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Bone JN, Joseph KS, Magee LA, Wang LQ, John S, Bedaiwy MA, Mayer C, Lisonkova S. Obesity, Twin Pregnancy, and the Role of Assisted Reproductive Technology. JAMA Netw Open 2024; 7:e2350934. [PMID: 38194230 PMCID: PMC10777255 DOI: 10.1001/jamanetworkopen.2023.50934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/05/2023] [Indexed: 01/10/2024] Open
Abstract
Importance The prevalence of overweight and obesity (body mass index [BMI] ≥25) has increased globally, and high BMI has been linked to higher rates of twin birth. However, evidence from large population-based studies is lacking; the issue needs careful study, as women with obesity are also more likely to use assisted reproductive technology (ART), which frequently results in twin pregnancy. Objective To examine the association between BMI and twin birth and the role of ART as a potential mediator in this association. Design, Setting, and Participants This retrospective cohort study included all live births and stillbirths with gestational age of 20 weeks or longer in British Columbia, Canada, from 2008 to 2020, using data from the British Columbia Perinatal Database Registry. Data analysis was conducted from November 2022 to June 2023. Exposures Prepregnancy BMI, calculated as weight in kilograms divided by height in meters squared, and use of ART. Main Outcomes and Measures The study assessed whether prepregnancy BMI is associated with the rate of twin vs singleton delivery and whether this association is explained by the differential use of ART in women with obesity. Results A total of 524 845 deliveries at 20 weeks' or longer gestation occurred in British Columbia during the study period, and 392 046 women had complete data on prepregnancy BMI. The median (IQR) age was 31.4 (27.7-35.0) years, approximately half were nulliparous (243 443 [46.4%]) and less than 10% smoked during pregnancy (36 894 [7.1%]). Overall, 8295 women had a twin delivery (15.8 per 1000 deliveries), and rates per 1000 deliveries by prepregnancy BMI categories were 11.9 (underweight), 15.1 (normal), 16.0 (overweight), 16.0 (obesity class I), 16.7 (obesity class II), and 18.9 (obesity class III). After adjustment for other covariates, women with underweight had relatively 16% fewer twins compared with women with normal BMI (adjusted risk ratio [aRR], 0.84; 95% CI, 0.74-0.95), while women with overweight, class I obesity, class II obesity, and class III obesity had 14% (aRR, 1.14; 95% CI, 1.07-1.21), 16% (aRR, 1.16; 95% CI, 1.06-1.27), 17% (aRR, 1.17; 95% CI, 1.02-1.34), and 41% higher rates (aRR, 1.41; 95% CI, 1.19-1.66), respectively. The proportion of women who conceived by ART increased with increasing BMI, and ART was associated with nearly a 12-fold higher rate of twin delivery (aRR, 11.80; 95% CI 11.10-12.54). ART explained about a quarter of the association between obesity class I and II and twin delivery (eg, obesity class I, 23% mediated; 95% CI, 7%-39% mediated), but none of this association was mediated by ART in women with class III obesity. Conclusions and relevance In this cohort study of 524 845 births, the rate of twin birth increased with increasing prepregnancy BMI. In women with a BMI between 30 and 40, approximately one-quarter of this association was explained by higher use of ART; however, there was no evidence of such mediation in women with BMI of 40 or greater.
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Affiliation(s)
- Jeffrey N. Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Children’s and Women’s Hospital and Health Centre, Vancouver, British Columbia, Canada
- Biostatistics, British Columbia Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - K. S. Joseph
- Department of Obstetrics and Gynaecology, University of British Columbia, Children’s and Women’s Hospital and Health Centre, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura A. Magee
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Li Qing Wang
- Department of Obstetrics and Gynaecology, University of British Columbia, Children’s and Women’s Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Sid John
- Department of Obstetrics and Gynaecology, University of British Columbia, Children’s and Women’s Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Mohamed A. Bedaiwy
- Department of Obstetrics and Gynaecology, University of British Columbia, Children’s and Women’s Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Chantal Mayer
- Department of Obstetrics and Gynaecology, University of British Columbia, Children’s and Women’s Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Children’s and Women’s Hospital and Health Centre, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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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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Nik Hazlina NH, Norhayati MN, Shaiful Bahari I, Nik Muhammad Arif NA. Worldwide prevalence, risk factors and psychological impact of infertility among women: a systematic review and meta-analysis. BMJ Open 2022; 12:e057132. [PMID: 35354629 PMCID: PMC8968640 DOI: 10.1136/bmjopen-2021-057132] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess the prevalence, risk factors and psychological impact of infertility among females. This review summarises the available evidence, effect estimates and strength of statistical associations between infertility and its risk factors. STUDY DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, CINAHL and ScienceDirect were searched through 23 January 2022. ELIGIBILITY CRITERIA The inclusion criteria involved studies that reported the psychological impact of infertility among women. We included cross-sectional, case-control and cohort designs, published in the English language, conducted in the community, and performed at health institution levels on prevalence, risk factors and psychological impact of infertility in women. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted and assess the quality of data using the Joanna Briggs Institute Meta-Analysis. The outcomes were assessed with random-effects model and reported as the OR with 95% CI using the Review Manager software. RESULTS Thirty-two studies with low risk of bias involving 124 556 women were included. The findings indicated the overall pooled prevalence to be 46.25% and 51.5% for infertility and primary infertility, respectively. Smoking was significantly related to infertility, with the OR of 1.85 (95% CI 1.08 to 3.14) times higher than females who do not smoke. There was a statistical significance between infertility and psychological distress among females, with the OR of 1.63 (95% CI 1.24 to 2.13). A statistical significance was noted between depression and infertility among females, with the OR of 1.40 (95% CI 1.11 to 1.75) compared with those fertile. CONCLUSIONS The study results highlight an essential and increasing mental disorder among females associated with infertility and may be overlooked. Acknowledging the problem and providing positive, supportive measures to females with infertility ensure more positive outcomes during the therapeutic process. This review is limited by the differences in definitions, diagnostic cut points, study designs and source populations. PROSPERO REGISTRATION NUMBER CRD42021226414.
