Background
As a steroid hormone, Vitamin D exerts effect by binding with vitamin D receptor, which is a member of the nuclear receptors families [
1,
2]. It was established that many tissues have vitamin D receptor, such as ovarian, endometrium, fallopian tube epithelial cells, placenta, decidual cells, hypothalamus, and pituitary [
3‐
6]. Vitamin D plays critical role in the system of female reproduction, such as oocyte development, production of anti-Mullerian (AMH), ovarian steroidogrnrsis, endometrial receptivity, et al. It was supposed that vitamin D is associated with clinical pregnancy outcome of IVF/ICSI cycles.
So far, there were myriads of studies evaluating the association between vitamin D level and the clinical outcomes after ART. Some studies have indicated that deficient vitamin D was associated with pregnancy rate [
7‐
13]. In contrast, some researchers found no association between vitamin D statuses with outcomes after IVF/ICSI cycles [
14‐
18].
At present, two meta-analysis studies have evaluated the association between vitamin D level and outcomes of IVF/ICSI. One was done by Vanni et al., including three studies with 353 women. The study only compared the one outcome that is
--clinical pregnancy rate, and found that deficient vitamin D was associated with lower probability of clinical pregnancy without statistically significance compared with vitamin D sufficient women [
19]. The other meta-analysis, including five studies with 1238 women, compared both clinical pregnancy rate and live birth rate. The results displayed that deficient vitamin D was uncorrelated with clinical pregnancy rate, but related to decreased probability of live birth [
20]. Although the design of the previous meta-analysis was suitable, the samples size of some studies was small.
So, it is necessary to conduct a systematic review and meta-analysis including more suitable studies to evaluated further whether deficient level vitamin D have effect on clinical pregnancy, ongoing pregnancy, and live birth after IVF/ICSI.
Discussion
So far, only two systematic reviews and meta-analyses have evaluated the association between vitamin D level and the clinical outcomes of IVF/ICSI cycles. To our knowledge, the present study is the largest in regard to sample size with 3693 IVF/ICSI cycles. In the present review, 9 studies, 2 studies and 3 studies were included to evaluate the association between vitamin D and clinical pregnancy, ongoing pregnancy and live birth, respectively. Vitamin D level was statistically associated with live birth (RR 0.74; 95%CI 0.58–0.90) and was not related to clinical pregnancy (RR 0.91; 95% CI 0.77–1.07) and ongoing pregnancy (RR 1.06; 95% CI 0.95–1.19). The three RR value demonstrated that deficient vitamin D was associated with a decreased chance of live birth, while had similar probability in clinical pregnancy and ongoing pregnancy with women with sufficient vitamin D. The conclusion was agreement with the systematic reviews by Valeria et al. and Lv et al. [
19,
20], but we included additional several publications and evaluated not only clinical pregnancy but also ongoing pregnancy and live birth after IVF/ICSI.
As mentioned above, Vitamin D plays an important role in the female reproductive system [
3,
6]. Therefore, a woman’s vitamin D level is supposed to be related to reproductive health and pregnant outcomes. The effect of deficient vitamin D level on reproduction has been investigated since the 1970s. Some studies believed that deficient vitamin D might have detrimental effect on the women infertility and pregnant outcomes of IVF [
7‐
10]. However, other studies found that vitamin D deficiency did not play a critical role in the outcome of ART [
14‐
16]. These discrepancies may be attributed to differences in patients’ mean age, ethnicity, race, BMI, countries, social economic status, the season, exposure categorization, analysis methods, and study design [
22].
Although the discrepancies between studies, the combined results indicated that vitamin D deficiency may bring negative effect on the outcome of ART. The possible mechanism may be as follows:
Firstly, it was reported that vitamin D might have effect on the development of follicle and embryo. Mice, in which the VDR genes have been knocked out, showed damaged folliculogenesis and underdevelopment of uterine in a previous animal experiments [
23]. Vitamin D brought beneficial effect on the ovarian steroidogenesis and stimulated the production of Insulin-like growth factor-binding protein-1 (IGFBP-1) in ovary. Vitamin D promotes the production of estradiol, estrone, and progesterone [
24]. Vitamin D level of reproductive age women was correlated with their serum AMH levels [
25], so vitamin D may involved in the production of AMH in adults.
Secondly, Vitamin D was identified with influence upon endometrial receptivity. It was identified that vitamin D receptor was expressed in the endometrium of mice [
26], whereas vitamin D receptor mutant female mice have an underdeveloped uterus and were infertile [
27]. One study demonstrated the 1,25(OH)
2D
3 administration could up-regulate the expression of HOXA10 mRNA and protein by combining with its receptor in the endometrial stromal cells, and HOXA10 is essential for female fertility and embryo implantation [
28]. This view was further supported by a vitro cell experiments with human endometrial cells lines, indicating that the 1a–hydroxylase enzyme was up-regulated in the endometrial stromal cells of early pregnancy [
29]. In an oocyte donor study, adjusted clinical pregnancy rates and live birth rate were lower in VD-deficient recipients than those of vitamin D sufficient recipients. This study suggested that vitamin D might affect the reproduction through mediating the endometrium, not the follicular or oocytes [
11].
Thirdly, recent researches demonstrated that vitamin D is significant not only for embryo implantation but also for gestation as well. Clinical studies have shown that pregnant women with deficient vitamin D are more likely to be with preeclampsia, gestational diabetes, and cesarean section [
30‐
32]. Varying levels expression of vitamin D and HOXA10 were tested in the endometrium, decidua and placenta throughout pregnancy [
33]. Therefore, it was suggested that vitamin D plays a crucial role in keeping healthy pregnancy [
34]. These may be the possible explanations for higher ongoing pregnancy rate while lower live birth rate.
Additionally, vitamin D affects the implantation and early pregnancy by involving the immune-modulating effect. Some studies showed that vitamin D may inhibit the activity of decidual T-cell and reduce the production of some cytokines such as interleukin 1 (IL-1), IL-6 and TNF-a, which are considered to be essential for embryo implantation and endometrial receptivity [
29,
35]. The vitamin leads to a transition from T helper 1(TH-1) to the more tolerant TH-2. Endometrial cells produce 1a hydroxylase, which activates 25-OH vitamin D and is up-regulated by IL-1β produced by the blastocyst. Lower level of vitamin D has a tendency to increase the percentage of B cells, INF-a producing Th cells and NK cytotoxicity, all of these were factors for RM [
36].
With regard to strength, the present study leads to a more accurate evaluation with the pooled RRs rather than individual study. The pooled results of included studies indicated that deficient vitamin D was associated with decreased chance of live birth after IVF/ICSI cycles. While evaluating the association between vitamin D and clinical pregnancy and ongoing pregnancy, the combined RRs showed a decreased trend in clinical pregnancy [RR 0.91; 95% CI 0.77–1.07] and an increased trend in ongoing pregnancy [RR 1.06; 95% CI 0.94–1.19] but the differences had no significances.
Certainly, the present meta-analysis still has its limitations. A major limitation was the obvious heterogeneity among these included studies’ characteristics, including varied study designs (retrospective/retrospective studies), different ovarian stimulation protocols (GnRH-a long or short protocol/GnRH-ant protocol), different treatment types (IVF / ICSI) and different threshold for deficient vitamin D level (20 ng/ml, 10 ng/ml or 75 nmol/L). In addition, small sample size of some included studies and short of meaningful confounders adjustment were also the limitations of the present study. In spite of these shortcomings, the present systematic review and meta-analysis reviewed and summarized the results of relative publications with valuable summary.