Practice Committee of the American Society for Reproductive Medicine. Obesity and reproduction: a committee opinion

Recent Lifestyle Parameters Are Associated with Increasing Caesarean Section Rates among Singleton Term Births in Austria

Caesarean section (CS) rates are increasing in many parts of the world, recently reaching about 20% worldwide. The postmodern lifestyle characteristics, obesity and delayed childbirth, have been put forward as the main reasons for high CS rates. The present study tests the association patterns between lifestyle parameters and delivery mode on a data set of 3786 births in Vienna between 2005 and 2013. The focus is exclusively on singleton term births. As well as maternal age, prepregnancy weight status, maternal body height and gestational weight gain, newborn size (birth weight, birth length, and head circumference), Apgar scores and child presentation were recorded. Planned as well as emergency CS rates increased significantly (p < 0.0001) with increasing maternal age and decreasing maternal body height. Emergency CS rates, however, increased significantly with increasing maternal prepregnancy weight status and gestational weight gain. An especially high risk of emergency CS occurred among four groups of mothers: those older than 40 years (OR = 2.68; 95% CI 1.87⁻3.86), those who were obese (OR = 1.44; 95% 1.15⁻1.81), those experiencing a gestational weight gain above 15 kg (OR = 1.32; 95% CI 1.13⁻1.54), and those shorter than 160 cm (OR = 1.216; 95% CI 1.02⁻1.45). Emergency CS rates were significantly higher among low-weight newborns (<2500 g) and macrosome newborns (>4000 g) than among normal-weight newborns. Furthermore, breech presentation was associated with an increased risk of caesarean delivery (OR 6.97; 95% CI 6.09⁻7.96). Logistic regression analyses reveal that maternal age, maternal body height, prepregnancy weight status, gestational weight gain, birth weight, newborn head circumference and child presentation show an independent, highly significant association with caesarean delivery. We conclude that maternal and newborn characteristics typical of recent lifestyle patterns, such as advanced maternal age, obesity, increased gestational weight gain and increased newborn size, are highly significantly associated with increased emergency CS rates. Moreover, maternal shortness and breech presentation are risk factors for emergency CS.

The effect of female body mass index on in vitro fertilization cycle outcomes: a multi-center analysis

PURPOSE

The aim of this study is to examine the impact of female body mass index (BMI) on IVF cycle outcomes.

METHODS

This is a retrospective cohort study including 51,198 women who initiated their first autologous IVF cycle in 13 fertility centers in the USA between 2009 and 2015. The effect of underweight, overweight, and obese BMI on four different IVF cycle outcomes (cycle cancellation, oocyte and embryo counts, and ongoing clinical pregnancy [OCP]) was evaluated in logistic or Poisson regression analyses with confounders adjusted.

RESULTS

Women with an overweight or obese BMI experienced worse outcomes than those with a normal BMI. These differences included (1) greater odds of cycle cancellation (aOR [95%CI] 1.17 [1.08, 1.26] for overweight, 1.28 [1.15, 1.41] for class-I obesity, and 1.50 [1.33, 1.68] for class-II/III obesity, P < .001 for all); (2) fewer oocytes retrieved (aIRR [95%CI] 0.98 [0.98,0.99] for class-I obesity, 0.93 [0.92,0.94] for class-II/III obesity, P < .001 for both); (3) fewer usable embryos (aIRR [95%CI] 0.98 [0.97,0.99] for overweight, 0.97 [0.96,0.99] for class-I obesity, 0.95 [0.93,0.97] for class-II/III obesity, P < .01 for all); and (4) lower odds of OCP (aOR [95%CI] 0.89 [0.83,0.95] for class-I obesity, 0.86 [0.79,0.93] for class-II/III obesity, P < .001 for both). In a subgroup analysis based on primary infertility diagnosis, these trends persisted in those with male or uterine factor and were especially pronounced in women with ovulatory dysfunction or PCOS.

CONCLUSIONS

A BMI above the normal range was an independent negative prognostic factor for multiple outcomes, including cycle cancellation, oocyte and embryo counts, and OCP. These negative outcomes were most profound in women with class-II/III obesity, ovulatory dysfunction, or PCOS.

Sleep, physical activity, waist circumference and diet as factors that influence health for reproductive age women in northern Greenland

BACKGROUND

This study explored community and individual factors that influence the health of reproductive age women in a settlement in northern Greenland. This is important because Greenland has a declining population, a high abortion rate and because of projected environmental shifts due to climate change.

