Temporary Increased LDL-C in Offspring with Extreme Elevation of Maternal Preconception Estradiol: A Retrospective Cohort Study

Figures & data

Table 1 Baseline Characteristics of Study Population

	Quartiles Based on Maternal E2				p value	Total (n=3690)
	Q1 (n=923) E2<2420	Q2 (n=922) 2420≤E2<3839	Q3 (n=922) 3839≤E2<5599	Q4 (n=923) E2≥5599
Parental characteristics
Maternal age at delivery, years	32.1(28.7, 34.9)	30.8(28.3, 33.9)	30.6(28.1, 33.7)	30.3(27.7, 33.1)	<0.001	30.8(28.2, 34.0)
Maternal BMI, kg/m^2	23.4(21.3, 26)	22.8(20.8, 25.5)	22.3(20.4, 24.6)	22.1(20.3, 24.3)	<0.001	22.7(20.7, 25.1)
Maternal education level (college or higher), n (%)	275(29.8)	276(29.9)	295(32.0)	275(29.8)	0.440	1121(30.4)
Nulliparity, n (%)	778(84.3)	805(87.3)	810(87.9)	812(88.0)	0.063	3205(86.9)
Paternal age at delivery, years	32.4(29.1, 35.9)	31.7(28.4, 35.2)	31.5(28.6, 34.6)	30.8(28.1, 34.1)	<0.001	31.6(28.6, 34.9)
Paternal BMI, kg/m^2	25.3(22.6, 27.9)	25.6(23.1, 28.1)	25.4(22.7, 28.1)	25.4(22.8, 27.8)	0.453	25.4(22.8, 28.0)
Paternal education level (college or higher), n (%)	305(33.0)	334(36.2)	354(38.4)	316(34.2)	0.172	1309(35.5)
IVF/ICSI Characteristics^†
E2 levels on hCG trigger day, pg/mL	1770(1399, 2094)	3111(2743, 3493)	4329(4300, 4991)	7043(6260, 8231)	<0.001	3839(2416, 5599)
Days of ovarian stimulation, days^†	10(8, 11)	10(9, 11)	10(9, 11)	10(9, 11)	<0.001	10(9, 11)
Gonadotropin dose, IU^†	1850(1350, 2475)	1800(1350, 2400)	1775(1350, 2275)	1575(1313, 2050)	<0.001	1725(1350, 2250)
Cycle type (Frozen), n (%)	249(27.0)	354(38.4)	472(51.2)	573(62.1)	<0.001	1648(44.7)
Number of embryos transfer>1, n (%)	557(60.3)	613(66.5)	571(61.9)	536(58.1)	0.002	2277(61.7)
Stage of embryo transfer (Blastocyst), n (%)	310(33.6)	356(38.6)	469(50.9)	563(61.0)	<0.001	1698(46.0)
ICSI used, n (%)	274(29.8)	281(30.5)	308(33.4)	304(32.9)	0.263	1167(31.7)
PGT used, n (%)	28(3.0)	23(2.5)	29(3.1)	25(2.7)	0.828	105(2.8)
Assisted hatching, n (%)	918(99.5)	916(99.3)	915(99.2)	917(99.3)	0.953	3666(99.3)
Perinatal characteristics
Birthweight, kg	3.5(3.2, 3.8)	3.5(3.2, 3.8)	3.5(3.2, 3.8)	3.5(3.2, 3.8)	0.834	3.5(3.2, 3.8)
Gestational age at birth, weeks	39.1(38.3, 40.0)	39.3(38.6, 40.0)	39.1(38.4, 40.0)	39.3(38.4, 40.0)	0.020	39.1(38.4, 40.0)
Caesarean birth, n (%)	726(78.7)	699(75.8)	681(73.9)	689(74.6)	0.084	2795(75.7)
Sex (male), n (%)	489(53.0)	459(49.8)	515(55.9)	491(53.2)	0.076	1954(53.0)
Children’s characteristics and lifestyle factors
No. of visits	1295	1273	1338	1332	–	5238
Age, years	4.0(3.0, 5.5)	4.0(3.1, 5.5)	4.1(3.0, 5.7)	4.5(3.2, 5.9)	<0.001	4.1(3.1, 5.6)
Intake of food and drink
2≤age<4
Vegetables daily, n (%)	515(80.0)	515(83.2)	537(84.3)	484(83.0)	0.203	2051(82.6)
Fruit daily, n (%)	561(87.1)	548(88.5)	581(91.2)	521(89.4)	0.124	2211(89.0)
Dairy food daily, n (%)	273(42.4)	257(41.5)	278(43.6)	236(40.5)	0.716	1044(42.0)
Marine products once or more weekly, n (%)	399(62.0)	371(59.9)	384(60.3)	338(58.0)	0.565	1492(60.1)
4≤age<10
Energy, kcal/day	1826(1511, 2291)	1797(1462, 2237)	1844(1503, 2292)	1802(1503, 2238)	0.261	1816(1491, 2264)

