Anxiety, depression, and body image among infertile women with and without polycystic ovary syndrome

STUDY QUESTION

In women undergoing fertility treatment, do those with polycystic ovary syndrome (PCOS) have a higher prevalence of symptoms of anxiety and depression and lower body appreciation than women without PCOS?

SUMMARY ANSWER

Having PCOS was not associated with symptoms of anxiety and depression but was associated with somewhat lower body appreciation.

WHAT IS KNOWN ALREADY

PCOS has been associated with a higher chance to develop mental health problems, like anxiety, and body image concerns. The International Guidelines on PCOS recommend that all women with PCOS should routinely be screened for anxiety and depressive disorders. In most studies in this field, the comparison group included healthy women without fertility problems.

STUDY DESIGN, SIZE, DURATION

We conducted a cross-sectional survey study between May 2021 and July 2023, using an online questionnaire. We informed women about this study at fertility clinics in the Netherlands through posters and leaflets and on the websites of the Dutch patient organizations Freya and Stichting PCOS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included women with infertility, with and without PCOS, who were undergoing fertility treatment. Women completed two assessment tools: the Hospital Anxiety and Depression Scale (HADS) and the Body Appreciation Scale-2 (BAS-2). Primary outcomes were clinically relevant symptoms of anxiety (score ≥ 11) and depression (score ≥ 11), and BAS-2 scores. Secondary outcomes were mean anxiety and depression scores and anxiety and depression scores of 8 and higher. Dichotomous outcomes and continuous outcomes were analysed using logistic and linear regression analyses adjusted for age, BMI, and duration of infertility.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1025 women currently undergoing infertility treatment participated, of whom 502 (49.0%) had PCOS and 523 (51.0%) had other infertility diagnoses. We found self-reported clinically relevant symptoms of anxiety in 33.1% of women with PCOS and in 31.0% of women with other infertility diagnoses (adjusted OR: 0.99, 95% CI 0.74-1.31). Clinically relevant symptoms of depression were reported in 15.5% of women with PCOS versus 14.5% of women with other infertility diagnoses (adjusted OR: 1.04, 95% CI 0.71-1.50). Women with PCOS reported slightly less body appreciation (adjusted mean difference: -1.34, 95% CI -2.32 to -0.36).

LIMITATIONS, REASONS FOR CAUTION

Results are based on self-report and may have been affected by sampling bias.

WIDER IMPLICATIONS OF THE FINDINGS

Although guidelines recommend screening women with PCOS, feelings of anxiety and depression can be present in any woman undergoing fertility treatments. We advise fertility clinics to be aware of women's mental health issues and to offer support accordingly, as a part of routine care.

STUDY FUNDING/COMPETING INTEREST(S)

This study did not receive specific funding. All authors report no conflict of interest related to the current research.

TRIAL REGISTRATION NUMBER

This study was pre-registered at OSF: https://osf.io/qbeav.

Resumption of ovulation in anovulatory women with PCOS and obesity is associated with reduction of 11β-hydroxyandrostenedione concentrations

STUDY QUESTION

Is resumption of ovulation after a 6-month lifestyle intervention in women with PCOS and obesity associated with differential changes in endocrine and metabolic parameters (weight, insulin resistance, anti-Müllerian hormone (AMH), and androgens) compared to women with PCOS who remained anovulatory?

SUMMARY ANSWER

Resumption of ovulation after a 6-month lifestyle intervention in women with PCOS and obesity is associated with changes in serum 11β-hydroxyandrostenedione (11OHA4) concentrations.

WHAT IS KNOWN ALREADY

Lifestyle interventions have been shown to reduce clinical and biochemical hyperandrogenism in women with PCOS. Weight loss of 5-10% may reverse anovulatory status, thereby increasing natural conception rates. However, the mechanisms underlying why some women with PCOS remain anovulatory and others resume ovulation after weight loss are unclear. Reproductive characteristics at baseline and a greater degree of change in endocrine and metabolic features with lifestyle intervention may be crucial for ovulatory response.

STUDY DESIGN, SIZE, DURATION

We used data and samples originating from an earlier randomized controlled trial (RCT), which examined the efficacy of a 6-month lifestyle intervention prior to infertility treatment compared to prompt infertility treatment on live birth rate in women with obesity. A total of 577 women with obesity (BMI > 29 kg/m2) were randomized between 2009 and 2012. Anovulatory women with PCOS who were allocated to the intervention arm of the original RCT (n = 95) were included in the current analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We defined women as having resumed ovulation (RO+) based on the following criteria: spontaneous pregnancy; or assignment to expectant management; or IUI in natural cycles as the treatment strategy after lifestyle intervention. Steroid hormones were measured using liquid chromatography tandem mass spectrometry. Generalized estimating equations with adjustment for baseline measures and interaction between group and time was used to examine differences in changes of endocrine and metabolic parameters between RO+ (n = 34) and persistently anovulatory women (RO-, n = 61) at 3 and 6 months after intervention.

MAIN RESULTS AND THE ROLE OF CHANCE

At baseline, the mean ± SD age was 27.5 ± 3.6 years in the RO+ group and 27.9 ± 4.1 years in the RO- group (P = 0.65), and the mean ± SD weights were 101.2 ± 9.5 kg and 105.0 ± 14.6 kg, respectively (P = 0.13). Baseline AMH concentrations showed significant differences between RO+ and RO- women (median and interquartile range [IQR] 4.7 [3.2; 8.3] versus 7.2 [5.3; 10.8] ng/ml, respectively). Baseline androgen concentrations did not differ between the two groups. During and after lifestyle intervention, both groups showed weight loss; changes in 11OHA4 were significantly different between the RO+ and RO groups (P-value for interaction = 0.03). There was a similar trend for SHBG (interaction P-value = 0.07), and DHEA-S (interaction P-value = 0.06), with the most pronounced differences observed in the first 3 months. Other parameters, such as AMH and FAI, decreased over time but with no difference between the groups.

LIMITATIONS, REASONS FOR CAUTION

No high-resolution transvaginal ultrasonography was used to confirm ovulatory status at the end of the lifestyle program. The small sample size may limit the robustness of the results.

WIDER IMPLICATIONS OF THE FINDINGS

Reduction of androgen concentrations during and after lifestyle intervention is associated with recovery of ovulatory cycles. If our results are confirmed in other studies, androgen concentrations could be monitored during lifestyle intervention to provide individualized recommendations on the timing of resumption of ovulation in anovulatory women with PCOS and obesity.

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 Gynecology of the UMCG received an unrestricted educational grant from Ferring Pharmaceuticals BV, The Netherlands. A.H. reports consultancy for the development and implementation of a lifestyle App MyFertiCoach developed by Ferring Pharmaceutical Company. All other authors have no conflicts to declare.

TRIAL REGISTRATION NUMBER

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

Long-term outcomes of switching to gonadotrophins versus continuing with clomiphene citrate, with or without intrauterine insemination, in women with normogonadotropic anovulation and clomiphene failure: follow-up study of a factorial randomized clinical trial

STUDY QUESTION

What are the long-term outcomes after allocation to use of gonadotrophins versus clomiphene citrate (CC) with or without IUI in women with normogonadotropic anovulation and clomiphene failure?

SUMMARY ANSWER

About four in five women with normogonadotropic anovulation and CC failure had a live birth, with no evidence of a difference in pregnancy outcomes between the allocated groups.

WHAT IS KNOWN ALREADY

CC has long been used as first line treatment for ovulation induction in women with normogonadotropic anovulation. Between 2009 and 2015, a two-by-two factorial multicentre randomized clinical trial in 666 women with normogonadotropic anovulation and six cycles of CC failure was performed (M-ovin trial). This study compared a switch to gonadotrophins with continued treatment with CC for another six cycles, with or without IUI within 8 months. Switching to gonadotrophins increased the chance of conception leading to live birth by 11% over continued treatment with CC after six failed ovulatory cycles, at a cost of €15 258 per additional live birth. The addition of IUI did not significantly increase live birth rates.

STUDY DESIGN, SIZE, DURATION

In order to investigate the long-term outcomes of switching to gonadotrophins versus continuing treatment with CC, and undergoing IUI versus continuing with intercourse, we conducted a follow-up study. The study population comprised all women who participated in the M-ovin trial.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participating women were asked to complete a web-based questionnaire. The primary outcome of this study was cumulative live birth. Secondary outcomes included clinical pregnancies, multiple pregnancies, miscarriage, stillbirth, ectopic pregnancy, fertility treatments, neonatal outcomes and pregnancy complications.

MAIN RESULTS AND THE ROLE OF CHANCE

We approached 564 women (85%), of whom 374 (66%) responded (184 allocated to gonadotrophins; 190 to CC). After a median follow-up time of 8 years, 154 women in the gonadotrophin group had a live birth (83.7%) versus 150 women in the CC group (78.9%) (relative risk (RR) 1.06, 95% CI 0.96-1.17). A second live birth occurred in 85 of 184 women (49.0%) in the gonadotrophin group and in 85 of 190 women (44.7%) in the CC group (RR 1.03, 95% CI 0.83-1.29). Women allocated to gonadotrophins had a third live birth in 6 of 184 women (3.3%) and women allocated to CC had a third live birth in 14 of 190 women (7.4%). There were respectively 12 and 11 twins in the gonadotrophin and CC groups. The use of fertility treatments in the follow-up period was comparable between both groups. In the IUI group, a first live birth occurred in 158 of 192 women (82.3%) and while in the intercourse group, 146 of 182 women (80.2%) reached at least one live birth (RR: 1.03 95% CI 0.93-1.13; 2.13%, 95% CI -5.95, 10.21).

