Body mass and probability of pregnancy during assisted reproduction treatment: retrospective study

Obesity and reproduction: a committee opinion

The purpose of this ASRM Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled, "Obesity and reproduction: an educational bulletin," last published in 2008 (Fertil Steril 2008;90:S21-9).

Circulating anti-Müllerian hormone levels in relation to nutritional status and selected adipokines levels in polycystic ovary syndrome

OBJECTIVE

The aim of the study was to analyse the relationship between nutritional status, selected adipokines and plasma anti-Müllerian hormone (AMH) levels in women with polycystic ovary syndrome (PCOS).

STUDY DESIGN PATIENTS AND MEASUREMENTS

A prospective, cross-sectional study, involving 87 PCOS (48 obese) women and 67 non-PCOS women (36 obese). Anthropometric parameters were measured, and body composition was determined by the bioimpedance method. Fasting serum glucose, androgens, FSH, LH, SHBG, insulin, AMH, apelin-36, adiponectin, leptin and omentin-1 were measured.

RESULTS

Plasma AMH levels were significantly higher in PCOS compared to the non-PCOS group (7.8 ± 4.3 ng/ml vs 44 ± 2.4 ng/ml; P < 0.001). Furthermore, AMH levels were higher in both PCOS and non-PCOS normal weight than in obese subgroups (8.9 ± 4.4 ng/ml vs 7.0 ± 4.0 ng/ml; P < 0.05 and 5.1 ± 2.4 ng/ml vs 3.9 ± 2.3 ng/ml; P < 0.05). There were negative correlations between AMH levels and anthropometric parameters (body mass, BMI, fat mass and percentage, as well as waist circumference) and plasma omentin-1 concentrations (R = -0.28, P < 0.001; R = -0.30, P < 0.001; R = -0.36, P < 0.001; R = -0.34, P < 0.001; R = -0.23, P < 0.01; and R = -0.20, P < 0.05, respectively) in all study groups. In multiple regression analysis, circulating AMH level variability was explained by omentin-1 levels and anthropometric parameters (excluding waist circumference).

CONCLUSIONS

In this observational study, nutritional status appears to be the main factor influencing circulating AMH levels independent of PCOS. The observed AMH association with omentin-1 levels suggests that this adipokine may be a link between hormonal dysfunction of adipose tissue related to obesity and decreased AMH secretion.

Increased body mass index negatively impacts blastocyst formation rate in normal responders undergoing in vitro fertilization

PURPOSE

The aim of this study is to investigate the effect of female BMI and metabolic dysfunction on blastocyst formation rate.

METHODS

This was a retrospective cohort study that was performed in an academic center for reproductive medicine. Patients who were normal weight, overweight with metabolic dysfunction, or obese who had ≥6 oocytes retrieved in a fresh IVF cycle were included in the study. The blastocyst formation rate was calculated from the number of ≥5 cell embryos on day 3 observed in culture until day 5 or day 6. Only good quality blastocysts were included in the calculation as defined by a morphologic grade of 3BB or better.

RESULTS

The blastocyst formation rate was significantly better in the normal-weight controls versus overweight/obese patients (57.2 versus 43.6 %, p < 0.007). There was no difference in blastocyst formation between the patients with a BMI 25-29.9 kg/m(2) with metabolic dysfunction and those with a BMI ≥30 kg/m(2).

CONCLUSION

The maternal metabolic environment has a significant impact on embryo quality as measured by blastocyst formation. A decreased blastocyst formation rate is likely a significant contributor to poorer reproductive outcomes in overweight and obese women with infertility.

Mechanical labor induction in the obese population: a secondary analysis of a prospective randomized trial

OBJECTIVE

The objective of this study was to estimate the influence of maternal body mass index (BMI) on progress and outcomes of labor induction using mechanical devices.

METHODS

This study was a secondary analysis of data collected during the Cook Catheter vs. Foley Catheter study, a series of prospective randomized trials of women requiring cervical ripening for labor induction. The duration, characteristics, and outcomes of labor were analyzed after stratification by BMI categories. Outcomes assessed included time from device insertion to delivery, successful ripening, cesarean delivery rates, and any maternal and neonatal adverse events.

RESULTS

One hundred and eighty-one patients were stratified according to BMI categories, with 102 study participants classified as normal weight (BMI ≤30) and 79 as obese (BMI >30). Maternal satisfaction from the induction process was significantly lower in the obese group compared to the normal weight group (5.95 ± 3.14 vs. 7.58 ± 2.7, respectively, in a 1-10 scale, p = 0.009). The cesarean delivery rate was similar in the normal weight and the obese groups (17.6 vs. 25.3 %, respectively, p = 0.27). No statistical differences were found in all other outcomes evaluated, including a sub-analysis of the different mechanical devices.

