Barker Hypothesis and Epigenetics: Optimizing the Health of Our IVF Offspring

Daniel A. Dumesic, M.D.Professor and Division Chief

Division of Reproductive Endocrinology and Infertility

Department of Obstetrics and Gynecology

University of California Los Angeles

Los Angeles, CA

29th Annual IVF & ET: A Comprehensive Update 2016Wednesday, July 20, 2016

Coronado Island Conference

Learning Objectives

Define the developmental origins theory of adult disease.

State one epigenetic mechanism of cellular plasticity.

Name an IVF factor that alters fetal development.

Describe an environmental factor with adverse trans-generational effects.

Fetal undernutrition causes disproportional fetal growth and programs later coronary heart disease.

Death from CHD rose in individuals small at birth (<2500 gm) due to growth failure rather than prematurity.

Trends in CHD by birth weight are paralleled by similar trends in diabetes and hypertension.

Highest prevalence of diabetes occurs in people who are small at birth and become obese as adults.

Highest blood pressures occur in people who at birth are small for gestational age and have large placentas.

Fetal undernutrition slows cell division during critical time intervals in various target tissues by altering cell number, function or distribution.

The Barker Hypothesis

Barker 1995

Developmental Origins of Health and Disease(DO-HaD)

Altered homeostasis during critical periods of development predispose individuals to adult-onset chronic diseases.

Environmental stress in utero favors survival of offspring with the greatest capacity for energy storage to endure prolonged episodes of privation as adults (the “thrifty phenotype”).

Epigenetics: ”heritable phenotype resulting from changes in a chromosome without alterations in the DNA sequence"

Estampador 2014, Rando 2016

Modulate environmental effects on the adult phenotype via transcriptional regulation via

Cytosine methylation: methylation of CpG islands in DNA

Chromatin packaging: post-translational modification of histone proteins (i.e., acetylation, methylation, phosphorylation ubiquitination)

RNAs: Long noncoding RNAs: short RNAs (<40 nt) siRNA, microRNAs, small fragments of rRNAs and tRNAs

Impart cellular plasticity to intrauterine events that program the fetal genome for survival after birth through

energy metabolism

adipogenesis

People exposed to famine

in early gestation have a more atherogenic lipid profile, and a higher BMI & waist size at 50 yrs (women),

in mid/late gestation have reduced glucose tolerance, and

in late gestation with decreased protein have hypertension.

Famine during the first trimester alters DNA methylation of CpGdinucleotides in genes of adult offspring that involve

cell growth/differentiation,

nutrient balance, and

intracellular cholesterol transport.

Dutch Famine 1944-1945

Ravelli 1998, 1999, Roseboom 2001, Tobi 2015

Gestational Age and Birth Weight by IVFNordic cohort of singletons born after FET (N=6647), fresh

IVF/ICSI (N=42,242) and spontaneous conception (N=288,542)

Wennerholm 2013, Pandey 2012

PTB, preterm birth; LBW, low birth weight; SGA, small for gestational age; LGA, large for gestational age. *, P < 0.05; ***, P < 0.001 versus FET

Perc

enta

ge

***

***

***

***

***

*

Absolute increased risks: 1-3%, all outcomes

Mean Birth Weight of Term IVF Singletons(N=25,777 births)

Nakashima 2013Mean difference, 90.9 grams

Peak serum E2 >3450 pg/mL (>90th

percentile)OR* 95% CI

Pre-eclampsia 4.8 1.6-14.8

SGA 9.4 3.2-27.5

Serum E2 during COH-IVF & Abnormal Placentation(292 Singletons by initial US)

Elevated E2 during COH-IVF is associated with greater odds of developing pre-eclampsia and delivery of an SGA singleton, perhaps from abnormal spiral artery remodeling and trophoblast invasion. Imudia 2012

*, adjusted for patient age, BMI, parity, number of embryos transferred, day of embryo transfer and/or gonadotropin dose.

