Should access to fertility treatment be determined by female body mass index?

Effect of weight loss before in vitro fertilization in women with obesity or overweight and infertility: a systematic review and meta-analysis

The effect of weight loss before in vitro fertilization (IVF) procedures on pregnancy outcomes in women with overweight or obesity and infertility remains controversial. In this systematic review and meta-analysis, we investigated whether weight loss before IVF in these women affected the IVF results and reproductive outcomes. PubMed, Embase, and the Cochrane Library databases were searched from the inception dates until December 2022, using combinations of relevant keywords. Only six randomized controlled trials, including 1627 women with obesity or overweight, were analyzed. The weight change in the intensive care group, compared to the control group who underwent IVF without weight loss was - 4.62 kg (mean difference; 95% confidence interval [CI] - 8.10, - 1.14). Weight loss before IVF did not significantly increase the live birth rate in women with obesity or overweight and infertility (odds ratio, 1.38; 95% CI 0.88, 2.10). The clinical pregnancy, miscarriage, ongoing pregnancy, and ectopic pregnancy rates did not differ between the weight loss and control groups before IVF. This meta-analysis demonstrated that even significant weight loss before IVF in women with obesity or overweight and infertility did not improve the live birth, clinical pregnancy, ongoing pregnancy, or ectopic pregnancy rates. PROSPERO Registration Number: CRD42023455800.

Memorable Messages About Fat Bodies Before, During, and After Pregnancy

Weight bias is prevalent for people in large bodies who are trying to conceive, pregnant, or postpartum. Using the theory of memorable messages as a framework, we explored the sources, valence, and content of messages that fat individuals (N = 237) recalled about their bodies before pregnancy through the postpartum stage. The most common source of memorable messages was healthcare providers, and most (77.2%) messages were negatively valenced. Thematic analysis revealed four overarching themes (fat mothers are bad mothers, denial of competent treatment, weight-normative commentary on fat bodies, and weight-inclusive counter-narratives). Our findings illuminate the significance of patient-practitioner communication across the pregnancy trajectory and highlight how counter-narratives can disrupt negative messages about fat pregnancy.

Evaluation of platelet parameters, coagulation markers, antiphospholipid syndrome, and thyroid function in palestinian women with recurrent pregnancy loss

BACKGROUND

Multiple etiologies contribute to recurrent pregnancy loss (RPL) including immunological, endocrine, anatomical, genetic and infection but more than 50% of cases remain unexplained. Evidences of thrombotic and inflammatory processes were observed at maternal-fetal interface and considered pathological findings in most RPL cases including unexplained cases. This study aimed to evaluate the association between RPL and several risk factors: platelet parameters, coagulation factors, antiphospholipid syndrome, and thyroid function.

METHODS

This is an unmatched case-control study that included 100 RPL and 100 control women. Anthropometric and health data were collected and a gynecologist examined participants to assure fitting the inclusion criteria. Platelet parameters [including Mean Platelet Mass (MPM), Concentration (MPC) and Volume (MPV)] and ratios (MPV/Platelet, MPC/Platelet, MPM/Platelet, Platelet/Mononuclear cells), coagulation markers [Protein C (PC), Protein S (PS), Antithrombin III, D-dimer], antiphospholipid antibodies [Anti-phospholipid (APA), Anti-cardiolipin (ACA) and anti-B2-glycoprotein 1], Lupus anticoagulant, Antinuclear antibodies, and thyroid function (Thyroid stimulating hormone and anti-thyroid peroxidase) were measured.

RESULTS

Mean ages of cases and controls at marriage were 22.5 years for both, and their current ages were 29.4 and 33.0, respectively. 92% of cases and 99% of controls aged blow 30 years at marriage. 75% of cases have 3-4 miscarriages and 9% have ≥ 7 miscarriages. Our results indicated significantly lower male/female age ratio (p = .019), PC (p = .036) and PS (p = .025) in cases compared to controls. Plasma D-dimer (p = .020) and antiphospholipid antibodies [ACA (IgM and IgG), APA (IgM)] were significantly higher in cases compared to controls. No significant differences were observed between cases and controls concerning APA (IgG), anti-B2-glycoprotein 1 (IgM and IgG), Lupus anticoagulant, Antinuclear antibodies, platelet parameters, thyroid markers, family history of miscarriage, consanguineous marriage, and other health data.