CONCLUSIONS

During the process of mechanical cervical ripening, maternal satisfaction, but not objective obstetrical parameters, was influenced by increased maternal BMI. The trial is registered at ClinicalTrials.gov, no: NCT00604487. Trial registry name is "Induction of Labor in Patients with Unfavorable Cervical Conditions."

Distinct localisation of lipids in the ovarian follicular environment

Obesity is associated with decreased pregnancy rates due, in part, to compromised oocyte quality. The aim of the present cross-sectional study of 84 women undergoing oocyte aspiration was to: (1) compare insulin, lipids and glucose in follicular fluid with serum; (2) determine whether increased body mass index (BMI) and waist circumference, hyperinsulinaemia, dyslipidaemia or metabolic syndrome altered follicular fluid metabolites; and (3) determine relative lipid content in oocytes to reveal any influence of these parameters on oocyte quality and IVF outcomes. Insulin, glucose, triglyceride and free fatty acids were lower in follicular fluid than blood and not strictly correlated between compartments. Insulin, glucose and triglyceride positively correlated with increasing BMI and waist circumference in blood and follicular fluid. Insulin increased in follicular fluid in association with metabolic syndrome. Free fatty acid composition analysis showed saturated fatty acids, particularly palmitic and stearic acid, to be more prevalent in follicular fluid than blood. There were no associations between follicular fluid metabolites or oocyte lipid content and clinical outcomes; however, oocyte immaturity correlated with follicular fluid glucose and fatty acid levels, as well as metabolic syndrome. The present study confirms that the human ovarian follicular environment surrounding the oocyte exhibits a unique metabolite profile compared with blood, with distinct localisation of lipids within follicular fluid and oocytes.

Modifiable Risk Factors and Infertility: What are the Connections?

Infertility is a relatively common condition, greatly affecting couples medically and psychologically. Although infertility treatment is safe, it can be time-intensive, expensive and increase the risk of multiple gestations. Thus, to reduce costs and risks, couples may initially consider lifestyle change to increase their fertility and chances of pregnancy. For many of the diet factors studied (for example: caffeine, soy, protein, iron), there are conflicting data. However, there are some items men and women consume that are detrimental to fertility, such as alcohol and tobacco. The data on exercise are varied but may have an effect on ovulation and fertility - positive or negative. Body mass index appears to impact fertility also, with obesity in both men and women negatively affecting pregnancy rates. In addition, there remains concern and a growing body of research on environmental toxin exposures and reproductive health. Finally, supporting patients through infertility diagnosis and treatment is critical, as psychological stress may impact conception. It is imperative that the relationship between lifestyle factors and fertility continue to be explored as to lessen the morbidity associated with infertility.

Metabolic control of oocyte development: linking maternal nutrition and reproductive outcomes

Obesity, diabetes, and related metabolic disorders are major health issues worldwide. As the epidemic of metabolic disorders continues, the associated medical co-morbidities, including the detrimental impact on reproduction, increase as well. Emerging evidence suggests that the effects of maternal nutrition on reproductive outcomes are likely to be mediated, at least in part, by oocyte metabolism. Well-balanced and timed energy metabolism is critical for optimal development of oocytes. To date, much of our understanding of oocyte metabolism comes from the effects of extrinsic nutrients on oocyte maturation. In contrast, intrinsic regulation of oocyte development by metabolic enzymes, intracellular mediators, and transport systems is less characterized. Specifically, decreased acid transport proteins levels, increased glucose/lipid content and elevated reactive oxygen species in oocytes have been implicated in meiotic defects, organelle dysfunction and epigenetic alteration. Therefore, metabolic disturbances in oocytes may contribute to the diminished reproductive potential experienced by women with metabolic disorders. In-depth research is needed to further explore the underlying mechanisms. This review also discusses several approaches for metabolic analysis. Metabolomic profiling of oocytes, the surrounding granulosa cells, and follicular fluid will uncover the metabolic networks regulating oocyte development, potentially leading to the identification of oocyte quality markers and prevention of reproductive disease and poor outcomes in offspring.

Body composition: A predictive factor of cycle fecundity

Objective

To study the effect of body composition on reproduction in women with unexplained infertility treated with a controlled ovarian hyperstimulation and intrauterine insemination programme.

Methods

This prospective observational study was conducted on 308 unexplained infertile women who were scheduled for a controlled ovarian hyperstimulation and intrauterine insemination programme and were grouped as pregnant and non-pregnant. Anthropometric measurements were performed using TANITA-420MA before the treatment cycle. Body composition was determined using a bioelectrical impedance analysis system.

Results

Body fat mass was significantly lower in pregnant women than in non-pregnant women (15.61±3.65 vs.18.78±5.97, respectively) (p=0.01). In a multiple regression analysis, body fat mass proved to have a stronger association with fecundity than the percentage of body fat, body mass index, or the waist/hip ratio (standardized regression coefficient≥0.277, t-value≥2.537; p<0.05). The cut-off value of fat mass, which was evaluated using the receiver operating characteristics curve, was 16.65 with a sensitivity of 61.8% and a specificity of 70.2%. Below this cut-off value, the odds of the pregnancy occurrence was found to be 2.5 times more likely.