Elevated E2 levels in vitro impair growth of human first trimester cytotrophoblast, suggesting abnormal spiral artery remodeling due to impaired trophoblast survival. Skafar 2012

Fetal Growth and Placentation

Transferring murine blastocysts from a natural mating to a female surrogate receiving gonadotropins impairs fetal growth and trophoblast differentiation and alters placental gene expression.

DNA methylation and gene expression patterns vary in cord blood and placental tissue of children conceived in vitro versus natural conception.

Some of these genes affect:

adipocyte differentiation, insulin signaling and/or obesity

trophoblast stem cell development

Mainigi 2014, Katari 2009, Turan 2010

Cardiovascular Remodeling and Assisted Reproduction(100 singletons conceived by ART; 100 control pregnancies*¶)

3rd Trimester Neonatal life 6 Months of Age

Bilaterally enlarged atria Diastolic BP Right atrial size &myocardial wall thickness

Right myocardial wall thickness

Carotid/aortic intima-mediathickness

Heart rate

Left ejection fraction Systolic & diastolic dysfunction

Systolic BP

Aortic IMT

*, vs. spontaneous conception¶, Adjusting for gestational age, birth weight, preeclampsia Valenzuela-Alcaraz 2013

Author Ages 3-18 yrs BMI SBP DBP TG FPGCeelen 2007 225 IVF;225 non-ART

singletonsNA NA

Belva 2007 150 ICSI; 147 non-ART singletons

NA NA NA

Belva 2012 217 ICSI; 223 non-ART singletons

NA NA

Miles 2007 69 IVF/ICSI; 71 non-ART singletons

NA NA

Sakka 2010* 106 IVF; 68 age-matched untreated

Scherrer2012¶

65 IVF/ICSI; 57 non-ART singletons

Green 2013 61 IVF; 91 non-ART singletons

NA NA

CVD Risk Factors in Children conceived by ART

Yeung 2013*, No differences in insulin resistance, serum adipokines and inflammatory markers¶, pulmonary and systemic endothelial dysfunction

IVF and Cell Culture

Feuer 2014

IVF KAAFlushed blastocysts

IVF and Cell Culture

Feuer 2014

Blastocysts Adults

Thioredoxin-interacting protein (TXNIP): integrates cellular nutrition with redox state to regulate mitochondrial function.

Mitochondrial Function and Embryogenesis

Zander-Fox 2015

Chemical uncoupling of oxidative phosphorylation in mouse zygotes reduces ATP production, decreases blastocyst growth, and reduces offspring birth weight followed by postnatal obesity.

Change in fat mass between 4 of 14 weeks of age

Controls FCCP-treated PValue

Grams 1.4±0.4 2.0±0.3 <0.05

Percent 1.8±0.9 3.9±0.9 <0.05

Plasma metabolites at 14 weeks of age

Controls FCCP-treated PValue

Glucose (mmol/L) 7.6±0.8 9.2±0.5 <0.05

HDL (mmol/L) 3.3±0.4 2.4±0.3 <0.05

Triglycerides (mmol/L) 0.6±0.1 0.7±0.1 NS

Developmental Programming of Obesity

Maternal Obesity

Low Birth Weight Infant

High Birth Weight Infant

Catch-up growth

Continued growth

OffspringObesity

Pettitt 2001, Desai 2013, Leary 2014

Oocytes from overweight women are smaller and less likely to complete embryogenesis. Post-fertilization, they reach the morula stage faster and, as blastocysts contain fewer cells, show reduced glucose consumption and elevated endogenous triglyceride levels

…”the relationship between human birth weight and adult obesity, hypertension, and/or insulin resistance is a U-shaped curve”

Percentage of Children with MBS(6-11 years of age [N=175])

Variable

Hazard Ratio

P value

95% CI

LGA 2.2 0.006 1.2-3.8MaternalObesity

1.8 0.04 1.0-3.2

Boney 2005

All Cause Mortality in Adult Offspring by Maternal BMI(37,709 people with birth records from 1950 to date)

MaternalBMI

Hazard ratio

95 CI

<18.5 1.0 0.8-1.118.5-24.9 1.0 1.025.0-29.9 1.1 1.0-1.2>30 1.3 1.2-1.5

Time to death (yrs)

Adjusted for maternal age, social class, gestational age, infant sex and birth weight

Reynolds 2013

Maternal Obesity Programs Obesity in Offspring

Shankar 2008, Borengasser 2013

• Altered DNA methylation of important genes• Increased expression of adipogenic genes• Greater stem cell differentiation to adipocytes • Upregulation of lipogenic pathways

Can we alter developmental programming in nonhuman primates during intrauterine life?

