Obesity and anovulatory infertility: A review

The Impact of High Adiposity on Endometrial Progesterone Response and Metallothionein Regulation

CONTEXT

Obesity is a disease with deleterious effects on the female reproductive tract, including the endometrium.

OBJECTIVE

We sought to understand the effects of excess adipose on the benign endometrium.

METHODS

A physiologic in vitro coculture system was developed, consisting of multicellular human endometrial organoids, adipose spheroids, and menstrual cycle hormones. Native human endometrial tissue samples from women with and without obesity were also analyzed. Benign endometrial tissues from premenopausal women ages 33 to 53 undergoing hysterectomy were obtained following written consent at Northwestern University Prentice Women's Hospital, Chicago, Illinois. Gene expression, protein expression, chromatin binding, and expression of DNA damage and oxidative damage markers were measured.

RESULTS

Under high adiposity conditions, endometrial organoids downregulated endometrial secretory phase genes, suggestive of an altered progesterone response. Progesterone specifically upregulated the metallothionein (MT) gene family in the epithelial cells of endometrial organoids, while high adiposity significantly downregulated the MT genes. Silencing MT genes in endometrial epithelial cells resulted in increased DNA damage, illustrating the protective role of MTs. Native endometrium from women with obesity displayed increased MT expression and oxidative damage in the stroma and not in the epithelium, indicating the cell-specific impact of obesity on MT genes.

CONCLUSION

Taken together, the in vitro and in vivo systems used here revealed that high adiposity or obesity can alter MT expression by decreasing progesterone response in the epithelial cells and increasing oxidative stress in the stroma.

Trajectory of primordial follicle depletion is accelerated in obese mice in response to 7,12-dimethylbenz[a]anthracene exposure†

Both obesity and exposure to environmental genotoxicants, such as 7,12-dimethylbenz[a]anthracene, negatively impair female reproductive health. Hyperphagic lean KK.Cg-a/a (n = 8) and obese KK.Cg-Ay/J (n = 10) mice were exposed to corn oil as vehicle control (CT) or 7,12-dimethylbenz[a]anthracene (1 mg/kg/day) for 7d intraperitoneally, followed by a recovery period. Obesity increased liver and spleen weight (P < 0.05), and 7,12-dimethylbenz[a]anthracene exposure decreased uterine weight (P < 0.05) in obese mice. Primordial follicle loss (P < 0.05) caused by 7,12-dimethylbenz[a]anthracene exposure was observed in obese mice only. Primary (lean P < 0.1; obese P < 0.05) and secondary (lean P < 0.05, obese P < 0.1) follicle loss initiated by 7,12-dimethylbenz[a]anthracene exposure continued across recovery. Reduced pre-antral follicle number in lean mice (P < 0.05), regardless of 7,12-dimethylbenz[a]anthracene exposure, was evident with no effect on antral follicles or corpora lutea number. Immunofluorescence staining of DNA damage marker, γH2AX, did not indicate ongoing DNA damage but TRP53 abundance was decreased in follicles (P < 0.05) of 7,12-dimethylbenz[a]anthracene-exposed obese mice. In contrast, increased (P < 0.05) superoxide dismutase was observed in the corpora lutea of 7,12-dimethylbenz[a]anthracene-exposed obese mice and reduced (P < 0.05) TRP53 abundance was noted in preantral and antral follicles of 7,12-dimethylbenz[a]anthracene-exposed obese mice. This study indicates that obesity influences ovotoxicity caused by a genotoxicant, potentially involving accelerated primordial follicle activation and hampering normal follicular dynamics.

Comparative efficacy of exercise, diet and/or pharmacological interventions on BMI, ovulation, and hormonal profile in reproductive-aged women with overweight or obesity: a systematic review and network meta-analysis

BACKGROUND

The increasing prevalence of obesity worldwide poses a significant threat to reproductive function owing, in part, to hormonal disturbances caused by negative feedback between excess adiposity and the hypothalamic-pituitary-ovarian axis. Consequently, finding the most appropriate strategies to lose weight and improve ovulation in women with overweight or obesity is a clinically relevant matter that needs to be investigated. A comprehensive comparison of the independent and combined efficacy of lifestyle and/or pharmacological interventions on BMI, ovulation, and hormonal profile in women with overweight or obesity at risk of anovulatory infertility would facilitate improving fertility strategies in this population.

OBJECTIVE AND RATIONALE

This study aimed to evaluate the comparative efficacy of exercise, diet, and pharmacological interventions on BMI, ovulation, and hormonal profile in reproductive-aged women with overweight or obesity.

SEARCH METHODS

A systematic review was performed by searching PubMed, Scopus, Web of Science, PsycINFO, and Cochrane Library up to 14 December 2023, for randomized controlled trials assessing the effects of exercise, diet and/or pharmacological interventions (i.e. weight-lowering drugs or ovulation inducers) on BMI, ovulation, and/or hormonal profile in reproductive-aged women with overweight or obesity. We performed frequentist random-effect network meta-analyses and rated the certainty of the evidence. The primary outcomes were BMI and ovulation rate, and the secondary outcomes were serum reproductive hormone levels (gonadotrophins, androgens, or oestrogens). We performed sensitivity analyses, including the studies that only involved women with PCOS.