Conclusion

Body fat mass can be predictive for pregnancy in patients with unexplained infertility scheduled for a controlled ovarian hyperstimulation and intrauterine insemination programme.

Evaluation of the ovarian reserve function in patients with metabolic syndrome in relation to healthy controls and different age groups

OBJECTIVE

To evaluate the ovarian reserve function in female patients with metabolic syndrome (MetS).

METHODS

This study evaluated 136 subjects, 67 with MetS and 69 controls. Subjects were divided into three age groups. Group I included 49 subjects aged 20-29 years, 22 with MetS and 27 controls; group II included 45 subjects aged 30-39 years, 22 with MetS and 23 controls; and group III included 42 subjects aged 40-49 years, 23 with MetS and 19 controls. Demographic characteristics, anthropometrics, blood biochemistry, and gonadotrophic hormones were compared as total ovarian volume and antral follicle count on ovarian transvaginal ultrasonography.

RESULTS

Serum levels of FSH, LH, E2 and progesterone were similar in the MetS and control groups, while testosterone levels were significantly higher in MetS patients than controls, both in the overall population (p = 0.024) and in those aged 20-29 years (p = 0.018). Total ovarian volume was significantly lower in MetS patients than controls, in both the overall population (p = 0.003) and those aged 20-29 years (p = 0.018), while antral follicle counts were similar. Ovarian volume correlated positively with antral follicle count (AFC) (r = 0.37; p < 0.001) and negatively with age (r = 0.34; p < 0.001) and FSH concentration (r = 0.21; p = 0.013). AFC was negatively correlated with age (r = 0.36; p < 0.001).

CONCLUSION

Ovarian reserve function is significantly lower in MetS patients than in healthy control subjects, particularly in women aged 20-29 years.

Insulin: its role in the central control of reproduction

Insulin has long been recognized as a key regulator of energy homeostasis via its actions at the level of the brain, but in addition, plays a role in regulating neural control of reproduction. In this review, we consider and compare evidence from animal models demonstrating a role for insulin for physiological control of reproduction by effects on GnRH/LH secretion. We also review the role that insulin plays in prenatal programming of adult reproduction, and consider specific candidate neurons in the adult hypothalamus by which insulin may act to regulate reproductive function. Finally, we review clinical evidence of the role that insulin may play in adult human fertility and reproductive disorders. Overall, while insulin appears to have a significant impact on reproductive neuroendocrine function, there are many unanswered questions regarding its precise sites and mechanisms of action, and their impact on developing and adult reproductive neuroendocrine function.

Relationship between follicular fluid adipocytokines and the quality of the oocyte and corresponding embryo development from a single dominant follicle in in vitro fertilization/intracytoplasmic sperm injection cycles

OBJECTIVE

To investigate the association of individual follicular fluid (FF) leptin and adiponectin levels with the quality of the corresponding oocyte and embryo.

METHODS

We prospectively enrolled 67 women who underwent controlled ovarian hyperstimulation with 89 FF samples. FF and the corresponding oocyte was obtained from a single dominant preovulatory follicle at the time of oocyte retrieval. Concentrations of leptin and adiponectin were measured by enzyme-linked immunosorbent assay in an individual follicle. The oocyte quality, fertilization rate, and corresponding embryo development were assessed.

RESULTS

The FF level of leptin was significantly associated with body mass index (r=0.334, p<0.01). The FF adiponectin level was significantly higher in the normal fertilization group than the abnormal fertilization group (p=0.009) in the non-obese women. A lower FF leptin level was associated with a trend toward mature oocytes, normal fertilization, and good embryo quality, although these relationships were not statistically significant. The leptin:adiponectin ratio of FF did not differ significantly according to oocyte and embryo quality. The quality of the oocyte and embryo was not associated with the FF leptin level tertile. However, the normal fertilization rate was positively associated with FF adiponectin level tertile. There was a trend towards improved oocytes and normal fertilization rates with the lowest tertile of the FF leptin:adiponectin ratio, but this difference was not statistically significant.

CONCLUSION

Our results suggest that a high FF adiponectin concentration could be a predictor of normal fertilization. However, the FF leptin concentration and leptin:adiponectin ratio is not significantly related to oocyte maturity and corresponding embryo development.