A maternal high-fat diet

changes fetal hepatic chromatin structure and postnatal gene expression

alters fetal protein translation via DNA methylation and histone and chromatin modifications

Increased maternal adiposity from anabolic steroids

alters SC adipogenesis and modifies DNA methylation of visceral fat in offspring.

induces a metabolic-like syndrome in adult offspring.

Nonhuman Primate Models of Maternal Obesity

Ganu 2012, Xu 2011, Abbott 2005, Keller 2014

Children (F2) of Fathers From the Dutch Famine Birth Cohort (F1) Who Were Undernourished in Utero

Exposed Unexposed P ValueNumber 52 99

Age 34 36 NS

Birth weight (gms) 3351 3342 NS

Adult weight (kg)* 78.8 73.5 <0.05

BMI (kg/m2)* 25.2 23.8 <0.05

Offspring from in utero undernourished fathers were heavier and more obese as adults than those from fathers and mothers not undernourished in utero

Veenendaal 2013

*, after correction for age and sex of F2

Avon Longitudinal Study of Parents and Children(303 probands & 1818 parents/grandparents born in northern

Sweden)

Pembrey 2006

Paternal grandfather's food supply is linked to the mortality rate of grandsons alone, suggesting that sex-specific, male-line trans-generational responses exist in humans

Intergenerational Epigenetic Information in Sperm

Rando 2016

Transgenerational Amplification of Obesity

NormalFemale

MaleHDF for 10 weeks22% adiposity,

Nl GTT

Male6% weight gain adiposity GT

NormalFemale

Female53% Adiposity

GT

Male

Female79% Adiposity

GT

NormalMale

Female Male38% Adiposity

GT

Fullston 2013

Transgenerational Amplification of Impaired Reproductive Health

NormalFemale

MaleHDF for 10 weeks22% adiposity,

Nl GTT

Malesperm ROS & DNA damage Motility

NormalFemale

Female oocyte ROSmitochondrial

stress

Malesperm ROS Motility

Femaleoocyte meiosis mitochondrial

stress

NormalMale

Femaleoocyte ROS

Malesperm ROS Motility

Testosterone

Fullston 2012, 2013F0 sperm have increased ROS and DNA damage with abnormal microRNA content & germ cell methylation

Nutrient transport

Developmentally regulated genes

Energy regulation & cell differentiation

Placental implantation

IVF culture systems

Fetal Growth & Development

IVF and Nutrient Pathways

Parenteral nutrition and environmental factorsCOH protocols

Placenta

Discuss metabolic and environmental health with the couple before beginning fertility therapy.

Optimize IVF cell culture conditions during preimplantationembryogenesis.

Consider liberal use of frozen embryo transfer to reduce the risk of elevated estradiol on placentation.

Monitor IVF-conceived offspring into adulthood to determine their risk of developing metabolic disease.

The Barker Hypothesis: How Can We Optimize the Health of Our IVF Offspring?

Question 1: Clinical

Which of the following factors most commonly impairs the health of adult human offspring?

A. IVF cell culture

B. Fresh embryo transfer

C. Maternal obesity

D. Paternal obesity

Question 2: Basic Science

Which of the following statements regarding epigenetics is true?

A. Nearly global erasure of cytosine methylation on the paternal genome occurs after fertilization.

B. The paternal genome is primarily packaged with protamines and susceptible to demethylation.

C. Parts of the gamete epigenome are protected from erasure at fertilization by a factor that associates with the genome.

D. All of the above

Dumesic DA

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