CONCLUSIONS

This is the first study that investigated the association between platelet, coagulation, antiphospholipid, autoimmune and thyroid parameters, and RPL in Palestinian women. Significant associations between male/female age ratio, PC, PS, D-dimer, ACA (IgM, IgG), APA (IgM) and RPL were observed. These markers could be used in evaluating RPL. These findings confirm the heterogeneous nature of RPL and emphasize the need for further studies to find out risk factors for RPL.

Obesity and reproduction: a committee opinion

The purpose of this American Society for Reproductive Medicine Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled "Obesity and reproduction: an educational bulletin" last published in 2015 (Fertil Steril 2015;104:1116-26).

Systematic review and meta-analysis of female lifestyle factors and risk of recurrent pregnancy loss

It is known that lifestyle factors affect sporadic miscarriage, but the extent of this on RPL (recurrent pregnancy loss) is less well known. A systematic review and meta-analysis was performed to assess the associations between lifestyle factors and RPL. Studies that analysed RPL in the context of BMI, smoking, alcohol and caffeine intake were included. The primary and secondary outcomes were odds of having RPL in the general population and odds of further miscarriage, respectively. Underweight and women with BMI > 25 are at higher odds of RPL in the general population (OR 1.2, 95% CI 1.12-1.28 and OR 1.21, 95% CI 1.06-1.38, respectively). In women with RPL, having BMI > 30 and BMI > 25 has increased odds of further miscarriages (OR 1.77, 95% CI 1.25-2.50 and OR 1.35, 95% CI 1.07-1.72, respectively). The quality of the evidence for our findings was low or very low. Being underweight and BMI > 25 contributes significantly to increased risk of RPL (general population). BMI > 25 or BMI > 30 increases the risk of further miscarriages (RPL population). Larger studies addressing the effects of alcohol, cigarette smoking and caffeine on the risk of RPL with optimisation of BMI in this cohort of women are now needed.

Efficacy of an Internet-Based Intervention to Promote a Healthy Lifestyle on the Reproductive Parameters of Overweight and Obese Women: Study Protocol for a Randomised Controlled Trial

Background: Infertility is estimated to affect 15% of couples of reproductive age. Weight management problems (being obese or overweight) are among the problems that produce infertility, both in women seeking spontaneous pregnancy and in those undergoing assisted reproduction techniques. Over the last few decades, the prevalence of obesity has increased alarmingly in our society and is now considered one of the most important public health problems. The combination of diet and exercise to achieve weight loss are currently considered an effective intervention for the improvement of reproductive parameters in overweight or obese infertile women. In other population groups, it has been shown that Internet-based interventions are just as effective as traditional ones, and these cover a larger population with a good cost–benefit ratio. However, to the best of our knowledge, no studies so far have analysed any specific online interventions for this group of infertile women. Thus, the objective of this project will be to evaluate the effectiveness of an online program to promote a healthy lifestyle among women who are overweight or obese who also have a diagnosis of infertility and are on the waiting list for in vitro fertilisation treatment. Methods: This will be a randomised controlled clinical trial conducted in 94 women which will compare a self-administered Internet-based intervention promoting a healthy lifestyle in terms of diet and exercise (n = 47) to a control group that will receive standard medical care. The online program will comprise nine modules, will last for 3 months, and will be monitored every 3 months after the intervention until the final follow-up at 12 months. The main outcome will be the spontaneous pregnancy rate. Secondary outcomes will include changes in body composition, dietary and physical exercise habits, glycaemic profiles, lipid profiles, hormonal profiles, and patient quality of life related to their fertility problems. The data analysis will be done on an intention-to-treat basis. Discussion: The aim of this study is to increase our knowledge of the effectiveness of online interventions specifically adapted to infertile women who are overweight or obese in the promotion of healthy lifestyles.