METHODS

This study collected mixed methods data to explore diet, physical activity, sleep and waist circumference for reproductive age women in Kullorsuaq, Greenland. The daily steps and sleeping hours of 13 reproductive age women were measured using activity monitoring bracelets. Waist circumference measurements and in-depth interviews about daily eating and physical activity were conducted with 15 participants and ethnographic participant observations were recorded using field notes.

RESULTS

Waist circumference measurements were above recommended cutoffs established by the World Health Organization. Physical activity measured by daily steps was within the 'active' range using the cutoff points established by Tudor and Locke. Physical activity is social and is important for communal relationships. Sleeping hours were within normal ranges based on US guidelines; however, the quality of this sleep, its variability across seasons and cultural expectations of what healthy sleep means must be further explored. Diets of women included a mixture of locally harvested meats and imported packaged foods. Study participants experienced less satiety and reported getting hungrier faster when eating packaged foods. This research took place in Spring 2016 and women reported that their sleep, physical activity and diet fluctuate seasonally.

CONCLUSION

The reported findings suggest further investigation of sleep, diet and physical activity combined with the measurement of reproductive hormones to determine linkages between lifestyle factors and reproductive health outcomes is needed.

Effect of Body Weight on Metabolic Hormones and Fatty Acid Metabolism in Follicular Fluid of Women Undergoing In Vitro Fertilization: A Pilot Study

INTRODUCTION

Obesity is an epidemic affecting more than one-third of adults in the United States. Obese women experience decreased fertility, explained in part by oocyte quality. Since follicular fluid (FF) provides an important microenvironment for oocyte growth, we sought to evaluate the effect of increased body weight on FF levels of 11 metabolic hormones and fatty acid metabolism.

METHODS

The FF was collected from 25 women (10 normal weight, 10 overweight, and 5 obese) with diminished ovarian reserve undergoing in vitro fertilization (IVF) following a minimal stimulation protocol. Hormone levels were determined by multiplex immunoassay using the MAGPIX (Luminex, Austin, Texas) instrument. Fatty acid metabolites were determined using gas and ultra-high pressure liquid chromatography coupled with mass spectrometry.

RESULTS

Levels of hormones related to glucose and energy homeostasis and regulation of fat stores (insulin, glucagon, glucagon-like peptide-1, C-peptide, and leptin) were increased significantly in FF from obese women compared to FF from nonobese(normal weight and overweight) women. Interestingly, FF levels of branched-chain amino acids (BCAA) isoleucine, leucine, and valine as well as uric acid, isocaproic acid, butanoic acid, tyrosine, threonine, glycine, and methionine correlated positively with body mass index.

CONCLUSION

This pilot study demonstrates significant alterations in the FF milieu of obese women undergoing IVF, which may contribute to the decreased fecundity of obese women. Although the impact of this environment on oocyte and embryo development is not fully realized, these changes may also lead to imprinting at the genomic level and long-term sequelae on offspring.

One-year impact of bariatric surgery on serum anti-Mullerian-hormone levels in severely obese women

INTRODUCTION

Although bariatric surgery seems to increase spontaneous fertility by improving ovulatory function in young women, its impact on ovarian reserve remains largely unknown.

OBJECTIVE

To evaluate changes in serum anti-Mullerian hormone (AMH) levels in reproductive-age severely obese women after bariatric surgery (BS).

METHODS

AMH levels were measured retrospectively in 39 women (mean age 34.6 ± 1.1 years, range 18-45) that underwent a sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) at baseline, and 6 and 12 months after BS. Metabolic and micronutrient status, including fasting plasma insulin and glucose, HOMA-IR, leptin, adiponectin, calcium, albumin, transthyretin, ferritin, vitamins (B9, B12, B1, A, E, D), zinc, and selenium, were assessed in all patients before and 1 year after BS.

RESULTS

Of the patients, 79% had class-3 obesity. At 6 and 12 months, mean total weight losses (TWL) were 26 and 30%; mean excess weight losses (EWL) were 61.7 and 70.2%. Compared to baseline, AMH levels significantly decreased by 18% at 6 months, and 32% at 12 months post-operatively (p = 0.010 and p = 0.001, respectively). There was no correlation between AMH variation and changes in metabolic parameters or micronutrient levels. Remarkably, changes in AMH levels did not differ between sleeve and RYGB patients and were not correlated with EWL.

CONCLUSION

This pilot study shows a drastic reduction in AMH levels at 1 year after BS in reproductive-age severely obese women, which was not related to weight loss: this suggests a negative impact of BS on ovarian reserve, at least in the short term.

