Clinical management of females seeking fertility treatment and of pregnant females with eating disorders

Nutritional and exercise interventions to improve conception in women suffering from obesity and distinct nosological entities

Infertility among women, particularly those living with obesity, presents a multifaceted challenge with implications for reproductive health worldwide. Lifestyle interventions, mainly focusing on weight loss, have emerged as promising strategies to improve fertility outcomes in this population. This review aims to explore the effectiveness of various lifestyle interventions, encompassing dietary modifications and exercise regimens, in enhancing fertility outcomes among women with obesity and associated conditions such as polycystic ovary syndrome, congenital adrenal hyperplasia, type 2 diabetes mellitus, premenopause, hypothyroidism and eating disorders. Methodology of study search encompass a broad spectrum, ranging from interventions targeting weight management through slow or rapid weight loss to dietary approaches emphasizing whole food groups, specific nutrients, and dietary patterns like low-carbohydrate or ketogenic diets, as well as the Mediterranean diet. By synthesizing existing findings and recommendations, this review contributes to the understanding of lifestyle interventions in addressing infertility, with an emphasis on the population of women of reproductive age with excess weight and known or unknown infertility issues, while promoting their integration into clinical practice to optimize reproductive health and overall well-being.

IVF-induced pregnancy and early motherhood among women with a history of severe eating disorders

Background

There is a higher prevalence of eating disorders among women seeking in vitro fertilization (IVF). Women with a history of eating disorders may be particularly vulnerable to eating disorder relapse during IVF, pregnancy, and early motherhood. The experience of these women during this process has hardly been studied scientifically, despite its high clinical relevance. The overall aim of this study is to describe how women with a history of eating disorders experience the process of becoming a mother through IVF, pregnancy, and the postpartum period.

Methods

We recruited women with a history of severe anorexia nervosa who had undergone IVF (n = 7) at public family health centers in Norway. Semi-openly, the participants were interviewed extensively first during pregnancy, and then 6 months after birth. The 14 narratives were analyzed using interpretative phenomenological analyses (IPA). All participants were required to complete the Eating Disorder Examination Questionnaire (EDE-Q) and were diagnosed (DSM-5) by using the Eating Disorder Examination (EDE), during both pregnancy and postpartum.

Results

All participants experienced a relapse of an eating disorder during IVF. They perceived IVF, pregnancy, and early motherhood to be overwhelming, confusing, a source of severe loss of control, and a source of body alienation. There were four core phenomena that were reported that were strikingly similar across all participants: "anxiousness and fear," "shame and guilt," "sexual maladjustment," and "non-disclosure of eating problems." These phenomena persisted continuously throughout IVF, pregnancy, and motherhood.

Conclusion

Women with a history of severe eating disorders are highly susceptible to relapse when undergoing IVF, pregnancy, and early motherhood. The process of IVF is experienced as extremely demanding and provoking. There is evidence that eating problems, purging, over-exercising, anxiousness and fear, shame and guilt, sexual maladjustment, and non-disclosure of eating problems continue throughout IVF, pregnancy, and the early years of motherhood. Therefore, it is necessary for healthcare workers providing services to women undergoing IVF to be attentive and intervene when they suspect a history of eating disorders.

Effectors of Pregorexia and Emesis among Pregnant Women: A Pilot Study

During pregnancy, women tend to improve their lifestyle habits and refine their dietary intake. Quite often, however, these dietary improvements take an unhealthy turn, with orthorexia nervosa (ON) practices being apparent. The aim of the present pilot cross-sectional study was to assess the prevalence of ON tendencies and the incidence of pica and record diet practices in a sample of pregnant women. A total of 157 pregnant women were recruited through private practice gynecologists during the first months of 2021. Nutrition-related practices were recorded, orthorexic tendencies were assessed using the translated and culturally adapted Greek version of the ORTO-15 questionnaire, pica practices were evaluated with a binary question and nausea and emesis during pregnancy (NVP) was evaluated using the translated modified Pregnancy-Unique Quantification of Emesis and Nausea (mPUQE). Only two women reported pica tendencies, with ice and snow being the consumed items. The majority (61.1%) of women reported improving their diet since conception was achieved. Folic acid and iron oral nutrient supplements (ONS) were reportedly consumed by the majority of participants (87.9% and 72.6%, respectively) and 9.6% reported using herbal medicine products. The ORTO-15 score was reduced with tertiary education attainment, ART conception, being in the third trimester of pregnancy, consumption of folic acid and MV supplements and was only increased among women who were at their first pregnancy. The majority of participants experienced severe NVP and the remaining experienced moderate NVP. NVP was associated with lower hemoglobin levels, lack of supplementary iron intake, avoidance of gluten-containing foods, as well as with increased gestational weight gain. The results highlight the need to screen pregnant women for disturbed eating behaviors and nutrition-related problems, in order to ensure a healthy pregnancy outcome.