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Affiliation(s)
- Nik Hussain Nik Hazlina
- Women's Health Development Unit, Universiti Sains Malaysia - Kampus Kesihatan, Kubang Kerian, Kelantan, Malaysia
| | - Mohd Noor Norhayati
- Department of Family Medicine, Universiti Sains Malaysia - Kampus Kesihatan, Kubang Kerian, Kelantan, Malaysia
| | - Ismail Shaiful Bahari
- Department of Family Medicine, Universiti Sains Malaysia - Kampus Kesihatan, Kubang Kerian, Kelantan, Malaysia
| | - Nik Ahmad Nik Muhammad Arif
- Women's Health Development Unit, Universiti Sains Malaysia - Kampus Kesihatan, Kubang Kerian, Kelantan, Malaysia
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Westerman R, Kuhnt AK. Metabolic risk factors and fertility disorders: A narrative review of the female perspective. REPRODUCTIVE BIOMEDICINE & SOCIETY ONLINE 2022; 14:66-74. [PMID: 34765754 PMCID: PMC8569630 DOI: 10.1016/j.rbms.2021.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/05/2021] [Accepted: 09/06/2021] [Indexed: 05/12/2023]
Abstract
Metabolic risk factors such as obesity are considered major obstacles to female fertility. Chronic infertility imposes psychological and social burdens on women because infertility violates societal gender roles. Although the prevalence of obesity among women is expected to increase in the future, the relevance of metabolic status for fertility is still underestimated. However, the assessment of metabolic risk factors is highly relevant for understanding fertility disorders and improving infertility treatment. This narrative review discusses the associations of metabolic risk factors (e.g. obesity, female athlete triad, oxidative stress) with significant infertility. An electronic search was conducted for studies published between 2006 and 2020 in Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, PubMed, Scopus, Google Scholar and related databases. In total, this search identified 19,309 results for polycystic ovary syndrome, 28,969 results for endometriosis, and only 1611 results for idiopathic and/or unknown infertility. For the present narrative review, 50 relevant studies were included: 19 studies were on obesity, 24 studies investigated the female athlete triad, and seven studies addressed other risk factors, including reactive oxygen species. This narrative review confirms the direct impact of obesity on female infertility, while the effect of other risk factors needs to be confirmed by large-scale population studies.
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Affiliation(s)
- Ronny Westerman
- Federal Institute of Population Research, Wiesbaden, Germany
| | - Anne-Kristin Kuhnt
- Department of Sociology and Demography, University of Rostock, Rostock, Germany
- Corresponding author.
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Gonzalez MB, Robker RL, Rose RD. Obesity and oocyte quality: Significant implications for ART and Emerging mechanistic insights. Biol Reprod 2021; 106:338-350. [PMID: 34918035 DOI: 10.1093/biolre/ioab228] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/22/2021] [Accepted: 12/07/2021] [Indexed: 11/14/2022] Open
Abstract
The prevalence of obesity in adults worldwide, and specifically in women of reproductive age, is concerning given the risks to fertility posed by the increased risk of type 2 diabetes, metabolic syndrome and other non-communicable diseases. Obesity has a multi-systemic impact in female physiology that is characterized by the presence of oxidative stress, lipotoxicity, and the activation of pro-inflammatory pathways, inducing tissue-specific insulin resistance and ultimately conducive to abnormal ovarian function. A higher body mass is linked to Polycystic Ovary Syndrome, dysregulated menstrual cycles, anovulation, and longer time to pregnancy, even in ovulatory women. In the context of ART, compared to women of normal BMI, obese women have worse outcomes in every step of their journey, resulting in reduced success measured as live birth rate. Even after pregnancy is achieved, obese women have a higher chance of miscarriage, gestational diabetes, pregnancy complications, birth defects, and most worryingly, a higher risk of stillbirth and neonatal death. The potential for compounding effects of ART on pregnancy complications and infant morbidities in obese women has not been studied. There is still much debate in the field on whether these poorer outcomes are mainly driven by defects in oocyte quality, abnormal embryo development or an unaccommodating uterine environment, however the clinical evidence to date suggests a combination of all three are responsible. Animal models of maternal obesity shed light on the mechanisms underlaying the effects of obesity on the peri-conception environment, with recent findings pointing to lipotoxicity in the ovarian environment as a key driver of defects in oocytes that have not only reduced developmental competence but long-lasting effects in offspring health.
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Affiliation(s)
- Macarena B Gonzalez
- Robinson Research Institute, School of Biomedicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Rebecca L Robker
- Robinson Research Institute, School of Biomedicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Ryan D Rose
- Robinson Research Institute, School of Biomedicine, University of Adelaide, Adelaide, South Australia, Australia.,Fertility SA, St. Andrews Hospital, Adelaide, South Australia, Australia
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Kapoor E, Faubion SS, Kling JM. Women's Health Endocrinology Update. J Womens Health (Larchmt) 2021; 30:1681-1685. [PMID: 34871065 DOI: 10.1089/jwh.2021.0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ekta Kapoor
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Women's Health, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephanie S Faubion
- Women's Health, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Juliana M Kling
- Women's Health, Mayo Clinic, Rochester, Minnesota, USA
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
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7
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Hunter E, Avenell A, Maheshwari A, Stadler G, Best D. The effectiveness of weight-loss lifestyle interventions for improving fertility in women and men with overweight or obesity and infertility: A systematic review update of evidence from randomized controlled trials. Obes Rev 2021; 22:e13325. [PMID: 34390109 DOI: 10.1111/obr.13325] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/02/2021] [Accepted: 07/02/2021] [Indexed: 01/05/2023]
Abstract
Being overweight or obese can have a negative impact on fertility outcomes. This systematic review updates randomized controlled trial (RCT) findings on the effectiveness of weight loss interventions in reducing weight and improving reproductive outcomes of women and men with overweight or obesity and infertility. Eligible studies, published since the last review, were identified by searching databases from March 20, 2016 until March 31, 2020. RCTs involving any type of lifestyle intervention were considered. Eight RCTs were identified and aggregated with seven RCTs included in our previous review. Meta-analyses revealed that women randomized to a combined diet and exercise intervention were more likely to become pregnant, risk ratio (RR) = 1.87 (95% CI 1.20, 2.93) and achieve a live birth RR = 2.20 (95% CI 1.23, 3.94), compared to women in control groups who received no or minimal intervention. This pattern was not replicated in trials where control groups received immediate access to assisted reproductive technology (ART). No eligible randomized trials involving men were identified. Data were largely obtained from small scale studies. Better designed, adequately powered, robust randomized trials are needed to better understand the effect of weight loss interventions on reproductive outcomes in both women and men.