Impact of Women Obesity and Obesity Severity on Live Birth Rate after In Vitro Fertilization

Access to in vitro fertilization (IVF) for obese women varies across centers, and the impact of obesity on IVF outcomes is widely discussed. We assessed the impact of obesity and its severity on live birth rate (LBR) after IVF. We included women treated for IVF in our center. Data were prospectively collected in the BabySentry^TM software. LBR per cycle and cumulative LBR including all attempts of the couple were calculated, considering transfer of both fresh and frozen embryos. Of 1588 included women (2379 controlled ovarian stimulations), 70.2%, 19.5%, 7.9%, and 2.4% were normal-weight, overweight, class I obesity, and class II/III obesity, respectively. For each cycle, LBR did not differ according to BMI category. Adjusted odds ratios (95% confidence intervals) for obtaining a live birth at the first cycle were 1.11 (0.78–1.58) for overweight, 1.17 (0.70–1.95) for class I obese, and 1.05 (0.48–2.31) for class II/III obese women, as compared with normal-weight women. Similarly, no significant associations were found at cycles 2, 3, and 4. Cumulative LBR increased with the number of cycles, independently of the BMI class (p log-rank = 0.91). After adjustment, obesity status did not impact significantly the miscarriage rate, regardless of the cycle. In conclusion, neither women obesity nor its severity impacted the cumulative LBR after IVF.

Does body mass index impact assisted reproductive technology treatment outcomes in gestational carriers

BACKGROUND

The purpose of this study was to assess whether increased body mass index (BMI) negatively affects assisted reproductive technology (ART) outcomes among gestational carriers.

METHODS

A retrospective matched case-control cohort, including all gestational carrier (GC) cycles performed at CReATe Fertility Centre (Toronto, ON, Canada) between 2003 and 2016.

SETTING

A Canadian fertility clinic, with a large surrogacy program.

PATIENTS

All gestational carriers that had undergone a cycle completed to a transfer at our clinic, and had BMI and outcome data available, were matched by BMI to infertile patients treated at our clinic during the same years provided they had undergone a cycle completed to a transfer, and had outcomes data available.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Clinical pregnancies rates, miscarriage rates and live birth rates.

RESULTS

BMI was not a reliable prediction factor of any of the measured outcomes. Importantly, the gestational carrier population had better outcomes and a significantly lower overall incidence of maternal, fetal and neonatal complications when compared with infertile patients, treated at our clinic during the same years.

CONCLUSION

BMI is not a reliable predictor of outcomes among gestational carriers.

Severe maternal morbidity in women with high BMI in IVF and unassisted singleton pregnancies

STUDY QUESTION

Is there a synergistic risk of severe maternal morbidity (SMM) in overweight/obese women who conceived by IVF compared to normal-weight women without IVF?

SUMMARY ANSWER

SMM was more common in IVF pregnancies, and among overweight/obese women, but we did not detect a synergistic effect of both factors.

WHAT IS KNOWN ALREADY

While much is known about the impact of overweight and obesity on success rates after IVF, there is less data on maternal health outcomes.

STUDY DESIGN, SIZE, DURATION

This is a population-based cohort study of 114 409 singleton pregnancies with conceptions dating from 11 January 2013 until 10 January 2014 in Ontario, Canada. The data source was the Canadian Assisted Reproductive Technologies Register (CARTR Plus) linked with the Ontario birth registry (BORN Information System).

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included women who delivered at ≥20 weeks gestation, and excluded those younger than 18 years or with twin pregnancies. Women were classified according to the mode of conception (IVF or unassisted) and according to pre-pregnancy BMI (high BMI (≥25 kg/m2) or low-normal BMI (<25 kg/m2)). The main outcome was SMM, a composite of serious complications using International Classification of Diseases, 10th revision (ICD-10) codes. Secondary outcomes were gestational hypertension, pre-eclampsia, gestational diabetes and cesarean delivery. Adjusted risk ratios (aRR) with 95% CI were estimated using log binomial regression, adjusted for maternal age, parity, education, income and baseline maternal comorbidity.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 114 409 pregnancies, 1596 (1.4%) were IVF conceptions. Overall, 41.2% of the sample had high BMI, which was similar in IVF and non-IVF groups. We observed 674 SMM events (rate: 5.9 per 1000 deliveries). IVF was associated with an increased risk of SMM (rate 11.3/1000; aRR 1.89, 95% CI: 1.06-3.39). High BMI was modestly associated with SMM (rate 7.0/1000; aRR 1.23, 95% CI: 1.04-1.45) There was no interaction between the two factors (P = 0.22). We noted supra-additive effects of high BMI and IVF on the risk of pre-eclampsia and gestational diabetes, but not gestational hypertension or cesarean delivery.

LIMITATIONS, REASONS FOR CAUTION

We were unable to assess outcomes according to reason for treatment. Type II error (beta ~25%) may affect our results.