Body mass index and pregnancy outcome after assisted reproduction treatment

The present study aimed to evaluate the impact of body mass index (BMI) on pregnancy outcome after intracytoplasmic sperm injection (ICSI). The study analyzed pregnancy outcome of 349 women who underwent ICSI by their BMI: <25, 25-<30, and ≥30 kg/m(2). The associations were generated by applying logistic regression models. A significant reduction in positive pregnancy outcome was observed among overweight and obese women (odds ratio (OR) = 0.50; 95% confidence interval (CI) = 0.25-0.99 for overweight women and OR = 0.45; 95% CI = 0.20-0.89 for obese women). These estimates show that the pregnancy rates are reduced with increasing BMI. The effect of obesity on pregnancy outcome was absent when three and more embryos were transferred. Our study contributes to the reports linking overweight and obesity with decreased positive pregnancy outcome after ICSI and suggests women's age, infertility type, and number of embryos transferred to modify this reducing effect.

A novel modified ultra-long agonist protocol improves the outcome of high body mass index women with polycystic ovary syndrome undergoing IVF/ICSI

In an attempt to evaluate the effectiveness of a novel modified ultra-long agonist (ULA) protocol on polycystic ovary syndrome (PCOS) patients undergoing in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI), a retrospective study of 499 women employed with either ULA or conventional long agonist (LA) protocol was analyzed. In high BMI group (>25 kg/m²), the ULA protocol yielded significant higher clinic pregnancy rate (PR) (70.2% versus 50.8%, p < 0.05), implantation rate (52.7% versus 35.7%, p < 0.05) and live birth rate (63.8% versus 39.0%, p < 0.05) when compared with LA protocol. In low BMI group (≤25 kg/m²), the ULA protocol also demonstrated a higher clinic PR (70.8% versus 59.5%, p < 0.05) whereas implantation rate and live birth rate are comparable. Within ULA protocol, the clinic PR, implantation rate and live birth rate are similar between high and low BMI patients. Similarly, the clinic PR and live birth rate demonstrated no significant difference within LA group but there is a significant lower implantation rate (35.7% versus 63.9%, p < 0.05) observed in high BMI patients. No difference in miscarriage rate and severe OHSS rate was found among all groups. In conclusion, ULA protocol benefits the IVF outcomes of PCOS patients with high BMI status.

Endocannabinoids as biomarkers of human reproduction

BACKGROUND

Infertility is a condition of the reproductive system that affects ∼10-15% of couples attempting to conceive a baby. More than half of all cases of infertility are a result of female conditions, while the remaining cases can be attributed to male factors, or to a combination of both. The search for suitable biomarkers of pregnancy outcome is a challenging issue in human reproduction, aimed at identifying molecules with predictive significance of the reproductive potential of male and female gametes. Among the various candidates, endocannabinoids (eCBs), and in particular anandamide (AEA), represent potential biomarkers of human fertility disturbances. Any perturbation of the balance between synthesis and degradation of eCBs will result in local changes of their tone in human female and male reproductive tracts, which in turn regulates various pathophysiological processes, oocyte and sperm maturation included.

METHODS

PubMed and Web of Science databases were searched for papers using relevant keywords like 'biomarker', 'endocannabinoid', 'infertility', 'pregnancy' and 'reproduction'.

RESULTS

In this review, we discuss different studies on the measurements of AEA and related eCBs in human reproductive cells, tissues and fluids, where the local contribution of these bioactive lipids could be critical in ensuring normal sperm fertilizing ability and pregnancy.

CONCLUSION

Based on the available data, we suggest that the AEA tone has the potential to be exploited as a novel diagnostic biomarker of infertility, to be used in association with assays of conventional hormones (e.g. progesterone, β-chorionic gonadotrophin) and semen analysis. However further quantitative research of its predictive capacity is required.

Intake of high saturated-fat diets disturbs steroidogenesis, lipid metabolism and development of obese-swine conceptuses from early-pregnancy stages

The current study indicates that life-long intake, from early-life, of an obesogenic diet with high saturated-fat (HSF) content induces dyslipidemia (high plasma concentrations of triglycerides in concurrence with low concentrations of HDL-cholesterol) in obese swine with leptin resistance (Iberian sows). In case of pregnancy, ovarian features (ovulatory efficiency and luteal steroidogenesis) of sows fed with HSF are not affected but embryo features are affected at so early stages like 28 days of pregnancy (first quarter), although embryo viability was still not affected. In this way, offspring from HSF sows showed a higher incidence of alterations in their developmental trajectory, mainly due to a higher incidence of growth retardation, in their steroidogenic activity and in their availability of triglycerides and cholesterol. In conclusion, the results obtained in the present study illustrate the deleterious effects of maternal dyslipidemia, induced by the intake of HSF diets, on the oestradiol secretion of the conceptuses at early-pregnancy stages and, thus, on their developmental and metabolic features. This article is part of a Special Issue entitled 'Pregnancy and steroids'.

Male adiposity impairs clinical pregnancy rate by in vitro fertilization without affecting day 3 embryo quality

OBJECTIVE

Male adiposity is detrimental for achieving clinical pregnancy rate (CPR) following assisted reproductive technologies (ART). The hypothesis that the association of male adiposity with decreased success following ART is mediated by worse embryo quality was tested.