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Affiliation(s)
- Emma Hunter
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Alison Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Abha Maheshwari
- Aberdeen Fertility Centre, Aberdeen Maternity Hospital, Aberdeen, UK
| | - Gertraud Stadler
- Institute of Gender in Medicine, Charité University Berlin, Germany & Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Damian Best
- Faculty of Medical Sciences, University of the West Indies, Bridgetown, Barbados
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8
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Benito E, Gómez-Martin JM, Vega-Piñero B, Priego P, Galindo J, Escobar-Morreale HF, Botella-Carretero JI. Fertility and Pregnancy Outcomes in Women with Polycystic Ovary Syndrome Following Bariatric Surgery. J Clin Endocrinol Metab 2020; 105:5868099. [PMID: 32754732 DOI: 10.1210/clinem/dgaa439] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/02/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Restoration of ovulation is quite common in women with polycystic ovary syndrome (PCOS) after surgically induced weight loss. Whether or not this results in an improvement of PCOS-associated infertility is uncertain. OBJECTIVE To study fertility and gestational outcomes in women with PCOS after bariatric surgery. DESIGN Unicenter cohort study. SETTING Academic hospital. PATIENTS Two hundred and sixteen premenopausal women were screened for PCOS before bariatric surgery. Women were followed-up after the intervention until mid-2019 regardless of having or not PCOS. INTERVENTIONS All participants underwent bariatric surgery from 2005 to 2015. MAIN OUTCOME MEASURES Pregnancy and live birth rates in the PCOS and control groups. RESULTS In women seeking fertility, pregnancy rates were 95.2% in PCOS and 76.9% in controls (P = 0.096) and live birth rates were 81.0% and 69.2%, respectively (P = 0.403). The time to achieve the first pregnancy after surgery was 34 ± 28 months in women with PCOS and 32 ± 25 months in controls. Albeit the mean birth weight was lower (P = 0.040) in newborns from women with PCOS (2763 ± 618 g) compared with those from controls (3155 ± 586 g), the number of newborns with low birth weight was similar in both groups (3 in the PCOS group and 1 in the controls, P = 0.137). Maternal (17.6% in PCOS and 22.2% in controls, P = 0.843) and neonatal (23.5% in PCOS and 14.8% in controls, P = 0.466) complications were rare, showing no differences between groups. CONCLUSIONS Pregnancy and fertility rates in very obese women with PCOS after bariatric surgery were high, with few maternal and neonatal complications.
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Affiliation(s)
- Estela Benito
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Jesús M Gómez-Martin
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Belén Vega-Piñero
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Pablo Priego
- Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Julio Galindo
- Department of General and Digestive Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM) & Instituto Ramón y Cajal de Investigación Sanitaria (IRyCIS), Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
| | - José I Botella-Carretero
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBEROBN) & IRyCIS, Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
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Koga F, Kitagami S, Izumi A, Uemura T, Takayama O, Koga T, Mizoguchi T. Relationship between nutrition and reproduction. Reprod Med Biol 2020; 19:254-264. [PMID: 32684824 PMCID: PMC7360971 DOI: 10.1002/rmb2.12332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/16/2020] [Accepted: 05/21/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recently, the relationship between nutrition and reproduction is being studied. In particular, when older women receive reproductive treatment, egg aging causes greater problems than organic factors. METHODS This study investigated the relationship between nutrition and reproduction with a focus on factors that cause aging, including oxidation, glycation, and chronic inflammation. A large volume of data concerning each nutrient's relationship with reproductive medicine was collected from a number of observational studies. MAIN FINDINGS The results showed that refined carbohydrates should be avoided and care should be taken to achieve proper intake of omega-3 fatty acids. Folic acid and vitamin D were also effective. For men, antioxidant measures are especially effective. The effects of antioxidants are related to insulin resistance, which causes chronic inflammation. CONCLUSION Recent research has shown that rather than meal content, meal intervals are more important for improving insulin resistance. Future research should examine lifestyle-related nutrition factors and their relationships to reproductive treatment.
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Harris R, Vernazza C, Laverty L, Lowers V, Burnside G, Brown S, Higham S, Ternent L. Presenting patients with information on their oral health risk: the PREFER three-arm RCT and ethnography. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
A new NHS dental practice contract is being tested using a traffic light (TL) system that categorises patients as being at red (high), amber (medium) or green (low) risk of poor oral health. This is intended to increase the emphasis on preventative dentistry, including giving advice on ways patients can improve their oral health. Quantitative Light-Induced Fluorescence (QLF™) cameras (Inspektor Research Systems BV, Amsterdam, the Netherlands) also potentially offer a vivid portrayal of information on patients’ oral health.
Methods
Systematic review – objective: to investigate how patients value and respond to different forms of information on health risks. Methods: electronic searches of nine databases, hand-searching of eight specialist journals and backwards and forwards citation-chasing followed by duplicate title, abstract- and paper-screening and data-extraction. Inclusion criteria limited studies to personalised information on risk given to patients as part of their health care. Randomised controlled trial (RCT) – setting: NHS dental practice. Objective: to investigate patients’ preferences for and response to different forms of information about risk given at check-ups. Design: a pragmatic, multicentred, three-arm, parallel-group, patient RCT. Participants: adults with a high/medium risk of poor oral health attending NHS dental practices. Interventions: (1) information given verbally supported by a card showing the patient’s TL risk category; (2) information given verbally supported by a QLF photograph of the patient’s mouth. The control was verbal information only (usual care). Main outcome measures: primary outcome – median valuation for the three forms of information measured by willingness to pay (WTP). Secondary outcomes included toothbrushing frequency and duration, dietary sugar intake, smoking status, self-rated oral health, a basic periodontal examination, Plaque Percentage Index and the number of tooth surfaces affected by caries (as measured by QLF). Qualitative study – an ethnography involving observations of 368 dental appointments and interviews with patients and dental teams.