WIDER IMPLICATIONS OF THE FINDINGS

Our results support previous data indicating a greater risk of SMM in IVF pregnancies, and among women with high BMI. However, these factors do not interact. Overweight and obese women who seek treatment with IVF should be counseled about pregnancy risks. The decision to proceed with IVF should be based on clinical judgment after considering an individual's chance of success and risk of complications.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Research Institute of the McGill University Health Centre (grant 6291) and also supported by the Trio Fertility (formerly Lifequest) Research Fund. The authors report no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Obesity and Reproduction

OBJECTIVE

To provide a comprehensive review and evidence-based recommendations for the delivery of fertility care to women with obesity.

OUTCOMES

The impact of obesity on fertility, fertility treatments, and both short and long-term maternal fetal outcomes was carefully considered.

EVIDENCE

Published literature was reviewed through searches of MEDLINE and CINAHL using appropriate vocabulary and key words. Results included systematic reviews, clinical trials, observational studies, clinical practice guidelines, and expert opinions.

VALUES

The Canadian Fertility & Andrology Society (CFAS) is a multidisciplinary, national non-profit society that serves as the voice of reproductive specialists, scientists, and allied health professionals working in the field of assisted reproduction in Canada. The evidence obtained for this guideline was reviewed and evaluated by the Clinical Practice Guideline (CPG) Committee of the CFAS under the leadership of the principal authors.

BENEFITS, HARMS, AND COSTS

The implementation of these recommendations should assist clinicians and other health care providers in counselling and providing reproductive care to women with obesity.

VALIDATION

This guideline and its recommendations have been reviewed and approved by the membership, the CPG Committee and the Board of Directors of the CFAS.

SPONSORS

Canadian Fertility & Andrology Society.

RECOMMENDATIONS

Twenty-one evidence based recommendations are provided. These recommendations specifically evaluate the impact of obesity on natural fertility, fertility treatments, and maternal-fetal outcomes. Strategies to lose weight and BMI cut-offs are also addressed.

Irresponsibly Infertile? Obesity, Efficiency, and Exclusion from Treatment

Many countries tightly ration access to publicly funded fertility treatments such as in vitro fertilisation (IVF). One basis for excluding people from access to IVF is their body mass index. In this paper, I consider a number of potential justifications for such a policy, based on claims about effectiveness and cost-efficiency, and reject these as unsupported by available evidence. I consider an alternative justification: that those whose subfertility results from avoidable behaviours for which they are responsible are less deserving of treatment. I ultimately stop short of endorsing or rejecting such a justification, though highlight some reasons for thinking it is unlikely to be practicable.

Effect of class III and class IV obesity on oocyte retrieval complications and outcomes

OBJECTIVE

To assess the effect of class III (body mass index [BMI] 40-49.9 kg/m²) and class IV obesity (BMI ≥ 50 kg/m²) on oocyte retrieval complications and outcomes.

DESIGN

Cohort study.

SETTING

Academic center.

PATIENT(S)

Women who underwent an oocyte retrieval from January 1, 2012 to May 31, 2017. Women with BMI ≥ 40 kg/m² (n = 144) were age-matched to women with BMI <25, 25-29.9, 30-34.9, and 35-39.9 kg/m² (n = 1,016).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Anesthetic and procedural outcomes during oocyte retrieval.

RESULT(S)

Overall, 1,924 of 1,947 oocyte retrievals (98.8%) were performed under total intravenous anesthesia. No patients with BMI ≥ 40 kg/m² required intraoperative conversion to endotracheal intubation or hospital admission. Two patients (0.8%) with BMI ≥ 40 kg/m² required a laryngeal mask airway intraoperatively owing to oxygen desaturation. An oral/nasal airway was used to resolve oxygen desaturation in 16 patients (6.25%) with BMI ≥ 40 kg/m², compared with in 17 patients (1.0%) with BMI < 40 kg/m². As BMI increased, a statistically significant increase in propofol dose, fentanyl dose, and procedure time was observed. Eighteen patients (7.0%) with BMI ≥ 40 kg/m² underwent a transabdominal retrieval, compared with 15 (0.9%) with BMI < 40 kg/m².

CONCLUSION(S)

Serious intraoperative and postoperative complications were uncommon across all BMI groups, though minor complications were more common with class III and class IV obesity. These patients were also more likely to require higher doses of propofol and fentanyl, have longer oocyte retrievals, and require a transabdominal retrieval. Overall, oocyte retrieval can be safely performed as an outpatient procedure in women with class III and class IV obesity.