Review of post bariatric surgery effects on common genitourinary physiology

Background: Obesity is a worldwide challenging health problem. Weight loss through medical management of obesity has not always been successful, thus, giving rise to the need for surgical intervention. Bariatric surgery has been shown to be helpful for morbidly obese patients. However, studies have also shown the effect of surgery on stone formation, fertility and erectile function. This review summarizes the main findings of several studies that analyze stone formation and fertility in men as well as erectile function post bariatric surgery. The underlying pathophysiologic alterations post bariatric surgery include increased absorption of oxalate leading to hyperoxaluria, hypocitraturia and increased urinary calcium oxalate supersaturation. Contradicting data exist on the effect of bariatric surgery on fertility and erectile function. Further studies are needed to analyze the mechanisms.

Promoting healthy lifestyle in fertility clinics; an Australian perspective

STUDY QUESTION

Are Australian fertility clinics adequately addressing unhealthy lifestyle in patients seeking fertility treatment?

SUMMARY ANSWER

This study has highlighted deficiencies in practices and education around managing patients with unhealthy lifestyle undergoing fertility treatment.

WHAT IS KNOWN ALREADY

The association between lifestyle and fertility is well documented, with obesity and smoking being of particular concern to fertility and pregnancy outcomes. Guidelines recommend that unhealthy lifestyle is addressed prior to conception, yet anecdotal experience suggests this is not being addressed. Lifestyle modification programmes can be effective in improving pregnancy rates and outcomes, however, recruitment to such programmes can be challenging.

STUDY DESIGN SIZE, DURATION

A cohort study of Australian fertility clinics’ attitudes and practices regarding lifestyle modification to augment reproductive treatment outcomes was conducted between August and October 2015.

PARTICIPANTS/MATERIALS, SETTING, METHOD

An online survey was administered to senior fertility nurses, from all registered fertility clinics in Australia. Data were collated and subjected to a univariate data analysis, where frequency tables were produced for each question. A separate qualitative analysis was undertaken of data from open ended questions.

MAIN RESULTS AND THE ROLE OF CHANCE

Fifty-three out of 85 potential respondents (62.4%), all from different clincis, completed the survey, with almost all acknowledging the importance of addressing unhealthy lifestyle before offering ART treatment. However, most clinics did not offer internal resources to assist with lifestyle modification. Whilst the promotion of healthy lifestyle was recognised as a key component of the role of a fertility nurse, participants did not feel that nurses were best equipped to provide lifestyle modification programmes, owing to a lack of resources and specific skills in this area. Suggested areas for improved practice included prioritising general health prior to offering treatment, and further utilising and upskilling nurses to assist with lifestyle modification programmes.

LIMITATIONS REASONS FOR CAUTION

The survey was completed by only one nurse from each clinic and as such may not be entirely representative of all clinic practices.

WIDER IMPLICATIONS OF THE FINDINGS

Fertility clinics are likely to see an increasing number of patients with unhealthy lifestyle, resulting in health concerns such as obesity. The results of this study provide an insight into how unhealthy lifestyle is currently being addressed in fertility clinics and suggested areas that could be targeted for improving practice and outcomes.

STUDY FUNDING/COMPETING INTERESTS

No conflict of interest to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

TRIAL REGISTRATION NUMBER

NA

C-Reactive protein in relation to fecundability and anovulation among eumenorrheic women

OBJECTIVE

To assess systemic inflammation in relation to fecundability and anovulation.

DESIGN

Prospective cohort study among participants in the Effects of Aspirin in Gestation and Reproduction trial who were assigned to the placebo.

SETTING

Academic medical centers.

PATIENT(S)

Healthy eumenorrheic women (n = 572), 18-40 years of age, with one or two pregnancy losses, attempting spontaneous pregnancy.

INTERVENTION(S)

Baseline serum high-sensitivity C-reactive protein (hsCRP) values <10 mg/L were categorized into tertiles.

MAIN OUTCOME MEASURE(S)

Discrete Cox proportional hazards models estimated the fecundability odds ratio (FOR) and 95% confidence interval (CI) and adjusted for potential confounders. Log-binomial regression estimated the risk ratio (RR) and 95% CI of anovulation. The algorithm to define anovulation used data on urinary concentrations of hCG, pregnanediol-3-glucuronide, and LH as well as fertility monitor readings.

RESULT(S)

Higher hsCRP was associated with reduced fecundability but not with an increased risk of anovulation.

CONCLUSION(S)

Among healthy women attempting pregnancy after one or two pregnancy losses, we found preliminary evidence that systemic inflammation is associated with reduced fecundability, but not independently from adiposity. Sporadic anovulation did not appear to drive this association.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT00467363.