DESIGN AND METHODS

Retrospective study including 344 infertile couples undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles was performed. Cycle determinants included number of oocytes retrieved, zygote PN-score, total number of embryos available on day 3, number of embryos transferred, composite day 3 grade for transferred embryos, composite day 3 grade per cycle, and CPR.

RESULTS

Couples with male body mass index (BMI) over 25 kg m(-2) (overweight and obese) exhibited significantly lower CPR compared to their normal weight counterparts (46.7% vs. 32.0% respectively, P = 0.02). No significant difference was observed for any embryo quality metrics when analyzed by male BMI: mean zygote PN-scores, mean composite day 3 grades for transferred embryos or composite day 3 grades per cycle. In a multivariable logistic regression analysis adjusting for female age, female BMI, number of embryos transferred and sperm concentration, male BMI over 25 kg m(-2) was associated with a lower chance for CPR after IVF (OR = 0.17 [95% CI: 0.04-0.65]; P = 0.01) but not after ICSI cycles (OR = 0.88 [95% CI: 0.41-1.88]; P = 0.75). In this cohort, male adiposity was associated with decreased CPR following IVF but embryo quality was not affected.

CONCLUSIONS

Embryo grading based on conventional morphologic criteria does not explain the poorer clinical pregnancy outcomes seen in couples with overweight or obese male partner.

[Body weight increase and quality of semen: a controversial association]

BACKGROUND

Infertility is a public health disorder affecting 10% of the population worldwide. Research on the impact of body mass index (BMI) on male fertility is very limited as compared to the multiple studies evaluating the impact of overweight in women's fertility. Although 25%-30% of the cases of couples consulting for infertility are attributable to male factors, studies evaluating the association between semen parameters and BMI are controversial.

OBJECTIVE

To assess the impact of BMI on semen parameters in a selected group of men with unexplained infertility.

METHOD

A retrospective analysis of 168 patients during the 2008-2010 period. They all had at least one semen analysis and related studies to rule out known causes of infertility. Median age of patients was 35 years (22-55), and they were divided into three groups: normal weight (BMI: 20-24.9kg/m(2)), overweight (BMI 25-29.9kg/m(2)), and obese (BMI ≥30kg/m(2)).

RESULTS

There were no significant differences in semen parameters evaluated between the three groups, and no significant correlation was found between the same parameters and BMI.

CONCLUSIONS

There was no significant association between BMI and conventional semen parameters, but we cannot exclude an impairment in other semen parameters that are not routinely assessed, which could result in a lower potential fertility in these individuals.

A novel approach to quantifying ovarian cell lipid content and lipid accumulation in vitro by confocal microscopy in lean women undergoing ovarian stimulation for in vitro fertilization (IVF)

PURPOSE

To quantify intracellular lipid levels in cumulus cells (CCs) and mural granulosa cells (MGCs) of lean women undergoing gonadotropin therapy for in vitro fertilization (IVF), based upon different cell preparation methods.

METHODS

CCs and MGCs from 16 lean women undergoing ovarian stimulation for IVF were studied. Cells were pooled by cell type, with each type of cell separated into two groups for determination of initial lipid content (Method 1) and subsequent lipid accumulation in vitro (Method 2). Cells for initial lipid content were immediately fixed at the time of the oocyte retrieval with 4% paraformaldehyde in suspension, while those for subsequent lipid accumulation in vitro were cultured for 4 h with 5% fetal calf serum and then fixed. Cells were treated with lipid fluorescent dye BODIPY® FL C16 and nuclear marker DAPI. Intracellular lipid was quantified by confocal microscopy, using ImageJ software analysis.

RESULTS

There was no significant effect of cell type (P = 0.2) or cell type-cell preparation method interaction (P = 0.8) on cell area (Method 1: CC 99.7 ± 5.1, MGC 132.8 ± 5.8; Method 2: CC 221.9 ± 30.4, MGC 265.1 ± 48.5 μm(2)). The mean area of all cells combined was significantly less for cells prepared by Method 1 (116.2 ± 4.9 μm(2)) vs. Method 2 (243.5 ± 22.5 μm(2), P < 0.00005). Intracellular lipid level, however, was significantly altered by cell preparation method (P < 0.05; cell preparation method-cell type interaction, P < 0.00001). Initial lipid content was significantly lower in CC (74.5 ± 9.3) than MGC (136.3 ± 16.7 fluorescence/cell area, P < 0.00005), while subsequent lipid accumulation in vitro was significantly higher in CC (154.0 ± 9.1) than MGC (104.6 ± 9.9 fluorescence/cell area, P < 0.00001). The relatively diminished initial CC lipid content compared to subsequent CC lipid accumulation in vitro (P < 0.00001), and the opposite pattern for MGC (P < 0.05), significantly lowered the CC/MGC lipid ratio in Method 1 (0.55 ± 0.04) vs. Method 2 (1.58 ± 0.10, P < 0.00001).