LIMITATIONS, REASONS FOR CAUTION

We have complete follow-up results for 57% of the women.There were 185 women who did not respond to the questionnaire, while 102 women had not been approached due to missing contact details. Five women had not started the original trial.

WIDER IMPLICATIONS OF THE FINDINGS

Women with normogonadotropic anovulation and CC failure have a high chance of reaching at least one live birth. In terms of pregnancy rates, the long-term differences between initially switching to gonadotrophins are small compared to continuing treatment with CC.

STUDY FUNDING/COMPETING INTEREST(S)

The original study received funding from the Dutch Organization for Health Research and Development (ZonMw number: 80-82310-97-12067). A.H. reports consultancy for development and implementation of a lifestyle App, MyFertiCoach, developed by Ferring Pharmaceutical Company. M.G. receives unrestricted grants for scientific research and education from Ferring, Merck and Guerbet. B.W.M. is supported by an NHMRC Investigatorgrant (GNT1176437). B.W.M. reports consultancy for ObsEva and Merck and travel support from Merck. All other authors have nothing to declare.

TRIAL REGISTRATION NUMBER

This follow-up study was registered in the OSF Register, https://osf.io/pf24m. The original M-ovin trial was registered in the Netherlands Trial Register, number NTR1449.

Thin endometrial lining: is it more prevalent in patients utilizing preimplantation genetic testing for monogenic disease (PGT-M) and related to prior hormonal contraceptive use?

STUDY QUESTION

Is a thin endometrial lining before ovulation triggering more prevalent in patients utilizing preimplantation genetic testing for monogenic disease (PGT-M) compared to the regular IVF/ICSI population and is this associated with prior hormonal contraceptive use?

SUMMARY ANSWER

Thin (<8 mm) endometrial lining is more prevalent in PGT-M patients compared to the regular IVF/ICSI population and is associated with both longer prior hormonal contraceptive use and a shorter cessation interval of hormonal contraceptives before IVF/ICSI treatment.

WHAT IS KNOWN ALREADY

Thin endometrial lining has been associated with lower pregnancy rates in IVF/ICSI cycles and increased chances of miscarriage and low birth weight. Endometrial thinning and atrophy occur during hormonal contraceptive use. Patients utilizing PGT-M typically use hormonal contraceptives up until treatment to avoid the risk of conception of a genetically affected child. Whether this could negatively affect endometrial thickness achieved during subsequent IVF/ICSI cycles is not known.

STUDY DESIGN, SIZE, DURATION

A retrospective case control study was performed, including all PGT-M patients attending the University Medical Centre Groningen (cases), between 2009 and 2018. The control group consisted of two non-PGT IVF/ICSI patients for each PGT-M patient, matched for age and treatment period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

First cycles of 122 PGT-M patients and 240 controls were included. Cessation interval of hormonal contraceptives was categorized as late cessation (cessation <1 year prior to treatment) or early cessation (>1 year prior to treatment). Endometrial thickness was routinely measured on the day of hCG triggering or 1 day prior. The prevalence of an endometrial lining <8 mm was compared between PGT-M patients and controls. Hormonal contraceptive use (both duration and cessation interval) was compared between both groups. Univariable and multivariable regression analyses were performed to identify risk factors for thin endometrial lining. In addition, cycle and pregnancy outcomes were compared within control/PGT-M groups between patients with endometrial lining > or <8 mm.

MAIN RESULTS AND THE ROLE OF CHANCE

Thin endometrial lining on the day of hCG triggering was found significantly more often in the PGT-M group, compared to controls: 32% vs 11% (mean difference 21.0%, 95% CI: 11.7, 30.3%). As expected, more patients in the PGT-M group ceased their hormonal contraception late (<1 year): 64% vs 2% in the control group (mean difference 61.9%, 95% CI: 53.0, 70.8%). Average duration of hormonal contraceptive use was 10.6 years in the PGT-M group vs 9.3 years in controls (mean difference 1.3 years, 95% CI: 0.2, 2.3 years). Multivariable logistic regression analysis identified late cessation (OR: 6.0, 95% CI: 1.9-19.2) and duration of prior hormonal contraceptive use (OR per year increase 1.1, 95% CI: 1.0-1.2) as significant independent risk factors for a thin endometrial lining. In relation to outcome, we found a statistically significant increase in miscarriage rate in PGT-M patients with an endometrial lining <8 mm compared to those with an endometrial lining >8 mm (20.0% vs 1.7%, mean difference 18.3%, 95% CI: 2.3, 34.3%). A trend towards lower birth weight and gestation- and gender-adjusted birth weight (z-score) was also found in this group. No statistically significant differences were detected in pregnancy rate, live birth rate, or incidence of preterm delivery or SGA. Within the control group, no statistically significant differences were found in outcomes between patients with an endometrial lining <8 compared to an endometrial lining >8 mm.

LIMITATIONS, REASONS FOR CAUTION

The study is retrospective. Various types of hormonal contraceptives were reported which possibly exert different effects on the endometrial lining. In relation to pregnancy outcome measures, numbers were very limited; therefore, no firm conclusions should be drawn.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides further insight into the role of prior hormonal contraceptive use as a possible contributor to the occurrence of thin endometrial lining during ART treatment. Future studies should provide more information on its clinical relevance, to determine whether PGT-M patients can be reassured, or should be counselled to stop hormonal contraceptive use and change to an alternative contraceptive method prior to PGT treatment.

STUDY FUNDING/COMPETING INTERESTS

No specific funding was used and no conflicts of interests are declared.

TRIAL REGISTRATION NUMBER

N/A.

Systemic microvascular response to insulin is associated with risk of heart failure with preserved ejection fraction in women with type 2 diabetes

Background

Endothelial microvascular dysfunction (MD) is a key pathophysiologic mechanism for heart failure with preserved ejection fraction (HFpEF). Comorbidities such as type 2 diabetes (T2D) indeed can affect the endothelium of both peripheral and coronary microcirculation, thereby triggering systemic derangements as well as left ventricular diastolic dysfunction (LVDD). Altered microvascular response to insulin is common in T2D but its clinical relevance and association with cardiovascular risk and particularly HFpEF remains unclear. Likewise, the involvement of systemic MD in early HFpEF and LVDD is uncertain. Finally, the influence of sex on MD and on its association with HFpEF needs further investigation to help understand the female predominance in HFpEF.

Purpose

We aimed to characterize systemic MD in T2D, and investigate its association with clinical and echocardiographic markers of LVDD/HFpEF. Further, we aimed to test for effect modification by sex in the association between MD and LVDD/HFpEF.

Methods

152 prospectively enrolled participants (77 men, 75 women) from the Hoorn Diabetes Care System Cohort underwent in vivo evaluation of MD, echocardiography and blood sampling. MD was assessed by laser speckle contrast analysis combined with iontophoresis of insulin (Ins), acetylcholine (ACh) and sodium nitroprusside (SNP). The association between indices of MD and markers of LVDD/HFpEF was assessed by multivariable linear regression analysis adjusted for confounders. LVDD was defined as presence of cardiac structural and functional abnormalities, according to current recommendation. Probability of HFpEF was estimated with the H2PEFF score.

Results

Mean age was 65±6y, mean HbA1c 7.5±1.2%, 70.6% were asymptomatic. Comorbidity burden and biomarkers did not significantly differ between the sexes. Women had smaller LV mass index (82.8±18.1 vs 99.2±20.3 g/m2) and higher E/E' (13.4±4.4 vs 11.3±2.8) compared to men. Skin perfusion plateau after application of each substance was higher in women than men but no significant differences between sexes were observed in terms of relative perfusion change, calculated as 100% × ([Perfusion plateau − Baseline flow] / Baseline flow) for any of the substances. The relative perfusion change due to Ins was associated with the H2PEFF score, independently of cardiovascular risk factors and cardiovascular drug use (1% increase in perfusion associated to 0.07% decrease of the H2PEFF score). Stratified by sex, this association was present only in women (1% increase in perfusion associated to 0.10% decrease of the H2PEFF score). No significant associations were observed between perfusion change after ACh and SNP and H2PEFF score or between any MD indices and LVDD markers.

Conclusions

Impaired endothelial-mediated vasodilation in response to insulin confers a higher risk of HFpEF in women with T2D. In vivo measures of systemic MD could represent novel cardiovascular risk markers, for refined risk prediction of HFpEF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Young Investigator award grant, Early HFpEF and ShePredicts programs, Hartstichting, The Netherlands.

P-590 Discriminatory value of steroid hormones on polycystic ovary syndrome in women with infertility and obesity

Study question

Which steroid hormone (ratio) has the highest discriminatory value in the biochemical diagnosis of polycystic ovary syndrome (PCOS) in women with infertility and obesity?

Summary answer

Androstenedione (A4) is a potentially useful discriminatory biomarker for PCOS in women with obesity, whereas Testosterone (T)/Dihydrotestosterone (DHT) and 11-oxygenated androgens are not.