Obesity in Pregnancy: Optimizing Outcomes for Mom and Baby

Obesity is common in women of childbearing age, and management of this population around the time of pregnancy involves specific challenges. Weight and medical comorbidities should be optimized both before and during pregnancy. During pregnancy, gestational weight gain should be limited, comorbidities should be appropriately screened for and managed, and fetal health should be monitored. Consideration should be given to the optimal timing of delivery and to reducing surgical and anesthetic complications. In the postpartum period, breastfeeding and weight loss should be promoted. Maternal obesity is associated with adverse metabolic effects in offspring, promoting an intergenerational cycle of obesity.

Obesity and Outcome of Assisted Reproduction in Patients With Polycystic Ovary Syndrome

Assisted reproduction, including in vitro fertilization and intracytoplasmic sperm injection, is increasingly being used for the management of infertility in patients with polycystic ovary syndrome (PCOS). However, there are limited data regarding the association between obesity and the outcome of assisted reproduction in this specific population as well as on the effects of weight loss. The aim of the present review is to summarize the existing evidence on the association between obesity and the outcome of assisted reproduction in patients with PCOS. Accumulating data suggest that obesity is associated with lower pregnancy and live birth rates in patients with PCOS who are undergoing assisted reproduction therapy. However, it remains unclear whether weight loss improves the outcome of this therapy. Notably, recent guidelines state that the health benefits of postponing pregnancy to achieve weight loss must be balanced against the risk of declining fertility with advancing age. Therefore, if weight loss is not achieved within a reasonable time period, assisted reproduction therapy should be offered in adequately selected patients with PCOS, regardless of the presence of obesity.

Should high BMI be a reason for IVF treatment denial?

Our aim was to examine the influence of BMI on the live-birth rate following IVF/ICSI and evaluate its specific contribution among other factors thus enabling accurate reproductive policy development. All patients that underwent IVF/ICSI at our center during January 2012-July 2015 were included in this retrospective study. A total of 1654 ICSI cycles were divided into four groups according to the patient's BMI (kg/m²): group I (normal weight): <25 (943 cycles); group II (overweight): 25-30 (403 cycles); group III (obese): 30-35 (212 cycles); group IV (morbid obesity): >35 (96 cycles). Comparing the four groups of BMI, mean age and number of previous ART cycles was significantly lower in group I compared to groups II, III and IV. Length of treatment was significantly shorter in group I compared to groups II, III and IV. Ovarian response to COH was comparable in terms of mean estradiol and progesterone levels on the day of hCG administration mean number of oocytes retrieved, fertilized and number of embryos transferred. Endometrial thickness was significantly lower in group IV. Outcome measures, such as implantation rate, clinical pregnancy rate (CPR) per cycle and per ET, as well as live-birth rates did not differ significantly between the groups, although in group IV LBR per cycle and per ET was lower. Multivariate logistic regression stepwise analysis found a significant correlation between age and BMI but did not find correlation between BMI and clinical pregnancy (p = 0.436) or LB (p = 0.206). The results of our relatively large retrospective study did not demonstrate a significant impact of BMI on the ART cycle outcome. Therefore, BMI should not be a basis for IVF treatment denial.

The diagnosis of male infertility: an analysis of the evidence to support the development of global WHO guidance-challenges and future research opportunities

BACKGROUND

Herein, we describe the consensus guideline methodology, summarize the evidence-based recommendations we provided to the World Health Organization (WHO) for their consideration in the development of global guidance and present a narrative review of the diagnosis of male infertility as related to the eight prioritized (problem or population (P), intervention (I), comparison (C) and outcome(s) (O) (PICO)) questions. Additionally, we discuss the challenges and research gaps identified during the synthesis of this evidence.

OBJECTIVE AND RATIONALE

The aim of this paper is to present an evidence-based approach for the diagnosis of male infertility as related to the eight prioritized PICO questions.

SEARCH METHODS

Collating the evidence to support providing recommendations involved a collaborative process as developed by WHO, namely: identification of priority questions and critical outcomes; retrieval of up-to-date evidence and existing guidelines; assessment and synthesis of the evidence; and the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation the quality of the supporting evidence was then graded and assessed for consideration during a WHO consensus.

OUTCOMES

Evidence was synthesized and recommendations were drafted to address the diagnosis of male infertility specifically encompassing the following: What is the prevalence of male infertility and what proportion of infertility is attributable to the male? Is it necessary for all infertile men to undergo a thorough evaluation? What is the clinical (ART/non ART) value of traditional semen parameters? What key male lifestyle factors impact on fertility (focusing on obesity, heat and tobacco smoking)? Do supplementary oral antioxidants or herbal therapies significantly influence fertility outcomes for infertile men? What are the evidence-based criteria for genetic screening of infertile men? How does a history of neoplasia and related treatments in the male impact on (his and his partner's) reproductive health and fertility options? And lastly, what is the impact of varicocele on male fertility and does correction of varicocele improve semen parameters and/or fertility?

