Background: Among the environmental factors, diet has received much attention because of growing bulk of data that discloses significant and substantial role for dietary elements, particularly, micronutrient in fertility pathophysiology. One of the major dietary elements that have been recently under focus is dietary folate. A number of vital cellular events, such as transfer RNA, synthesis of DNA, methionine and cysteine, require folate as an essential molecular participant. A number of previous studies have documented that folate supplementation can improve fertility outcome; whereas, other studies have denied such an association between folate supplementation and fertility outcomes.
Aim of the study: to study a possible correlation between plasma and follicular fluid folate levels and the pregnancy rate in women enrolled in ICSI cycles.
Patients and methods: The present study was done on 65 infertile couples who were chosen from those attended the High Institute of Infertility Diagnosis and Assisted Reproductive Technologies who were subjected to an intracytoplasmic sperm injection (ICSI) cycles. Their ages ranged from 18 to 42 years. Both primary and secondary types of infertility were involved, with heterogeneous causes. From each woman, venous blood sample and follicular fluid sample was obtained for folate concentration determination using ELISA technique. 
Results: The biochemical pregnancy rate was 32.3 %. There was significant association between plasma folate level and positive pregnancy outcome (P < 0.05), when comparing the pregnancy rate of deficient group, lower normal group and high group with that of normal group. The highest pregnancy rate was observed in women with normal plasma folate and it equals 56.7 %, therefore it was considered a reference group for purpose of comparison. Pregnancy rate of deficient folate group was significantly lower than that of normal folate group, 11.1 % versus 56.7 % (P = 0.043). In addition, pregnancy rate of lower normal folate group was significantly lower than that of normal folate group, 10.0 % versus 56.7 % (P = 0.028). Moreover, pregnancy rate of high folate group was significantly lower than that of normal group, 12.2 % versus 56.7 % (P = 0.004). 
Conclusion: Both high and low plasma folate are associated with low pregnancy rate; therefore, it should be recommended that serum folate should be monitored when prescribing folate to infertile women and that it should be discontinued once its level reaches the maximum normal plasma range.


  • Bliek J.B, de Klein A, Luider TM, Lindemans J, Hulsman L, Guzel C, de Groot C.J, Steegers-Theunissen R.P (2004) New approach for the identification of folate-related pathways in human embryogenesis, Cell Mol Biol (Noisy-le-grand) ; 50: 939-944.
  • Blount B.C, Mack M. M, Wehr C .M, MacGregor J. T, Hiatt R. A, Wang G, Wickramasinghe S .N, Everson R .B, & Ames B. N (1997) Folate deficiency causes uracil misincorporation into human DNA and chromosome breakage: implications for cancer and neuronal damage, Proc Natl Acad Sci USA, 94, pp. 3290-3295.
  • Boxmeer J.C, Macklon N.S, Lindemans J, Beckers N.G, Eijkemans M.J, Laven J.S, Steegers E.A, Steegers-Theunissen R.P (2009) IVF outcomes are associated with biomarkers of the homocysteine pathway in monofollicular fluid. Hum Reprod ,24:1059–66.
  • Cetorelli V. (2014) The Effect on Fertility of the 2003-2011 War in Iraq. Popul Dev Rev,40(4):581‐604.
  • Chandracharya P.L, Rohini A, Mamatha H, Konuri A, Kumar A (2018) Role of folic acid supplementation and/ or its absence during pregnancy on implantation of embryos – An experimental study of Wistar rats. Journal of the Anatomical Society of India, 67: 80–85.
  • Chavarro J.E, Rich-Edwards J.W, Rosner B.A, Willett W.C (2008) Use of multivitamins, intake of B vitamins, and risk of ovulatory infertility. Fertil Steril,9:668–76.
  • Ebisch I.M, Thomas C.M, Peters W.H, Braat D.D, Steegers-Theunissen R.P (2007) The importance of folate, zinc and antioxidants in the pathogenesis and prevention of subfertility. Hum Reprod Update,13:163–74.
  • Elhussein O.G, Ahmed M.A, Suliman S.O, Yahya L.I, Adam I (2019) Epidemiology of infertility and characteristics of infertile couples requesting assisted reproduction in a low-resource setting in Africa, Sudan. Fertil Res Pract,5:7.
  • Forges T, Monnier-Barbarino P, Alberto J.M, Gueant-Rodriguez R.M, Daval J.L, Gueant J.L (2007) Impact of folate and homocysteine metabolism on human reproductive health. Hum Reprod Update,13:225–38.
  • Gaskins A.J, Afeiche M.C, Wright D.L, et al (2014). Dietary folate and reproductive success among women undergoing assisted reproduction. Obstet Gynecol. ,124(4):801‐809.
  • Gaskins A.J, Chavarro J.E.,(2018). Diet and fertility a review. Am J Obstet Gynecol,218(4):379‐389.
  • Gaskins A.J, Mumford S.L, Chavarro J.E, Zhang C, Pollack A.Z, Wactawski-Wende J, Perkins N.J, Schisterman E.F (2012). The impact of dietary folate intake on reproductive function in premenopausal women: a prospective cohort study. PLoS ONE,7:e46276.