Results
Systematic review – the review identified 12 papers (nine of which were RCTs). Eight studies involved the use of computerised risk assessments in primary care. Intervention effects were generally modest, even with respect to modifying risk perceptions rather than altering behaviour or clinical outcomes. RCT – the trial found that 51% of patients identified verbal information as their most preferred form, 35% identified QLF as most preferred and 14% identified TL information as most preferred. The median WTP for TL was about half that for verbal information alone. Although at 6 and 12 months patients reported taking less sugar in drinks, and at 12 months patients reported longer toothbrushing, there was no difference by information group. Qualitative study – there was very little explicit risk talk. Lifestyle discussions were often cursory to avoid causing shame or embarrassment to patients.
Limitations
Only 45% of patients were retained in the trial at 6 months and 31% were retained at 12 months. The trial was conducted in four dental practices, and five dental practices were involved in the qualitative work.
Conclusions
Patients prefer personal, detailed verbal advice on oral health at their check-up. A new NHS dental practice contract using TL categorisation might make this less likely.
Future work
Research on how to deliver, within time constraints, effective advice to patients on preventing poor oral health. More research on ‘risk work’ in wider clinical settings is also needed.
Trial registration
Current Controlled Trials ISRCTN71242343.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rebecca Harris
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | | | - Louise Laverty
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Victoria Lowers
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Girvan Burnside
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Stephen Brown
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Susan Higham
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Laura Ternent
- Institute of Health and Social Care, Newcastle University, Newcastle upon Tyne, UK
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Saber SM, Abd El-Rahman HA. Liraglutide treatment effects on rat ovarian and uterine tissues. Reprod Biol 2019; 19:237-244. [DOI: 10.1016/j.repbio.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/08/2019] [Accepted: 07/12/2019] [Indexed: 02/03/2023]
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12
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Sasaki RSA, Approbato MS, Maia MCS, Ferreira EABFE, Zanluchi N. Ovulatory status of overweight women without Polycystic Ovary Syndrome. JBRA Assist Reprod 2019; 23:2-6. [PMID: 30614235 PMCID: PMC6364286 DOI: 10.5935/1518-0557.20180071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective: Obesity is one of the extra hypothalamic-pituitary-ovarian axis factors that
can influence ovulation. The isolated impact of obesity on ovulation without
other comorbidities needs to be further studied. Our goal is to evaluate the
association between the anovulation in the ultrasonographic monitoring of
the ovulation cycle and the body mass increase of infertile patients without
polycystic ovaries of a university service. Methods: Case-control study performed at the Human Reproduction Laboratory of the
University Hospital. We evaluated 1,356 ultrasound monitoring reports of
ovulation between January 2011 and December 2015. We named case those
patients who ovulated on the monitored cycle. After applying the exclusion
criteria, we consolidated a total of 110 cases and 118 controls. The
exposure variables were normal BMI or patients classified with a BMI above
normal. Data analysis was performed using SPSS 22.0. Differences in
proportions were assessed by X2 test Pearson, Fisher and Wilcoxon
test. The value of p<0.05 was considered statistically
significant. Results: The groups were comparable in age, age at menarche, number of pregnancies,
deliveries, cesarean sections and abortions, number of antral follicles,
FSH, prolactin and TSH values. Among the anovulatory patients, 57 (51.82%)
were overweight, while among ovulatory patients, 44 (37.29%) were in this
same BMI category. The odds ratio was 1.8655, with a significant p value
(p<0.05). Conclusion: There was an association between anovulation and increase in the Body Mass
Index, with an increased risk of anovulation in patients with BMI above
normal.
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Affiliation(s)
- Reinaldo S A Sasaki
- Assisted Reproduction Laboratory - Hospital das Clínicas - Federal University of Goiás
| | - Mário S Approbato
- Assisted Reproduction Laboratory - Hospital das Clínicas - Federal University of Goiás
| | - Mônica C S Maia
- Assisted Reproduction Laboratory - Hospital das Clínicas - Federal University of Goiás
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Reynolds RM, Gordon A. Obesity, fertility and pregnancy: can we intervene to improve outcomes? J Endocrinol 2018; 239:R47-R55. [PMID: 30400070 DOI: 10.1530/joe-18-0199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/24/2018] [Indexed: 12/14/2022]
Abstract
Rates of obesity among women of reproductive age have risen dramatically in recent decades. Obesity impacts on health of women across their reproductive lifespan with adverse effects on not only fertility and short-term complications of pregnancy, but also on longer term health outcomes for both women and their children. This places considerable burden and cost on health services. Here, we review the evidence linking maternal obesity to adverse fertility, pregnancy and longer term health outcomes for women and their children. We discuss the outcomes of recent lifestyle, pharmacological and surgical intervention studies. As many of these studies have not shown a significant improvement in clinical outcomes, we discuss the need for better study design in future trials.
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Affiliation(s)
- Rebecca M Reynolds
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Adrienne Gordon
- Charles Perkins Centre, University of Sydney, Sydney, Australia
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Abstract
Polycystic ovary syndrome (PCOS) is one of the most common endocrine and metabolic disorders in premenopausal women. Heterogeneous by nature, PCOS is defined by a combination of signs and symptoms of androgen excess and ovarian dysfunction in the absence of other specific diagnoses. The aetiology of this syndrome remains largely unknown, but mounting evidence suggests that PCOS might be a complex multigenic disorder with strong epigenetic and environmental influences, including diet and lifestyle factors. PCOS is frequently associated with abdominal adiposity, insulin resistance, obesity, metabolic disorders and cardiovascular risk factors. The diagnosis and treatment of PCOS are not complicated, requiring only the judicious application of a few well-standardized diagnostic methods and appropriate therapeutic approaches addressing hyperandrogenism, the consequences of ovarian dysfunction and the associated metabolic disorders. This article aims to provide a balanced review of the latest advances and current limitations in our knowledge about PCOS while also providing a few clear and simple principles, based on current evidence-based clinical guidelines, for the proper diagnosis and long-term clinical management of women with PCOS.