OUTCOMES

Among 1190 records screened, 148 full texts were assessed for eligibility resulting in 95 trials (9910 women), of which 53% presented a high or unclear risk of bias. The network meta-analyses revealed that, compared to control: diet combined with weight-lowering drugs (mean difference (MD) -2.61 kg/m2; 95% CI -3.04 to -2.19; τ2 = 0.22) and adding exercise (MD -2.35 kg/m2; 95% CI -2.81 to -1.89; τ2 = 0.22) led to the greatest decrease in BMI; exercise combined with diet and ovulation inducers (risk ratio (RR) 7.15; 95% CI 1.94-26.40; τ2 = 0.07) and exercise combined with diet and weight-lowering drugs (RR 4.80; 95% CI 1.67-13.84; τ2 = 0.07) produced the highest increase in ovulation rate; and exercise combined with diet and weight-lowering drugs was the most effective strategy in reducing testosterone levels (standardized mean difference (SMD) -2.91; 95% CI -4.07 to -1.74; τ2 = 2.25), the third most effective strategy in increasing sex hormone-binding globulin levels (SMD 2.37; 95% CI 0.99-3.76; τ2 = 2.48), and it was coupled with being ranked first in terms of free androgen index reduction (SMD -1.59; 95% CI -3.18 to 0.01; τ2 = 1.91). The surface under the cumulative ranking curve scores suggested that: diet combined with weight-lowering drugs is the strategy most likely (94%) to produce the highest BMI reduction; and exercise combined with diet and ovulation inducers is the strategy most likely (89%) to produce the highest ovulation rate improvement. The sensitivity analyses, which exclusively included studies involving women diagnosed with PCOS, were consistent with the results presented above.

WIDER IMPLICATIONS

Overall, the findings of this network meta-analysis indicate that the combination of exercise, diet, and pharmacological interventions is effective for weight loss, improving ovulation, and normalizing the androgen levels of women with overweight or obesity. Although higher quality studies are needed, these results support that the optimal treatment strategy for women with overweight or obesity wishing to conceive must consider exercise, diet, and pharmacological interventions during the shared decision-making process.

Associations of weight-adjusted-waist index and depression with secondary infertility

Background

Obesity and psychological factors were identified as risk factors for female infertility. The study investigated the correlation between WWI, depression, and secondary infertility, focusing on the potential mediating role of depression.

Methods

According to the data from NHANES, this cross-sectional study used multiple regression analysis, subgroup analysis, and smooth curve fitting to explore the relationship between WWI, depression, and secondary infertility. The diagnostic ability of WWI was evaluated and compared to other obesity indicators using the ROC curve. The mediating effect test adopted the distribution of the product.

Results

This study involved 2778 participants, including 381 (13.7%) women with secondary infertility. Results showed that higher WWI (OR = 1.31; 95% CI, 1.11-1.56) and depression scores (OR = 1.03; 95% CI, 1.01-1.06) were associated with secondary infertility. There was a positive correlation between WWI and secondary infertility (nonlinear p = 0.8272) and this association was still consistent in subgroups (all P for interaction> 0.05). Compared with other obesity indicators, WWI (AUC = 0.588) also shows good predictive performance for secondary infertility. Mediation analysis showed that depression mediated the relationship between 3.94% of WWI and secondary infertility, with a confidence interval of Za * Zb excluding 0.

Conclusion

WWI exhibited a relatively good correlation in predicting secondary infertility than other obesity indicators, and depression may be a mediator between WWI and secondary infertility. Focusing on the potential mediating role of depression, the risk of secondary infertility due to obesity may be beneficially reduced in women.

The association of maternal pre-pregnancy Body Mass Index and gestational weight gain with pregnancy and neonatal outcomes

BACKGROUND

Overweight and obesity epidemic is still expanding, and it is affecting women of childbearing age. Multiple studies have shown unmatched results concerning the effect of body mass index (BMI) besides gestational weight gain (GWG) on pregnancy and neonatal outcomes. This study aims to determine the effect of each of the two anthropometric indicators: pre-gestational BMI and gestational weight gain on the course of pregnancy, and neonatal outcomes.

METHODS

A retrospective study was conducted at Notre Dame de Secours University Hospital (CHU-NDS) Jbeil-Lebanon. The data was collected from the hospital archive. Out of 804 deliveries during 2020, 583 women were included after randomly choosing their files and eliminating those with exclusion criteria or incomplete data.

