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Shaikh S, Srivastava G, Homburg R. Should women with high body mass index be denied fertility treatments? HUM FERTIL 2023; 26:1179-1184. [PMID: 37527665 DOI: 10.1080/14647273.2022.2152741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/26/2022] [Indexed: 08/03/2023]
Abstract
Obesity is an emerging global epidemic with a negative impact on fertility. Almost all guidelines and policies have a stringent limit of body mass index (BMI) to access fertility services which has promoted a debate amongst fertility practitioners globally. Proponents of placing such a limit point to the negative impact of elevated BMI on the outcome of fertility treatment, its cost effectiveness and the risk it poses to the intending mother and unborn child. Opponents of placing a restriction base their arguments on the lack of conclusive, robust evidence regarding the variables along with the ethical dilemmas of promoting discrimination and stigmatization by denying a couple their basic right of parenthood. In this review, we analyse these medical and ethical dilemmas in the light of current evidence. The focus is on female infertility.
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Affiliation(s)
- Sadaf Shaikh
- Homerton Fertility Centre, Homerton University Hospital, London, UK
| | | | - Roy Homburg
- Homerton Fertility Centre, Homerton University Hospital, London, UK
- Department of Reproductive Medicine, Queen Mary University of London, London, UK
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2
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Overweight, obesity and assisted reproduction: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2022; 271:117-127. [DOI: 10.1016/j.ejogrb.2022.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 11/01/2021] [Accepted: 01/18/2022] [Indexed: 12/12/2022]
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3
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Xiong Y, Wang J, Huang S, Liu C, Liu Y, Qi Y, Li L, Wang W, Zou K, Tan J, Sun X. Association between maternal prepregnancy body mass index and pregnancy outcomes following assisted reproductive technology: A systematic review and dose-response meta-analysis. Obes Rev 2021; 22:e13219. [PMID: 33554474 DOI: 10.1111/obr.13219] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/05/2021] [Accepted: 01/22/2021] [Indexed: 02/05/2023]
Abstract
This systematic review investigated dose-response relationship between maternal prepregnancy body mass index (BMI) and pregnancy outcomes following assisted reproductive technology, including clinical pregnancy rate (CPR), miscarriage rate (MR), and live birth rate (LBR). We searched four major databases and finally included 105 studies involving more than 271,632 pregnant women. We performed linear or nonlinear dose-response meta-analyses using random effects models. At per-woman level, pooling of unadjusted estimates shown an inverted J-shaped relationship between maternal BMI and CPR; pooling of adjusted estimates showed a linear association, suggesting statistical association between higher maternal BMI and lower CPR (adjusted OR [aOR] for 5-unit increase in BMI: 0.96, 95%CI: 0.94-0.98). At per-cycle level, linear dose-response relationship was found between maternal BMI and CPR (crude relative risk, RR, [cRR] for 5-unit increase in BMI 0.97, 0.96-0.98; aOR 0.96, 0.94-0.99). Linear dose-response relationship was established between maternal BMI and the outcomes of MR or LBR (higher BMI associated with higher MR [cRR 1.15, 1.08-1.22] and lower LBR [cRR 0.91, 0.88-0.94] at per-woman level). Sensitivity analyses showed no significant changes. In conclusion, there is dose-response relationship between maternal BMI and pregnancy outcomes following assisted reproductive technology. Higher BMI values may suggest suboptimal pregnancy outcomes.
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Affiliation(s)
- Yiquan Xiong
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Wang
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Shiyao Huang
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Chunrong Liu
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yanmei Liu
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yana Qi
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ling Li
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wen Wang
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Kang Zou
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Tan
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
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Turner S, Maclean E, Dick S, Aucott L, Maheshwari A. Is conception by in vitro fertilization associated with altered antenatal and postnatal growth trajectories? Fertil Steril 2020; 114:1216-1224. [PMID: 33069371 DOI: 10.1016/j.fertnstert.2020.06.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/22/2020] [Accepted: 06/22/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To study whether the growth trajectory of the first, second, and third trimester, birth, and 5 years of age differs between children born following fresh embryo transfer (fresh ET), frozen-thawed embryo transfer (FET), and children born after natural conception (NC). DESIGN Historical cohort study of children. The analysis compared cross-sectional and longitudinal differences in measurement between individuals stratified by method of conception. SETTING Not applicable. PATIENTS Participants were born between 1997 and 2012 by NC (n = 65,683), fresh ET (n = 576), and FET (n = 179). Data were available for method of conception and fetal, maternal, and neonatal characteristics and measurements at 5 years. INTERVENTION (S) None MAIN OUTCOME MEASURE(S): Size at first, second, and third trimester, birth, and 5 years. RESULT(S) In the longitudinal model, first trimester crown-rump length was significantly longer after fresh ET compared to NC. Second trimester head size was larger after fresh ET and after FET compared to NC. Birth weight was lower after fresh ET conception compared to FET. At 5 years of age, children conceived by fresh ET and FET were no heavier than peers conceived by NC. CONCLUSION(S) Individuals conceived by in vitro fertilization have significantly different antenatal growth trajectories during the first and second trimester compared to those conceived by NC, and differences persist at birth for weight and head size. The relevance of these different growth trajectories remains uncertain, and larger prospective studies are required.