Understanding the Effects of Disordered Eating on Fertility and Fertility Outcomes

Disordered eating and subthreshold eating disorders can affect fertility. A negative cumulative energy balance that occurs through inadequate nutrition and excessive exercise is often found in individuals engaging in disordered eating behaviors; these disruptions can affect the normal functioning of the hypothalamic-pituitary-gonadal axis and, thus, fertility. Appropriate screening; assessment; and medical, nutritional, and psychosocial interventions are needed to successfully treat these individuals. Educating nurses about the impact of disordered eating on fertility status will enable those who work with clients of reproductive age to better recognize signs and symptoms of disordered eating and to ultimately provide better care. This article addresses how to appropriately recognize and treat individuals presenting with infertility and disordered eating symptomatology.

Prevalence and phenotype of eating disorders in assisted reproduction: a systematic review

Background

Eating disorders (EDs) are common conditions that mainly affect women of reproductive age and have a major impact on fertility. Our systematic review focuses on the prevalence of EDs in patients in the process of assisted reproductive technique (ART) and describes the phenotypes of EDs identified.

Methods

Our systematic review is based on the PRISMA criteria. Articles were collected using the Medline/Pubmed, Web Of Science and Cochrane databases. The articles chosen had to mention the prevalence of ED in infertile patients undergoing ART and be cohort or case–control studies assessing the prevalence of ED during fertility treatment.

Main findings

Fifteen articles were included in this review. The prevalence of active ED varied between 0.13 and 44% depending on the types considered in each study. The main phenotypes described were EDNOS (eating disorder not otherwise specified) and binge eating disorders (BED) occurring in women with a normal body mass index (BMI) and a history of ED. Mainly subthreshold forms with cognitive distortions were described.

Conclusion

This review highlights a 6 times higher prevalence of EDs in infertile patients undergoing fertility treatment compared to regular pregnant women. However, diagnosing these conditions is complex. As a result, it is essential that professionals in contact with this population are alert to symptoms consistent with these conditions in order to refer them to specialized psychiatric care.

Eating disorders are frequent pathologies that primarily affect women of childbearing age. Numerous articles reveal an increased risk for the mother and the child in case of an active disorder during pregnancy.

We conducted a systematic review to determine the prevalence and phenotypes of eating disorders in infertile subjects undergoing fertility treatment.

The results of the fifteen articles included show a prevalence six times higher than in pregnant women in the general population. Subjects with eating disorders have normal body mass indexes. The active forms are mainly characterized by episodes of binge eating disorders or other unspecified forms. Studies also describe incomplete forms characterized by the presence of dysfunctional thoughts around shape and weight without associated compensatory behavior.

Professionals working in the field of reproductive medicine and providing fertility treatment have a major role to play in identifying and referring these subjects at risk to specialized care.

Disordered eating and eating disorders among women seeking fertility treatment: A systematic review