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Affiliation(s)
- Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Universidad de Alcalá, Alcalá de Henares, Spain
- Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
- Instituto Ramón y Cajal de Investigación Santiaria (IRYCIS), Madrid, Spain
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Sacha CR, Page CM, Goldman RH, Ginsburg ES, Zera CA. Are women with obesity and infertility willing to attempt weight loss prior to fertility treatment? Obes Res Clin Pract 2017; 12:125-128. [PMID: 29221938 DOI: 10.1016/j.orcp.2017.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess attitudes towards weight loss interventions in patients seeking infertility treatment. METHODS We evaluated prior weight loss experiences, attitudes towards future interventions by body mass index (BMI), and willingness to delay fertility treatment for weight loss interventions stratified by BMI using logistic regression amongst women ≤45years old with infertility over three months or recurrent pregnancy loss. RESULTS The average age of our convenience sample of respondents (148 of 794 eligible women, 19%) was 34.5 years old, with a mean BMI of 26.7±7.4kg/m2, including 37 with a BMI >30kg/m2 (25%). Most women had attempted conception over 1year. The majority of women with overweight or obesity were attempting weight loss at the time of survey completion (69%). While 47% of these women reported interest in a supervised medical weight loss program, 92% of overweight women and 84% of women with obesity were not willing to delay fertility treatment more than 3 months to attempt weight loss. CONCLUSION Most women with obesity and infertility in our population are unwilling to postpone fertility treatment for weight loss interventions.
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Affiliation(s)
- C R Sacha
- Dept. of Obstetrics & Gynecology, Center for Infertility and Reproductive Surgery, Brigham & Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.
| | - C M Page
- Dept. of Obstetrics & Gynecology, Center for Infertility and Reproductive Surgery, Brigham & Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.
| | - R H Goldman
- Dept. of Obstetrics & Gynecology, Center for Infertility and Reproductive Surgery, Brigham & Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.
| | - E S Ginsburg
- Dept. of Obstetrics & Gynecology, Center for Infertility and Reproductive Surgery, Brigham & Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.
| | - C A Zera
- Dept. of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.
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Garalejic E, Arsic B, Radakovic J, Bojovic Jovic D, Lekic D, Macanovic B, Soldatovic I, Perovic M. A preliminary evaluation of influence of body mass index on in vitro fertilization outcome in non-obese endometriosis patients. BMC WOMENS HEALTH 2017; 17:112. [PMID: 29145852 PMCID: PMC5691874 DOI: 10.1186/s12905-017-0457-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 10/31/2017] [Indexed: 11/17/2022]
Abstract
Background/aims Obese and overweight women experience a lower probability for pregnancy after IVF. However, despite the increasing prevalence of obesity, the large majority of infertile women are non-obese. One of the most common indications for IVF is endometriosis. Thought-provoking inverse correlation has been established between BMI and endometriosis. Lower BMI is a risk factor for development of endometriosis and a predictive factor for severe endometriosis. Since severe endometriosis carries lower reproductive chances, even after IVF, we preliminary tested a hypothesis that higher BMI among non-obese endometriosis patients improves IVF outcomes. Methods Preliminary retrospective observational cross-sectional study was performed in women with endometriosis as a sole infertility cause who underwent IVF. During analyzed period we performed 2782 IVF procedures. In order to achieve highly homogenous study sample and to eliminate almost all confound factors that could lead to bias, we implemented strict study criteria. The number of eligible subjects was 156 and they were divided into underweight, normal weight and overweight groups. Primary outcomes were number of retrieved oocytes, good quality oocytes, embryos, and the rates of biochemical, clinical and ongoing pregnancies. For group comparisons, we used parametric test, analysis of variance, and non-parametric tests (Kruskal-Wallis test, Chi-square test). Logistic regression and General linear model was used to assess correlation between BMI and dependent variables (outcome and stimulation duration) when adjusted for age. Results Endometriosis as a single infertility factor among IVF couples had prevalence of 5.61%. Underweight women accounted for 10.26%, normal weight 71.15% and overweight 18.59% of study population. Significant differences were not found in number of retrieved oocytes (p = 0.880), good quality oocytes (p = 0.476), obtained embryos (p = 0.706), and biochemical (p = 0.298), clinical (p = 0.770) and ongoing (p = 0.822) pregnancy rates between study groups. Conclusion Although preliminary results do not support our hypothesis, increase in BMI did not adversely affect the outcome of IVF in non-obese endometriosis patients, which is in contrast to literature data as regards general population of infertile women undergoing IVF. Prospective studies with large number of patients with endometriosis or prospective case-control studies should address these issues and provide more comprehensive counseling of infertile endometriosis patients regarding achievement of optimal BMI prior to IVF with the intention of achievement higher pregnancy rates.
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Affiliation(s)
- Eliana Garalejic
- IVF Department, Clinic for Gynecology and Obstetrics "Narodni front", Kraljice Natalije 62, Belgrade, 11000, Serbia.,School of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, 11000, Serbia
| | - Biljana Arsic
- IVF Department, Clinic for Gynecology and Obstetrics "Narodni front", Kraljice Natalije 62, Belgrade, 11000, Serbia
| | - Jovana Radakovic
- IVF Department, Clinic for Gynecology and Obstetrics "Narodni front", Kraljice Natalije 62, Belgrade, 11000, Serbia
| | - Dragana Bojovic Jovic
- IVF Department, Clinic for Gynecology and Obstetrics "Narodni front", Kraljice Natalije 62, Belgrade, 11000, Serbia
| | - Dragana Lekic
- IVF Department, Clinic for Gynecology and Obstetrics "Narodni front", Kraljice Natalije 62, Belgrade, 11000, Serbia
| | - Biljana Macanovic
- IVF Department, Clinic for Gynecology and Obstetrics "Narodni front", Kraljice Natalije 62, Belgrade, 11000, Serbia
| | - Ivan Soldatovic
- School of Medicine, University of Belgrade, Dr Subotica 8, Belgrade, 11000, Serbia.,Institute of Medical Statistics and Informatics, Dr Subotica 15, Belgrade, 11000, Serbia
| | - Milan Perovic
- IVF Department, Clinic for Gynecology and Obstetrics "Narodni front", Kraljice Natalije 62, Belgrade, 11000, Serbia. .,Faculty of health, legal and business studies, Singidunum University, Zeleznicka 5, Valjevo, 14000, Serbia.