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Affiliation(s)
- Steve Turner
- Child Heath, Royal Aberdeen Children's Hospital, University of Aberdeen, Aberdeen, United Kingdom.
| | - Eilidh Maclean
- Child Heath, Royal Aberdeen Children's Hospital, University of Aberdeen, Aberdeen, United Kingdom
| | - Smita Dick
- Child Heath, Royal Aberdeen Children's Hospital, University of Aberdeen, Aberdeen, United Kingdom
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Abha Maheshwari
- Aberdeen Fertility Centre, NHS Grampian, Foresterhill, Aberdeen, United Kingdom
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5
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ElMokhallalati Y, van Eekelen R, Bhattacharya S, McLernon DJ. Treatment-independent live birth after in-vitro fertilisation: a retrospective cohort study of 2,133 women. Hum Reprod 2020; 34:1470-1478. [PMID: 31306480 DOI: 10.1093/humrep/dez099] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/29/2019] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION What is the chance of a treatment-independent live birth following IVF (including ICSI) treatment? SUMMARY ANSWER Over 5 years of follow-up, the treatment-independent live birth rate was 17% in unsuccessfully treated women and 15% in those who had a live birth after IVF. WHAT IS KNOWN ALREADY A limited number of studies have investigated the chance of treatment-independent conception following completion of IVF, but most of them have been based on surveys with poor response rates and limited sample sizes. STUDY DESIGN, SIZE, DURATION This is a population-based, retrospective cohort study of 2133 women who received IVF treatment between 1998 and 2011 at a single regional IVF Unit and were followed for a minimum of 1 year and maximum of 15 years after their last IVF or ICSI treatment cycle. PARTICIPANTS/MATERIALS, SETTING, METHODS This study included all women, residing in the north-east of the UK, who attended the Aberdeen Fertility Clinic and received IVF treatment between 1998 and 2011. Clinical and diagnostic information of all women was linked with treatment and pregnancy outcome data. A total of 2133 women were divided into two groups: (i) those who achieved a live birth following successful IVF or ICSI treatment (n = 1060) and (ii) those in whom treatment was unsuccessful i.e. resulted in either no pregnancy or pregnancy loss (n = 1073). The two groups were followed from the date of the last embryo transfer until the first treatment-independent live birth or 31 December 2012, whichever came first. The primary outcome was the treatment-independent live birth rate at 1, 2.5, 5 and 10 years of follow-up. Cox regression was used to determine factors associated with treatment-independent live birth in each group. MAIN RESULTS AND THE ROLE OF CHANCE Within 5 years of follow-up, the treatment-independent live birth rate was 17% (95% CI, 15-19%) among women whose IVF or ICSI treatment was unsuccessful and 15% (95% CI, 12-17%) among women whose treatment resulted in live birth. In both groups, shorter duration of infertility, younger female age and IVF as compared to ICSI were associated with a higher chance of achieving treatment-independent live birth. Among unsuccessfully treated women, the chance of post-IVF live birth was reduced in those with tubal factor infertility. Three or more previous IVF or ICSI embryo transfers were associated with a lower chance of treatment-independent live birth among successfully treated women. LIMITATIONS, REASONS FOR CAUTION The study was conducted in a single fertility centre, which could compromise the generalizability of the findings. Moreover, data were unavailable on the women's use of contraception or active attempts to get pregnant, both of which could influence treatment-independent live birth rates. WIDER IMPLICATIONS OF THE FINDINGS This study provides a better understanding of the long-term prognosis for treatment-independent live birth after completion of IVF or ICSI treatment. The results will inform women of their chances of a treatment-independent live birth following failed or successful treatment and the factors that are associated with it. STUDY FUNDING/COMPETING INTEREST(S) This work was funded by a Chief Scientist Office Postdoctoral Training Fellowship in Health Services Research and Health of the Public Research (Ref PDF/12/06). The views expressed here are those of the authors and not necessarily those of the Chief Scientist Office. The authors have no competing interests. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- Yousuf ElMokhallalati
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Aberdeen, UK
