Medical and surgical interventions to improve outcomes in obese women planning for pregnancy

Infertility Improvement after Medical Weight Loss in Women and Men: A Review of the Literature

Infertility is a modern health problem. Obesity is another expanding health issue associated with chronic diseases among which infertility is also included. This review will focus on the effects of weight loss by medical therapy on fertility regarding reproductive hormonal profile, ovulation rates, time to pregnancy, implantation rates, pregnancy rates, normal embryo development, and live birth rates. We comprised medicine already used for weight loss, such as orlistat and metformin, and emerging medical treatments, such as Glucagon-Like Peptide-1 receptor agonists (GLP-1 RA). Their use is not recommended during a planned pregnancy, and they should be discontinued in such cases. The main outcomes of this literature review are the following: modest weight loss after medication and the duration of the treatment are important factors for fertility improvement. The fecundity outcomes upon which medical-induced weight loss provides significant results are the female reproductive hormonal profile, menstrual cyclicity, ovulation and conception rates, and pregnancy rates. Regarding the male reproductive system, the fertility outcomes that feature significant alterations after medically induced weight loss are as follows: the male reproductive hormonal profile, sperm motility, movement and morphology, weight of reproductive organs, and sexual function. The newer promising GLP-1 RAs show expectations regarding fertility improvement, as they have evidenced encouraging effects on improving ovulation rates and regulating the menstrual cycle. However, more human studies are needed to confirm this. Future research should aim to provide answers about whether medical weight loss therapies affect fertility indirectly through weight loss or by a possible direct action on the reproductive system.

A Single-dose, Two-Period Crossover Bioequivalence Study Comparing Two Liraglutide Formulations in Healthy Chinese Subjects

Liraglutide, a glucagon-like peptide 1 receptor agonist, is indicated as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes. The original liraglutide products are costly, which limits patient access to this therapeutic treatment. Herein, a biosimilar was developed that is highly similar to the reference drug in molecular structure and bioactivity, and is expected to have similar pharmacokinetic (PK) and safety profiles in clinical studies. This study aimed to primarily evaluate the bioequivalence of 2 liraglutide formulations and secondarily assess their safety in healthy Chinese subjects following a single-dose subcutaneous injection. Thirty-two healthy volunteers were recruited in this randomized, open-label, single-dose, 2-period crossover bioequivalence study (ChiCTR2100043348). The geometric mean ratios (GMRs) of the test drug to the reference drug (T/R) and corresponding 90% confidence intervals (CIs) for maximum concentration (C_max ) and the area under the concentration-time curve from time 0 to the time of the last quantifiable concentration (AUC_0-t ) were estimated using a mixed-effects model, and bioequivalence was determined to have been achieved if the 2-sided 90%CI fell within the predefined range of 80%-125%. PK parameters were comparable between T and R, with GMRs of T/R for C_max and AUC_0-t being 105.7% and 107.7%, respectively, the 90%CI of which met the acceptance criteria for bioequivalence. We also observed a similar and favorable safety profile in the T and R arms, with adverse events being predominantly mild in severity and of gastrointestinal origin. Our findings indicate that the test drug is safe and well tolerated, bioequivalent to the reference drug, and warrants further testing in a phase III clinical trial.

Anti-Mullerian Hormone Levels Increase After Bariatric Surgery in Obese Female Patients With and Without Polycystic Ovary Syndrome

This study was aimed to investigate the effect of weight loss by bariatric surgery on the level of anti-Mullerian hormone (AMH) in morbidly obese female patients with or without polycystic ovary syndrome (PCOS). This prospective study includes 70 females, obese, and fertile patients of reproductive age. All patients were evaluated to determine the changes in weight, body mass index (BMI), serum AMH, and other biochemical parameters at the end of six months. The mean levels of the preop and postop AMH were 1.66±0.87 ng/ml and 5.99±1.39 ng/ml in the PCOS group; 1.35±0.76 ng/ml and 6.23±1.47 ng/ml in the non-PCOS group, respectively. The postop AMH levels were significantly higher than the preop levels for both groups (p<0.001). There were significant differences in the level of glucose, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride, total cholesterol, hemoglobin A1c, HOMA-IR, insulin between preop and postop 6th month. A negative correlation was found between postop AMH and body weight in all patients (r=-0.337, p=0.031). Postop AMH levels were negatively correlated with postop BMI levels in the non-PCOS patient group (r=-0.408, p=0.043). No significant difference was observed between the PCOS and non-PCOS groups in terms of all the parameters examined. In conclusion, our study suggests that the significantly increased AMH levels by losing weight with bariatric surgery in patients with morbid obesity with and without PCOS may indicate the improvement of fertilization potential. It could be considered when evaluating fertility in patients with morbid obesity.