Cost-effectiveness analysis of lifestyle intervention in obese infertile women

STUDY QUESTION

What is the cost-effectiveness of lifestyle intervention preceding infertility treatment in obese infertile women?

SUMMARY ANSWER

Lifestyle intervention preceding infertility treatment as compared to prompt infertility treatment in obese infertile women is not a cost-effective strategy in terms of healthy live birth rate within 24 months after randomization, but is more likely to be cost-effective using a longer follow-up period and live birth rate as endpoint.

WHAT IS KNOWN ALREADY

In infertile couples, obesity decreases conception chances. We previously showed that lifestyle intervention prior to infertility treatment in obese infertile women did not increase the healthy singleton vaginal live birth rate at term, but increased natural conceptions, especially in anovulatory women. Cost-effectiveness analyses could provide relevant additional information to guide decisions regarding offering a lifestyle intervention to obese infertile women.

STUDY DESIGN, SIZE, DURATION

The cost-effectiveness of lifestyle intervention preceding infertility treatment compared to prompt infertility treatment was evaluated based on data of a previous RCT, the LIFEstyle study. The primary outcome for effectiveness was the vaginal birth of a healthy singleton at term within 24 months after randomization (the healthy live birth rate). The economic evaluation was performed from a hospital perspective and included direct medical costs of the lifestyle intervention, infertility treatments, medication and pregnancy in the intervention and control group. In addition, we performed exploratory cost-effectiveness analyses of scenarios with additional effectiveness outcomes (overall live birth within 24 months and overall live birth conceived within 24 months) and of subgroups, i.e. of ovulatory and anovulatory women, women <36 years and ≥36 years of age and of completers of the lifestyle intervention. Bootstrap analyses were performed to assess the uncertainty surrounding cost-effectiveness.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Infertile women with a BMI of ≥29 kg/m2 (no upper limit) were allocated to a 6-month lifestyle intervention programme preceding infertility treatment (intervention group, n = 290) or to prompt infertility treatment (control group, n = 287). After excluding women who withdrew informed consent or who were lost to follow-up we included 280 women in the intervention group and 284 women in the control group in the analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Total mean costs per woman in the intervention group within 24 months after randomization were €4324 (SD €4276) versus €5603 (SD €4632) in the control group (cost difference of -€1278, P < 0.05). Healthy live birth rates were 27 and 35% in the intervention group and the control group, respectively (effect difference of -8.1%, P < 0.05), resulting in an incremental cost-effectiveness ratio of €15 845 per additional percentage increase of the healthy live birth rate. Mean costs per healthy live birth event were €15 932 in the intervention group and €15 912 in the control group. Exploratory scenario analyses showed that after changing the effectiveness outcome to all live births conceived within 24 months, irrespective of delivery within or after 24 months, cost-effectiveness of the lifestyle intervention improved. Using this effectiveness outcome, the probability that lifestyle intervention preceding infertility treatment was cost-effective in anovulatory women was 40%, in completers of the lifestyle intervention 39%, and in women ≥36 years 29%.

LIMITATIONS, REASONS FOR CAUTION

In contrast to the study protocol, we were not able to perform the analysis from a societal perspective. Besides the primary outcome of the LIFEstyle study, we performed exploratory analyses using outcomes observed at longer follow-up times and we evaluated subgroups of women; the trial was not powered on these additional outcomes or subgroup analyses.

WIDER IMPLICATIONS OF THE FINDINGS

Cost-effectiveness of a lifestyle intervention is more likely for longer follow-up times, and with live births conceived within 24 months as the effectiveness outcome. This effect was most profound in anovulatory women, in completers of the lifestyle intervention and in women ≥36 years old. This result indicates that the follow-up period of lifestyle interventions in obese infertile women is important. The scenario analyses performed in this study suggest that offering and reimbursing lifestyle intervention programmes in certain patient categories may be cost-effective and it provides directions for future research in this field.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by a grant from ZonMw, the Dutch Organization 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. B.W.J.M. is a consultant for ObsEva, Geneva.

TRIAL REGISTRATION NUMBER

The LIFEstyle RCT was registered at the Dutch trial registry (NTR 1530). http://www.trialregister.nl/trialreg/admin/rctview.asp?TC = 1530.