The purpose of this systematic review is to evaluate the prevalence of disordered eating and eating disorders among women seeking fertility treatment.Observational studies were searched in Ovid MEDLINE, Web of Science, Embase, and PsycInfo. Studies published prior to September 2020 when the search was conducted were considered. Inclusion criteria included (1) original and empirical research, (2) published in a peer-reviewed journal, and (3) reported on disordered eating among women seeking fertility treatment in the sample or reported on prevalence of eating disorders among women seeking fertility treatment in the sample. Independent screening of abstracts was conducted by two authors (LH and AH). Ten studies met the inclusion criteria. Sample size, study location, measures, and results for each study in this review were reported.Among women pursuing fertility treatment, rates of current eating disorders ranged from 0.5 to 16.7%, while past eating disorder prevalence rates ranged from 1.4 to 27.5%. Current anorexia nervosa or bulimia nervosa was reported by up to 2% and 10.3% of women, respectively, while history of anorexia nervosa or bulimia nervosa was reported by up to 8.5% and 3.3% of women, respectively. Binge eating disorder or other eating disorders were reported by up to 18.5% and 9.1% of women, respectively. Disordered eating pathology was endorsed by 1.6 to 48% of women seeking fertility treatment. Endorsement of pathological eating attitudes was generally higher among women seeking fertility treatment with current or past eating disorders as compared to community samples, with the exception of dietary restraint. Rates of current and past eating disorders are higher among women seeking fertility treatment than in the general population. Providers treating women with infertility should be cognizant of these prevalence rates and consider screening for eating pathology in their patients as this may contribute to their likelihood of successful conception and/or subsequent pregnancy outcomes.

Development and validation across trimester of the Prenatal Eating Behaviors Screening tool

Rapid screening tools are useful for identifying at-risk patients and referring them for further assessment and treatment, but none exist that consider the unique medical needs of pregnant women with eating disorders (EDs). There is a need for a rapid, sensitive, and specific screening tool that can be used to identify a potential ED in pregnancy. We started with a set of 25 questions, developed from our qualitative work along with other ED screening tools, and tested on a development (n = 190) and validation sample (n = 167). Statistical analysis included factor analysis and logistic regressions with ROC curves. Development and validation samples were combined for trimester analysis (n = 357). Refining the tool to 12 items demonstrated strong internal reliability (development alpha = 0.95, validation alpha = 0.91). With correlated errors, questions demonstrated acceptable CFA fit (development: GFI: 0.91, RMSEA: 0.10, NNFI: 0.95; validation: GFI: 0.85, RMSEA: 0.14, NNFI: 0.86). Similar fits were seen by trimester: first trimester n = 127, GFI: 0.89, RMSEA: 0.12, NNFI: 0.94; second trimester n = 150, GFI: 0.83, RMSEA: 0.14, NNFI: 0.88; third trimester n = 80, GFI: 0.99, NNFI: 0.99. Validation against current ED diagnosis demonstrated acceptable sensitivity and specificity using a cutoff of 39 (development sensitivity = 80.7%, specificity = 79.7%, OR = 16.42, 95% CI: 7.51, 35.88; validation sensitivity = 69.2%, specificity = 86.5%, OR: 17.43, 95% CI: 6.46, 47.01). Findings suggest the PEBS tool can reliably and sensitively detect EDs across pregnancy trimesters with 12 questions. A further implication of this work is to reduce health and mental health treatment disparities through this standard and rapid screening measure to ensure early identification and treatment.

Prevalence of lifetime eating disorders in infertile women seeking pregnancy with pulsatile gonadotropin-releasing hormone therapy

OBJECTIVES

Relationships between weight and fertility are well known. The aim of this study is to assess the prevalence of lifetime eating disorder (ED) in a sample of infertile women seeking a specific infertility treatment, pulsatile gonadotropin-releasing hormone (pGnRH) treatment, and to compare it to the prevalence of lifetime ED in a sample of infertile women seeking other types of assisted reproductive technology (ART) treatments.

DESIGN

Non-randomized, observational study including infertile female patients. Two-group design including consecutive women treated with GnRH pump (pGnRH) or with other types of ART.

SETTING

Multi-centric infertility centers, France METHODS: Twenty one consecutive women treated with pGnRH treatment were compared to 21 consecutive women receiving other types of infertility treatment. Diagnosis of ED was based on DSM-IV and the Composite International Diagnostic Interview (CIDI).

RESULTS

Twenty patients (95.2%) from the sample of women treated with pulsatile GnRH treatment and 5 patients (23.8%) from the patients receiving other types of infertility treatment met the criteria of lifetime ED diagnosis (p < 0.000).