What is known already

The best biomarker to assess biochemical hyperandrogenism in PCOS is still under discussion. Serum total or free T, followed by Free Androgen Index (FAI), and Dehydroepiandrosterone Sulfate (DHEA-S) are the most widely used biomarkers. T/DHT ratio has been proposed as a useful biomarker for PCOS. Moreover, a recent study demonstrated 11-oxygenated androgens represent the majority of circulating androgens in PCOS. Whether this is also relevant in women with obesity is unclear. We aimed to assess the discriminatory value of different steroid hormones and their ratios for PCOS as well as adverse metabolic phenotype within PCOS in women with obesity.

Study design, size, duration

We used the baseline data and samples originating from an RCT that examined whether a six-month lifestyle intervention prior infertility treatment in women with obesity improved live birth rate, compared to prompt infertility treatment. In total of 577 women with obesity were randomized between 2009 and 2012. Women were diagnosed with PCOS according to the Rotterdam criteria. Metabolic syndrome was diagnosed based on the revised criteria of the National Cholesterol Education Program.

Participants/materials, setting, methods

Women with PCOS comprised the study group (N = 132). Ovulatory women with idiopathic, tubal or male factor infertility were the control group (N = 83). Women were excluded when blood sampling was performed in the luteal phase or when baseline samples were unavailable. The steroid hormones were measured using LC-MS/MS. 11β-hydroxyandrostenedione (11OHA4) and 11-ketotestosterone (11KT) were analyzed using LC-MS/MS in a separate method. The discriminatory value was based on receiver operator characteristic (ROC) curves with adjustment for age.

Main results and the role of chance

The mean age was 28.1 years in the PCOS group and 30.9 years in the control group (p &lt; 0.001). BMI was not significantly different (36.0±3.2 versus 35.7±3.5, p = 0.51). Among the tested steroid hormones (ratios), SHBG, A4, T, DHT, 11KT, FAI, T/DHT ratio, and T/A4 ratio showed statistically significant differences between the PCOS and the control group. DHEA, DHEA-S, 11OHA4 did not differ between the groups. The crude AUCs of FAI, T, A4, T/DHT ratio, SHBG, 11KT, T/A4 ratio, and DHT in ROC analysis for representing PCOS were 0.85, 0.84, 0.81, 0.70, 0.62, 0.59, 0.58, and 0.57 respectively. Among the markers with crude AUCs≥0.70, the incremental value of the marker A4 (AUC difference: 0.14, 95%CI: 0.07 to 0.21), T (0.18, 95%CI: 0.10 to 0.25), and FAI (0.18, 95%CI: 0.10 to 0.25) in addition to age showed significant improvement, but T/DHT ratio (0.02, 95%CI: –0.01 to 0.04) did not. However, the combination of A4 together with T or FAI did improve discriminatory value of individual T or FAI (AUC difference: –0.001, 95%CI: –0.004 to 0.003 and 0.007, –0.007 to 0.02, respectively). None of the measured steroid hormones (ratios) have promising discriminatory value for adverse metabolic phenotype within PCOS in women with obesity.

Limitations, reasons for caution

This is a post-hoc analysis and no power calculation was performed. There was a significant difference in age between women with and without PCOS, and residual confounding might exist. All PCOS patients in this analysis were infertile and obese, and it is conceivable that milder PCOS phenotypes are not represented.

Wider implications of the findings

T/DHT ratio and 11-oxygenated androgens might not serve as a promising discriminatory biomarker for PCOS in women with obesity, nor for adverse metabolic phenotype within PCOS in these women. A4 is a potential biomarker for PCOS diagnosis in women with infertility and obesity, however, its utility potency needs further validation.

Trial registration number

NTR 1530

P-643 Long-term pregnancy outcomes in women with normogonadotropic anovulation and clomiphene failure: follow-up study of the M-ovin trial

Study question

What are the long-term outcomes after gonadotrophins versus clomiphene citrate (CC) with or without intrauterine insemination (IUI) in women with normogonadotropic anovulation and clomiphene failure?

Summary answer

The long-term cumulative chance for delivering at least one live birth is 78% for continuing CC and 84% for switching to gonadotrophins.

What is known already

CC has long been used as first line treatment for ovulation induction in women with normogonadotropic anovulation, but the best treatment for CC failure was unknown. Between 2009 and 2015, 666 women with normogonadotropic anovulation and CC failure were randomised to gonadotrophins or continued treatment with CC for another six cycles, with or without IUI. Switching to gonadotrophins increased the chance of live birth by 11% over continued treatment with CC after six failed ovulatory cycles, at a cost of €15 258 per additional live birth, while the addition of IUI did not increase live birth rates.

Study design, size, duration

We asked women that had been included in the M-ovin trial 6 to 13 years ago for consent to participate in this follow-up study. In the M-ovin trial, 666 women that failed to conceive over 6 ovulatory cycles had been allocated to switching to gonadotrophins versus continuing treatment with CC.

Participants/materials, setting, methods

The participating women were asked to complete a web-based questionnaire. The primary outcome of this study was cumulative live birth. Secondary outcomes included fertility treatments, clinical pregnancies, multiple pregnancies, miscarriage, stillbirth, ectopic pregnancy, neonatal outcomes and pregnancy complications.

Main results and the role of chance

We managed to contact 570 women of the 666 (85.6%) and retrieved follow-up data for 347 women of whom 176 had been originally allocated to gonadotrophins and 171 to CC. After a median follow-up time of 8 years (range 6-13), 148 women had a live birth (84.1%) in the gonadotrophin group and 133 women had a live birth (77.8%) in the CC group (RR 1.40 95% CI 0.90 – 2.17). A second live birth occurred in 80 of 176 women (45.5%) in the gonadotrophin group and in 77 of 171 women in the CC group (45.0%) (RR 1.01, 95% CI 0.83 – 1.22). A third live birth occurred in 7 of 176 women (4.0%) in the gonadotrophin group and in 11 of 171 women (6.4%) in the CC group. The use of fertility treatments in the follow-up period was comparable between both groups. The number of twin pregnancies were also comparable.

Limitations, reasons for caution

In 10.7% of the women, most having a follow-up period above 10 years, contact details had been lost. Therefore, not all eligible women could be approached to participate in this study. It should be realised that preliminary results are presented.

Wider implications of the findings

In women with normogonadotropic anovulation and CC failure, continuous treatment with CC for another six cycles is an effective alternative in view of the long-term live birth rates, without the extra costs of gonadotrophins.

Trial registration number

This follow-up study was registered in the OSF Register, https://osf.io/pf24m. The original M-ovin trial was registered in the Netherlands Trial Register, number NTR1449.

The role of PCOS in mental health and sexual function in women with obesity and a history of infertility

STUDY QUESTION

Do mental health and sexual function differ between women with or without polycystic ovary syndrome (PCOS) with comparable BMI and fertility characteristics?

SUMMARY ANSWER

Women with PCOS have a poorer mental quality of life than women without PCOS, but there were no differences in symptoms of depression, anxiety, physical quality of life or sexual function.

WHAT IS KNOWN ALREADY

Various studies suggest that women with PCOS have poorer mental health, such as higher symptoms of anxiety and depression with a lower quality of life, and have an impaired sexual function compared to women without PCOS. However, in most studies, BMI and infertility status differ between women with and without PCOS, which may hamper comparability.

STUDY DESIGN SIZE DURATION

This study is a cross-sectional analysis of a 5-year follow-up of a randomized controlled trial (RCT) among women with obesity and a history of infertility.

PARTICIPANTS/MATERIALS SETTING METHODS

Participants in this follow-up study of an RCT were women with obesity and infertility randomized to a lifestyle intervention followed by infertility treatment or prompt infertility treatment (control), stratified by ovulatory status and trial centre. In total, 173 (30.0%) women of the 577 women randomized in the initial trial participated in this follow-up study, with a mean follow-up of 5.5 years (range 3.7-7.0 years); of these women 73 had been diagnosed with PCOS and 100 did not have PCOS. Participants completed questionnaires on symptoms of anxiety and depression (Hospital Anxiety and Depression scale (HADS)), quality of life (36-item Short Form Health Survey (SF-36)) and sexual function (McCoy Female Sexuality Questionnaire (MFSQ)). We also compared quality of life subscale scores in women with and without PCOS and compared them to an age-matched Dutch reference population with average BMI. Effect sizes were calculated to assess the differences.

MAIN RESULTS AND THE ROLE OF CHANCE

Symptoms of anxiety and depression, physical quality of life and sexual function did not differ significantly between obese women with and without PCOS. However, women with PCOS had a worse mental quality of life summary component score (-3.60 [95% CI -6.72 to -0.56]), mainly due to a lower score on the subscale 'role limitations due to emotional problems' (-12.41 [95% CI -22.78 to -2.28]), compared to women without PCOS. However, compared to an age-matched Dutch reference population, the obese infertile women with and without PCOS both scored lower on almost all physical and mental quality of life subscales.

LIMITATIONS REASONS FOR CAUTION

These are secondary analyses of the follow-up study of the RCT. No power analysis was performed for the outcomes included in this analysis and, as our study had a relatively small sample size, the null findings could be based on insufficient power to detect small differences between the groups. Our study population had a high mean BMI (average total group 34.5 [SD ± 5.1]); therefore, our results may only be generalizable to women with obesity.

WIDER IMPLICATIONS OF THE FINDINGS

Our results indicate that PCOS status is associated with impaired mental quality of life. Anxiety and depression, physical quality of life and sexual function in obese infertile women with PCOS seem more related to the obesity than the PCOS status.