| | - Rik van Eekelen
- Centre for Reproductive Medicine, Academic Medical Centre, Meibergdreef 9, Amsterdam, The Netherlands
| | - Siladitya Bhattacharya
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Aberdeen, UK
| | - David J McLernon
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Aberdeen, UK
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6
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McLernon DJ, Lee AJ, Maheshwari A, van Eekelen R, van Geloven N, Putter H, Eijkemans MJ, van der Steeg JW, van der Veen F, Steyerberg EW, Mol BW, Bhattacharya S. Predicting the chances of having a baby with or without treatment at different time points in couples with unexplained subfertility. Hum Reprod 2020; 34:1126-1138. [PMID: 31119290 DOI: 10.1093/humrep/dez049] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/17/2019] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Can we develop a prediction model that can estimate the chances of conception leading to live birth with and without treatment at different points in time in couples with unexplained subfertility? SUMMARY ANSWER Yes, a dynamic model was developed that predicted the probability of conceiving under expectant management and following active treatments (in vitro fertilisation (IVF), intrauterine insemination with ovarian stimulation (IUI + SO), clomiphene) at different points in time since diagnosis. WHAT IS KNOWN ALREADY Couples with no identified cause for their subfertility continue to have a realistic chance of conceiving naturally, which makes it difficult for clinicians to decide when to intervene. Previous fertility prediction models have attempted to address this by separately estimating either the chances of natural conception or the chances of conception following certain treatments. These models only make predictions at a single point in time and are therefore inadequate for informing continued decision-making at subsequent consultations. STUDY DESIGN, SIZE, DURATION A population-based study of 1316 couples with unexplained subfertility attending a regional clinic between 1998 and 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS A dynamic prediction model was developed that estimates the chances of conception within 6 months from the point when a diagnosis of unexplained subfertility was made. These predictions were recomputed each month to provide a dynamic assessment of the individualised chances of conception while taking account of treatment status in each month. Conception must have led to live birth and treatments included clomiphene, IUI + SO, and IVF. Predictions for natural conception were externally validated using a prospective cohort from The Netherlands. MAIN RESULTS AND THE ROLE OF CHANCE A total of 554 (42%) couples started fertility treatment within 2 years of their first fertility consultation. The natural conception leading to live birth rate was 0.24 natural conceptions per couple per year. Active treatment had a higher chance of conception compared to those who remained under expectant management. This association ranged from weak with clomiphene to strong with IVF [clomiphene, hazard ratio (HR) = 1.42 (95% confidence interval, 1.05 to 1.91); IUI + SO, HR = 2.90 (2.06 to 4.08); IVF, HR = 5.09 (4.04 to 6.40)]. Female age and duration of subfertility were significant predictors, without clear interaction with the relative effect of treatment. LIMITATIONS, REASONS FOR CAUTION We were unable to adjust for other potentially important predictors, e.g. measures of ovarian reserve, which were not available in the linked Grampian dataset that may have made predictions more specific. This study was conducted using single centre data meaning that it may not be generalizable to other centres. However, the model performed as well as previous models in reproductive medicine when externally validated using the Dutch cohort. WIDER IMPLICATIONS OF THE FINDINGS For the first time, it is possible to estimate the chances of conception following expectant management and different fertility treatments over time in couples with unexplained subfertility. This information will help inform couples and their clinicians of their likely chances of success, which may help manage expectations, not only at diagnostic workup completion but also throughout their fertility journey. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by a Chief Scientist Office postdoctoral training fellowship in health services research and health of the public research (ref PDF/12/06). B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck, and Guerbet. None of the other authors declare any conflicts of interest.