CONCLUSIONS

Differential uptake or utilization of lipid by CC and MGC occurs during oocyte maturation and steroidogenesis, respectively, with the amount of lipid present in ovarian cells a function of both the follicular microenvironment at the time of the oocyte retrieval and the capacity of these cells to accumulate lipid in vitro over time.

Obesity and oral contraceptives: a clinician's guide

Obesity and unintended pregnancy are two of the major health epidemics we are currently facing worldwide. Patient education is a clinician's greatest tool in combating both epidemics but many clinicians may be uncomfortable with counselling and prescribing contraception for obese women. Overall, the prevention of unintended pregnancy in obese women far outweighs any risk associated with oral contraceptive use. This review aims to provide the clinician with a practical guide to the use of oral contraceptive pills in obese women.

Infertility patients' knowledge of the effects of obesity on reproductive health outcomes

OBJECTIVE

The objective of the study was to assess the infertility patient knowledge of reproductive outcomes affected by obesity.

STUDY DESIGN

This was a prospective survey study of 150 female infertility patients in an academic medical center. Subjects were administered the Rapid Estimate of Adult Literacy in Medicine-Short Form and a questionnaire on the health risks of obesity, and investigators obtained height and weight measurements.

RESULTS

Subjects' age ranged from 21 to 45 years (mean 34.8 ± 4.94 SD) and body mass index ranged from 17.9 to 62.9 kg/m(2) (mean 26.5 ± 7.54 SD). The following percentages of women were aware that obesity increases the risk of infertility (82.7%), irregular periods (70.0%), miscarriage (60.7%), cesarean section (48.7%), breast cancer (38.7%), birth defects (29.3%), stillbirth (22.7%), and endometrial cancer (20.7%).

CONCLUSION

Among women with infertility, there is limited knowledge of reproductive outcomes affected by obesity. Public education is needed to increase awareness. Women undergoing fertility treatment are motivated for reproductive success and may be uniquely receptive to obesity education and weight loss intervention.

Parental diet-induced obesity leads to retarded early mouse embryo development and altered carbohydrate utilisation by the blastocyst

Maternal obesity results in reproductive complications, whereas the impact of paternal obesity is unclear. In the present study, the effects of parental obesity on preimplantation embryo cell cycle length and carbohydrate utilisation were investigated. Maternal and paternal obesity were assessed independently by deriving zygotes from normal or obese C57BL/6 female mice mated with normal Swiss male mice (maternal obesity), or from normal Swiss female mice mated with normal or obese C57BL/6 male mice (paternal obesity). Zygotes were cultured in vitro and development was then assessed by time-lapse microscopy and metabolism determined using ultramicrofluorescence. Maternal obesity was associated with a significant delay in precompaction cell cycle kinetics from the 1-cell stage. A significant increase in glucose consumption by embryos from obese compared with normal females occurred after compaction, although glycolysis remained unchanged. Similarly, paternal obesity led to significant delays in cell cycle progression during preimplantation embryo development. However, this developmental delay was observed from the second cleavage stage onwards, following embryonic genome activation. Blastocysts from obese males showed disproportionate changes in carbohydrate metabolism, with significantly increased glycolysis. Overall, metabolic changes were not inhibitory to blastocyst formation; however, blastocyst cell numbers were significantly lower when either parent was obese. These data suggest that both maternal and paternal obesity significantly impacts preimplantation embryo physiology.

Infertility: evaluation and initial management

Treating the infertile client with competence and compassion is within the scope of practice for advanced practice clinicians. However, due to both a lack of emphasis on infertility treatment in many advanced practice education programs and confusion regarding diagnosis and treatment by many practitioners, infertility is often undertreated by these providers. A basic infertility evaluation, patient counseling, and prescriptive therapy with oral ovulation-inducing agents by a knowledgeable practitioner is cost-effective and may result in successful pregnancy in women who otherwise may not be adequately and quickly treated prior to referral to a reproductive endocrinologist. A diagnosis of infertility is often stressful and frustrating for a couple. Midwives and advanced practice nurses are uniquely qualified to provide both compassionate care and competent treatment during this time. This article provides the clinician with an overview of infertility diagnosis, evaluation, and initial management with lifestyle modifications and oral ovulation-inducing agents.

Ovarian stimulation in women with high and normal body mass index: GnRH agonist versus GnRH antagonist

In modern society, obesity has become a major health problem and has been associated with impaired fertility. The aim of this study is to assess the role of obesity in women undergoing controlled ovarian hyperstimulation (COH) stimulated either with GnRH agonists or with GnRH antagonists. Records of 463 women undergoing in vitro fertilization (IVF) treatment were reviewed. The influence of body mass index (BMI) on treatment outcome was examined, after accounting for differences in stimulation protocols. In the agonist group (286 patients), the total amount of gonadotropins used was significantly higher in patients with a BMI ≥ 25 kg/m², when compared to those with a normal BMI. The same result was found in the antagonist group (177 patients). No significant differences were found in length of stimulation, number of oocytes retrieved or number of embryos transferred. In both the antagonist and the agonist group, the number of clinical pregnancies was found to be higher in patients with normal BMI, suggesting that obesity could impair the ovarian response to exogenous gonadotropins. Considering the results obtained and the many theoretical advantages of GnRH antagonists, ovarian stimulation with GnRH antagonists is an efficient treatment for both women with normal and high BMI.