STUDY FUNDING/COMPETING INTERESTS

The initial study and follow-up were supported by grants from: ZonMw (50-50110-96-518), the Dutch Heart Foundation (2013T085) and the European Commission (633595). The Department of Obstetrics and Gynaecology of the UMCG received an unrestricted educational grant from Ferring pharmaceuticals BV, The Netherlands, outside the submitted work. A.H. reports consultancy for Ferring pharmaceuticals. B.W.J.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.J.M. reports consultancy for ObsEva, Merck Merck KGaA, iGenomix and Guerbet. All other authors declare no competing interests.

TRIAL REGISTRATION NUMBER

The initial trial was registered on 16 November 2008 in the Dutch trial register; clinical trial registry number NTR1530.

P–633 lifestyle intervention prior to IVF does not improve embryo utilization rate and cumulative live birth rate in women with obesity

Study question

Does lifestyle intervention prior to in vitro fertilization (IVF) improve embryo utilization rate (EUR) and cumulative live birth rate (CLBR) in women with obesity?

Summary answer

A six-month lifestyle intervention preceding IVF improved neither EUR, nor CLBR in women with obesity.

What is known already

A randomized controlled trial (RCT) evaluating the efficacy of a low caloric liquid formula diet (LCD) preceding IVF in women with obesity was unable to demonstrate an effect of LCD on embryo quality and live birth rate. In that study, only one fresh embryo transfer (ET) or, in case of freeze-all strategy, the first transfer with frozen-thawed embryos was reported. We hypothesized that any effect on embryo quality of a lifestyle intervention in women with obesity undergoing IVF treatment is better revealed by EUR and CLBR after transfer of fresh and frozen-thawed embryos.

Study design, size, duration

This is a nested cohort study within an RCT. The LIFEstyle study examined whether a six-month lifestyle intervention prior to assisted reproductive technology (ART) in women with obesity improved live birth rate, compared to prompt ART within 24 months after randomization. In the original study, 577 women with obesity and infertility were assigned to a lifestyle intervention followed by ART (N = 290) or to prompt ART (N = 287) between 2009 and 2012.

Participants/materials, setting, methods

The first IVF cycle with successful oocyte retrieval was included, resulting in 51 participants in the intervention group and 72 in the control group. EUR was defined as the proportion of inseminated/injected oocytes that could be transferred or cryopreserved as an embryo. Analysis was performed per cycle and per oocyte/embryo. CLBR was defined as the percentage of participants with at least one live birth from the first fresh and subsequent frozen-thawed ET(s).

Main results and the role of chance

The overall mean age was 31.64 years, and the mean BMI was 35.40 ± 3.21 kg/m2 in the intervention group, and 34.86 ± 2.86 kg/m2 in the control group (P = 0.33). The mean difference of weight change at six months between the two groups was in favor of the intervention group (mean difference in kg: –3.14, 95% CI: –5.73 – –0.56). The median (Q25; Q75) of EUR was 33.3% (12.5; 60.0) in the intervention group and 33.3% (16.7; 50.0) in the control group in the per cycle analysis (adjusted B: 2.7%, 95% CI: –8.6 – 14.0). In the per oocyte/embryo analysis, in total 280 oocytes were injected or inseminated in the intervention group, 113 were utilized (transferred or cryopreserved embryos, EUR = 40.4%); in the control group EUR was 30.8% (142/461). The lifestyle intervention did not significantly improve EUR (adjusted OR: 1.36, 95% CI: 0.94 – 1.98) in the per oocyte/embryo analysis taking into account the interdependency of the oocytes per participant. CLBR was not significantly different between the intervention group and the control group after adjusting for type of infertility (male factor and unexplained) and smoking (27.5% vs 22.2%, adjusted OR: 1.03, 95% CI: 0.43 – 2.47).

Limitations, reasons for caution

This study is a nested cohort study within an RCT, and no power calculation was performed. The randomization was not stratified for indicated treatment. The limited absolute weight loss and the short duration of the lifestyle intervention might be insufficient to affect EUR and CLBR.

Wider implications of the findings: Our data do not support the hypothesis of a beneficial effect of lifestyle intervention on embryo quality and CLBR after IVF in women with obesity.

Trial registration number

NTR 1530

Birthweight and other perinatal outcomes of singletons conceived after assisted reproduction compared to natural conceived singletons in couples with unexplained subfertility: follow-up of two randomized clinical trials

STUDY QUESTION

Does assisted reproduction, such as ovarian stimulation and/or laboratory procedures, have impact on perinatal outcomes of singleton live births compared to natural conception in couples with unexplained subfertility?

SUMMARY ANSWER

Compared to natural conception, singletons born after intrauterine insemination with ovarian stimulation (IUI-OS) had a lower birthweight, while singletons born after IVF had comparable birthweights, in couples with unexplained subfertility.

WHAT IS KNOWN ALREADY

Singletons conceived by assisted reproduction have different perinatal outcomes such as low birthweight and a higher risk of premature birth than naturally conceived singletons. This might be due to the assisted reproduction, such as laboratory procedures or the ovarian stimulation, or to an intrinsic factor in couples with subfertility.

STUDY DESIGN, SIZE, DURATION

We performed a prospective cohort study using the follow-up data of two randomized clinical trials performed in couples with unexplained subfertility. We evaluated perinatal outcomes of 472 live birth singletons conceived after assisted reproduction or after natural conception within the time horizon of the studies.

PARTICIPANTS/MATERIALS, SETTING, METHODS

To assess the possible impact of ovarian stimulation we compared the singletons conceived after IUI with FSH or clomiphene citrate (CC) and IVF in a modified natural cycle (IVF-MNC) or standard IVF with single embryo transfer (IVF-SET) to naturally conceived singletons in the same cohorts. To further look into the possible effect of the laboratory procedures, we put both IUI and IVF groups together into IUI-OS and IVF and compared both to singletons born after natural conception. We only included singletons conceived after fresh embryo transfers. The main outcome was birthweight presented as absolute weight in grams and gestational age- and gender-adjusted percentiles. We calculated differences in birthweight using regression analyses adjusted for maternal age, BMI, smoking, parity, duration of subfertility and child gender.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, there were 472 live birth singletons. Of the 472 singleton pregnancies, 209 were conceived after IUI-OS (136 with FSH and 73 with CC as ovarian stimulation), 138 after IVF (50 after IVF-MNC and 88 after IVF-SET) and 125 were conceived naturally.Singletons conceived following IUI-FSH and IUI-CC both had lower birthweights compared to naturally conceived singletons (adjusted difference IUI-FSH -156.3 g, 95% CI -287.9 to -24.7; IUI-CC -160.3 g, 95% CI -316.7 to -3.8). When we compared IVF-MNC and IVF-SET to naturally conceived singletons, no significant difference was found (adjusted difference IVF-MNC 75.8 g, 95% CI -102.0 to 253.7; IVF-SET -10.6 g, 95% CI -159.2 to 138.1). The mean birthweight percentile was only significantly lower in the IUI-FSH group (-7.0 percentile, 95% CI -13.9 to -0.2). The IUI-CC and IVF-SET group had a lower mean percentile and the IVF-MNC group a higher mean percentile, but these groups were not significant different compared to the naturally conceived group (IUI-CC -5.1 percentile, 95% CI -13.3 to 3.0; IVF-MNC 4.4 percentile, 95% CI -4.9 to 13.6; IVF-SET -1.3 percentile, 95% CI -9.1 to 6.4).Looking at the laboratory process that took place, singletons conceived following IUI-OS had lower birthweights than naturally conceived singletons (adjusted difference -157.7 g, 95% CI -277.4 to -38.0). The IVF group had comparable birthweights with the naturally conceived group (adjusted difference 20.9 g, 95% CI -110.8 to 152.6). The mean birthweight percentile was significantly lower in the IUI-OS group compared to the natural group (-6.4 percentile, 95% CI -12.6 to -0.1). The IVF group was comparable (0.7 percentile, 95% CI -6.1 to 7.6).

LIMITATIONS, REASONS FOR CAUTION

The results are limited by the number of cases. The data were collected prospectively alongside the randomized controlled trials, but analyzed as treated.

WIDER IMPLICATIONS OF THE FINDINGS

Our data suggest IUI in a stimulated cycle may have a negative impact on the birthweight of the child and possibly on pre-eclampsia. Further research should look into the effect of different methods of ovarian stimulation on placenta pathology and pre-eclampsia in couples with unexplained subfertility using naturally conceived singletons in the unexplained population as a reference.

STUDY FUNDING/COMPETING INTEREST(S)

Both initial trials were supported by a grant from ZonMW, the Dutch Organization for Health Research and Development (INeS 120620027, SUPER 80-83600-98-10192). The INeS study also had a grant from Zorgverzekeraars Nederland, the Dutch association of healthcare insurers (09-003). B.W.J.M. is supported by an NHMRC investigator Grant (GNT1176437) and reports consultancy for ObsEva, Merck Merck KGaA, Guerbet and iGenomix, outside the submitted work. A.H. reports grants from Ferring Pharmaceutical company (the Netherlands), outside the submitted work. F.J.M.B. receives monetary compensation as a member of the external advisory board for Merck Serono (the Netherlands), Ferring Pharmaceutics BV (the Netherlands) and Gedeon Richter (Belgium), he receives personal fees from educational activities for Ferring BV (the Netherlands) and for advisory and consultancy work for Roche and he receives research support grants from Merck Serono and Ferring Pharmaceutics BV, outside the submitted work. The remaining authors have nothing to disclose.