WIDER IMPLICATIONS

This evidence synthesis analysis has been conducted in a manner to be considered for global applicability for the diagnosis of male infertility.

Contraception and Conception After Bariatric Surgery

OBJECTIVE

To examine contraceptive practices and conception rates after bariatric surgery.

METHODS

The Longitudinal Assessment of Bariatric Surgery-2 is a multicenter, prospective cohort study of adults undergoing first-time bariatric surgery as part of routine clinical care at 10 U.S. hospitals. Recruitment occurred between 2005 and 2009. Participants completed preoperative and annual postsurgical assessments for up to 7 years until January 2015. This report was restricted to women 18-44 years old with no history of menopause, hysterectomy, or estrogen and progesterone therapy. Primary outcomes were self-reported contraceptive practices, overall conception rate, and early (less than 18 months) postsurgical conception. Contraceptive practice (no intercourse, protected intercourse, unprotected intercourse, or tried to conceive) was classified based on the preceding year. Conception rates were determined from self-reported pregnancies.

RESULTS

Of 740 eligible women, 710 (95.9%) completed follow-up assessment(s). Median (interquartile range) preoperative age was 34 (30-39) years. In the first postsurgical year, 12.7% (95% CI 9.4-16.0) of women had no intercourse, 40.5% (95% CI 35.6-45.4) had protected intercourse only, 41.5% (95% CI 36.4-46.6) had unprotected intercourse while not trying to conceive, and 4.3% (95% CI 2.4-6.3) tried to conceive. The prevalence of the first three groups did not significantly differ across the 7 years of follow-up (P for all >.05); however, more women tried to conceive in the second year (13.1%, 95% CI 9.3-17.0; P<.001). The conception rate was 53.8 (95% CI 40.0-71.1) per 1,000 woman-years across follow-up (median [interquartile range] 6.5 [5.9-7.0] years); 42.3 (95% CI 30.2-57.6) per 1,000 woman-years in the 18 months after surgery. Age (adjusted relative risk 0.41 [95% CI 0.19-0.89] per 10 years, P=.03), being married or living as married (adjusted relative risk 4.76 [95% CI 2.02-11.21], P<.001), and rating future pregnancy as important preoperatively (adjusted relative risk 8.50 [95% CI 2.92-24.75], P<.001) were associated with early conception.

CONCLUSIONS

Postsurgical contraceptive use and conception rates do not reflect recommendations for an 18-month delay in conception after bariatric surgery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT00465829.

Body Mass Index Effects Kruger's Criteria in Infertile Men

Background

The aim of this study is to evaluate the relationship between sperm parameters and body mass index (BMI) in the male spouses with infertility complaints, who had reffered to our clinic.

Materials and Methods

The male spouses from 159 couples reffering to our clinic because of infertility, during a six-month period, were included in the study. In this prospective case control study, the included men were catego- rized as non-obese (BMI<25 kg/m²), overweight (BMI 25-29 kg/m²) and obese (BMI ≥30 kg/m²) according to their BMIs. The assessed sperm parameters consisted of; sperm concentration, Kruger morphology, progressive motility level, and volume pH levels. The statistical significant level was set as less than 0.05 .

Results

The assessed group consisted of 159 patients applying to our clinic with infertility symptoms. Fifty-three non-obese, 53 overweight and 53 obese men were eligible for the study. There was statistically significant differences in sperm volume (P<0.001), progressive motility (P<0.001), postwash sperm count (P<0.001) and Kruger (P<0.001) morphology among the patient groups grouping according to the BMI levels.

Conclusion

In this study, increased BMI was associated with decreased semen quality, affecting volume, concentra- tion, and motility. further studies with a wider range of prospective cases need to be conducted in order to investigate the effects on male fertility in more detail.

The adverse effect of overweight in assisted reproduction treatment outcomes

OBJECTIVE

To assess Body Mass Index (BMI) effects on the results obtained from ICSI cycles.

METHODS

We studied 266 ICSI cycles performed between January 2014 and December 2016. The patients were grouped according to their BMI in: Normal (18.5-24.9), Overweight (25.0-29.9) and Obese (>30). We compared the following variables between the groups: number of antral follicles, ovarian stimulation length, gonadotropin dose used, maximum estradiol level, follicles developed/antral follicles, retrieved oocytes/developed follicles and mature/retrieved oocytes, normal fertilization rate, embryo achieved/normal fertilized oocytes, clinical pregnancy and implantation rates. We used the Kruskal-Wallis and the Chi square tests. p<0.05 was considered significant.