  • Gopalakrishnan, S. B., Kalaiarasi, T., & Gnanendra, S. (2016). Evaluation of phytochemical constituents of the fruits of cucumis sativus linn. for their hepatoprotective activity by molecular docking studies. Journal of Food Technology Research, 3(1), 12-22.
  • Gurunath S, Pandian Z, Anderson R.A, Bhattacharya, S (2011). Defining infertility—a systematic review of prevalence studies. Hum Reprod Update,17(5):575–88.
  • Habibzadeh N, Schorah C.J, Smithells R.W (1986). The effects of maternal folic acid and vitamin C nutrition in early pregnancy on reproductive performance in the guinea-pig. Br J Nutr, 55:23–35.
  • Haggarty P, McCallum H, McBain H, Andrews K, Duthie S, McNeill G, Templeton A, Haites N, Campbell D, Bhattacharya S (2006). Effect of B vitamins and genetics on success of in-vitro fertilisation: prospective cohort study. Lancet,367:1513–9.
  • Hruska K.S, Furth P. A, Seifer D. B, Sharara F. I, Flaws J .A (2000). Environmental factors in infertility. Clin Obstet Gynecol,43:821–829.
  • Jaroudi S & SenGupta S (2007). DNA repair in mammalian embryos. Mutat Res, 35: 53-77.
  • Kiefer J .C (2007). Epigenetics in development. Dev Dyn, 36: 1144-1156.
  • Koury M .J, Horne D. W, Brown Z .A, & Pietenpol J. A, Blount B.C, Ames B. N, Hard R, Koury S. T (1997). Apoptosis of late-stage erythroblasts in megaloblastic anemia: association with DNA damage and macrocyte production, Blood,9: 4617-4623.
  • Kwong W.Y, Adamiak S.J, Gwynn A, Singh R, Sinclair K.D (2010.) Endogenous folates and single-carbon metabolism in the ovarian follicle, oocyte and pre-implantation embryo. Reproduction,139:705–15.
  • LaFlamme B. A, & Wolfner M .F (2013). Identification and function of proteolysis regulators in seminal fluid. Molecular reproduction and development, 80(2), pp.80-101.
  • Matte J.J, Girard C.L, Brisson G.J (1984). Folic acid and reproductive performances of sows. J Anim Sci,59:1020–5.
  • Obeid R, & Herrmann W (2012). The emerging role of unmetabolized folic acid in human diseases: Myth or reality?. Current Drug Metabolism, 13(8): 1184–1195.
  • Ocal P, Ersoylu B, Cepni I, et al (2012). The association between homocysteine in the follicular fluid with embryo quality and pregnancy rate in assisted reproductive techniques. J Assist Reprod Genet,29(4):299‐304.
  • O’Neill C (1998). Endogenous folic acid is essential for normal development of preimplantation embryos. Hum Reprod,13:1312–6.
  • Öztekin Ü, Caniklioğlu M, Sarı S, Selmi V, Gürel A, Işıkay L (2019). Evaluation of Male Infertility Prevalence with Clinical Outcomes in Middle Anatolian Region. Cureus,11(7):e5122.
  • Steegers-Theunissen R .P, Steegers E. A, Thomas C.M, Hollanders H. M, Peereboom-Stegeman J. H, Trijbels F .J, & Eskes T .K (1993). Study on the presence of homocysteine in ovarian follicular fluid. Fertil Steril, 60: 1006-1010.
  • Steegers-Theunissen R.P, Twigt J, Pestinger V, Sinclair K.D (2013). The periconceptional period, reproduction and long-term health of offspring: the importance of one-carbon metabolism. Hum Reprod Update,19:640–55.
  • Sundrani D, Chavan G. P, Mehendale S & Joshi S (2011). Altered metabolism of maternal micronutrients and omega 3 fatty acids epigenetically regulate matrix metalloproteinases in preterm pregnancy: a novel hypothesis. Medical Hypotheses77878–883. (doi:10.1016/j.mehy.2011.08.001)
  • Szymanski W, Kazdepka-Zieminska A (2003). Effect of homocysteine concentration in follicular fluid on a degree of oocyte maturity. Ginekol Pol,74:1392–6.
  • Tremblay G.F, Matte J.J, Dufour J.J, Brisson G.J (1989). Survival rate and development of fetuses during the first 30 days of gestation after folic acid addition to a swine diet. J Anim Sci,67:724–32.
  • Vander Borght M, Wyns C (2018). Fertility and infertility: definition and epidemiology. Clin Biochem, 62:2–10.
  • Venkatesh T, Suresh P.S, Tsutsumi R (2014). New insights into the genetic basis of infertility. Appl Clin Genet,7:235‐243.
  • WHO handbook for guideline development. Geneva, World Health Organization,( 2012).
  • X.i.e K, X.u P, F.u. Z et al (2019) Association of maternal folate status in the second trimester of pregnancy with the risk of gestational diabetes mellitus. Food Sci Nutr, 7(11): 3759‐3765.
  • Zorrilla M, Yatsenko A.N (2013). The Genetics of Infertility: Current Status of the Field. Curr Genet Med Rep, 1(4):10.


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