TRIAL REGISTRATION NUMBER

INeS study Trial NL915 (NTR939); SUPER Trial NL3895 (NTR4057).

Long-term cardiometabolic disease risk in women with PCOS: a systematic review and meta-analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with cardiometabolic disease, but recent systematic reviews and meta-analyses of longitudinal studies that quantify these associations are lacking.

OBJECTIVE AND RATIONALE

Is PCOS a risk factor for cardiometabolic disease?

SEARCH METHODS

We searched from inception to September 2019 in MEDLINE and EMBASE using controlled terms (e.g. MESH) and text words for PCOS and cardiometabolic outcomes, including cardiovascular disease (CVD), stroke, myocardial infarction, hypertension (HT), type 2 diabetes (T2D), metabolic syndrome and dyslipidaemia. Cohort studies and case–control studies comparing the prevalence of T2D, HT, fatal or non-fatal CVD and/or lipid concentrations of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TGs) between women with and without PCOS of ≥18 years of age were eligible for this systematic review and meta-analysis. Studies were eligible regardless of the degree to which they adjusted for confounders including obesity. Articles had to be written in English, German or Dutch. Intervention studies, animal studies, conference abstracts, studies with a follow-up duration less than 3 years and studies with less than 10 PCOS cases were excluded. Study selection, quality assessment (Newcastle–Ottawa Scale) and data extraction were performed by two independent researchers.

OUTCOMES

Of the 5971 identified records, 23 cohort studies were included in the current systematic review. Women with PCOS had increased risks of HT (risk ratio (RR): 1.75, 95% CI 1.42 to 2.15), T2D (RR: 3.00, 95% CI 2.56 to 3.51), a higher serum concentration of TC (mean difference (MD): 7.14 95% CI 1.58 to 12.70 mg/dl), a lower serum concentration of HDL-C (MD: −2.45 95% CI −4.51 to −0.38 mg/dl) and increased risks of non-fatal cerebrovascular disease events (RR: 1.41, 95% CI 1.02 to 1.94) compared to women without PCOS. No differences were found for LDL-C (MD: 3.32 95% CI −4.11 to 10.75 mg/dl), TG (MD 18.53 95% CI −0.58 to 37.64 mg/dl) or coronary disease events (RR: 1.78, 95% CI 0.99 to 3.23). No meta-analyses could be performed for fatal CVD events due to the paucity of mortality data.

WIDER IMPLICATIONS

Women with PCOS are at increased risk of cardiometabolic disease. This review quantifies this risk, which is important for clinicians to inform patients and to take into account in the cardiovascular risk assessment of women with PCOS. Future clinical trials are needed to assess the ability of cardiometabolic screening and management in women with PCOS to reduce future CVD morbidity.

Trimethylamine-N-oxide is present in human follicular fluid and is a negative predictor of embryo quality

STUDY QUESTION

Are levels of trimethylamine-N-oxide (TMAO) in human follicular fluid (FF) related to IVF outcomes?

SUMMARY ANSWER

Higher levels of TMAO are a negative predictor of oocyte fertilization and embryo quality.

WHAT IS KNOWN ALREADY

TMAO is a metabolic product of dietary choline and l-carnitine produced via subsequent enzymatic modifications by the intestinal microbiota and hepatocytes. TMAO promotes inflammatory and oxidative stress pathways and has been characterized as a causative biomarker for the development of cardiometabolic disease.

STUDY DESIGN, SIZE, DURATION

For the present cross-sectional study, samples (FF and plasma) from 431 modified natural cycle (MNC)-IVF cycles of 132 patients were collected prospectively between October 2014 and March 2018 in a single academic medical center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

TMAO and its precursors (choline, l-carnitine and gamma-butyrobetaine) were measured by ultra-high-performance liquid chromatography/mass spectrometry in (i) matched FF and plasma from 63 MNC-IVF cycles, in order to compare metabolite levels in the two matrices and (ii) FF from 232 MNC-IVF cycles in which only one oocyte was retrieved at follicular puncture. The association between metabolite levels and oocyte fertilization, embryo fragmentation percentage, embryo quality and the occurrence of pregnancy was analyzed using multilevel generalized estimating equations with adjustment for patient and cycle characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

The level of choline was higher in FF as compared to matched plasma (P < 0.001). Conversely, the levels of TMAO and gamma-butyrobetaine were lower in FF as compared to plasma (P = 0.001 and P = 0.075, respectively). For all metabolites, there was a positive correlation between FF and plasma levels. Finally, levels of TMAO and its gut-derived precursor gamma-butyrobetaine were lower in FF from oocytes that underwent normal fertilization (TMAO: odds ratio [OR] 0.66 [0.49–0.90], P = 0.008 per 1.0-μmol/L increase; gamma-butyrobetaine: OR 0.77 [0.60–1.00], P = 0.047 per 0.1-μmol/L increase) and developed into top-quality embryos (TMAO: OR 0.56 [0.42–0.76], P < 0.001 per 1.0-μmol/L increase; gamma-butyrobetaine: OR 0.79 [0.62–1.00], P = 0.050 per 0.1-μmol/L increase) than in FF from oocytes of suboptimal development.

LIMITATIONS, REASONS FOR CAUTION

The individual contributions of diet, gut bacteria and liver to the metabolite pools have not been quantified in this analysis.

WIDER IMPLICATIONS OF THE FINDINGS

More research on the contribution of diet and the effect of gut bacteria on FF TMAO is warranted. Since TMAO integrates diet, microbiota and genetic setup of the person, our results indicate potential important clinical implications for its use as biomarker for lifestyle interventions to improve fertility.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was received for this project. The Department of Obstetrics and Gynecology of the University Medical Center Groningen received an unrestricted educational grant of Ferring Pharmaceutical BV, the Netherlands. The authors have no other conflicts of interest.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register number NTR4409.

Septum resection in women with a septate uterus: a cohort study

STUDY QUESTION

Does septum resection improve reproductive outcomes in women with a septate uterus?

SUMMARY ANSWER

In women with a septate uterus, septum resection does not increase live birth rate nor does it decrease the rates of pregnancy loss or preterm birth, compared with expectant management.

WHAT IS KNOWN ALREADY

The septate uterus is the most common uterine anomaly with an estimated prevalence of 0.2-2.3% in women of reproductive age, depending on the classification system. The definition of the septate uterus has been a long-lasting and ongoing subject of debate, and currently two classification systems are used worldwide. Women with a septate uterus may be at increased risk of subfertility, pregnancy loss, preterm birth and foetal malpresentation. Based on low quality evidence, current guidelines recommend removal of the intrauterine septum or, more cautiously, state that the procedure should be evaluated in future studies.

STUDY DESIGN, SIZE, DURATION

We performed an international multicentre cohort study in which we identified women mainly retrospectively by searching in electronic patient files, medical records and databases within the time frame of January 2000 until August 2018. Searching of the databases, files and records took place between January 2016 and July 2018. By doing so, we collected data on 257 women with a septate uterus in 21 centres in the Netherlands, USA and UK.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included women with a septate uterus, defined by the treating physician, according to the classification system at that time. The women were ascertained among those with a history of subfertility, pregnancy loss, preterm birth or foetal malpresentation or during a routine diagnostic procedure. Allocation to septum resection or expectant management was dependent on the reproductive history and severity of the disease. We excluded women who did not have a wish to conceive at time of diagnosis. The primary outcome was live birth. Secondary outcomes included pregnancy loss, preterm birth and foetal malpresentation. All conceptions during follow-up were registered but for the comparative analyses, only the first live birth or ongoing pregnancy was included. To evaluate differences in live birth and ongoing pregnancy, we used Cox proportional regression to calculate hazard rates (HRs) and 95% CI. To evaluate differences in pregnancy loss, preterm birth and foetal malpresentation, we used logistic regression to calculate odds ratios (OR) with corresponding 95% CI. We adjusted all reproductive outcomes for possible confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 257 women were included in the cohort. Of these, 151 women underwent a septum resection and 106 women had expectant management. The median follow-up time was 46 months. During this time, live birth occurred in 80 women following a septum resection (53.0%) compared to 76 women following expectant management (71.7%) (HR 0.71 95% CI 0.49-1.02) and ongoing pregnancy occurred in 89 women who underwent septum resection (58.9%), compared to 80 women who had expectant management (75.5%) (HR 0.74 (95% CI 0.52-1.06)). Pregnancy loss occurred in 51 women who underwent septum resection (46.8%) versus 31 women who had expectant management (34.4%) (OR 1.58 (0.81-3.09)), while preterm birth occurred in 26 women who underwent septum resection (29.2%) versus 13 women who had expectant management (16.7%) (OR 1.26 (95% CI 0.52-3.04)) and foetal malpresentation occurred in 17 women who underwent septum resection (19.1%) versus 27 women who had expectant management (34.6%) (OR 0.56 (95% CI 0.24-1.33)).