Notes: Data are presented as median (interquartile range) or n (%). Statistical differences were tested using the Kruskal–Wallis test for continuous variables and the Fisher’s exact test for categorical variables. Statistical significance was set at P <0.05, and the results are highlighted in bold. ^†For the Q2 group, two data points were missing in the days of ovarian stimulation and gonadotropin dose.

Abbreviations: BMI, body mass index; E₂, estradiol; ICSI, intracytoplasmic sperm injection; IVF, in vitro fertilization; PGT, preimplantation genetic testing.

Table 2 Mean Differences (95% CI) for Metabolic Variables of Children Across Quartiles of Maternal E₂ Levels

		Quartiles Based on Maternal E2
		Q1 (1295 Visits) E2<2420	Q2 (1273 Visits) 2420≤E2<3839	p value	Q3 (1338 Visits) 3839≤E2<5599	p value	Q4 (1332 Visits) E2≥5599	p value
BMI, kg/m^2	Crude model	Ref	0.01(−0.25, 0.26)	1.000	0.08(−0.18, 0.33)	0.866	0.08(−0.17, 0.34)	0.830
	Adjusted model	Ref	0.02(−0.22, 0.25)	0.998	0.15(−0.09, 0.39)	0.390	0.10(−0.15, 0.34)	0.750
FBG, mmol/l	Crude model	Ref	−0.01(−0.05, 0.04)	0.978	0(−0.04, 0.05)	0.999	0.03(−0.02, 0.07)	0.339
	Adjusted model	Ref	0(−0.05, 0.04)	0.995	0(−0.04, 0.05)	0.991	0.03(−0.02, 0.07)	0.330
Insulin, pmol/l^†	Crude model	Ref	0.05(−0.03, 0.13)	0.381	0(−0.07, 0.08)	0.999	0.05(−0.03, 0.12)	0.437
	Adjusted model	Ref	0.04(−0.03, 0.11)	0.509	0.01(−0.06, 0.08)	0.993	0.02(−0.05, 0.09)	0.883
HOMA-IR^†	Crude model	Ref	0.05(−0.04, 0.13)	0.465	0(−0.08, 0.09)	0.999	0.05(−0.03, 0.13)	0.387
	Adjusted model	Ref	0.04(−0.04, 0.11)	0.582	0.01(−0.07, 0.08)	0.992	0.03(−0.05, 0.10)	0.815
HOMA-β^†	Crude model	Ref	0.05(−0.01, 0.12)	0.166	0.02(−0.05, 0.09)	0.864	0.02(−0.04, 0.09)	0.781
	Adjusted model	Ref	0.04(−0.02, 0.10)	0.313	0.02(−0.04, 0.09)	0.821	0(−0.07, 0.07)	1.000
TC, mmol/l	Crude model	Ref	−0.02(−0.09, 0.06)	0.962	0.01(−0.07, 0.09)	0.970	0.03(−0.05, 0.11)	0.723
	Adjusted model	ref	0(−0.09, 0.08)	0.999	0.04(−0.04, 0.12)	0.600	0.07(−0.01, 0.16)	0.114
TG, mmol/l	Crude model	Ref	0.01(−0.02, 0.05)	0.790	0.01(−0.02, 0.05)	0.775	0.01(−0.03, 0.04)	0.954
	Adjusted model	Ref	0.01(−0.03, 0.04)	0.907	0.02(−0.02, 0.05)	0.671	0.01(−0.03, 0.05)	0.898
LDL-C, mmol/l	Crude model	Ref	−0.01(−0.08, 0.06)	0.982	0.01(−0.05, 0.08)	0.964	0.03(−0.04, 0.09)	0.769
	Adjusted model	Ref	0(−0.07, 0.07)	0.999	0.04(−0.03, 0.11)	0.487	0.07(0, 0.14)	0.056
HDL-C, mmol/l	Crude model	Ref	−0.01(−0.05, 0.02)	0.839	0(−0.03, 0.03)	1.000	0(−0.03, 0.04)	0.999
	Adjusted model	Ref	0(−0.04, 0.03)	0.984	0(−0.04, 0.03)	0.999	−0.01(−0.04, 0.03)	0.962