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van Oers AM, Groen H, Mutsaerts MAQ, Burggraaff JM, Kuchenbecker WKH, Perquin DAM, Koks CAM, van Golde R, Kaaijk EM, Schierbeek JM, Oosterhuis GJE, Broekmans FJ, Vogel NEA, Land JA, Mol BWJ, Hoek A. Effectiveness of lifestyle intervention in subgroups of obese infertile women: a subgroup analysis of a RCT. Hum Reprod 2016; 31:2704-2713. [PMID: 27798042 DOI: 10.1093/humrep/dew252] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 07/21/2016] [Accepted: 07/26/2016] [Indexed: 11/14/2022] Open
Abstract
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).
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Affiliation(s)
- A M van Oers
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, 9700RB Groningen, The Netherlands
| | - H Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, 9700RB Groningen, The Netherlands
| | - M A Q Mutsaerts
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, 9700RB Groningen, The Netherlands.,Department of General Practice, University of Utrecht, University Medical Center Utrecht, 3508GA Utrecht, The Netherlands
| | - J M Burggraaff
- Department of Obstetrics and Gynaecology, Scheper Hospital, 7800RA Emmen, The Netherlands
| | - W K H Kuchenbecker
- Department of Obstetrics and Gynaecology, Isala Clinics, 8000GK Zwolle, The Netherlands
| | - D A M Perquin
- Department of Obstetrics and Gynaecology, Medical Center Leeuwarden, 8901BR Leeuwarden, The Netherlands
| | - C A M Koks
- Department of Obstetrics and Gynaecology, Maxima Medical Center, 5500MB Veldhoven, The Netherlands
| | - R van Golde
- Department of Obstetrics and Gynaecology, University of Maastricht, Maastricht University Medical Center, 6202AZ Maastricht, The Netherlands
| | - E M Kaaijk
- Department of Obstetrics and Gynaecology, OLVG, 1090HM Amsterdam, The Netherlands
| | - J M Schierbeek
- Department of Obstetrics and Gynaecology, Deventer Hospital, 7400GC Deventer, The Netherlands
| | - G J E Oosterhuis
- Department of Obstetrics and Gynaecology, St. Antonius Hospital, 3430EM Nieuwegein, The Netherlands
| | - F J Broekmans
- Department for Reproductive Medicine, Division Female and Baby, University of Utrecht, University Medical Center Utrecht, 3508GA Utrecht, The Netherlands
| | - N E A Vogel
- Department of Obstetrics and Gynaecology, Martini Hospital, 9700RM Groningen, The Netherlands
| | - J A Land
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, 9700RB Groningen, The Netherlands
| | - B W J Mol
- The Robinson Research Institute, School of Pediatrics and Reproductive Health, University of Adelaide, 5000SA Adelaide, Australia
| | - A Hoek
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, 9700RB Groningen, The Netherlands
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Rothberg A, Lanham M, Randolph J, Fowler C, Miller N, Smith Y. Feasibility of a brief, intensive weight loss intervention to improve reproductive outcomes in obese, subfertile women: a pilot study. Fertil Steril 2016; 106:1212-1220. [PMID: 27336206 PMCID: PMC5797426 DOI: 10.1016/j.fertnstert.2016.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/02/2016] [Accepted: 06/02/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the feasibility of a brief, intensive weight loss intervention (IWL) to improve reproductive outcomes in obese subfertile women. DESIGN Pilot study of IWL versus standard-of-care nutrition counseling (SCN). SETTING Single-site, academic institution. PATIENT(S) Obese women (body mass index, 35-45 kg/m2) with anovulatory subfertility. INTERVENTION(S) Women were rigorously prescreened to rule out secondary causes of subfertility. Eligible women were randomized to IWL or SCN. IWL consisted of 12 weeks of very-low-energy diet (800 kcal/day) + 4 weeks of a low-calorie conventional food-based diet (CFD) to promote 15% weight loss. SCN consisted of 16 weeks of CFD to promote ≥5% weight loss. Women were transitioned to weight maintenance diets and referred back to reproductive endocrinology for ovulation induction. MAIN OUTCOME MEASURE(S) Feasibility of recruitment, randomization, intervention implementation, and retention. RESULT(S) Thirty-nine women were screened; 25 (64%) were eligible to participate, and 14 of those eligible (56%) agreed to be randomized, seven in each group. One withdrew from the IWL group and two from the SCN group. Percent weight loss was greater in the IWL group than in the SCN group (13% ± 5% vs. 4% ± 4%). Three of six women in the IWL group conceived and delivered term pregnancies. No pregnancies occurred in the SCN group. CONCLUSION(S) After rigorous screening, 44% of eligible women completed the study. IWL was associated with greater percentage weight loss and improvements in insulin sensitivity. CLINICAL TRIAL REGISTRATION NCT01894074.
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Affiliation(s)
- Amy Rothberg
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan.
| | - Michael Lanham
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - John Randolph
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Christine Fowler
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Nicole Miller
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Yolanda Smith
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Best D, Bhattacharya S. Obesity and fertility. Horm Mol Biol Clin Investig 2016; 24:5-10. [PMID: 26351959 DOI: 10.1515/hmbci-2015-0023] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/13/2015] [Indexed: 11/15/2022]
Abstract
The prevalence of overweight and obesity in women of reproductive age has increased over the past 30 years. Infertility affects 1 in 7 couples, and female obesity is associated with anovulation. The mechanisms by which excessive fat delays time to pregnancy (TTP) appear rooted in ovulatory problems and direct effects on oocytes, causing poorer embryo development, as well as in effects on the endometrium. Weight loss in women has been shown to improve conception, but not necessarily live birth rates following fertility treatment, and further research in this area is needed. The obesity epidemic has been accompanied by a potential rise in male infertility, which has been attributed to hormonal disturbances and compromised semen parameters.
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20
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Obesity in Women: The Clinical Impact on Gastrointestinal and Reproductive Health and Disease Management. Gastroenterol Clin North Am 2016; 45:317-31. [PMID: 27261901 DOI: 10.1016/j.gtc.2016.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Approximately 36% of adult women in the United States are obese. Although obesity affects women similarly to men in terms of prevalence, there seem to be gender-specific differences in the pathophysiology, clinical manifestations, and treatment of obesity. Obesity is linked to comorbid diseases involving multiple organ systems, including the gastrointestinal tract, like gastroesophageal reflux disease, fatty liver disease, and gallstones. This article focuses on obesity in women, specifically the impact of obesity on gastrointestinal diseases and reproductive health, as well as the treatment of obesity in women.