Endoplasmic reticulum (ER) stress in cumulus-oocyte complexes impairs pentraxin-3 secretion, mitochondrial membrane potential (DeltaPsi m), and embryo development

Fatty acids such as palmitic acid at high levels are known to induce endoplasmic reticulum (ER) stress and lipotoxicity in numerous cell types and thereby contribute to cellular dysfunctions in obesity. To understand the impact of high fatty acids on oocytes, ER stress and lipotoxicity were induced in mouse cumulus-oocyte complexes during in vitro maturation using the ER Ca(2+) channel blocker thapsigargin or high physiological levels of palmitic acid; both of which significantly induced ER stress marker genes (Atf4, Atf6, Xbp1s, and Hspa5) and inositol-requiring protein-1α phosphorylation, demonstrating an ER stress response that was reversible with the ER stress inhibitor salubrinal. Assessment of pentraxin-3, an extracellular matrix protein essential for fertilization, by immunocytochemistry and Western blotting showed dramatically impaired secretion concurrent with ER stress. Mitochondrial activity in oocytes was assessed by 5,5',6,6'-tetrachloro-1,1',3,3'-tetraethylbenzimidazolylcarbocyanine iodide staining of inner mitochondrial membrane potential, and oocytes matured in thapsigargin or high-dose palmitic acid had significantly reduced mitochondrial activity, reduced in vitro fertilization rates, and were slower to develop to blastocysts. The deficiencies in protein secretion, mitochondrial activity, and oocyte developmental competence were each normalized by salubrinal, demonstrating that ER stress is a key mechanism mediating fatty acid-induced defects in oocyte developmental potential.

Fertility treatment response: is it better to be more optimistic or less pessimistic?

OBJECTIVE

To evaluate the prospective relation between dispositional traits of optimism and pessimism and in vitro fertilization (IVF) treatment failure among women seeking medical intervention for infertility.

METHODS

Among 198 women (aged 24-45 years, mean [standard deviation] = 35.1 [4.1] years; white, 77%), the outcome of each participant's first IVF treatment cycle was examined. Treatment outcome was classified as being successful (versus failed) if the woman either delivered a baby or was pregnant because of the cycle by the end of the 18-month study period. At baseline, optimism and pessimism were measured as a single bipolar dimension and as separate unipolar dimensions according to the Life Orientation Test total score and the optimism and pessimism subscale scores, respectively.

RESULTS

Optimism/pessimism, measured as a single bipolar dimension, predicted IVF treatment failure initially (B = -0.09, p = .02, odds ratio [OR] = 0.917, 95% confidence interval [CI] = 0.851-0.988), but this association attenuated after statistical control for trait negative affect (B = -0.06, p = .13, OR = 0.938, 95% CI = 0.863-1.020). When examined as separate unipolar dimensions, pessimism (B = 0.14, p = .04, OR = 1.146, 95% CI = 1.008-1.303), not optimism (B = -0.09, p = .12, OR = 0.912, 95% CI = 0.813-1.023), predicted IVF treatment failure independently of risk factors for poor IVF treatment response and trait negative affect.

CONCLUSIONS

Being pessimistic may be a risk factor for IVF treatment failure. Future research should attempt to delineate the biological and behavioral mechanisms by which pessimism may negatively affect treatment outcomes.

Miscarriage after sonographic confirmation of an ongoing pregnancy in women with moderate and severe obesity

OBJECTIVE

To compare the incidence of spontaneous miscarriage in women with moderate to severe obesity to that in women with a normal BMI after sonographic confirmation of the foetal heart rate in the first trimester.

METHODS

Women were enrolled in a prospective observational study at their convenience in the first trimester after an ultrasound confirmed an ongoing singleton pregnancy with foetal heart activity present. Maternal height and weight were measured digitally and BMI was calculated.

RESULTS

In the 3,000 women enrolled, the miscarriage rate overall was 3.9% (n = 117). The mean gestational age at enrolment was 11.1 weeks. In the class 2-3 (BMI > 34.9 kg/m(2)) obese primigravidas the miscarriage rate was 11.3% (n = 8) compared with 2.7% (n = 24) in the normal BMI category (p = 0.003), and 3.7% (n = 5) in the class 1 obese category (not significant). In multigravidas, there was no increased rate of miscarriage among class 2-3 obese women compared with multigravidas in the normal BMI category. The mean body composition values showed that primigravidas who miscarried had both increased fat and fat-free masses compared with those who did not, but multigravidas who miscarried had a similar fat mass and fat-free mass with those who did not.