Notes: Mean differences were obtained using a linear mixed-effects regression model. ^†Loge-transformed Insulin, HOMA-IR, HOMA-β values were considered continuous variables. Adjusted model: adjusted for maternal age, BMI, paternal age, BMI, cycle type, number of embryos transfer, stage of embryo transfer, offspring gestational age, birth weight, sex and age at visit.

Abbreviations: BMI, body mass index; E₂, estradiol; FBG, fasting blood glucose; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; HOMA-β, homeostatic model assessment of beta cell function; LDL-C, low-density lipoprotein cholesterol; TC, total cholesterol; TG, triacylglycerol.

Table 3 Characteristics of Children Aged 2 to 3 Yrs

	Quartiles Based on Maternal E2				Total (n=2398)
	Q1(n=614) E2<2420	Q2(n=597) 2420≤E2<3839	Q3(n=618) 3839≤E2<5599	Q4(n=569) E2≥5599
Perinatal characteristics
Birthweight, kg	3.47±0.55	3.46±0.52	3.44±0.50	3.45±0.49	3.45±0.52
Gestational age at birth, weeks	38.91±1.56	39.03±1.58	39.02±1.57	39.06±1.53	39.01±1.56
Sex (male), n (%)	335(54.6)	299(50.1)	352(57.0)	303(53.3)	1289(53.8)
Metabolic variables
No. of visits	644	619	637	583	2483
BMI, kg/m^2	15.88±1.46	15.92±1.51	15.91±1.45	15.91±1.47	15.90±1.47
FBG, mmol/l	4.87±0.39	4.89±0.39	4.86±0.39	4.89±0.41	4.87±0.40
Insulin, pmol/l	3.27(2.04, 4.90)	3.40(2.27, 5.03)	3.24(2.18, 4.90)	3.39(2.12, 4.91)	3.32(2.14, 4.93)
HOMA-IR	0.71(0.43, 1.10)	0.74(0.48, 1.12)	0.71(0.46, 1.09)	0.73(0.43, 1.08)	0.72(0.45, 1.09)
HOMA-β	50.81(34.13, 69.21)	50.57(36.48, 74.09)	49.00(34.50, 73.21)	50.54(35.78, 69.18)	50.21(34.97, 71.05)
TC, mmol/l	4.05±0.66	4.02±0.71	4.08±0.71	4.10±0.74	4.06±0.70
TG, mmol/l	0.73±0.33	0.74±0.29	0.73±0.29	0.74±0.28	0.73±0.30
LDL-C, mmol/l	2.42±0.55	2.41±0.59	2.45±0.59	2.49±0.60	2.44±0.58
HDL-C, mmol/l	1.40±0.29	1.39±0.30	1.40±0.30	1.38±0.30	1.39±0.30

Notes: Data are presented as the mean ± SD, median (interquartile range), or n (%).

Abbreviations: BMI, body mass index; E₂, estradiol; FBG, fasting blood glucose; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; HOMA-β, homeostatic model assessment of beta cell function; LDL-C, low-density lipoprotein cholesterol; TC=total cholesterol; TG, triacylglycerol.