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

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN, SIZE, DURATION

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

PARTICIPANTS/MATERIALS, SETTING, METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS, REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTERESTS

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

TRIAL REGISTRATION NUMBER

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

Feasibility of a brief, intensive weight loss intervention to improve reproductive outcomes in obese, subfertile women: a pilot study

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.

Obesity and fertility

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.

[Infertility: A key time to follow a medical nutritional management. Our experience on 78 patients]

OBJECTIVES

The prevalence of female obesity is increasing. Obesity leads to increased infertility and difficulties in the management of Assisted Reproductive Technology (ART). A specialized nutritional consultation was created in 2008 at University Hospital of Lille, to support infertile obese and overweight patients and to achieve a BMI below 35kg/m(2) before pregnancy. The aim of this retrospective study was to evaluate our practice of nutritional support on weight and pregnancy rate.

METHODS

Seventy-eight obese or overweight patients, followed in nutrition and ART for at least two years, were compared to a control group of 119 normal weight patients. The nutritional strategy was mainly based on lifestyle changes, to establish healthier food and higher physical activity.

RESULTS

The mean initial BMI was 37.5kg/m(2) vs 35.6kg/m(2) after nutritional support (significant weight loss, [P<0.001]). Obese or overweight patients had more frequently metabolic syndrome (P<0.01). The chances of pregnancy, after weight loss, were similar to the control group both in IUI and IVF/ICSI. However, gonadotropin doses were increased in the obese and overweight group (P=0.007). The hypocaloric diet was the most effective nutritional strategy to achieve a weight loss greater than 5% of initial weight (P=0.017). Regular physical activity practice allowed also more frequently to achieve this goal (P=0.074). Even after weight loss, a significant number of gestational diabetes (25% of pregnancies in our population) occurred in the obese or overweight group.

CONCLUSION

This nutritional consultation promotes weight loss in infertile obese or overweight patients. The maternity desire is a strong motivational lever to weight loss, which leads to satisfying pregnancy rate.

A Focus on Maternal Health Before Assisted Reproduction: Results From a Pilot Survey of Canadian IVF Medical Directors

OBJECTIVE

To describe current physician practice patterns in Canada with regard to performing in vitro fertilization in high-risk patients.

METHODS

All medical directors of IVF clinics registered with the Canadian Fertility and Andrology Society (n=35) were invited to participate in an online survey between January and May 2014. We carried out descriptive analyses of participants' responses regarding implementation of local restrictive policies for access to IVF. Whether practice patterns differed in hospital versus community-based clinics was assessed using chi-square testing with significance set at alpha<0.05.

RESULTS

The response rate was 77.1%. More than one half of clinics (55.6%) were university-affiliated, and 29.6% were hospital-based. The majority of respondents (70.4%) used an upper age limit for permitting IVF (median 50 years, IQR 44 to 50), mostly because of lower pregnancy and live birth rates. Approximately one half of respondents limited treatment according to BMI (median upper permitted BMI 38 kg/m2, IQR 35 to 40 kg/m2) to minimize complications during pregnancy. Most respondents (77.8%) believed that routine pre-IVF medical assessment would be useful in their daily practice. There was a non-significant trend towards more restrictive policies in hospital-based clinics compared with community-based clinics.

CONCLUSION

Our findings confirm that Canadian reproductive medicine physicians are taking maternal health factors into consideration when assessing patients' suitability for IVF. Nevertheless, there is between-clinic variability in the parameters used to assess eligibility for treatment. In light of the changing maternal demographic, more research is needed on assisted reproductive technology and perinatal outcomes in women who are at risk for pregnancy complications.

The effect of mode of conception on obstetrical outcomes differs by body mass index