RESULTS

Underweight/healthy BMI mothers had a higher chance of having low GWG (45.5%), vaginal delivery (51.3%), and a baby of appropriate size (78.6%) or small size for gestational age (10.4%). Obese women had a higher risk of excessive GWG (49.3%), delivery via C-section. (69.3%), and large for gestational age babies (26.7%). Mothers who had low GWG were at a higher risk of having babies of appropriate size (80.1%) or small size for gestational age (13.1%). Mothers who had high GWG had a higher risk of having baby boys (58.9%), large for their gestational age (26.1%), with hypoglycemia at birth (20.6%).

CONCLUSION

Both extremes of BMI and GWG are linked to adverse neonatal outcomes. This highlights the importance of weight monitoring even during pregnancy to prevent its negative impact on neonates.

Association between obesity and fecundity in patients undergoing intrauterine insemination

Objective

To determine if an association exists between body mass index (BMI) and fecundity after intrauterine insemination (IUI).

Design

Retrospective cohort study.

Setting

Academic-based fertility clinic.

Patients

Patients undergoing IUI July 2007 to May 2012.

Interventions

None.

Main Outcome Measures

Primary outcome: live-birth rate (LBR) per IUI cycle; secondary outcomes: positive pregnancy test and clinical pregnancy rates (CPRs).

Results

A total of 1959 cycles were performed on 661 women (mean age, 31.9 ± 4.9 years). When examined by obesity class, LBR and CPR were similar for women with class I, II, and III obesity when compared with women with normal BMI. However, class III obese women (adjusted risk ratio [aRR], 1.70; 95% confidence interval [CI], 1.12-2.59) had increased pregnancy rates compared with normal BMI, but no differences in pregnancy rates were observed for women with class I or II obesity. In addition, pregnancy rates (aRR, 1.50; 95% CI, 1.12-2.02) and CPR (aRR, 1.51; 95% CI, 1.07-2.14) were higher in overweight women relative to normal BMI. Notably, among patients with ovulatory dysfunction, CPRs after IUI were reduced by 43% in obese women (aRR, 0.57; 95% CI, 0.37-1.07), whereas women without ovulatory dysfunction were twice as likely to achieve a clinical pregnancy when they were obese (aRR, 1.96; 95% CI, 1.19-3.24). The CIs for the obesity risk ratios in each stratum of ovulatory function exhibited no overlap, suggesting evidence of potential effect modification by ovulatory function.

Conclusions

LBRs after IUI were similar across BMI subgroups. This is in contrast to research of in vitro fertilization treatments showing lower LBR with increasing BMI. However, obesity may adversely affect IUI CPR in those with ovulatory dysfunction in particular. The reason for this discrepancy is unclear and warrants further study.

Estrogen receptors as potential therapeutic target in endometrial cancer

Endometrial cancer (EC) is one of the most common gynecological carcinomas in both developed and developing countries. Majority of the gynecological malignancies are hormonally driven where estrogen signaling acts as an oncogenic signal. Estrogen's effects are mediated via classical nuclear estrogen receptors; estrogen receptor alpha and beta (ERα and ERβ) and a trans-membrane G protein-coupled estrogen receptor (GPR30 and GPER). ERs and GPER through ligand binding triggers multiple downstream signaling pathways causing cell cycle regulation, cell differentiation, migration, and apoptosis in various tissues including endometrium. Although the molecular aspect of estrogen function in ER-mediated signaling is now partly understood, the same is not true for GPER-mediated signaling in endometrial malignancies. Understanding the physiological roles of ERα and GPER in EC biology therefore leads to the identification of some novel therapeutic targets. Here we review the effect of estrogen signaling through ERα-and GPER in EC, major types, and some affordable treatment approaches for endometrial tumor patients which has interesting implications in understanding uterine cancer progression.

Characterization of Fertility Clinic Attendees in the Abu Dhabi Emirate, United Arab Emirates: A Cross-Sectional Study

This study describes the primary and secondary infertility in patients attending fertility clinics and reports factors associated with primary infertility. A cross-sectional survey was conducted in two fertility clinics in Abu Dhabi Emirate, United Arab Emirates (UAE) between December 2020 and May 2021. The collected information covered sociodemographic, lifestyle, medical, and fertility-related characteristics. The mean age and age at marriage (±SD) of the 928 patients were 35.7 (±6.7) and 25.2 (±6.3) years, respectively. Of the total, 72.0% were obese and overweight, 26.6% reported a consanguineous marriage, and 12.5% were smokers. Secondary infertility (62.5%) was more frequent than primary infertility (37.5%). Primary infertility was inversely associated with age (aOR, 0.94, 95% CI: 0.91-0.98) and not being overweight (aOR, 0.6, 95% CI: 0.4-0.9) while positively associated with a nationality other than Middle Eastern nationality (aOR, 1.9, 95% CI: 1.1-3.3), married for ≤5 years (aOR, 6.0, 95% CI: 3.9-9.3), in a nonconsanguineous marriage (aOR, 2.4, 95% CI: 1.5-3.9), having a respiratory disease (aOR, 2.3, 95% CI: 1.1-4.6), an increased age at puberty (aOR, 1.2, 95% CI: 1.0-1.3), and self-reported 6-<12 months (aOR, 2.4, 95% CI: 1.2-5.1) and ≥12 months (aOR, 3.4, 95% CI: 1.8-6.4) infertility. Patients with primary infertility were more likely to be diagnosed with infertility of an ovulation, tubal, or uterine origin (aOR, 3.9, 95% CI: 1.9-7.9). Secondary infertility was more common than primary infertility. Several preventable fertility-related risk factors including overweight, smoking, and diabetes were found to be common among the fertility clinic attendees.