RESULTS

Normal, Overweight and Obese patients presented comparable values for number of antral follicles (11.6±5.4, 12.5±5.5, 12.2±5.7), ovarian stimulation length (7.5±1.4, 7.6±1.1, 7.8±1.3) and gonadotropin dose used (2043±489, 1940±536, 2109±605). Obese patients had lower values of estradiol (1560±610, 1511±635, 1190±466; p=0.018), developed follicles (81%, 76%, 70%; p<0.0001), and retrieved oocytes (91%, 90%, 84%; p=0.0017); and not significantly lower values of mature oocytes (82%, 82%, 77%; p=0.26). The groups had comparable fertilization rates (72%, 73%, 69%) and embryo achieved rates (67%, 63%, 72%). The normal group had higher, but not significantly higher pregnancy and implantation rates (43%, 40%, 38%, p=0.53; and 33%, 26%, 23%; p=0.11), and significantly higher ongoing pregnancy rates (37%, 33%, 33%, p=0.042).

CONCLUSION

Increased BMI patients had impaired ovarian response and lower pregnancy rates in ICSI cycles.

Management of weight loss in obesity-associated male infertility: a spotlight on bariatric surgery

In recent years, there has been a paralleled increase between male obesity and infertility rates. Obesity is associated with impaired hypothalamic-pituitary-gonadal axis, aberrant semen parameters, and subfertility or infertility. Weight loss is strongly recommended for the management of obesity-associated infertility. Lifestyle modifications that include caloric restriction and increased physical activity have a short-lived impact. Bariatric surgery is a better and more durable weight loss alternative. Comprehensive information about the benefits of weight loss on obesity-associated male infertility following bariatric surgery is still emerging. In this review, we discuss the hormonal, physical and environmental mechanism contributing to obesity-associated infertility. We then assess weight loss approaches, which include lifestyle modification, medical and surgical approaches, that can improve fertility in obese men. This review focuses also on bariatric surgery for the management of obese men seeking fertility treatment. Anecdotal evidence suggesting that bariatric surgery can impair fertility is also discussed.

Morbid obesity and pregnancy outcomes after single blastocyst transfer: a retrospective, North American study

PURPOSE

Maternal obesity has been shown to affect reproductive function and pregnancy outcomes following in vitro fertilization. More recently, studies have demonstrated lower live birth rates after single blastocyst transfer (SBT) in patients who are overweight or obese. However, the impact of morbid obesity on pregnancy outcomes after SBT has not been well elucidated. The present study aimed to determine whether morbid obesity has a detrimental impact on pregnancy outcomes after SBT in a North American population.

METHODS

A retrospective, cohort study including 520 nulliparous and multiparous women undergoing top-quality SBT between August 2010 and March 2014 at a University Health Centre in North America was conducted. Primary outcomes included: miscarriage rate, clinical pregnancy rate, and live birth rate. Subjects were divided into different BMI categories (kg/m²), including <20, 20-24.9, 25.0-29.9, 30-40, and 40 or more.

RESULTS

The miscarriage rate per pregnancy for each group, respectively, was 36, 64, 59, 61, and 50% (p = 0.16); the clinical pregnancy (per patient) rate per group was 36, 52, 38, 26, and 10% (p = 0.009); and the live birth rate (per patient) per group was 35, 50, 38, 26 and 10% (p = 0.03).

CONCLUSION

Morbid obesity is a strong and independent predictor of poor pregnancy outcomes in patients undergoing top-quality SBT.

Relationship between obesity and anti-Müllerian hormone in reproductive-aged African American women

OBJECTIVE

To determine whether there is an association between obesity and anti-Müllerian hormone (AMH) among reproductive-aged African American women (AAW).

METHODS

From the women participating in an ongoing National Institute of Environmental Health Sciences study, 1,654 AAW aged 23 to 35 were included in this study. Anthropometric measurements, personal health information, and serum AMH and adipokine levels were analyzed.

RESULTS

The median body mass index (BMI) was 32.4 kg/m2 , and the median AMH was 3.18 ng/mL. Participants with obesity had AMH concentrations that were 23.7% lower than those with a BMI ≤25 kg/m2 (2.9 ng/mL vs. 3.8 ng/mL). In multivariable linear regression models, current BMI (β = -0.015; 95% CI -0.021 to -0.009), BMI at age 18 (β = -0.016; 95% CI -0.024 to -0.008), heaviest reported lifetime weight (β = -0.002; 95% CI -0.003 to -0.001), and leptin (β = -0.016; 95% CI -0.025 to -0.007) were inversely associated with AMH. There was no significant association between adiponectin and AMH. AMH was significantly lower (mean log = 0.91, SE = 0.11) in participants with obesity at age 18 and at enrollment when compared with those who were underweight or normal weight at age 18 but had obesity at enrollment (mean log = 1.16, SE = 0.12).