This study compared the odds of adverse obstetrical outcomes of pregnancies in women who conceived from IVF (n = 464) versus spontaneous conception (n = 1171) after stratification into three body mass index (BMI) groups: normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)) and obese (>30 kg/m(2)). With increasing BMI, incidences of complications between IVF and spontaneously conceived groups narrowed. Among women with normal BMI, IVF pregnancies were associated with increased odds of placental ischaemic disorders (11.3% versus 7.0%, adjusted odds ratio [aOR] = 2.24; 95% confidence interval [CI] = 1.25-4.04) and low birthweight <2500 g (10.6% versus 8.0%, aOR = 2.08; 95% CI = 1.12-3.88). Among overweight women, only low birthweight (<2500 g) was significantly increased (15.6% versus 6.2%, aOR = 4.33; 95%, CI = 1.61-11.63). For obese women, there were no differences between IVF and spontaneously conceived pregnancies for either placental ischaemic disorders (12.5 versus 20.2%, OR = 0.43, 95% CI = 0.17-1.1) or low birthweight (10.0% versus 11.0%, aOR = 0.7, 95% CI = 0.24-2.08). Overall, the odds of adverse obstetrical outcomes were not significantly greater in IVF singleton pregnancies compared with those conceived spontaneously as BMI increased.

Effects of female increased body mass index on in vitro fertilization cycles outcome

BACKGROUND

As being overweight can impair female spontaneous fertility or after assisted reproductive technology (ART) cycles, the aim of this study was to compare in vitro fertilization (IVF) outcome according to women's body mass index (BMI).

METHODS

Retrospective study conducted from 2006 to 2009 in the IVF unit of Nantes University Hospital, France. 582 patients undergoing standard infertility workup and controlled ovarian stimulation were categorized according to BMI into two groups: group 1: normal weight (20-24.9 kg/m(2); n=409) and group 2: overweight and obese (≥25 kg/m(2); n=149). Basal hormonal status, smoking habitus, infertility duration, IVF cycle parameters and outcome were recorded.

RESULTS

Basal LH, FSH and estradiol levels were higher in group 1 than group 2, but ovarian reserve markers were comparable across the two BMI groups. Higher doses of gonadotropins were required in group 2 to obtain equivalent ovarian response than in group 1. No difference was observed on ovarian response and embryonic parameters. Cycle outcome were not significantly different between both groups, but we found a strong trend towards increasing transfer cancellation and miscarriage rates in group 2.

CONCLUSION

Although overweight and obesity do not compromise ovarian stimulation results whenever adaptation of recombinant FSH doses is made, our data suggest an increased risk of cancellation transfer and miscarriage rate, leading to poorer IVF outcome.

Combined impact of high body mass index and in vitro fertilization on preeclampsia risk: a hospital-based cohort study

OBJECTIVES

Overweight and obese women may be heavy users of in vitro fertilization (IVF) owing to obesity-related oligo-anovulation. The higher doses of gonadotropins required to achieve pregnancy in obese women may contribute to impaired placentation and the development of preeclampsia. This study was designed to assess the combined effect of high maternal body mass index (BMI) and IVF on risk of preeclampsia and to evaluate for an interaction between the two factors.

METHODS

This is a hospital-based cohort study of 10,013 singleton pregnancies that delivered from 2001 to 2008 at a tertiary hospital in Montreal, Canada. The combined effect of high BMI and IVF on preeclampsia versus no risk factors was estimated in multivariate logistic regression models fitted with an interaction term between high BMI (> 25 or > 30 kg/m(2) ) and IVF.

RESULTS

IVF pregnancies in obese women had a considerably higher risk of preeclampsia than spontaneous nonobese pregnancies (OR 6.7, 95% CI 3.3-13.8; p interaction 0.03). IVF was not independently associated with preeclampsia (OR 0.6, 95% CI 0.3-1.4). Analyses were similar in subgroup analyses and in analyses correcting for bias.

CONCLUSIONS

High BMI is strongly associated with preeclampsia, and this risk is compounded in IVF pregnancies.

Does weight loss in overweight or obese women improve fertility treatment outcomes? A systematic review

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.

Polycystic ovary syndrome: current status and future perspective

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.

Prospective Study of Effect of Body Weight on in vitro Fertilization Outcome in Reproductive Age Group

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.

Infertility patients' knowledge of the effects of obesity on reproductive health outcomes

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.

Body mass index and short-term weight change in relation to treatment outcomes in women undergoing assisted reproduction

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.

Obesity and reproductive dysfunction in women

Overweight and obesity are significant and increasing health problems associated with increased risks of morbidity, quality of life, and metabolic and reproductive health consequences. In women, being overweight or obese is associated with impaired fertility and decreased chance of conception both in natural and assisted reproductive technology births. During pregnancy, overweight and obesity are associated with increased risk of adverse maternal and infant health outcomes. Attention to weight loss before conception may improve fertility and maternal and infant health outcomes during pregnancy.

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

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