Prevalence of Polycystic Ovarian Syndrome in India: A Systematic Review and Meta-Analysis

Stein-Leventhal syndrome, often known as polycystic ovarian syndrome (PCOS), is a syndrome that affects women's reproductive health. PCOS is one of the most common endocrine and metabolic disorders in women of reproductive age. The etiology of PCOS remains unknown mainly, and the estimation of PCOS burden in a specific geographical location will impact disease control strategies. Hence, this study estimated the pooled prevalence of PCOS in Indian women. Databases such as PubMed, CINHAL, Scopus, and Google Scholar were thoroughly searched. Only those published Indian studies that reported the prevalence of PCOS from 2010 to 2021 and had at least one of the following diagnostic PCOS criteria were included in the systematic review: the National Institutes of Health (NIH), Rotterdam's criteria, or/and Androgen Excess Society (AES). MetaXL version 5.3 software was used for data analysis. The risk of bias was assessed using modified Joanna Briggs Institute criteria for cross-sectional studies. Out of 17132 articles, 11 articles were selected for systematic review and meta-analysis. The pooled prevalence of PCOS was 11.33(7.69-15.59) using the random effect. The proportion of Hirsute using the Ferriman-Gallwey score was highly variable, ranging from 1.6% to 37.9% (n=6). The prevalence rate of PCOS is high among Indian women. The pooled prevalence of PCOS was close to 10% using Rotterdam's criteria and AES criteria, while it was 5.8% using NIH criteria. The study's overall finding emphasizes the need for more acceptable and uniform diagnostic criteria for screening PCOS. At the same time, policy-makers should consider giving more importance to PCOS in their effort to control non-communicable diseases.

Endocrine disruptor chemicals, adipokines and reproductive functions

The prevalence of adult obesity has risen markedly in recent decades. The endocrine system precisely regulates energy balance, fat abundance and fat deposition. Interestingly, white adipose tissue is an endocrine gland producing adipokines, which regulate whole-body physiology, including energy balance and reproduction. Endocrine disruptor chemicals (EDCs) include natural substances or chemicals that affect the endocrine system by multiple mechanisms and increase the risk of adverse health outcomes. Numerous studies have associated exposure to EDCs with obesity, classifying them as obesogens by their ability to activate different mechanisms, including the differentiation of adipocytes, increasing the storage of triglycerides, or elevating the number of adipocytes. Moreover, in recent years, not only industrial deception and obesity have intensified but also the problem of human infertility. Reproductive functions depend on hormone interactions, the balance of which may be disrupted by various EDCs or obesity. This review gives a brief summary of common EDCs linked with obesity, the mechanisms of their action, and the effect on adipokine levels, reproduction and connected disorders, such as polycystic ovarian syndrome, decrease in sperm motility, preeclampsia, intrauterine growth restriction in females and decrease of sperm motility in males.

The relationship between overweight and female infertility

Excessive weight seems to negatively influence fertility, and as it is a modifiable factor, understanding this relationship can contribute to infertility treatment. Adipose tissue is responsible for releasing several hormones and cytokines related to the reproductive system, such as leptin, TNF-a, and Interleukin-6, substances that can negatively impact female fertility. Additionally, a woman's diet and lifestyle can influence body weight and fertility. Food consumption, characterized by a high intake of foods with high energy density, high levels of sugar, saturated fat, and poor nutrients, as well as physical inactivity, can favor excessive weight. Thus, losing body weight obtained through a healthy diet associated with physical activity may restore fertility in overweight women.

The relationship between modified Nordic diet and resting metabolic rate among overweight and obese women in Tehran, Iran: A cross-sectional study

PURPOSE

Obesity as a worldwide phenomenon is a multifactorial condition. Healthy diets have effect on obesity-related factors like resting metabolic rate (RMR). In the present study, we investigate the association between adherence to modified Nordic diet and RMR among overweight and obese participants.

METHODS

We enrolled 404 overweight and obese (BMI ≥ 25 kg/m² ) women aged 18-48 years in this cross-sectional study. For each participant, anthropometrics measurements, biochemical tests and blood pressure were evaluated. RMR was measured by indirect calorimetry. RMR/kg was also measured. Modified Nordic diet score was measured using a validated 147-item food frequency questionnaire (FFQ).