LIMITATIONS, REASONS FOR CAUTION

Our retrospective study has a less robust design compared with a randomized controlled trial. Over the years, the ideas about the definition of the septate uterus has changed, but since the 257 women with a septate uterus included in this study had been diagnosed by their treating physician according to the leading classification system at that time, the data of this study reflect the daily practice of recent decades. Despite correcting for the most relevant patient characteristics, our estimates might not be free of residual confounding.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest that septum resection, a procedure that is widely offered and associated with financial costs for society, healthcare systems or individuals, does not lead to improved reproductive outcomes compared to expectant management for women with a septate uterus. The results of this study need to be confirmed in randomized clinical trials.

STUDY FUNDING/COMPETING INTEREST(S)

A travel for JFWR to Chicago was supported by the Jo Kolk Studyfund. Otherwise, no specific funding was received for this study. The Department of Obstetrics and Gynaecology, University Medical Centre, Groningen, received an unrestricted educational grant from Ferring Pharmaceutical Company unrelated to the present study. BWM reports grants from NHMRC, personal fees from ObsEva, personal fees from Merck, personal fees from Guerbet, other payment from Guerbet and grants from Merck, outside the submitted work. The other authors declare no conficts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Preconception lifestyle intervention reduces long term energy intake in women with obesity and infertility: a randomised controlled trial

Background

The preconceptional period may be an optimal window of opportunity to improve lifestyle. We previously showed that a 6 month preconception lifestyle intervention among women with obesity and infertility was successful in decreasing the intake of high caloric snacks and beverages, increasing physical activity and in reducing weight in the short term. We now report the effects of the preconception lifestyle intervention on diet, physical activity and body mass index (BMI) at 5.5 years (range = 3.7–7.0 years) after the intervention.

Methods

We followed women who participated in the LIFEstyle study, a multicentre RCT in which women with obesity and infertility were assigned to a six-month lifestyle intervention program or prompt infertility treatment (N = 577). Diet and physical activity 5.5 years later were assessed with an 173-item food frequency questionnaire (N = 175) and Actigraph triaxial accelerometers (N = 155), respectively. BMI was calculated from self-reported weight and previously measured height (N = 179). Dietary intake, physical activity, and BMI in the intervention and control group were compared using multivariate regression models. Additionally, dietary intake, physical activity and BMI of women allocated to the intervention arm with successful weight loss during the intervention (i.e. BMI < 29 kg/m² or ≥ 5% weight loss), unsuccessful weight loss and the control group were compared with ANCOVA.

Results

Although BMI did not differ between the intervention and control group 5.5 years after the intervention (− 0.5 kg/m² [− 2.0;1.1]; P = 0.56), the intervention group did report a lower energy intake (− 216 kcal/day [− 417;-16]; P = 0.04). Women in the intervention arm who successfully lost weight during the intervention had a significantly lower BMI at follow-up compared to women in the intervention arm who did not lose weight successfully (− 3.4 kg/m² [− 6.3;-0.6]; P = 0.01), and they reported a significantly lower energy intake compared to the control group (− 301 kcal [− 589;-14]; P = 0.04). Macronutrient intake, diet quality, and physical activity did not differ between the intervention and control group, irrespective of successful weight loss during the intervention.

Conclusions

In our study population, a preconception lifestyle intervention led to reduced energy intake 5.5 years later. Additionally, women allocated to the intervention group who were successful in losing weight during the intervention also had a lower BMI at follow-up. This shows the potential sustainable effect of a preconception lifestyle intervention.

Trial registration

This trial was registered on 16 November 2008 in the Dutch trial register; clinical trial registry number NTR1530.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0761-6) contains supplementary material, which is available to authorized users.

A systematic review and meta-analysis of lifestyle interventions in women of reproductive age with overweight or obesity: the effects on symptoms of depression and anxiety

Obesity is a rising problem, especially among women of reproductive age. Overweight and obesity reduce both physical and mental health. Lifestyle interventions could have beneficial effects on both, but an overview of the effects on mental health, especially in women of reproductive age, is currently lacking. Therefore, the aim of this review was to assess the effect of lifestyle interventions on symptoms of depression and anxiety in women of reproductive age with overweight or obesity. The databases MEDLINE, EMBASE and PsycINFO were searched from inception to June 2018 for published randomized controlled trials (RCTs). We included lifestyle intervention RCTs in women of reproductive age with overweight or obesity that assessed effects on symptoms of depression and/or anxiety. The difference between baseline and post-intervention scores on symptoms of depression and anxiety for the intervention and control group was analysed. Meta-analysis was performed with a random effects model. The search resulted in 5,316 citations, and after screening five RCTs were included, in which 571 women were randomized. The effect of lifestyle interventions on depression scores was investigated among 224 women from five RCTs. The pooled estimate for the mean difference was -1.35 (95% CI, -2.36 to -0.35, p = 0.008). The effect of lifestyle interventions on anxiety levels was studied among 148 women from four RCTs, resulting in a pooled estimate of -1.74 (-2.62 to -0.87, p < 0.001). Based on five RCTs, meta-analyses showed that lifestyle interventions in women of reproductive age with overweight or obesity consistently reduce symptoms of depression and anxiety.

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).

A randomized controlled, non-inferiority trial of modified natural versus artificial cycle for cryo-thawed embryo transfer

STUDY QUESTION

Are live birth rates (LBRs) after artificial cycle frozen-thawed embryo transfer (AC-FET) non-inferior to LBRs after modified natural cycle frozen-thawed embryo transfer (mNC-FET)?

SUMMARY ANSWER

AC-FET is non-inferior to mNC-FET with regard to LBRs, clinical and ongoing pregnancy rates (OPRs) but AC-FET does result in higher cancellation rates.

WHAT IS ALREADY KNOWN

Pooling prior retrospective studies of AC-FET and mNC-FET results in comparable pregnancy and LBRs. However, these results have not yet been confirmed by a prospective randomized trial.

STUDY DESIGN, SIZE AND DURATION

In this non-inferiority prospective randomized controlled trial (acronym 'ANTARCTICA' trial), conducted from February 2009 to April 2014, 1032 patients were included of which 959 were available for analysis. The primary outcome of the study was live birth. Secondary outcomes were clinical and ongoing pregnancy, cycle cancellation and endometrium thickness. A cost-efficiency analysis was performed.

PARTICIPANT/MATERIALS, SETTING, METHODS

This study was conducted in both secondary and tertiary fertility centres in the Netherlands. Patients included in this study had to be 18-40 years old, had to have a regular menstruation cycle between 26 and 35 days and frozen-thawed embryos to be transferred had to derive from one of the first three IVF or IVF-ICSI treatment cycles. Patients with a uterine anomaly, a contraindication for one of the prescribed medications in this study or patients undergoing a donor gamete procedure were excluded from participation. Patients were randomized based on a 1:1 allocation to either one cycle of mNC-FET or AC-FET. All embryos were cryopreserved using a slow-freeze technique.

MAIN RESULTS AND THE ROLE OF CHANCE

LBR after mNC-FET was 11.5% (57/495) versus 8.8% in AC-FET (41/464) resulting in an absolute difference in LBR of -0.027 in favour of mNC-FET (95% confidence interval (CI) -0.065-0.012; P = 0.171). Clinical pregnancy occurred in 94/495 (19.0%) patients in mNC-FET versus 75/464 (16.0%) patients in AC-FET (odds ratio (OR) 0.8, 95% CI 0.6-1.1, P = 0.25). 57/495 (11.5%) mNC-FET resulted in ongoing pregnancy versus 45/464 (9.6%) AC-FET (OR 0.7, 95% CI 0.5-1.1, P = 0.15). χ(2) test confirmed the lack of superiority. Significantly more cycles were cancelled in AC-FET (124/464 versus 101/495, OR 1.4, 95% CI 1.1-1.9, P = 0.02). The costs of each of the endometrial preparation methods were comparable (€617.50 per cycle in NC-FET versus €625.73 per cycle in AC-FET, P = 0.54).

LIMITATIONS, REASONS FOR CAUTION

The minimum of 1150 patients required for adequate statistical power was not achieved. Moreover, LBRs were lower than anticipated in the sample size calculation.

WIDER IMPLICATIONS OF THE FINDINGS

LBRs after AC-FET were not inferior to those achieved by mNC-FET. No significant differences in clinical and OPR were observed. The costs of both treatment approaches were comparable.

STUDY FUNDING/COMPETING INTERESTS

An educational grant was received during the conduct of this study. Merck Sharpe Dohme had no influence on the design, execution and analyses of this study. E.R.G. received an education grant by Merck Sharpe Dohme (MSD) during the conduct of the present study. B.J.C. reports grants from MSD during the conduct of the study. A.H. reports grants from MSD and Ferring BV the Netherlands and personal fees from MSD. Grants from ZonMW, the Dutch Organization for Health Research and Development. J.S.E.L. reports grants from Ferring, MSD, Organon, Merck Serono and Schering-Plough during the conduct of the study. F.J.M.B. receives monetary compensation as member of the external advisory board for Merck Serono, consultancy work for Gedeon Richter, educational activities for Ferring BV, research cooperation with Ansh Labs and a strategic cooperation with Roche on automated anti Mullerian hormone assay development. N.S.M. reports receiving monetary compensations for external advisory and speaking work for Ferring BV, MSD, Anecova and Merck Serono during the conduct of the study. All reported competing interests are outside the submitted work. No other relationships or activities that could appear to have influenced the submitted work.

TRIAL REGISTRATION NUMBER

Netherlands trial register, number NTR 1586.