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Affiliation(s)
- D J McLernon
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - A J Lee
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - A Maheshwari
- Aberdeen Centre for Reproductive Medicine, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - R van Eekelen
- Centre for Reproductive Medicine, Academic Medical Centre, AZ Amsterdam, The Netherlands.,Department of Biostatistics and Research Support, University Medical Centre Utrecht-Julius Centre, GA Utrecht, The Netherlands
| | - N van Geloven
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, RC Leiden, The Netherlands
| | - H Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, RC Leiden, The Netherlands
| | - M J Eijkemans
- Department of Biostatistics and Research Support, University Medical Centre Utrecht-Julius Centre, GA Utrecht, The Netherlands
| | - J W van der Steeg
- Department for Obstetrics and Gynaecology, Jeroen Bosch Ziekenhuis, GZ 's-Hertogenbosch, The Netherlands
| | - F van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, AZ Amsterdam, The Netherlands
| | - E W Steyerberg
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, RC Leiden, The Netherlands.,Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, CN Rotterdam, The Netherlands
| | - B W Mol
- The Robinson Institute-School of Medicine, University of Adelaide, Adelaide, Australia
| | - S Bhattacharya
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Purewal S, Chapman SCE, van den Akker OBA. A systematic review and meta-analysis of lifestyle and body mass index predictors of successful assisted reproductive technologies. J Psychosom Obstet Gynaecol 2019; 40:2-18. [PMID: 29172958 DOI: 10.1080/0167482x.2017.1403418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Lifestyle (smoking, drinking alcohol) and body mass index (BMI) predictors of successful outcomes in assisted reproductive technology (ART) treatments were examined in this meta-analysis. METHOD A bibliographic search was undertaken using six databases. The review was informed by PRISMA/MOOSE guidelines. Meta-analytic data were analysed using random effects models. RESULTS We included 77 studies examining effects of BMI, smoking and drinking alcohol. Patients with a BMI< =24.9 were significantly more likely to achieve LB/pregnancy than with BMI> =25 OR = 1.219 (95% CI:1.128-1.319, z = 4.971, p < .001; I2 = 53.779%, p = .001). Non-smokers were significantly more likely to achieve a LB or pregnancy than smokers OR = 1.457 (95% CI:1.228-1.727, z = 4.324, p < .001; I2 = 51.883; p = .001). Meta-regression revealed the number of embryos transferred significantly moderated the effects of smoking on ART outcomes, and there was a trend indicating primary infertility and high BMI were also significant moderators. The evidence for drinking alcohol was inconclusive due to the small number of studies. CONCLUSIONS This meta-analysis confirms that ART treatment success can be predicted with lifestyle factors. Further, non-smokers' relative odds of pregnancy/live birth increase as more embryos were transferred but there was a trend that the odds of pregnancy/live birth decrease with primary infertility and high BMI.
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Affiliation(s)
- Satvinder Purewal
- a Institute of Psychology, Faculty of Education, Health and Wellbeing , University of Wolverhampton , Wolverhampton , UK
| | - S C E Chapman
- b Department of Pharmacy & Pharmacology , University of Bath , Bath , UK
| | - O B A van den Akker
- c Department of Psychology, School of Science and Technology , Middlesex University , London , UK
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Koning A, Mol BW, Dondorp W. It is not justified to reject fertility treatment based on obesity. Hum Reprod Open 2017; 2017:hox009. [PMID: 30895227 PMCID: PMC6276680 DOI: 10.1093/hropen/hox009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 06/06/2017] [Accepted: 06/17/2017] [Indexed: 11/14/2022] Open
Abstract
Obesity can lead to anovulation and subfertility. Around the world fertility treatment is withheld from women above a certain BMI, with a threshold ranging from 25 to 40 kg/m2. The proponents of this policy use three different arguments to justify their restrictions: risks for the woman, health and wellbeing of the future child, and importance for society. In this article we critically appraise these arguments. We conclude that obese women should be informed about the consequences of their weight on fertility and pregnancy complications and encouraged to lose weight. If, however, a woman is unable to lose weight despite effort, we feel there is no argument to withhold treatment from her. This would be unjustified with respect to the treatment of other women with a high risk of complications.
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Affiliation(s)
- Aafke Koning
- Ziekenhuis Amstelland, Department of Obstetrics and gynecology, Laan van de Helende Meesters 8, Amstelveen, The Netherlands
| | - Ben Willem Mol
- University of Adelaide, The Robinson Institute, School of Pediatrics and Reproductive Health, Adelaide, Australia
| | - Wybo Dondorp
- Maastricht University, Health, Ethics and Society-Research schools CAPHRI and GROW, Universiteitssingel 40, Maastricht, The Netherlands
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9
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Sim KA, Partridge SR, Sainsbury A. Does weight loss in overweight or obese women improve fertility treatment outcomes? A systematic review. Obes Rev 2014; 15:839-50. [PMID: 25132280 DOI: 10.1111/obr.12217] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/26/2014] [Accepted: 06/23/2014] [Indexed: 11/29/2022]
Abstract
This systematic review assessed the effect of weight loss in overweight and/or obese women undergoing assisted reproductive technology (ART) on their subsequent pregnancy outcome. Weight losses achieved by diet and lifestyle changes, very-low-energy diets, non-surgical medical interventions and bariatric surgery translated into significantly increased pregnancy rates and/or live birth in overweight and/or obese women undergoing ART in 8 of the 11 studies reviewed. In addition, regularization of the menstrual pattern, a decrease in cancellation rates, an increase in the number of embryos available for transfer, a reduction in the number of ART cycles required to achieve pregnancy and a decrease in miscarriage rates were reported. There were also a number of natural conceptions in five of the six studies that reported this outcome. Non-surgical medical weight loss procedures and bariatric surgery induced the greatest weight losses, but their use, as well as that of very-low-energy diets, for weight loss prior to ART requires careful consideration. While the overall quality of the studies included in this review was poor, these results support the clinical recommendation of advising overweight and/or obese women to lose weight prior to ART. Prospective randomized controlled trials are required to establish efficacious evidence-based guidelines for weight loss interventions in overweight and/or obese women prior to ART treatment.