RESULTS

Among all participants, the mean and standard deviation (SD) for age and body mass index (BMI) were 36.67 years (SD = 9.10) and 31.26 kg/m2 (SD = 4.29), respectively. There was a significant association between RMR/kg status and age, body mass index (BMI), RMR (P < .001), respiratory quotient (RQ), fat percentage (P = .01), systolic blood pressure (SBP) (P = .03) and diastolic blood pressure (DBP) (P = .04), after adjustment for age, BMI, energy intake and physical activity. Participants with the highest adherence to modified Nordic diet had lower odds of hypometabolic status after adjusting for confounders and it was significant (odds ratio (OR) = 3.15, 95% CI = 0.97-10.15, P = .05).

CONCLUSIONS

The present results indicate that adherence to modified Nordic diet is associated with lower odds of hypometabolic status in overweight and obese women. However, more studies are needed to confirm our findings.

Heavy Menstrual Bleeding in Adolescent: Normal or a Sign of an Underlying Disease?

Heavy, and often irregular, menstrual bleeding (HMB) is a common gynecologic complaint among adolescents. During the first few post-menarcheal years, anovulatory cycles related to immaturity of the hypothalamic-pituitary-ovarian axis are the most common etiology for abnormal uterine bleeding and should be considered as a part of normal pubertal development rather than a disease. If an already regular menstrual cycle becomes irregular, secondary causes of anovulation should be ruled out. Inherited and acquired bleeding disorders, such as von Willebrand disease, and quantitative and qualitative abnormalities of platelets are relatively common findings in adolescents with HMB from menarche. History of excessive bleeding or a diagnosed bleeding disorder in the family supports this etiology, warranting specialized laboratory testing. First-line treatment of HMB among adolescents is medical management with hormonal therapy or nonhormonal options. Levonorgestrel-releasing intrauterine device is an effective tool also for all adolescents with menstrual needs.

Central Adiposity and Subsequent Risk of Breast Cancer by Menopause Status

BACKGROUND

Increased body mass index (BMI) is associated with higher postmenopausal breast cancer risk and lower premenopausal breast cancer risk. Less is known about the central adiposity-breast cancer risk association, particularly for tumor subtypes.

METHODS

We used prospective waist (WC) and hip circumference (HC) measures in the Nurses' Health Studies. We examined associations of WC, HC, and waist-to-hip ratio (WHR) with breast cancer independent of BMI, by menopausal status. Cox proportional hazards models estimated the hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for breast cancer risk factors, with and without BMI.

RESULTS

Adjusting for BMI, WC and HC were not associated, and WHR was positively associated with premenopausal breast cancer risk (WHR, quintile 5 vs 1: HRQ5vQ1, BMI-adjusted = 1.27, 95% CI = 1.04 to 1.54; Ptrend = .01), particularly for estrogen receptor-negative (ER-) and progesterone receptor-negative (PR-) and basal-like breast cancers. Premenopausal WC, HC, and WHR were not associated with postmenopausal breast cancer risk, with or without BMI adjustment. Postmenopausal WC, HC, and WHR were each positively associated with postmenopausal breast cancer (eg, WC HRQ5vsQ1 = 1.59, 95% CI = 1.36 to 1.86); after adjustment for BMI, only WC remained statistically significant (HRQ5vsQ1, BMI-adjusted = 1.38, 95% CI = 1.15 to 1.64; Ptrend = .002). In postmenopausal women, associations were stronger among never-users of hormone therapy and for ER+/PR+ breast cancers.

CONCLUSIONS

Central adiposity was positively associated with pre- and postmenopausal breast cancers independent of BMI. This suggests that mechanisms other than estrogen may also play a role in the relationship between central adiposity and breast cancer. Maintaining a healthy waist circumference may decrease pre- and postmenopausal breast cancer risk.

Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents

IMPORTANCE

Heavy menstrual bleeding is a common cause of anemia and reduced quality of life in adolescents. There is a higher prevalence of bleeding disorders in girls with heavy menstrual bleeding than in the general population. Pediatricians should be comfortable with the initial evaluation of heavy menstrual bleeding and the indications for referral to subspecialty care.

OBSERVATIONS

The most common cause of heavy menstrual bleeding in adolescents is ovulatory dysfunction, followed by coagulopathies. The most common inherited bleeding disorder is von Willebrand disease, and its incidence in adolescents with heavy menstrual bleeding is high. Distinguishing the etiology of heavy menstrual bleeding will guide treatment, which can include hemostatic medications, hormonal agents, or a combination of both. Among hormonal agents, the 52-mg levonogestrel intrauterine device has been shown to be superior in its effect on heavy menstrual bleeding and is safe and effective in adolescents with bleeding disorders.

CONCLUSIONS AND RELEVANCE

Anemia, need for transfusion of blood products, and hospitalization may be avoided with prompt recognition, diagnosis, and treatment of heavy menstrual bleeding, especially when in the setting of bleeding disorders. Safe and effective treatment methods are available and can greatly improve quality of life for affected adolescents. A multidisciplinary approach to the treatment of girls with bleeding disorders and history of heavy menstrual bleeding is optimal.