Syzygium cumini (L.) Skeels improves metabolic and ovarian parameters in female obese rats with malfunctioning hypothalamus-pituitary-gonadal axis

Background

Obesity is a chronic and multifactorial disease characterized by increased adipose tissue. In females, obesity leads to reduced ovulation and lower chances of conception in diseases like polycystic ovary syndrome, making it important to characterize complementary medicine to attenuate such deleterious effects. Therefore, the aim of this study was to assess the effects of a hydroethanolic extract from Syzigium cumini leaves in female reproductive impairments present in the obesity model of neonatal L-monosodium glutamate injection.

Methods

Newborn Wistar rats received saline (CTRL) or L-monosodium glutamate 4 mg/g BW (MSG). At 90 days of age, CTRL and some MSG rats received saline, while others received hydroethanolic extract of S. cumini leaves (HESc 500 mg/kg/day, MSG-Syz group) for 30 consecutive days. Estrous cycle was determined by daily vaginal washes. On days 26 and 28 of treatment, oral glucose tolerance test and blood collection were performed for biochemical assessment. At the end, animals were euthanized during estrous phase; blood was collected to measure sex hormones and organs collected for weighing and histological evaluation.

Results

MSG-Syz showed reduced Lee Index, retroperitoneal fat pads and restored gluco-insulin axis. Moreover, HESc treatment reduced serum cholesterol levels when compared to MSG. Treatment with HESc did not restore the oligociclicity observed in obese animals, though MSG-Syz reestablished ovarian follicle health back to CTRL levels, with proliferating primordial follicles – these effects were followed by a decrease on periovarian adipocyte area.

Conclusions

This is the first report to show the reversibility of the reproductive dysfunctions seen in MSG female rats through ethnopharmacological treatment. Moreover, it expands the use of HESc as a prominent tool to treat metabolic and reproductive disorders. Finally, we provide novel evidence that, without a functioning hypothalamus-pituitary-gonads axis, metabolic improvement is ineffective for estrous cyclicity, but critical for ovarian follicle health.

Obstetric and perinatal outcomes in subfertile patients who conceived following low technology interventions for fertility enhancement: a comprehensive review

PURPOSE

Low technology interventions for fertility enhancement (LTIFE) are strategies that avoid retrieval, handling, and manipulation of female gametes. The definition of LTIFE is yet to be widely accepted and clarified, but they are commonly used in milder cases of infertility and subfertility. Based on these considerations, the aim of the present study was comprehensively to review and investigate the obstetric and perinatal outcomes in subfertile patients who underwent LTIFE.

METHODS

A literature search up to May 2017 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science, and Google Scholar. An evidence-based hierarchy was used according to The Oxford Centre for Evidence-Based Medicine to determine which articles to include and analyze, and to provide a level of evidence of each association between intervention and outcome.

RESULTS

This analysis identified preliminary and low-grade evidence on the influence of LTIFE on obstetric and perinatal outcomes in subfertile women.

CONCLUSIONS

LTIFE women should deserve major consideration from Clinicians/Researchers of Reproductive Medicine, because these treatments could be potentially responsible for mothers' and babies' complications. So far, the lack of well-designed and unbiased studies makes further conclusions difficult to be drawn.

Understanding the Effect of Obesity on Fertility Among Reproductive-Age Women

Obesity is a major public health concern, and obesity among women of childbearing age can have a negative impact on fertility. The mechanism of action between obesity and infertility is complex and includes hormonal factors, alterations in ovulation, and changes in the menstrual cycle. Maternal obesity has also been linked to spontaneous abortion and poorer maternal and fetal health outcomes. Many interventions exist to help childbearing women achieve a lower body mass index. These include lifestyle modifications (diet/physical activity) and surgical and pharmacologic interventions. This article reviews the pathophysiology of the relationship between obesity and infertility and discusses evidence-based interventions for improving fertility among obese childbearing women.

Preconception consultations with Maternal Fetal Medicine for obese women: a retrospective chart review

Background

Obesity is associated with impaired fertility and pregnancy complications, and preconception weight loss may improve some of these outcomes. The purpose of this study was to evaluate the quality and effectiveness of Maternal Fetal Medicine (MFM) preconception consults for obese women.

Methods

We performed a retrospective chart review examining 162 consults at an academic medical center from 2008 to 2014. The main outcome measures included consultation content – e.g. discussion of obesity-related pregnancy complications, screening for comorbidities, and referrals for weight loss interventions – and weight loss.

Results

Screening for diabetes and hypertension occurred in 48% and 51% of consults, respectively. Discussion of obesity-related pregnancy complications was documented in 96% of consults. During follow-up (median 11 months), 27% of patients saw a nutritionist, 6% saw a provider for a medically supervised weight loss program, and 6% underwent bariatric surgery. The median weight change was a loss of 0.6% body weight.