Table 4 Mean Differences (95% CI) for Metabolic Variables of Children Aged 2 to 3 Yrs Across Quartiles of Maternal E₂ Levels

		Quartiles Based on Maternal E2
		Q1 (644 Visits) E2<2420	Q2 (619 Visits) 2420≤E2<3839	p value	Q3 (637 Visits) 3839≤E2<5599	p value	Q4 (583 Visits) E2≥5599	p value
BMI, kg/m^2	Crude model	Ref	0.05(−0.25, 0.35)	0.971	0.06(−0.23, 0.36)	0.944	0.07(−0.23, 0.37)	0.937
	Adjusted model	Ref	0.07(−0.21, 0.35)	0.912	0.16(−0.13, 0.44)	0.495	0.15(−0.15, 0.44)	0.569
FBG, mmol/l	Crude model	Ref	0.01(−0.05, 0.06)	0.986	−0.02(−0.07, 0.04)	0.877	0.01(−0.05, 0.07)	0.962
	Adjusted model	Ref	0.01(−0.04, 0.07)	0.909	−0.01(−0.06, 0.05)	0.979	0.03(−0.03, 0.08)	0.676
Insulin, pmol/l^†	Crude model	Ref	0.08(−0.02, 0.17)	0.139	0(−0.09, 0.09)	0.999	0.04(−0.06, 0.13)	0.736
	Adjusted model	Ref	0.07(−0.02, 0.16)	0.188	0.01(−0.08, 0.10)	0.988	0.04(−0.05, 0.14)	0.631
HOMA-IR^†	Crude model	Ref	0.08(−0.02, 0.18)	0.168	−0.01(−0.10, 0.09)	0.999	0.04(−0.06, 0.14)	0.744
	Adjusted model	Ref	0.07(−0.02, 0.17)	0.206	0.01(−0.09, 0.11)	0.994	0.05(−0.05, 0.15)	0.599
HOMA-β^†	Crude model	Ref	0.07(−0.01, 0.15)	0.133	0.03(−0.05, 0.11)	0.796	0.03(−0.05, 0.12)	0.752
	Adjusted model	Ref	0.06(−0.02, 0.14)	0.247	0.04(−0.04, 0.12)	0.650	0.03(−0.06, 0.11)	0.825
TC, mmol/l	Crude model	Ref	−0.04(−0.14, 0.06)	0.753	0.01(−0.08, 0.11)	0.985	0.05(−0.05, 0.15)	0.561
	Adjusted model	Ref	−0.03(−0.13, 0.07)	0.887	0.04(−0.06, 0.14)	0.768	0.09(−0.02, 0.19)	0.135
TG, mmol/l	Crude model	Ref	0.01(−0.04, 0.05)	0.974	0.01(−0.04, 0.05)	0.988	0.01(−0.03, 0.06)	0.857
	Adjusted model	Ref	0(−0.04, 0.05)	0.999	0.01(−0.04, 0.05)	0.975	0.02(−0.03, 0.06)	0.819
LDL-C, mmol/l	Crude model	Ref	−0.02(−0.1, 0.06)	0.919	0.03(−0.05, 0.11)	0.793	0.07(−0.01, 0.15)	0.121
	Adjusted model	Ref	−0.01(−0.1, 0.07)	0.973	0.05(−0.03, 0.14)	0.345	0.11(0.02, 0.20)	0.005*
HDL-C, mmol/l	Crude model	Ref	−0.01(−0.05, 0.03)	0.895	0(−0.05, 0.04)	0.995	−0.03(−0.07, 0.01)	0.333
	Adjusted model	Ref	0(−0.05, 0.04)	0.994	0(−0.05, 0.04)	0.994	−0.03(−0.07, 0.01)	0.317

Notes: Mean differences were obtained using a linear mixed-effects regression model, *P<0.05, in bold. ^†Loge-transformed insulin, HOMA-IR, and HOMA-β values were considered continuous variables. Adjusted model: adjusted for maternal age, BMI, paternal age, BMI, cycle type, number of embryos transfer, stage of embryo transfer, offspring gestational age, birth weight, sex and age at visit.

Abbreviations: BMI, body mass index; E₂, estradiol; FBG, fasting blood glucose; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; HOMA-β, homeostatic model assessment of beta cell function; LDL-C, low-density lipoprotein cholesterol; TC, total cholesterol; TG, triacylglycerol.

Figure 1 Differences in metabolic variables of children across quarters of maternal E2 levels stratified by embryo frozen Association between maternal E₂ and metabolic variables in offspring after Fresh (A) and Frozen (B) embryo transfer.Abbreviations: FBG, fasting blood glucose; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TC, total cholesterol; TG, triacylglycerol.