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21
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Kaye L, Sueldo C, Engmann L, Nulsen J, Benadiva C. Survey assessing obesity policies for assisted reproductive technology in the United States. Fertil Steril 2015; 105:703-706.e2. [PMID: 26690012 DOI: 10.1016/j.fertnstert.2015.11.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/25/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine what assisted reproductive technologies (ART) policies, if any, have been instituted in response to an increasingly overweight and obese patient population. DESIGN Cross-sectional survey. SETTING University-affiliated IVF clinic. PATIENT(S) Women in the overweight and obese body mass index (BMI) categories seeking ART treatments. INTERVENTION(S) Anonymous survey sent to medical directors at 395 IVF centers listed in Society for Assisted Reproductive Technology database. MAIN OUTCOME MEASURE(S) Assessment of recommendations, policies, and restrictions for patients who are overweight/obese and who desire treatment for infertility, including in IVF, IUI, and donor egg cycles. RESULT(S) Seventy-seven anonymous responses were received (19.5% response rate): 64.9% of centers have a formal policy for obesity, and 84% of those have a maximum BMI at which they will perform IVF, while 38% of those have a maximum BMI for performing IUI; 64.6% of respondents reported anesthesia requirements/concerns as the primary criteria for patient exclusion. Other primary considerations included safety during ongoing pregnancy and ART outcomes. CONCLUSION(S) Centers that have policies regarding obesity and access to ART consider efficacy, procedural safety, safety in pregnancy, and overall health status. Policies vary widely. The patient's autonomy must be balanced with nonmaleficence and the avoidance of interventions that may be unsafe both immediately and long term.
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Affiliation(s)
- Leah Kaye
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Connecticut
| | - Carolina Sueldo
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Connecticut
| | - Lawrence Engmann
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Connecticut
| | - John Nulsen
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Connecticut
| | - Claudio Benadiva
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, Connecticut.
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Dağ ZÖ, Dilbaz B. Impact of obesity on infertility in women. J Turk Ger Gynecol Assoc 2015; 16:111-7. [PMID: 26097395 PMCID: PMC4456969 DOI: 10.5152/jtgga.2015.15232] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/22/2015] [Indexed: 12/14/2022] Open
Abstract
The prevalence of obesity and overweight are increasing and have become an epidemic worldwide. Obesity has detrimental influences on all systems, including reproductive health. The prevalence of obesity in infertile women is high, and it is well known that there is an association between obesity and infertility. The relationship between obesity and reproductive functions is still being explored. Overweight women have a higher incidence of menstrual dysfunction and anovulation. Overweight and obese women are at a high risk for reproductive health. The risk of subfecundity and infertility, conception rates, miscarriage rates, and pregnancy complications are increased in these women. They have poor reproductive outcomes in natural as well as assisted conception. These poor reproductive outcomes include assisted reproduction such as ovulation induction, in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), and ovum donation cycles. Weight loss has beneficial effects on the reproductive outcomes in these patients.
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Affiliation(s)
- Zeynep Özcan Dağ
- Department of Obstetrics and Gynecology, Kırıkkale University Faculty of Medicine, Kırıkkale, Turkey
| | - Berna Dilbaz
- Clinic of Reproductive Endocrinology and Infertility, Ankara Etlik Zübeyde Hanım Women’s Health Education and Research Hospital, Ankara, Turkey
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Robotic single-site myomectomy: initial report and technique. Fertil Steril 2015; 103:1370-7.e1. [DOI: 10.1016/j.fertnstert.2015.02.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/18/2015] [Accepted: 02/18/2015] [Indexed: 02/08/2023]
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Turner-McGrievy GM, Grant BL. Prevalence of body mass index and body weight cut-off points for in vitro fertilization treatment at U.S. clinics and current clinic weight loss strategy recommendations. HUM FERTIL 2015; 18:215-9. [DOI: 10.3109/14647273.2015.1022606] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Sabounchi NS, Hovmand PS, Osgood ND, Dyck RF, Jungheim ES. A novel system dynamics model of female obesity and fertility. Am J Public Health 2014; 104:1240-6. [PMID: 24832413 DOI: 10.2105/ajph.2014.301898] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Our objective was to create a system dynamics model specific to weight gain and obesity in women of reproductive age that could inform future health policies and have the potential for use in preconception interventions targeting obese women. METHODS We used our system dynamics model of obesity in women to test various strategies for family building, including ovulation induction versus weight loss to improve ovulation. Outcomes included relative fecundability, postpartum body mass index, and mortality. RESULTS Our system dynamics model demonstrated that obese women who become pregnant exhibit increasing obesity levels over time with elevated morbidity and mortality. Alternatively, obese women who lose weight prior to pregnancy have improved reproductive outcomes but may risk an age-related decline in fertility, which can affect overall family size. CONCLUSIONS Our model highlights important public health issues regarding obesity in women of reproductive age. The model may be useful in preconception counseling of obese women who are attempting to balance the competing risks associated with age-related declines in fertility and clinically meaningful weight loss.
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Affiliation(s)
- Nasim S Sabounchi
- Nasim S. Sabounchi and Peter S. Hovmand are with the Social System Design Lab, George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO. Nathaniel D. Osgood is with the Department of Computer Science, University of Saskatchewan, Saskatoon. Roland F. Dyck is with the Department of Medicine, College of Medicine, University of Saskatchewan. Emily S. Jungheim is with the Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
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Jungheim ES, Travieso JL, Hopeman MM. Weighing the impact of obesity on female reproductive function and fertility. Nutr Rev 2014; 71 Suppl 1:S3-8. [PMID: 24147921 DOI: 10.1111/nure.12056] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Obesity in women is associated with serious reproductive sequelae. Given its prevalence among women of reproductive age, much recent attention has focused on the mechanisms by which obesity affects female reproductive function and fertility. This review summarizes the literature investigating the epidemiology and pathophysiology of obesity in women of reproductive age and proposes research strategies that may help inform approaches to improve reproductive function and outcomes among obese women.