CONCLUSIONS

In reproductive-aged AAW there is a significant association between obesity and AMH, suggesting that excess adiposity may compromise ovarian reserve. Effects of obesity on AMH may be cumulative.

Transmission of Metabolic Dysfunction Across Generations

Recent human and animal studies investigating the roles of the genome, epigenome, and environmental cues have identified associations between offspring predisposition to life-long obesity/metabolic disease and epigenetic modifications such as DNA methylation. This review explores the mechanisms by which maternal exposures impair the health of not only the next generation but also potentially future generations of offspring.

Hormone-Based Treatments in Subfertile Males

Subfertility is defined as the condition of being less than normally fertile though still capable of effecting fertilization. When these subfertile couples seek assistance for conception, a thorough evaluation of male endocrine function is often overlooked. Spermatogenesis is a complex process where even subtle alterations in this process can lead to subfertility or infertility. Male endocrine abnormalities may suggest a specific diagnosis contributing to subfertility; however, in many patients, the underlying etiology is still unknown. Optimizing underlying endocrine abnormalities may improve spermatogenesis and fertility. This manuscript reviews reproductive endocrine abnormalities and hormone-based treatments.

Effectiveness of lifestyle intervention in subgroups of obese infertile women: a subgroup analysis of a RCT

STUDY QUESTION

Do age, ovulatory status, severity of obesity and body fat distribution affect the effectiveness of lifestyle intervention in obese infertile women?

SUMMARY ANSWER

We did not identify a subgroup in which lifestyle intervention increased the healthy live birth rate however it did increase the natural conception rate in anovulatory obese infertile women.

WHAT IS KNOWN ALREADY

Obese women are at increased risk of infertility and are less likely to conceive after infertility treatment. We previously demonstrated that a 6-month lifestyle intervention preceding infertility treatment did not increase the rate of healthy live births (vaginal live birth of a healthy singleton at term) within 24 months of follow-up as compared to prompt infertility treatment in obese infertile women. Natural conceptions occurred more frequently in women who received a 6-month lifestyle intervention preceding infertility treatment.

STUDY DESIGN, SIZE, DURATION

This is a secondary analysis of a multicentre RCT (randomized controlled trial), the LIFEstyle study. Between 2009 and 2012, 577 obese infertile women were randomly assigned to a 6-month lifestyle intervention followed by infertility treatment (intervention group) or to prompt infertility treatment (control group). Subgroups were predefined in the study protocol, based on frequently used cut-off values in the literature: age (≥36 or <36 years), ovulatory status (anovulatory or ovulatory), BMI (≥35 or <35 kg/m²) and waist-hip (WH) ratio (≥0.8 or <0.8).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data of 564 (98%) randomized women who completed follow-up were analyzed. We studied the effect of the intervention program in various subgroups on healthy live birth rate within 24 months, as well as the rate of overall live births (live births independent of gestational age, mode of delivery and health) and natural conceptions within 24 months. Live birth rates included pregnancies resulting from both treatment dependent and natural conceptions. Logistic regression models with randomization group, subgroup and the interaction between randomization group and subgroup were used. Significant interaction was defined as a P-value <0.1.

MAIN RESULTS AND THE ROLE OF CHANCE

Neither maternal age, ovulatory status nor BMI had an impact on the healthy live birth rate within 24 months, nor did they influence the overall live birth rate within 24 months after randomization. WH ratio showed a significant interaction with the effect of lifestyle intervention on healthy live birth rate (P = 0.05), resulting in a lower healthy live birth rate in women with a WH ratio <0.8. WH ratio had no interaction regarding overall live birth rate (P = 0.27) or natural conception rate (P = 0.38). In anovulatory women, the effect of lifestyle intervention resulted in more natural conceptions compared to ovulatory women (P-value for interaction = 0.02). There was no interaction between other subgroups and the effect of the intervention on the rate of natural conception.

LIMITATIONS, REASONS FOR CAUTION

Since this was a subgroup analysis of a RCT and sample size determination of the trial was based on the primary outcome of the study, the study was not powered for analyses of all subgroups.