CONCLUSION

This study highlights the fact that the prevalence of ED is considerably higher in women receiving GnRH pulsatile treatment, when compared to women receiving other kinds of infertility treatment. In our study population ED were under-diagnosed, particularly in women receiving pulsatile GnRH treatment. Fertility clinicians should use reliable diagnostic tools to identify promptly ED in women presenting with hypothalamic amenorrhea and difficulties in conceiving. Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

The effect of underweight on female and male reproduction

Chronic energy deficiency can impair the hypothalamic-pituitary-gonadal (HPG) axis and lead to hypothalamic anovulation in underweight women. This review presents the syndromes related to underweight status that are associated with infertility, summarizes the underlying mechanisms, and reviews the available treatment options. Eating disorders, such as anorexia nervosa (AN), constitute the most common cause of infertility in underweight women, who, in addition, experience miscarriages, and sexual dysfunction. The relative energy deficiency in sports (RED-S; former terminology: athlete's triad) involves menstrual dysfunction due to low energy availability, which results in anovulation. Moreover, lipodystrophies, malnutrition, starvation, systematic illnesses (malignancies, endocrinopathies, infectious diseases, advanced chronic diseases, neurologic illnesses), and the utilization of drugs can cause excessive weight loss. They may result in fertility problems due to the loss of adipose tissue and the subsequent hormonal disturbances. Each of these conditions requires multidisciplinary management. Nutritional counseling should target the restoration of energy balance by increasing intake and reducing output. Medical treatment, recommended only for patients who did not respond to standard treatment, may include antipsychotics, antidepressants, or leptin administration. Finally, psychiatric treatment is considered an integral part of the standard treatment.

Eating Disorders During Gestation: Implications for Mother's Health, Fetal Outcomes, and Epigenetic Changes

Introduction: Eating disorders (EDs) have increased globally in women of childbearing age, related to the concern for body shape promoted in industrialized countries. Pregnancy may exacerbate a previous ED or conversely may be a chance for improving eating patterns due to the mother's concern for the unborn baby. EDs may impact pregnancy evolution and increase the risk of adverse outcomes such as miscarriage, preterm delivery, poor fetal growth, or malformations, but the knowledge on this topic is limited. Methods: We performed a systematic review of studies on humans in order to clarify the mechanisms underpinning the adverse pregnancy outcomes in patients with EDs. Results: Although unfavorable fetal development could be multifactorial, maternal malnutrition, altered hormonal pathways, low pre-pregnancy body mass index, and poor gestational weight gain, combined with maternal psychopathology and stress, may impair the evolution of pregnancy. Environmental factors such as malnutrition or substance of abuse may also induce epigenetic changes in the fetal epigenome, which mark lifelong health concerns in offspring. Conclusions: The precocious detection of dysfunctional eating behaviors in the pre-pregnancy period and an early multidisciplinary approach comprised of nutritional support, psychotherapeutic techniques, and the use of psychotropics if necessary, would prevent lifelong morbidity for both mother and fetus. Further prospective studies with large sample sizes are needed in order to design a structured intervention during every stage of pregnancy and in the postpartum period.

The Impact of Maternal Eating Disorders on Dietary Intake and Eating Patterns during Pregnancy: A Systematic Review

Maternal nutrition in pregnancy has a key influence on optimum fetal health. Eating disorders (EDs) during pregnancy may have detrimental effects on fetal growth and the child’s early development. There is limited knowledge concerning the eating behavior, dietary intake and derived nutritional biomarkers as well as the nutrient supplementation in women with EDs during pregnancy. We performed a systematic review according to the PRISMA statement to synthesize current evidence in this field. Of N = 1203 hits, 13 full-texts were included in the qualitative synthesis. While women with current Binge Eating Disorder (BED) showed higher energy and fat intakes during pregnancy, women with a lifetime Anorexia Nervosa (AN), Bulimia Nervosa (BN) or both (AN + BN) had similar patterns of nutrient intake and dietary supplement use as healthy women. There is evidence, that women with a history of EDs have a sufficient diet quality and are more likely to be vegetarian. Dieting and bingeing improved substantially with pregnancy. The highlighted differences in the consumption of coffee/caffeine and artificially sweetened beverages as well as the elevated prevalence of iron deficiency anemia in women with a past or active ED during pregnancy might have an important impact on fetal development.