which had a very high chance of being spontaneously aborted during the first trimester of pregnancy (Kaufman, 1997).
A potential biological effect of alcohol on the male gamete was demonstrated in the mouse model. Chronic biparental beer intake had a noxious effect on implantation in mice, manifested by delayed attachment of blastocysts, absence of the decidual reaction, and resynchronization of the implantation process (Fazakas-Todea, 1995).
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Caffeine and IVF |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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Female and male caffeine consumption and IVF
In assisted reproductive technique studies, caffeine was added in in vitro medium to stimulate hamster sperm motility. The results were inconsistent. The addition of caffeine to medium increased motility of cryopreserved sperm (Barkay et al., 1977; Harrison, 1978; Aitken et al., 1983; Hammitt et al., 1989), reduced percentage of penetrated oocytes (Hammitt et al., 1989), and decreased fertilizing ability and embryonic development (Imoedemhe et al., 1992).
A total of 95 abstracts was retrieved from the databases, and 94 abstracts were excluded based on eligibility criteria (e.g. meeting abstracts, case reports, comments, animal data, caffeine in fertile medium, caffeine added to frozen–thawed, human semen as an endpoint, motility of preserved sperm as an endpoint, in vitro caffeine treatments, did not address primary question, did not have any IVF endpoints). This resulted in one article being included for review.
There is only one study to date that has investigated the effect of caffeine consumption by men and women on success rates of IVF (Klonoff-Cohen et al., 2002). In this study, female caffeine intake had a profound effect on miscarriages [OR ranging from 19.8 (CI 1.3–300.9) to 6.2 (CI 0.9–40.8) depending on the amount and timing of consumption], not achieving a live birth [OR 2.9 (CI 1.1–7.5, P=0.01)–3.9 (CI 1.3–11.6, P=0.01) depending on timing and amount of caffeine], and infant gestational age [OR decreases of 3.5 (CI–6.7–0.3, P=0.10) to 3.8 (CI–6.9 to–0.7, P=0.06) weeks based on timing] (Klonoff-Cohen et al., 2002) (Figure 1 and Table IV). Male caffeine intake did not affect any sperm parameters, IVF endpoints, or neonatal characters (Klonoff-Cohen et al., 2002).
Body of evidence for effect of caffeine on IVF
The findings of this one study require confirmation in several new prospective studies. The evidence for an association between caffeine and IVF is inadequate at present due to the scarcity of studies.
Mechanism
There are several biological pathways by which caffeine could affect female reproduction. It could affect ovulation through alterations in hormone levels. Caffeine consumption is inversely correlated with levels of estradiol in pregnant women (Hatch and Bracken, 1993) and positively correlated with levels of sex hormone-binding globulin (Hatch and Bracken, 1993). Caffeine decreases plasma levels of prolactin in non-pregnant, healthy women (Casas et al., 1989), and may inhibit ovulation or corpus luteum function (Bolumar et al., 1997).
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What is known and unknown |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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Figure 1 shows what is currently known about female and male lifestyle habits and IVF. There is compelling evidence that smoking has a negative influence on IVF outcomes (i.e. oocyte retrieval, fertilization, embryo transfer, pregnancy, live births, and spontaneous abortion), whereas for stress, the evidence is suggestive of negative IVF outcomes (i.e. oocyte retrieval, fertilization, pregnancy, spontaneous abortion, live births, multiple gestation, low birthweight) but insufficient due to the heterogeneity of studies. The body of evidence for the effects of alcohol and caffeine on IVF is inadequate, and therefore unknown, due to the scarcity of studies. A final avenue of exploration will be to determine whether there is an indirect effect of lifestyle habits on infants as they progress to children, teenagers, and adults.
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Future studies |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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There is a need for methodologically sound studies that: (i) investigate the most important IVF outcomes, specifically healthy live birth delivery and neonatal characteristics, (ii) consider lifetime versus procedural timing of the lifestyle habit, (iii) determine the quantity, frequency, and duration of the lifestyle habit, and which standardized instruments or samples are used, (iv) investigate the combination of two or more lifestyle habits, (v) separate the male versus female role, (vi) include a comparison group, (vii) address the lack of standardization of semen analyses and sperm processing methods, (viii) adjust for potential confounders (i.e. type of ovarian stimulation, use of fresh versus frozen–thawed embryos, and other lifestyle habits), (ix) collect multiple samples of cotinine, blood alcohol, cortisol and paraxanthine levels (primary metabolite of caffeine) throughout the procedure, (x) obtain an adequate sample size and good follow-up rates, (xi) employ a longitudinal design to follow patients at the initial clinic visit, throughout the IVF procedure, pregnancy and delivery, and (xii) identify underlying mechanisms attributable to each lifestyle habit and endpoint of IVF.
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Summary |
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TOPAbstractIntroductionMaterials and methodsSmoking and IVFStress and IVFAlcohol and IVFCaffeine and IVFWhat is known and...Future studiesSummaryReferences |
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There are currently 19 237 articles cited in Index Medicus in October 2004 dealing with IVF; however, only a few of them have examined the effect of one specific lifestyle habit on IVF.
The imperative to constantly improve IVF success rates is the engine that drives the field of reproductive endocrinology (Van Blerkom and Gregory, 2004). Understanding the effects of lifestyle habits on IVF may help create guidelines for clinicians, increase success rates, and provide a forceful impetus for both men and women undergoing assisted reproductive techniques to modify or abstain from negative lifestyle habits. By integrating laboratory-related (i.e. technical) aspects of the procedure with patient characteristics (e.g. lifestyle habits, maternal age, aetiology and duration of infertility, and parity), one will obtain a more complete understanding of the importance and inter-relatedness of both factors on IVF.
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Acknowledgements |
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I would like to thank Drs Richard Marrs, Bill Yee, Michael Kettel, Jane Frederick, Eric Surrey, Snunit Ben-Ozer, for their contribution to this research. In addition, I am extremely grateful to Tomomi Lager, Project Manager, for her editorial expertise, as well as her and Joel Wright's assistance with collecting and reviewing the all articles for the tables.
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References |
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