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Affiliation(s)
- K A Sim
- The Boden Institute for Obesity, Nutrition, Exercise & Eating Disorders, The University of Sydney, Sydney, NSW, Australia
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Abstract
Despite the development of in vitro fertilization (IVF) more than 30 years ago, the cost of treatment remains high. Furthermore, over the years, more sophisticated technologies and expensive medications have been introduced, making IVF increasingly inaccessible despite the increasing need. Globally, the option to undergo IVF is only available to a privileged few. In recent years, there has been growing interest in exploring strategies to reduce the cost of IVF treatment, which would allow the service to be provided in low-resource settings. In this review, we explore the various ways in which the cost of this treatment can be reduced.
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Affiliation(s)
- Pek Joo Teoh
- Aberdeen Fertility Centre, Aberdeen Maternity Hospital, University of Aberdeen, Aberdeen, UK
| | - Abha Maheshwari
- Aberdeen Fertility Centre, Aberdeen Maternity Hospital, University of Aberdeen, Aberdeen, UK
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11
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Pandey S, McLernon DJ, Scotland G, Mollison J, Wordsworth S, Bhattacharya S. Cost of fertility treatment and live birth outcome in women of different ages and BMI. Hum Reprod 2014; 29:2199-211. [PMID: 25061026 DOI: 10.1093/humrep/deu184] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the impact of different age and BMI groups on total investigation and treatment costs in women attending a secondary/tertiary care fertility clinic? SUMMARY ANSWER Women in their early to mid-30s and women with normal BMI had higher cumulative investigation and treatment costs, but also higher probability of live birth. WHAT IS KNOWN ALREADY Female age and BMI have been used as criteria for rationing publically funded fertility treatments. Population-based data on the costs of investigating and treating infertility are lacking. STUDY DESIGN, SIZE AND DURATION A retrospective cohort study of 2463 women was conducted in a single secondary/tertiary care fertility clinic in Aberdeen, Scotland from 1998 to 2008. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants included all women living in a defined geographical area referred from primary care to a specialized fertility clinic over an 11-year period. Women were followed up for 5 years or until live birth if this occurred sooner. Mean discounted cumulative National Health Service costs (expressed in 2010/2011 GBP) of fertility investigations, treatments (including all types of assisted reproduction), and pregnancy (including delivery episode) and neonatal admissions were calculated and summarized by age (≤ 30, 31-35, 36-40, >40 years) and BMI groupings (<18.50, 18.50-24.99 (normal BMI), 25.00-29.99, 30.00-34.99, ≥ 35.00 kg/m(2)). Further multivariate modelling was carried out to estimate the impact of age and BMI on investigation and treatment costs and live birth outcome, adjusting for covariates predictive of the treatment pathway and live birth. MAIN RESULTS AND THE ROLE OF CHANCE Of the 2463 women referred, 1258 (51.1%) had a live birth within 5 years, with 694 (55.1%) of these being natural conceptions. The live birth rate was highest among women in the youngest age group (64.3%), and lowest in those aged >40 years (13.4%). Overall live birth rates were generally lower in women with BMI >30 kg/m(2). The total costs of investigations were generally highest among women younger than 30 years (£491 in those with normal BMI), whilst treatment costs tended to be higher in 31-35 year olds (£1,840 in those with normal BMI). Multivariate modelling predicted a cost increase associated with treatment which was highest among women in the lowest BMI group (across all ages), and also highest among women aged 31-35 years. The increase in the predicted probability of live birth with exposure to treatment was consistent across age and BMI categories (∼ 10%), except in the oldest age group where a slightly smaller increase in the probability of live birth was observed. The ratio of increased costs to the increased probability of live birth in women who were treated increased markedly in women over the age of 40 years, but tended to fall as BMI increased within all age groups. LIMITATIONS AND REASON FOR CAUTION Our results, based on retrospective observational data from a single centre, have limited generalizability and are not free from clinician and clinic selection bias which can influence the choice of treatments as well as their costs. WIDER IMPLICATIONS OF THE FINDINGS Spontaneous live birth rates were particularly high in younger women with unexplained infertility, suggesting that expectant management is a reasonable option in this group. The policy of not over-investigating older women and offering early treatment where appropriate still incurred the highest costs per additional live birth associated with treatment, owing to the lower probability of treatment success. The increased additional cost for each live birth associated with treatment for women with decreasing BMI across all age groups, suggests that it may be possible to identify a more targeted approach to treatment. STUDY FUNDING/COMPETING INTERESTS This study was partly funded by an NHS endowment grant (Grant Number 12/48) and D.J.M. by a Chief Scientist Office Postdoctoral Fellowship (Ref PDF/12/06). There are no conflicts of interest to declare.