CONCLUSIONS

In women with sonographic evidence of foetal heart activity in the first trimester, the rate of spontaneous miscarriage is low. It was increased in moderate to severely obese primigravidas, but was not increased in other obese women compared to women in the normal BMI category.

Complications and outcome of assisted reproduction technologies in overweight and obese women

BACKGROUND

Based on a presumed negative impact of overweight and obesity on reproductive capacity and pregnancy outcome, some national guidelines and clinicians have argued that there should be an upper limit for a woman's BMI to access assisted reproductive technologies (ART). However, evidence on the risk of complications or expected success rate of ART in obese women is scarce. We therefore performed a systematic review on the subject.

METHODS

We searched the literature for studies reporting on complications or success rates in overweight and obese women undergoing ART. Articles were scored on methodological quality. We calculated pooled odds ratios (ORs) to express the association between overweight and obesity on the one hand, and complications and success rates of ART on the other hand. We only pooled results if data were available per woman instead of per cycle or embryo transfer.

RESULTS

We detected 14 studies that reported on the association between overweight and complications during or after ART, of which 6 reported on ovarian hyperstimulation syndrome (OHSS), 7 on multiple pregnancies and 6 on ectopic pregnancies. None of the individual studies found a positive association between overweight and ART complications. The pooled ORs for overweight versus normal weight for OHSS, multiple pregnancy and ectopic pregnancy were 1.0 [95% confidence interval (CI) 0.77-1.3], 0.97 (95% CI 0.91-1.04) and 0.96 (95% CI 0.54-1.7), respectively. In 27 studies that reported on BMI and the success of ART, the pooled ORs for overweight versus normal weight on live birth, ongoing and clinical pregnancy following ART were OR 0.90 (95% CI 0.82-1.0), 1.01 (95% CI 0.75-1.4) and OR 0.94 (95% CI 0.69-1.3), respectively.

CONCLUSIONS

Data on complications following ART are scarce and therefore a registration system should be implemented in order to gain more insight into this subject. In the available literature, there is no evidence of overweight or obesity increasing the risk of complications following ART. Furthermore, they only marginally reduce the success rates. Based on the currently available data, overweight and obesity in itself should not be a reason to withhold ART.

Obesity and reproductive dysfunction in women

Overweight and obesity are significant and increasing health problems associated with increased risks of morbidity, quality of life, and metabolic and reproductive health consequences. In women, being overweight or obese is associated with impaired fertility and decreased chance of conception both in natural and assisted reproductive technology births. During pregnancy, overweight and obesity are associated with increased risk of adverse maternal and infant health outcomes. Attention to weight loss before conception may improve fertility and maternal and infant health outcomes during pregnancy.

BMI not WHR modulates BOLD fMRI responses in a sub-cortical reward network when participants judge the attractiveness of human female bodies

In perceptual terms, the human body is a complex 3d shape which has to be interpreted by the observer to judge its attractiveness. Both body mass and shape have been suggested as strong predictors of female attractiveness. Normally body mass and shape co-vary, and it is difficult to differentiate their separate effects. A recent study suggested that altering body mass does not modulate activity in the reward mechanisms of the brain, but shape does. However, using computer generated female body-shaped greyscale images, based on a Principal Component Analysis of female bodies, we were able to construct images which covary with real female body mass (indexed with BMI) and not with body shape (indexed with WHR), and vice versa. Twelve observers (6 male and 6 female) rated these images for attractiveness during an fMRI study. The attractiveness ratings were correlated with changes in BMI and not WHR. Our primary fMRI results demonstrated that in addition to activation in higher visual areas (such as the extrastriate body area), changing BMI also modulated activity in the caudate nucleus, and other parts of the brain reward system. This shows that BMI, not WHR, modulates reward mechanisms in the brain and we infer that this may have important implications for judgements of ideal body size in eating disordered individuals.

Influence of body condition on reproductive output in the guinea pig

Reproduction is expensive. Substantial body reserves (i.e. high body condition) are usually required for females to undertake offspring production. In many vertebrates, maternal body condition positively influences reproductive output, and emaciated individuals skip reproduction. However, the impact of extremely high body condition, more specifically obesity, on animal reproductive performance remains poorly understood and research has generated contradictory results. For instance, obesity negatively affects fertility in women, but does not influence reproductive capacity or reproductive output in laboratory rodents. We examined the influence of high body condition on reproductive status and reproductive output in the guinea pig. In captivity, when fed ad libitum, guinea pigs store large amounts of fat tissues and exhibit a tendency for obesity. Our results show that obesity negatively affected reproduction in this species: both the proportion of fertile females and litter size were lower in the fattest females. Therefore, guinea pigs may represent suitable organisms to better understand the negative effect of obesity on reproduction.