TRIAL REGISTRATION DATE

13 January 2009.

FIRST PATIENT INCLUDED

20 April 2009.

Presence of bile acids in human follicular fluid and their relation with embryo development in modified natural cycle IVF

STUDY QUESTION

Are bile acids (BA) and their respective subspecies present in human follicular fluid (FF) and do they relate to embryo quality in modified natural cycle IVF (MNC-IVF)?

SUMMARY ANSWER

BA concentrations are 2-fold higher in follicular fluid than in serum and ursodeoxycholic acid (UDCA) derivatives were associated with development of top quality embryos on Day 3 after fertilization.

WHAT IS KNOWN ALREADY

Granulosa cells are capable of synthesizing BA, but a potential correlation with oocyte and embryo quality as well as information on the presence and role of BA subspecies in follicular fluid have yet to be investigated.

STUDY DESIGN, SIZE, DURATION

Between January 2001 and June 2004, follicular fluid and serum samples were collected from 303 patients treated in a single academic centre that was involved in a multicentre cohort study on the effectiveness of MNC-IVF.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Material from patients who underwent a first cycle of MNC-IVF was used. Serum was not stored from all patients, and the available material comprised 156 follicular fluid and 116 matching serum samples. Total BA and BA subspecies were measured in follicular fluid and in matching serum by enzymatic fluorimetric assay and liquid chromatography-mass spectrometry, respectively. The association of BA in follicular fluid with oocyte and embryo quality parameters, such as fertilization rate and cell number, presence of multinucleated blastomeres and percentage of fragmentation on Day 3, was analysed.

MAIN RESULTS AND THE ROLE OF CHANCE

Embryos with eight cells on Day 3 after oocyte retrieval were more likely to originate from follicles with a higher level of UDCA derivatives than those with fewer than eight cells (P < 0.05). Furthermore, follicular fluid levels of chenodeoxycholic derivatives were higher and deoxycholic derivatives were lower in the group of embryos with fragmentation compared with those without (each P < 0.05). Levels of total BA were 2-fold higher in follicular fluid compared with serum (P < 0.001), but had no predictive value for oocyte and embryo quality.

LIMITATIONS, REASONS FOR CAUTION

Only samples originating from first cycle MNC-IVF were used, which resulted in 14 samples only from women with an ongoing pregnancy, therefore further prospective studies are required to confirm the association of UDCA with IVF pregnancy outcomes. The inter-cycle variability of BA levels in follicular fluid within individuals has yet to be investigated. We checked for macroscopic signs of contamination of follicular fluid by blood but the possibility that small traces of blood were present within the follicular fluid remains. Finally, although BA are considered stable when stored at -20°C, there was a time lag of 10 years between the collection and analysis of follicular fluid and serum samples.

WIDER IMPLICATIONS OF THE FINDINGS

The favourable relation between UDCA derivatives in follicular fluid and good embryo development and quality deserves further prospective research, with live birth rates as the end-point.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by a grant from the Netherlands Organisation for Scientific Research (VIDI Grant 917-56-358 to U.J.F.T.). No competing interests are reported.

Follicle pool, ovarian surgery and the risk for a subsequent trisomic pregnancy

STUDY QUESTION

Is there an association between trisomic pregnancy, a marker for decreased oocyte quality, and the reduced oocyte quantity that follows ovarian surgery?

SUMMARY ANSWER

Previous ovarian surgery is not associated with an increased risk for a subsequent trisomic pregnancy.

WHAT IS KNOWN ALREADY

Ovarian surgery diminishes the number of oocytes. The risk for a trisomic pregnancy is suggested to be higher in women with fewer oocytes, independent of their chronological age.

STUDY DESIGN, SIZE, DURATION

This is a matched case-control study. Cases are women with a confirmed trisomic pregnancy occurring between 1 January 2000 and 31 December 2010 regardless of pregnancy outcome and controls are women that had a live born child without a trisomy. In total, there were 8573 participants in the study; 1723 cases and 6850 controls.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data were obtained from Danish medical registries. Matching criteria were maternal age and year of conception. Number of controls matched per case ranged from one to four. Among cases and controls with a trisomic pregnancy, 2.7% (46/1723) versus 2.5% (172/6850) had undergone ovarian surgery before pregnancy.

MAIN RESULTS AND ROLE OF CHANCE

History of ovarian surgery is not associated with a higher risk for a subsequent trisomic pregnancy (odds ratio = 1.00, 95% confidence interval 0.99-1.01). Subgroup analyses by indication of surgery and interval between ovarian surgery and pregnancy do not show an effect on trisomic pregnancy risk.

LIMITATIONS, REASONS FOR CAUTION

The medical registries used to select cases and controls did not contain information on surgical technique nor volume of ovarian tissue resected, previous trisomic pregnancy prior to the ovarian surgery or long-term use of oral contraceptives. Therefore, correction for these factors was not performed.

WIDER IMPLICATIONS OF THE FINDINGS

We did not confirm the hypothesis that ovarian surgery, a marker for decreased oocyte quantity, is related to trisomic pregnancy, a marker for decreased oocyte quality. This suggests that ovarian surgery, which has a direct reductive effect on the size of the follicle pool, may affect oocyte quality differently when compared with the reduction in follicle pool size due to ageing.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by grants from the Gratama Stichting, University of Groningen and the University Medical Center Groningen, The Netherlands. Ø.L. has within the last 3 years received honoraria for speeches in pharmacoepidemiological issues, not related to this study. The Department of Obstetrics and Gynaecology receives unrestricted educational grants from Ferring Pharmaceuticals. A.H. received a grant from ZonMW (i.e. National Dutch Scientific funding) for a RCT not related to this publication. Dr A.H. received speakers fee from MSD for an educational presentation. All other authors have no conflict of interest.

Prevention of multiple pregnancies in couples with unexplained or mild male subfertility: randomised controlled trial of in vitro fertilisation with single embryo transfer or in vitro fertilisation in modified natural cycle compared with intrauterine insemination with controlled ovarian hyperstimulation

OBJECTIVES

To compare the effectiveness of in vitro fertilisation with single embryo transfer or in vitro fertilisation in a modified natural cycle with that of intrauterine insemination with controlled ovarian hyperstimulation in terms of a healthy child.

DESIGN

Multicentre, open label, three arm, parallel group, randomised controlled non-inferiority trial.

SETTING

17 centres in the Netherlands.

PARTICIPANTS

Couples seeking fertility treatment after at least 12 months of unprotected intercourse, with the female partner aged between 18 and 38 years, an unfavourable prognosis for natural conception, and a diagnosis of unexplained or mild male subfertility.

INTERVENTIONS

Three cycles of in vitro fertilisation with single embryo transfer (plus subsequent cryocycles), six cycles of in vitro fertilisation in a modified natural cycle, or six cycles of intrauterine insemination with ovarian hyperstimulation within 12 months after randomisation.

MAIN OUTCOME MEASURES

The primary outcome was birth of a healthy child resulting from a singleton pregnancy conceived within 12 months after randomisation. Secondary outcomes were live birth, clinical pregnancy, ongoing pregnancy, multiple pregnancy, time to pregnancy, complications of pregnancy, and neonatal morbidity and mortality

RESULTS

602 couples were randomly assigned between January 2009 and February 2012; 201 were allocated to in vitro fertilisation with single embryo transfer, 194 to in vitro fertilisation in a modified natural cycle, and 207 to intrauterine insemination with controlled ovarian hyperstimulation. Birth of a healthy child occurred in 104 (52%) couples in the in vitro fertilisation with single embryo transfer group, 83 (43%) in the in vitro fertilisation in a modified natural cycle group, and 97 (47%) in the intrauterine insemination with controlled ovarian hyperstimulation group. This corresponds to a risk, relative to intrauterine insemination with ovarian hyperstimulation, of 1.10 (95% confidence interval 0.91 to 1.34) for in vitro fertilisation with single embryo transfer and 0.91 (0.73 to 1.14) for in vitro fertilisation in a modified natural cycle. These 95% confidence intervals do not extend below the predefined threshold of 0.69 for inferiority. Multiple pregnancy rates per ongoing pregnancy were 6% (7/121) after in vitro fertilisation with single embryo transfer, 5% (5/102) after in vitro fertilisation in a modified natural cycle, and 7% (8/119) after intrauterine insemination with ovarian hyperstimulation (one sided P=0.52 for in vitro fertilisation with single embryo transfer compared with intrauterine insemination with ovarian hyperstimulation; one sided P=0.33 for in vitro fertilisation in a modified natural cycle compared with intrauterine insemination with controlled ovarian hyperstimulation).

CONCLUSIONS

In vitro fertilisation with single embryo transfer and in vitro fertilisation in a modified natural cycle were non-inferior to intrauterine insemination with controlled ovarian hyperstimulation in terms of the birth of a healthy child and showed comparable, low multiple pregnancy rates.Trial registration Current Controlled Trials ISRCTN52843371; Nederlands Trial Register NTR939.

Overtreatment in couples with unexplained infertility

STUDY QUESTION

What is the percentage of overtreatment, i.e. fertility treatment started too early, in couples with unexplained infertility who were eligible for tailored expectant management?

SUMMARY ANSWER

Overtreatment occurred in 36% of couples with unexplained infertility who were eligible for an expectant management of at least 6 months.