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Affiliation(s)
- Shilpi Pandey
- Reproductive Medicine, CARE Fertility, 6 Lawrence Drive, Nottingham NG8 6PZ, UK
| | - David J McLernon
- Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Aberdeen AB25 2ZD, UK
| | - Graham Scotland
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Jill Mollison
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Sarah Wordsworth
- Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Siladitya Bhattacharya
- Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Aberdeen AB25 2ZD, UK
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12
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Sharma R. Prospective Study of Effect of Body Weight on in vitro Fertilization Outcome in Reproductive Age Group. ACTA ACUST UNITED AC 2014. [DOI: 10.5005/jp-journals-10016-1082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
ABSTRACT
Background
Various prognostic factors in assisted reproduction procedures have been described and analyzed which includes woman's age, cause of infertility, ovarian response and uterine receptivity, the semen quality, and the body mass index (BMI). Optimal BMI is required for an optimal response. There is controversy among various reports, which is partly caused by the varying focus of investigators and differences in study designs, which led us to examine the relationship between BMI, in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) outcome in our unit.
Objective
To study impact of BMI on IVF outcome prospectively
Materials and methods
It is a prospective study over a period of 1 year in the age group 25 to 35 years attending the IVF clinic was conducted at a tertiary infertility center in Bangalore, India between November 2010 and October 2011.
Results
There is a close association of increased BMl in particular when BMl is > 30 kg/m2 and the reduced outcomes of IVF/ ICSI treatment in the form of decreased clinical pregnancy and higher early pregnancy loss. Furthermore, increased BMl is related to higher dosage and duration of gonadotropins requirement increased risk of cancellation and fewer collected oocytes.
Conclusion
Obesity is associated with an increased risk of early pregnancy loss. Also need of high dose of gonadotropin, less number of collected oocytes is observed. Implantation rate, pregnancy rate and miscarriage rate was comparable but live births are high in normal weight and overweight as compared to extremes of BMI. So will be appropriate to recommend life style modifications including weight loss to achieve an appropriate BMI prior to IVF.
How to cite this article
Sharma R. Prospective Study of Effect of Body Weight on in vitro Fertilization Outcome in Reproductive Age Group. Int J Infertil Fetal Med 2014;5(2):58-63.
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Badawy A. Should overweight or obese women be denied access to ART? MIDDLE EAST FERTILITY SOCIETY JOURNAL 2013. [DOI: 10.1016/j.mefs.2013.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Chavarro JE, Ehrlich S, Colaci DS, Wright DL, Toth TL, Petrozza JC, Hauser R. Body mass index and short-term weight change in relation to treatment outcomes in women undergoing assisted reproduction. Fertil Steril 2012; 98:109-16. [PMID: 22607889 DOI: 10.1016/j.fertnstert.2012.04.012] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 03/13/2012] [Accepted: 04/06/2012] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the relation between body mass index (BMI) and short-term weight change with assisted reproductive technology (ART) outcomes. DESIGN Prospective cohort study. SETTING Fertility center. PATIENT(S) A total of 170 women undergoing 233 ART cycles. INTERVENTION(S) Baseline BMI and short-term weight change were related to ART outcomes. Regression models accounting for repeated observations were used to adjust data for potential confounders. MAIN OUTCOME MEASURE(S) Peak E2 levels, oocyte yield, MII yield, fertilization rate, embryo quality, postive [beta]-hCH, clinical pregnancy and live birth rates. RESULT(S) Overweight and obesity were associated with lower live birth rates. The adjusted live birth rate (95% confidence interval) was 42% (28%-58%) among women with a BMI between 20 and 22.4 kg/m(2) and 23% (14%-36%) among overweight or obese women. Short-term weight loss was associated with a higher proportion of metaphase II (MII) oocytes retrieved. The adjusted proportion of MII eggs was 91% (87%-94%) for women who lost 3 kg or more and 86% (81%-89%) for women whose weight remained stable. This association was stronger among women who were overweight or obese at baseline. Short-term weight loss was unrelated to positive β-hCG, clinical pregnancy, or live birth rates. CONCLUSION(S) Overweight and obesity were related to lower live birth rates in women undergoing ART. Short-term weight loss was related to higher MII yield, particularly among overweight and obese women, but unrelated to clinical outcomes.