The Impact of a Diet Containing Sucrose and Systematically Repeated Starvation on the Oxidative Status of the Uterus and Ovary of Rats

The effect of a sucrose diet and repeated one-day starvation on oxidative status in the ovary and uterus is still unknown. Our analysis focused on carbohydrate-lipid metabolism parameters and the changes in red blood cells, ovary and uterus superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) activities and malonylodialdehyde (MDA) concentration in rats fed with a diet containing 16% of sucrose and subjected to systematic one-day starvation when using such a diet. It was found that a diet with 16% sucrose contributed to the increase of antioxidant enzyme activity in the blood (GPx and CAT) and uterus (SOD), without changes in MDA concentrations, which indicates an increase in reactive oxygen species (ROS) concentration in these tissues, being balanced by an increase in antioxidant enzyme activity. The introduction of a regular one-day starvation period into the diet intensified oxidative stress and led to a redox imbalance in the reproductive tissues of female rats. This was manifested by higher GPx activity, lower CAT activity and higher MDA concentration in the uterus and lower GPx and CAT activities and lower MDA concentration in the ovaries. The observed changes may be the cause of fertility disorders and possible problems with fertilised egg cell implantation into the uterine tissue.

Serum Vitamin D Levels in Fertile and Infertile Women with Polycystic Ovary Syndrome

Introduction In polycystic ovary syndrome, serum vitamin D levels are known to correlate with metabolic conditions such as diabetes mellitus, metabolic syndrome and cardiovascular disease. However, there are not enough studies showing such a relationship with female fertility. We aimed to compare serum vitamin D levels in fertile and infertile women with polycystic ovary syndrome to evaluate whether vitamin D may play a role in the pathogenesis of fertility problems in women with polycystic ovary syndrome.

Materials and Methods 274 infertile and 111 fertile women with polycystic ovary syndrome were included in this retrospective study. Infertile and fertile groups were matched by age, body mass index and homeostasis model assessment of insulin resistance. Anthropometric, clinical and laboratory characteristics of the women were recorded. Serum 25(OH)D ₃ levels were used to assess serum vitamin D levels.

Results No significant differences were detected between groups in terms of anthropometric, clinical and laboratory features except for serum 25(OH)D ₃ levels and the incidence of vitamin D deficiency. Vitamin D levels were significantly lower and vitamin D deficiency was more common in the infertile group compared to the fertile group. When the groups were stratified into obese/non-obese or insulin resistance positive/negative, infertile obese and infertile insulin resistance-positive women had the lowest serum 25(OH)D ₃ levels.

Conclusion Serum vitamin D levels are lower in infertile women with polycystic ovary syndrome compared to fertile women. When insulin resistance or obesity was present, vitamin D levels were reduced further. Thus, in polycystic ovary syndrome, lower vitamin D levels may play a role in the pathogenesis of fertility problems.

Estrogen Signaling in Endometrial Cancer: a Key Oncogenic Pathway with Several Open Questions

Endometrial cancer is the most common gynecological cancer in the developed world, and it is one of the few cancer types that is becoming more prevalent and leading to more deaths in the USA each year. The majority of endometrial tumors are considered to be hormonally driven, where estrogen signaling through estrogen receptor α (ER) acts as an oncogenic signal. The major risk factors and some treatment options for endometrial cancer patients emphasize a key role for estrogen signaling in the disease. Despite the strong connections between estrogen signaling and endometrial cancer, important molecular aspects of ER function remain poorly understood; however, progress is being made in our understanding of estrogen signaling in endometrial cancer. Here, we discuss the evidence for the importance of estrogen signaling in endometrial cancer, details of the endometrial cancer-specific actions of ER, and open questions surrounding estrogen signaling in endometrial cancer.

Obesity associated advanced glycation end products within the human uterine cavity adversely impact endometrial function and embryo implantation competence

STUDY QUESTION

Do obese levels of advanced glycation end products (AGEs) within the uterine cavity detrimentally alter tissue function in embryo implantation and placental development?

SUMMARY ANSWER

Obese levels of AGEs activate inflammatory signaling (p65 NFκB) within endometrial epithelial cells and alter their function, cause endoplasmic reticulum (ER) stress in endometrial stromal cells and impair decidualization, compromise implantation of blastocyst mimics and inhibit trophoblast invasion.

WHAT IS KNOWN ALREADY

Obese women experience a higher incidence of infertility, recurrent miscarriage and pregnancy complications compared with lean women. Oocyte donation cycles suggest a detrimental uterine environment plays a role in these outcomes.