WHAT IS KNOWN ALREADY

Prognostic models in reproductive medicine can help to identify infertile couples that would benefit from fertility treatment. In couples with unexplained infertility with a good chance of natural conception within 1 year, based on the Hunault prediction model, an expectant management of 6-12 months, as recommended in international fertility guidelines, prevents unnecessary treatment.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study in 25 participating clinics, with follow-up of all couples who were seen for infertility in 2011-2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all, 9818 couples were seen for infertility in the participating clinics. Couples were eligible to participate if they were diagnosed with unexplained infertility and had a good prognosis of natural conception (>30%) within 1 year based on the Hunault prediction model. Data to assess overtreatment were collected from medical records. Multilevel regression analyses were performed to investigate associations of overtreatment with patient and clinic characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

Five hundred and forty-four couples eligible for expectant management were included in this study. Among these, overtreatment, i.e. starting medically assisted reproduction within 6 months, occurred in 36%. The underlying quality indicators showed that in 34% no prognosis was calculated and that in 42% expectant management was not recommended. Finally, 16% of the couples for whom a correct recommendation of expectant management for at least 6 months was made, started treatment within 6 months anyway. Overtreatment was associated with childlessness, higher female age and a longer duration of infertility. No associations between overtreatment and clinic characteristics were found.

LIMITATIONS, REASONS FOR CAUTION

The response rate was low compared with other fertility studies. Evaluation of possible selection bias showed that responders had a higher socio-economic status than non-responders.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings show that developing and publishing guideline recommendations on tailored expectant management (TEM) is not enough and that overtreatment still occurs frequently. Future research should focus on tailored efforts to implement guideline recommendations on TEM.

STUDY FUNDING/COMPETING INTERESTS

Supported by Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none.

TRIAL REGISTRATION NUMBER

www.trialregister.nl NTR3405.

Effectiveness of indometacin to prevent ovulation in modified natural-cycle IVF: a randomized controlled trial

Modified natural-cycle IVF has a lower pregnancy rate per started cycle as compared with IVF with ovarian stimulation due to, for example, premature ovulation. Indometacin administered before ovulation prevents follicle rupture. Therefore, addition of indometacin may improve the effectiveness of modified natural-cycle IVF. This double-blind, randomized, placebo-controlled trial with indometacin or placebo in 120 women aged 27-36 years compared the number of patients without premature ovulation as compared with the number of patients with one or more ovulations in a maximum of six cycles. Indometacin had no significant influence on the probability of a premature ovulation in patients during the six cycles (OR 2.38, 95% CI 0.94-6.04). A subgroup analysis showed a significant influence of indometacin in decreasing the probability of a premature ovulation in cycles without LH surge at the day of human chorionic gonadotrophin administration (OR 8.29, 95% CI 1.63-42.3, P=0.009). Although this study could not detect a significantly lower ovulation rate in the indometacin group versus the placebo group, the data suggest that a subgroup of patients without LH surge prior to oocyte retrieval might benefit from indometacin in modified natural-cycle IVF.

Factors associated with dizygotic twinning after IVF treatment with double embryo transfer

BACKGROUND

Dizygotic twin pregnancies after IVF treatment are the result of multiple embryos transferred into the uterine cavity, followed by successful double implantation. Factors that increase the chance of multiple implantation after IVF are relatively unknown. The present study aimed to investigate whether features of body composition, such as maternal height, weight and body mass index (BMI) are associated with an increased chance of dizygotic twinning after IVF with double embryo transfer (DET).

METHODS

This study was conducted using data from a large Dutch nationwide cohort that comprised 19 861 women who had IVF or ICSI treatment between 1983 and 1995 (OMEGA study). First 'fresh' IVF and ICSI cycles with DET resulting in a delivery of a singleton or twin (living as well as stillborn) were selected. A multivariable logistic regression analysis was performed, with the delivery of a singleton or twin as the dependent variable and height, weight, BMI, maternal age, number of retrieved oocytes, use of alcohol, smoking, highest level of education and parity as independent variables.

RESULTS

Of the 6598 women who completed their first IVF or ICSI cycle, 2375 had DET, resulting in 496 deliveries of 371 singletons and 125 twins. Multivariable regression analysis revealed that tall women (>1.74 cm) and women with a high number of retrieved oocytes (>8) had an increased chance of dizygotic twinning [OR: 1.8 (95% CI: 1.0-3.4) and OR: 2.2 (95% CI: 1.3-3.8), respectively].

CONCLUSIONS

Our data demonstrate that tall stature and increased number of retrieved oocytes independently increase the chance of dizygotic twinning after IVF with DET.

The influence of maternal and paternal factors on time to pregnancy--a Dutch population-based birth-cohort study: the GECKO Drenthe study

BACKGROUND

Both maternal and paternal factors have been suggested to influence a couple's fecundity. To investigate this, we examined the role of several maternal and paternal lifestyle and socio-demographic factors as determinants of time to pregnancy (TTP) in a Dutch birth-cohort.

METHODS

Groningen Expert Center for Kids with Obesity (GECKO) Drenthe is a population-based birth-cohort study of children born between April 2006 and April 2007 in Drenthe, a province of The Netherlands. Both partners received extensive questionnaires during pregnancy. Univariable and multivariable Cox regression analyses were used to determine the impact of the investigated factors on TTP.

RESULTS

A total of 4778 children were born, and the parents of 2997 children (63%) gave their consent to participate. After excluding unintended pregnancies and pregnancies as a result of fertility treatment, the data of 1924 couples were available for analysis. Hazards ratios and 95% confidence intervals of factors influencing TTP in multivariable Cox regression analysis were: maternal age 1.23 (0.98-1.54) for age <25 years, 1.17 (1.03-1.32) for age 25-30 years and 0.72 (0.61-0.85) for age >35 years (reference category: 30-35 years); paternal age: 1.31 (0.94-1.82) for age <25 years, 1.11 (0.97-1.28) for age 25-30 years and 0.91 (0.80-1.04 for age >35 years (reference category: 30-35 years); nulliparity: 0.76 (0.68-0.85) versus multiparity; menstrual cycle length: 1.12 (0.95-1.30) for 3 weeks, 0.72 (0.62-0.83) for 4-6 weeks, 0.68 (0.40-1.16) for >6 weeks and 0.66 (0.54-0.81) for irregular cycle (reference category: 4 weeks); prior contraceptive use: 0.78 (0.67-0.91) for no contraception, 1.68 (1.45-1.95) for condom use, 1.08 (0.89-1.33) for condom use combined with oral contraception, 1.40 (1.16-1.70) for intrauterine device and 0.50 (0.25-1.01) for contraceptive injection (reference category: oral contraception); and maternal educational level 0.75 (0.62-0.92) for low education level and 0.81 (0.73-0.90) for medium educational level (reference category: high educational level).

CONCLUSIONS

This population-based birth-cohort study performed in fertile couples who had conceived revealed neither maternal nor paternal modifiable lifestyle factors were significantly associated with TTP after adjustment for confounding by socio-demographic factors. In contrast, several non-modifiable maternal socio-demographic factors are significant predictors of a couple's fecundity.

Complications and outcome of assisted reproduction technologies in overweight and obese women

BACKGROUND

Based on a presumed negative impact of overweight and obesity on reproductive capacity and pregnancy outcome, some national guidelines and clinicians have argued that there should be an upper limit for a woman's BMI to access assisted reproductive technologies (ART). However, evidence on the risk of complications or expected success rate of ART in obese women is scarce. We therefore performed a systematic review on the subject.

METHODS

We searched the literature for studies reporting on complications or success rates in overweight and obese women undergoing ART. Articles were scored on methodological quality. We calculated pooled odds ratios (ORs) to express the association between overweight and obesity on the one hand, and complications and success rates of ART on the other hand. We only pooled results if data were available per woman instead of per cycle or embryo transfer.

RESULTS

We detected 14 studies that reported on the association between overweight and complications during or after ART, of which 6 reported on ovarian hyperstimulation syndrome (OHSS), 7 on multiple pregnancies and 6 on ectopic pregnancies. None of the individual studies found a positive association between overweight and ART complications. The pooled ORs for overweight versus normal weight for OHSS, multiple pregnancy and ectopic pregnancy were 1.0 [95% confidence interval (CI) 0.77-1.3], 0.97 (95% CI 0.91-1.04) and 0.96 (95% CI 0.54-1.7), respectively. In 27 studies that reported on BMI and the success of ART, the pooled ORs for overweight versus normal weight on live birth, ongoing and clinical pregnancy following ART were OR 0.90 (95% CI 0.82-1.0), 1.01 (95% CI 0.75-1.4) and OR 0.94 (95% CI 0.69-1.3), respectively.

CONCLUSIONS

Data on complications following ART are scarce and therefore a registration system should be implemented in order to gain more insight into this subject. In the available literature, there is no evidence of overweight or obesity increasing the risk of complications following ART. Furthermore, they only marginally reduce the success rates. Based on the currently available data, overweight and obesity in itself should not be a reason to withhold ART.

A rare cause of congenital adrenal hyperplasia: Antley-Bixler syndrome due to POR deficiency

Cytochrome P450 oxidoreductase (POR) deficiency is a recently discovered new variant of congenital adrenal hyperplasia. Distinctive features of POR deficiency are the presence of disorders of sexual development in both sexes, glucocorticoid deficiency and skeletal malformations similar to those observed in the Antley-Bixler syndrome.