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Affiliation(s)
- Jorge E Chavarro
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts 02115, USA.
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Influence of female bodyweight on IVF outcome: a longitudinal multicentre cohort study of 487 infertile couples. Reprod Biomed Online 2011; 23:490-9. [DOI: 10.1016/j.rbmo.2011.06.010] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 06/16/2011] [Accepted: 06/16/2011] [Indexed: 11/18/2022]
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Economic costs of adult obesity: A review of recent European studies with a focus on subgroup-specific costs. Maturitas 2011; 69:220-9. [DOI: 10.1016/j.maturitas.2011.04.005] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 04/05/2011] [Indexed: 11/19/2022]
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Yates AP, Rustamov O, Roberts SA, Lim HYN, Pemberton PW, Smith A, Nardo LG. Anti-Mullerian hormone-tailored stimulation protocols improve outcomes whilst reducing adverse effects and costs of IVF. Hum Reprod 2011; 26:2353-62. [DOI: 10.1093/humrep/der182] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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The LIFESTYLE study: costs and effects of a structured lifestyle program in overweight and obese subfertile women to reduce the need for fertility treatment and improve reproductive outcome. A randomised controlled trial. BMC WOMENS HEALTH 2010; 10:22. [PMID: 20579357 PMCID: PMC2907305 DOI: 10.1186/1472-6874-10-22] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 06/25/2010] [Indexed: 11/16/2022]
Abstract
Background In the Netherlands, 30% of subfertile women are overweight or obese, and at present there is no agreement on fertility care for them. Data from observational and small intervention studies suggest that reduction of weight will increase the chances of conception, decrease pregnancy complications and improve perinatal outcome, but this has not been confirmed in randomised controlled trials. This study will assess the cost and effects of a six-months structured lifestyle program aiming at weight reduction followed by conventional fertility care (intervention group) as compared to conventional fertility care only (control group) in overweight and obese subfertile women. We hypothesize that the intervention will decrease the need for fertility treatment, diminish overweight-related pregnancy complications, and will improve perinatal outcome. Methods/Design Multicenter randomised controlled trial in subfertile women (age 18-39 year) with a body mass index between 29 and 40 kg/m2. Exclusion criteria are azoospermia, use of donor semen, severe endometriosis, premature ovarian failure, endocrinopathies or pre-existent hypertensive disorders. In the intervention group the aim is a weight loss of at least 5% to10% in a six-month period, to be achieved by the combination of a diet, increase of physical activity and behavioural modification. After six months, in case no conception has been achieved, these patients will start fertility treatment according to the Dutch fertility guidelines. In the control group treatment will be started according to Dutch fertility guidelines, independently of the patient's weight. Outcome measures and analysis The primary outcome measure is a healthy singleton born after at least 37 weeks of gestation after vaginal delivery. Secondary outcome parameters including pregnancy outcome and complications, percentage of women needing fertility treatment, clinical and ongoing pregnancy rates, body weight, quality of life and costs. Data will be analysed according to the intention to treat principle, and cost-effectiveness analysis will be performed to compare the costs and health effects in the intervention and control group. Discussion The trial will provide evidence for costs and effects of a lifestyle intervention aiming at weight reduction in overweight and obese subfertile women and will offer guidance to clinicians for the treatment of these patients. Trial registration Dutch Trial Register NTR1530
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Connolly MP, Hoorens S, Chambers GM. The costs and consequences of assisted reproductive technology: an economic perspective. Hum Reprod Update 2010; 16:603-13. [PMID: 20530804 DOI: 10.1093/humupd/dmq013] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite the growing use of assisted reproductive technologies (ART) worldwide, there is only a limited understanding of the economics of ART to inform policy about effective, safe and equitable financing of ART treatment. METHODS A review was undertaken of key studies regarding the costs and consequences of ART treatment, specifically examining the direct and indirect costs of treatment, economic drivers of utilization and clinical practice and broader economic consequences of ART-conceived children. RESULTS The direct costs of ART treatment vary substantially between countries, with the USA standing out as the most expensive. The direct costs generally reflect the costliness of the underlying healthcare system. If unsubsidized, direct costs represent a significant economic burden to patients. The level of affordability of ART treatment is an important driver of utilization, treatment choices, embryo transfer practices and ultimately multiple birth rates. The costs associated with caring for multiple-birth ART infants and their mothers are substantial, reflecting the underlying morbidity associated with such pregnancies. Investment analysis of ART treatment and ART-conceived children indicates that appropriate funding of ART services appears to represent sound fiscal policy. CONCLUSIONS The complex interaction between the cost of ART treatment and how treatments are subsidized in different healthcare settings and for different patient groups has far-reaching consequences for ART utilization, clinical practice and infant outcomes. A greater understanding of the economics of ART is needed to inform policy decisions and to ensure the best possible outcomes from ART treatment.