STUDY DESIGN, SIZE, DURATION

Uterine lavage and tissues from lean (BMI 19.5-24.9, n = 17) and obese (BMI > 30, n = 16) women examined. Cell culture experiments utilizing human endometrial epithelial, trophectoderm and trophoblast cell lines and primary human stromal cells used to examine the functional impact of obese levels of AGEs.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Levels of AGEs examined within uterine lavage assessed by ELISA to determine differences between lean and obese women. Expression and localization of AGEs, receptor for AGEs (RAGE) and NFκB within endometrial tissues obtained from lean and obese women determined by immunohistochemistry. Endometrial epithelial cells (ECC-1), primary human stromal cells and trophoblast cells (HTR8-SVneo) treated with lean (2000 nmol/mol lysine) or obese (8000 nmol/mol lysine) uterine levels of AGEs and p65 NFκB (western immunoblot), real-time adhesion, proliferation migration and invasion (xCelligence real-time cell function analysis), decidualization (cell morphology and prolactin release), ER stress (western immunoblot for p-PERK) determined. Co-cultures of endometrial epithelial cells and blastocyst mimics (trophectoderm spheroids) similarly treated with lean or obese uterine levels of AGEs to determine their impact on embryo implantation.

MAIN RESULTS AND THE ROLE OF CHANCE

AGEs were significantly elevated (P = 0.004) within the obese (6503.59 μmol/mol lysine) versus lean (2165.88 μmol/mol lysine) uterine cavity (uterine lavage) with increased immunostaining for AGEs, RAGE and NFkB within obese endometrial tissues during the proliferative phase of the menstrual cycle. Obese uterine levels of AGEs inhibited adhesion and proliferation of endometrial epithelial (ECC-1) cells compared to treatment with lean uterine levels of AGEs. Obese uterine AGE levels impacted primary human endometrial stromal cell decidualization and activated ER stress within these cells. Obese uterine levels of AGEs also inhibited trophectodermal spheroid adhesion to hormonally primed endometrial epithelial cells and trophoblast cell line HTR8/SV-neo invasion.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

Mechanistic studies are performed in vitro and may not completely recapitulate cell function in vivo.

WIDER IMPLICATIONS OF THE FINDINGS

These data corroborate clinical data suggesting the presence of an altered uterine environment in obese women and demonstrate that elevated uterine levels of AGEs within these women may detrimentally impact endometrial function, embryo implantation and placental development. Uterine AGE assessment in infertility work up may prove useful in determining underlying causes of infertility. AGEs can be targeted pharmacologically and such treatments may prove effective in improving reproductive complications experience by obese women.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by NHMRC Fellowship (#1002028 to L.A.S.), and the Victorian Government's Operational Infrastructure Support Program. MTC is supported by a JDRF Australia Clinical Research Network Career Development Award. The authors have declared that no conflict of interest exists.

Impact of Female Obesity on Cumulative Live Birth Rates in the First Complete Ovarian Stimulation Cycle

Background: Female overweight/obesity has been reported to be associated with compromised pregnancy outcomes in fresh embryo transfer cycles. It is unclear whether the cumulative live birth rate (CLBR) is adversely affected after all viable embryos are transferred from the first ovarian stimulation cycle. Objectives: To investigate whether the CLBR was compromised in obese women. Method: A total of 9,772 young women underwent their first IVF/ICSI cycles from January 2012 to October 2017. Pregnancy outcomes were compared according to female BMI. Results: Among 1,671 women with polycystic ovary syndrome (PCOS), those with a BMI ≥ 28 kg/m² had a lower cumulative clinical pregnancy rate (CCPR) and CLBR during the first complete ovarian stimulation cycle. Additionally, the pregnancy loss rate was increased in this group, although the difference was not significant. Among the 8,101 women without PCOS, the CCPR and CLBR of obese patients was also significantly decreased, and this group also showed increased pregnancy loss rates. Moreover, overweight women also had a decreased CLBR. Conclusions: Female obesity adversely affected the CLBR after utilizing the viable embryos from first oocytes retrieval.

Impact of method of endometrial preparation for frozen blastocyst transfer on pregnancy outcome: a retrospective cohort study

OBJECTIVE

To determine whether live birth rates differ by type of endometrial preparation in frozen embryo transfer (FET) cycles.

DESIGN

Retrospective cohort study.

SETTING

Academic fertility center.

PATIENT(S)

Reproductive-aged women undergoing autologous vitrified-warmed blastocyst FETs.

INTERVENTION(S)

Comparison of two methods of endometrial preparation: programmed FET (known as group A: luteal phase GnRH agonist suppression, oral E2, and IM P starting 5 days before ET) versus unstimulated FET (known as group B: hormone and ultrasound monitoring for follicle collapse to time transfer).

MAIN OUTCOME MEASURE(S)

Live birth rates in group A and group B.

RESULT(S)

Group A consisted of 923 cycles, and group B consisted of 105. When stratified by age at transfer, there was no difference in any of the measured outcomes, including live birth rates in adjusted models (adjusted odds ratio 1.0, 95% confidence interval 0.6-1.5), except in patients older than 40 years. These patients in group B had a 100% failure rate (n = 6).

CONCLUSION(S)

In most women, unstimulated endometrial preparation with luteal support before FET has similar success compared with exogenous hormone preparation. Women older than 40 years may benefit from programmed FETs owing to the challenges of increased cycle variability expected in that age group.