Conclusions

In this discovery cohort, a large proportion of MFM preconception consultations lacked appropriate screening for obesity-related comorbidities. While the vast majority of consultations included a discussion of potential pregnancy complications, relatively few patients achieved significant weight loss. More emphasis is needed on weight loss resources and delaying pregnancy to achieve weight loss goals.

Eligibility and Success Criteria for Bariatric/Metabolic Surgery

Obesity is a worldwide main health concern, with a high treatment failure. This chapter focuses on the definition of obesity, based on excessive fat accumulation and thus underscores the importance of body composition, and the clinical tools currently used to diagnose it, mainly body mass index that is only a proxy measure of body composition. It also highlights the importance of the personal commitment to comply to a healthy diet and physical activity recommendations since surgery is most effective when accompanied by lifestyle modifications. Additionally, it addresses the description of types of patients who could benefit most from surgical management of excessive body fat percentage and metabolic derangements, as well as on the indications for surgery that are currently valid.

Effects of obesity and mild hypohydration on local sweating and cutaneous vascular responses during passive heat stress in females

The purpose of this study was to evaluate the effect of obesity and mild hypohydration on local sweating (LSR) and cutaneous vascular conductance (CVC) responses during passive heat stress in females. Thirteen obese (age, 24 ± 4 years; 45.4% ± 5.2% body fat) and 12 nonobese (age, 22 ± 2 years; 25.1% ± 3.9% body fat) females were passively heated (1.0 °C rectal temperature increase) while either euhydrated (EUHY) or mildly hypohydrated (HYPO; via fluid restriction). Chest and forearm LSR (ventilated capsule) and CVC (Laser Doppler flowmetry) onset, sensitivity, and plateau/steady state were recorded as mean body temperature increased (ΔTb). Participants began trials EUHY (urine specific gravity, Usg = 1.009 ± 0.006) or HYPO (Usg = 1.025 ± 0.004; p < 0.05), and remained EUHY or HYPO. Independent of obesity, HYPO decreased sweat sensitivity at the chest (HYPO = 0.79 ± 0.35, EUHY = 0.95 ± 0.39 Δmg·min(-1)·cm(-2)/°C ΔTb) and forearm (HYPO = 0.82 ± 0.39, EUHY = 1.06 ± 0.34 Δmg·min(-1)·cm(-2)/°C ΔTb); forearm LSR plateau was also decreased (HYPO = 0.66 ± 0.19, EUHY = 0.78 ± 0.23 mg·min(-1)·cm(-2); all p < 0.05). Overall, obese females had lower chest-sweat sensitivity (0.72 ± 0.35 vs. 1.01 ± 0.33 Δmg·min(-1)·cm(-2)/°C ΔTb) and plateau (0.55 ± 0.27 vs. 0.80 ± 0.25 mg·min(-1)·cm(-2); p < 0.05). While hypohydrated, obese females had a lower chest LSR (p < 0.05) versus nonobese females midway (0.45 ± 0.26 vs. 0.73 ± 0.23 mg·min(-1)·cm(-2)) and at the end (0.53 ± 0.27 vs. 0.81 ± 0.24 mg·min(-1)·cm(-2)) of heating. Furthermore, HYPO (relative to the EUHY trials) led to a greater decrease in CVC sensitivity in obese (-28 ± 27 Δ% maximal CVC/°C ΔTb) versus nonobese females (+9.2 ± 33 Δ% maximal CVC/°C ΔTb; p < 0.05). In conclusion, mild hypohydration impairs females' sweating responses during passive heat stress, and this effect is exacerbated when obese.

Bariatric and metabolic surgery: a shift in eligibility and success criteria

The obesity epidemic, combined with the lack of available and effective treatments for morbid obesity, is a scientific and public health priority. Worldwide, bariatric and metabolic surgeries are increasingly being performed to effectively aid weight loss in patients with severe obesity, as well as because of the favourable metabolic effects of the procedures. The positive effects of bariatric surgery, especially with respect to improvements in type 2 diabetes mellitus, have expanded the eligibility criteria for metabolic surgery to patients with diabetes mellitus and a BMI of 30-35 kg/m(2). However, the limitations of BMI, both in the diagnosis and follow-up of patients, need to be considered, particularly for determining the actual adiposity and fat distribution of the patients following weight loss. Understanding the characteristics shared by bariatric and metabolic surgeries, as well as their differential aspects and outcomes, is required to enhance patient benefits and operative achievements. For a holistic approach that focuses on the multifactorial effects of bariatric and metabolic surgery to be possible, a paradigm shift that goes beyond the pure semantics is needed. Such a shift could lead to profound clinical implications for eligibility criteria and the definition of success of the surgical approach.