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Affiliation(s)
- Emily S Jungheim
- Washington University School of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Washington University, St. Louis, Missouri, USA
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Barthelmess EK, Naz RK. Polycystic ovary syndrome: current status and future perspective. Front Biosci (Elite Ed) 2014; 6:104-19. [PMID: 24389146 DOI: 10.2741/e695] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a widespread reproductive disorder that encompasses many associated health conditions and has an impact on various metabolic processes. PCOS is depicted by hyperandrogenism, polycystic ovaries, and anovulation. It increases the risk of insulin resistance (IR), type 2 diabetes, obesity, and cardiovascular disease. The etiology of the disease remains unclear, and the subjective phenotype makes a united diagnosis difficult among physicians. It seems to be a familial genetic syndrome caused by a combination of environmental and genetic factors. It can be linked with metabolic disorders in first-degree family members. PCOS is the cause of up to 30% of infertility in couples seeking treatment. Currently, there is no cure for PCOS. Despite the growing incidence of this syndrome, limited research has been done that encompasses the entirety of PCOS spectrum. In this review, the current status and possible future perspective will be discussed.
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Affiliation(s)
- Erin K Barthelmess
- Reproductive Immunology and Molecular Biology Lab, Department of Obstetrics and Gynecology, West Virginia University School of Medicine, Health Sciences Center, Morgantown, WV 26506-9186
| | - Rajesh K Naz
- Reproductive Immunology and Molecular Biology Lab, Department of Obstetrics and Gynecology, West Virginia University School of Medicine, Health Sciences Center, Morgantown, WV 26506-9186
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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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Public Opinion Regarding Utilization of Assisted Reproductive Technology (ART) in Obese Women. J Womens Health (Larchmt) 2013; 22:978-82. [DOI: 10.1089/jwh.2013.4399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Infertility patients' knowledge of the effects of obesity on reproductive health outcomes. Am J Obstet Gynecol 2012; 207:509.e1-509.e10. [PMID: 22981319 DOI: 10.1016/j.ajog.2012.08.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 07/29/2012] [Accepted: 08/10/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of the study was to assess the infertility patient knowledge of reproductive outcomes affected by obesity. STUDY DESIGN This was a prospective survey study of 150 female infertility patients in an academic medical center. Subjects were administered the Rapid Estimate of Adult Literacy in Medicine-Short Form and a questionnaire on the health risks of obesity, and investigators obtained height and weight measurements. RESULTS Subjects' age ranged from 21 to 45 years (mean 34.8 ± 4.94 SD) and body mass index ranged from 17.9 to 62.9 kg/m(2) (mean 26.5 ± 7.54 SD). The following percentages of women were aware that obesity increases the risk of infertility (82.7%), irregular periods (70.0%), miscarriage (60.7%), cesarean section (48.7%), breast cancer (38.7%), birth defects (29.3%), stillbirth (22.7%), and endometrial cancer (20.7%). CONCLUSION Among women with infertility, there is limited knowledge of reproductive outcomes affected by obesity. Public education is needed to increase awareness. Women undergoing fertility treatment are motivated for reproductive success and may be uniquely receptive to obesity education and weight loss intervention.
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Koning AMH, Mutsaerts MAQ, Kuchenbecker WKH, Kuchenbecher WKH, Broekmans FJ, Land JA, Mol BW, Hoek A. Complications and outcome of assisted reproduction technologies in overweight and obese women. Hum Reprod 2011; 27:457-67. [PMID: 22144420 DOI: 10.1093/humrep/der416] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Based on a presumed negative impact of overweight and obesity on reproductive capacity and pregnancy outcome, some national guidelines and clinicians have argued that there should be an upper limit for a woman's BMI to access assisted reproductive technologies (ART). However, evidence on the risk of complications or expected success rate of ART in obese women is scarce. We therefore performed a systematic review on the subject. METHODS We searched the literature for studies reporting on complications or success rates in overweight and obese women undergoing ART. Articles were scored on methodological quality. We calculated pooled odds ratios (ORs) to express the association between overweight and obesity on the one hand, and complications and success rates of ART on the other hand. We only pooled results if data were available per woman instead of per cycle or embryo transfer. RESULTS We detected 14 studies that reported on the association between overweight and complications during or after ART, of which 6 reported on ovarian hyperstimulation syndrome (OHSS), 7 on multiple pregnancies and 6 on ectopic pregnancies. None of the individual studies found a positive association between overweight and ART complications. The pooled ORs for overweight versus normal weight for OHSS, multiple pregnancy and ectopic pregnancy were 1.0 [95% confidence interval (CI) 0.77-1.3], 0.97 (95% CI 0.91-1.04) and 0.96 (95% CI 0.54-1.7), respectively. In 27 studies that reported on BMI and the success of ART, the pooled ORs for overweight versus normal weight on live birth, ongoing and clinical pregnancy following ART were OR 0.90 (95% CI 0.82-1.0), 1.01 (95% CI 0.75-1.4) and OR 0.94 (95% CI 0.69-1.3), respectively. CONCLUSIONS Data on complications following ART are scarce and therefore a registration system should be implemented in order to gain more insight into this subject. In the available literature, there is no evidence of overweight or obesity increasing the risk of complications following ART. Furthermore, they only marginally reduce the success rates. Based on the currently available data, overweight and obesity in itself should not be a reason to withhold ART.
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Affiliation(s)
- A M H Koning
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Harris ID, Python J, Roth L, Alvero R, Murray S, Schlaff WD. Physicians' perspectives and practices regarding the fertility management of obese patients. Fertil Steril 2011; 96:991-2. [PMID: 21840519 DOI: 10.1016/j.fertnstert.2011.07.1111] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 07/19/2011] [Accepted: 07/19/2011] [Indexed: 11/26/2022]
Abstract
To assess the practice patterns and personal beliefs of fertility physicians who care for obese patients seeking assisted reproduction, we conducted a national survey of fertility program directors from both private and academic practices and discovered that although few practices have firm guidelines regarding the management of obese patients, the overwhelming majority of providers believe that body mass index guidelines or cutoffs should exist.
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Affiliation(s)
- Isiah D Harris
- Division of Advanced Reproductive Medicine, Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado, USA.
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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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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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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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