High-Fat, High-Sugar Diet Disrupts the Preovulatory Hormone Surge and Induces Cystic Ovaries in Cycling Female Rats

Diet-induced obesity has been associated with various metabolic and reproductive disorders, including polycystic ovary syndrome. However, the mechanisms by which obesity influences the reproductive system are still not fully known. Studies have suggested that impairments in hormone signaling are associated with the development of symptoms such as acyclicity and ovarian cysts. However, these studies have often failed to address how these hormonal changes arise and how they might contribute to the progression of reproductive diseases. In the present study, we used a high-fat, high-sugar (HFHS) diet to induce obesity in a female rodent model to determine the changes in critical reproductive hormones that might contribute to the development of irregular estrous cycling and reproductive cycle termination. The HFHS animals exhibited impaired estradiol, progesterone (P4), and luteinizing hormone (LH) surges before ovulation. The HFHS diet also resulted in altered basal levels of testosterone (T) and LH. Furthermore, alterations in the basal P4/T ratio correlated strongly with ovarian cyst formation in HFHS rats. Thus, this model provides a method to assess the underlying etiology of obesity-related reproductive dysfunction and to examine an acyclic reproductive phenotype as it develops.

The adverse effect of overweight in assisted reproduction treatment outcomes

OBJECTIVE

To assess Body Mass Index (BMI) effects on the results obtained from ICSI cycles.

METHODS

We studied 266 ICSI cycles performed between January 2014 and December 2016. The patients were grouped according to their BMI in: Normal (18.5-24.9), Overweight (25.0-29.9) and Obese (>30). We compared the following variables between the groups: number of antral follicles, ovarian stimulation length, gonadotropin dose used, maximum estradiol level, follicles developed/antral follicles, retrieved oocytes/developed follicles and mature/retrieved oocytes, normal fertilization rate, embryo achieved/normal fertilized oocytes, clinical pregnancy and implantation rates. We used the Kruskal-Wallis and the Chi square tests. p<0.05 was considered significant.

RESULTS

Normal, Overweight and Obese patients presented comparable values for number of antral follicles (11.6±5.4, 12.5±5.5, 12.2±5.7), ovarian stimulation length (7.5±1.4, 7.6±1.1, 7.8±1.3) and gonadotropin dose used (2043±489, 1940±536, 2109±605). Obese patients had lower values of estradiol (1560±610, 1511±635, 1190±466; p=0.018), developed follicles (81%, 76%, 70%; p<0.0001), and retrieved oocytes (91%, 90%, 84%; p=0.0017); and not significantly lower values of mature oocytes (82%, 82%, 77%; p=0.26). The groups had comparable fertilization rates (72%, 73%, 69%) and embryo achieved rates (67%, 63%, 72%). The normal group had higher, but not significantly higher pregnancy and implantation rates (43%, 40%, 38%, p=0.53; and 33%, 26%, 23%; p=0.11), and significantly higher ongoing pregnancy rates (37%, 33%, 33%, p=0.042).

CONCLUSION

Increased BMI patients had impaired ovarian response and lower pregnancy rates in ICSI cycles.

Prohibitin-induced obesity leads to anovulation and polycystic ovary in mice

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder and the most common cause of female infertility. However, its etiology and underlying mechanisms remain unclear. Here we report that a transgenic obese mouse (Mito-Ob) developed by overexpressing prohibitin in adipocytes develops polycystic ovaries. Initially, the female Mito-Ob mice were equally fertile to their wild-type littermates. The Mito-Ob mice began to gain weight after puberty, became significantly obese between 3-6 months of age, and ∼25% of them had become infertile by 9 months of age. Despite obesity, female Mito-Ob mice maintained glucose homeostasis and insulin sensitivity similar to their wild-type littermates. Mito-Ob mice showed morphologically distinct polycystic ovaries and elevated estradiol, but normal testosterone and insulin levels. Histological analysis of the ovaries showed signs of impaired follicular dynamics, such as preantral follicular arrest and reduced number, or absence, of corpus luteum. The ovaries of the infertile Mito-Ob mice were closely surrounded by periovarian adipose tissue, suggesting a potential role in anovulation. Collectively, these data suggest that elevated estradiol and obesity per se might lead to anovulation and polycystic ovaries independent of hyperinsulinemia and hyperandrogenism. As obesity often coexists with other abnormalities known to be involved in the development of PCOS such as insulin resistance, compensatory hyperinsulinemia and hyperandrogenism, the precise role of these factors in PCOS remains unclear. Mito-Ob mice provide an opportunity to study the effects of obesity on anovulation and ovarian cyst formation independent of the major drivers of obesity-linked PCOS.

Summary: Obesity-related overgrowth of periovarian adipose tissue and elevated estradiol levels cause anovulation and ovarian cyst formation in mice, independent of hyperinsulinemia and hyperandrogenism.