WIDER IMPLICATIONS OF THE FINDINGS

Our finding that lifestyle intervention leads to increased natural conception in anovulatory obese women could be used in the counselling of these women, but requires further research using an appropriately powered study in order to confirm this result.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by a grant from ZonMw, the Dutch Organisation for Health Research and Development (50-50110-96-518). The Department of Obstetrics and Gynaecology of the UMCG received an unrestricted educational grant from Ferring pharmaceuticals BV, The Netherlands. Ben Mol is a consultant for ObsEva, Geneva. Annemieke Hoek received a speaker's fee for a postgraduate education from MSD pharmaceutical company, outside the submitted work.

TRIAL REGISTRATION NUMBER

The LIFEstyle study was registered at the Dutch trial registry (NTR 1530).

Randomized Trial of a Lifestyle Program in Obese Infertile Women

BACKGROUND

Small lifestyle-intervention studies suggest that modest weight loss increases the chance of conception and may improve perinatal outcomes, but large randomized, controlled trials are lacking.

METHODS

We randomly assigned infertile women with a body-mass index (the weight in kilograms divided by the square of the height in meters) of 29 or higher to a 6-month lifestyle intervention preceding treatment for infertility or to prompt treatment for infertility. The primary outcome was the vaginal birth of a healthy singleton at term within 24 months after randomization.

RESULTS

We assigned women who did not conceive naturally to one of two treatment strategies: 290 women were assigned to a 6-month lifestyle-intervention program preceding 18 months of infertility treatment (intervention group) and 287 were assigned to prompt infertility treatment for 24 months (control group). A total of 3 women withdrew consent, so 289 women in the intervention group and 285 women in the control group were included in the analysis. The discontinuation rate in the intervention group was 21.8%. In intention-to-treat analyses, the mean weight loss was 4.4 kg in the intervention group and 1.1 kg in the control group (P<0.001). The primary outcome occurred in 27.1% of the women in the intervention group and 35.2% of those in the control group (rate ratio in the intervention group, 0.77; 95% confidence interval, 0.60 to 0.99).

CONCLUSIONS

In obese infertile women, a lifestyle intervention preceding infertility treatment, as compared with prompt infertility treatment, did not result in higher rates of a vaginal birth of a healthy singleton at term within 24 months after randomization. (Funded by the Netherlands Organization for Health Research and Development; Netherlands Trial Register number, NTR1530.).

Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause, and Beyond

OBJECTIVES

To provide health care professionals in Canada with the basic knowledge and tools to provide nutrition guidance to women through their lifecycle.

OUTCOMES

Optimal nutrition through the female lifecycle was evaluated, with specific focus on adolescence, pre-conception, pregnancy, postpartum, menopause, and beyond. The guideline begins with an overview of guidance for all women, followed by chapters that examine the evidence and provide recommendations for the promotion of healthy nutrition and body weight at each life stage. Nutrients of special concern and other considerations unique to each life stage are discussed in each chapter.

EVIDENCE

Published literature, governmental and health agency reports, clinical practice guidelines, grey literature, and textbook sources were used in supporting the recommendations made in this document.

VALUES

The quality of evidence was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. CHAPTER 2: GENERAL FEMALE NUTRITION: Summary Statements Recommendations CHAPTER 3: ADOLESCENCE NUTRITION: Summary Statements Recommendations CHAPTER 4: PRE-CONCEPTUAL NUTRITION: Summary Statement Recommendations CHAPTER 5: NUTRITION IN PREGNANCY: Summary Statements Recommendations CHAPTER 6: POSTPARTUM NUTRITION AND LACTATION: Summary Statements Recommendations CHAPTER 7: NUTRITION DURING MENOPAUSE AND BEYOND: Summary Statement Recommendations.

CpG Oligodeoxynucleotides Downregulate Placental Adiponectin and Increase Embryo Loss in Non-Obese Diabetic Mice

PROBLEM

CpG oligodeoxynucleotides (ODNs) can induce immunological changes in non-obese diabetic (NOD) mice and increase embryo loss, but little is known about the mechanism. This study aimed to determine the role of adiponectin in CpG ODN-induced pregnancy failure.

METHOD OF STUDY

Oligodeoxynucleotide 1826 was intraperitoneally injected to NOD mice, and ODN 2216, ODN 2006, and ODN 2395 were used to stimulate human trophoblast cell lines to investigate adiponectin expression patterns and its possible effects on trophoblast function.

RESULTS

CpG ODNs downregulated adiponectin via the cJun N-terminal kinase signaling pathway and led to increased embryo loss (from 6.9 to 33.3%). ODN 2006 impaired human trophoblast cell migration, which was successfully rescued by adiponectin treatment.

CONCLUSION

CpG ODNs decreased placental adiponectin expression in NOD mice and impaired human trophoblast function and was associated with increased embryo loss. Adiponectin may therefore play an important protective role in the prevention of bacteria-induced pregnancy failure.