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Affiliation(s)
- Mark P Connolly
- Department of Pharmacy, Unit of Pharmacoepidemiology and Pharmacoeconomics (PE2), University of Groningen, Groningen, The Netherlands
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Current world literature. Curr Opin Obstet Gynecol 2010; 22:255-8. [PMID: 20436325 DOI: 10.1097/gco.0b013e32833ae363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhang D, Zhu Y, Gao H, Zhou B, Zhang R, Wang T, Ding G, Qu F, Huang H, Lu X. Overweight and obesity negatively affect the outcomes of ovarian stimulation and in vitro fertilisation: a cohort study of 2628 Chinese women. Gynecol Endocrinol 2010; 26:325-32. [PMID: 20192898 DOI: 10.3109/09513591003632100] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To explore the effects of overweight and obesity on the outcomes of in vitro fertilisation (IVF) in Chinese infertile patients. STUDY DESIGN A retrospective cohort study was carried out in 2222 normal weight (18.5 <or= BMI < 25), 379 overweight (25 <or= BMI < 30) and 27 obese (BMI >or= 30) women who underwent their first IVF cycles between 2002 and 2008. Cycle characteristics and IVF outcomes were analysed. RESULTS Obese women required significantly higher dose of rFSH (3272 IU vs. 2587 IU, p < 0.001) and days of stimulation (11.89 +/- 4.57 vs. 10.42 +/- 2.03, p < 0.001), but exhibited less oocytes retrieved and significantly lower fertilisation rate (54.1% vs. 61.1%, p < 0.001) than normal weight women. Compared with normal weight women, overweight women displayed significantly less oocytes retrieved (12.98 +/- 6.91 vs. 14.49 +/- 7.96, p < 0.001), lower fertilisation rate (60.8 +/- 23.3 vs. 61.1 +/- 23.0, p < 0.001), less cleavaged embryos (7.55 +/- 4.86 vs. 8.67 +/- 5.90, p < 0.001), less high-grade embryos (4.65 +/- 3.96 vs. 5.59 +/- 4.81, p < 0.001) and cryopreserved embryos (4.44 +/- 4.55 vs. 5.49 +/- 5.55, p < 0.001). All parameters of pregnancy outcomes, including pregnancy rate, miscarriage rate and live birth rate, were comparable among three groups. CONCLUSIONS Overweight and obesity are related with impared ovarian response, and negatively affect the outcomes of IVF.
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Affiliation(s)
- Dan Zhang
- Department of Reproductive Endocrinology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Pandey S, Maheshwari A, Bhattacharya S. Should access to fertility treatment be determined by female body mass index? Hum Reprod 2010; 25:815-20. [PMID: 20129994 DOI: 10.1093/humrep/deq013] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Resource allocation towards fertility treatment has been extensively debated in countries where fertility treatment is publicly-funded. Medical, social and ethical aspects have been evaluated prior to allocation of resources. Analysis of cost-effectiveness, risks and benefits and poor success rates have led to calls of restricting fertility treatment to obese women. In this debate article, we critically appraise the evidence underlying this issue and highlight the problems with such a policy. Poor success rate of treatment is unsubstantiated as there is insufficient evidence to link high body mass index (BMI) to reduction in live birth. Obstetric complications have a linear relationship with BMI but are significantly influenced by maternal age. The same is true for miscarriage rates which are influenced by the confounding factors of polycystic ovary syndrome and age. Studies have shown that the direct costs per live birth are no greater for overweight and obese women. With changing demographics over half the reproductive-age population is overweight or obese. Restricting fertility treatment on the grounds of BMI would cause stigmatization and lead to inequity, feelings of injustice and social tension as affluent women manage to bypass these draconian restrictions. Time lost and poor success of conventional weight loss strategies would jeopardize the chances of conception for many women.
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Affiliation(s)
- S Pandey
- Assisted Reproduction Unit, University of Aberdeen, Aberdeen Maternity Hospital, Forresterhill Road, Aberdeen AB25 2ZL, UK.
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Obesity alters retrieved oocyte count and clinical pregnancy rates in high and poor responder women after in vitro fertilization. Arch Gynecol Obstet 2010; 282:89-96. [DOI: 10.1007/s00404-010-1359-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
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Maheshwari A. Overweight and obesity in infertility: cost and consequences. Hum Reprod Update 2010; 16:229-30. [DOI: 10.1093/humupd/dmp058] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2009; 16:470-80. [PMID: 19858911 DOI: 10.1097/med.0b013e3283339a46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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