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Objective The main objective of this study was to assess the prevalence of overweight and obesity among patients undergoing assisted reproductive technology (ART) in Latin America and its consequences on treatment outcomes. Methods We used the Latin American Registry of ART to obtain women's age and body mass index (BMI), cancellation rate, number of oocytes retrieved and embryos transferred, clinical pregnancy, live birth and miscarriage rates from 107.313 patients undergoing autologous IVF and ICSI during four years; a multivariable analysis was performed to determine the effect of BMI on cancellation, oocytes retrieved, pregnancy, live birth and miscarriage, adjusting for age, number of embryos transferred and embryo developmental stage upon embryo transfer, when appropriate. Results The prevalence of overweight and obesity was 16.1% and 42.4%, respectively; correcting for age of female partner, overweight and obesity were associated to an increase in the odds of cancellation and to a lower mean number of oocytes retrieved; after adjusting for age, number of embryos transferred and stage of embryo development at transfer, we found that the BMI category was not associated to a change in the likelihoods of pregnancy, live birth and miscarriage. Conclusions The prevalence of obesity among women seeking ART in Latin America is surprisingly high; however, BMI does not influence the outcome of ART performed in these women.
Received December 9, 2016
Accepted March 28, 2017
Original Article
Outcome of assisted reproductive technology in overweight and
obese women
Antonio MacKenna1,2, Juan Enrique Schwarze1,3, Javier A Crosby1,2, Fernando Zegers-Hochschild1,2,4
1Latin American Network of Assisted Reproduction
2Unit of Reproductive Medicine, Clinica Las Condes, Santiago, Chile
3Unit of Reproductive Medicine, Clinica Monteblanco, Santiago, Chile
4Program of Ethics and Public Policies in Human Reproduction, University Diego Portales, Santiago, Chile
Objective: The main objective of this study was to
assess the prevalence of overweight and obesity among
patients undergoing assisted reproductive technology
(ART) in Latin America and its consequences on treatment
Methods: We used the Latin American Registry of
ART to obtain women´s age and body mass index (BMI),
cancellation rate, number of oocytes retrieved and embryos
transferred, clinical pregnancy, live birth and miscarriage
rates from 107.313 patients undergoing autologous IVF
and ICSI during four years; a multivariable analysis was
performed to determine the eect of BMI on cancellation,
oocytes retrieved, pregnancy, live birth and miscarriage,
adjusting for age, number of embryos transferred and
embryo developmental stage upon embryo transfer, when
Results: The prevalence of overweight and obesity
was 16.1% and 42.4%, respectively; correcting for age
of female partner, overweight and obesity were associated
to an increase in the odds of cancellation and to a lower
mean number of oocytes retrieved; after adjusting for
age, number of embryos transferred and stage of embryo
development at transfer, we found that the BMI category
was not associated to a change in the likelihoods of
pregnancy, live birth and miscarriage.
Conclusions: The prevalence of obesity among women
seeking ART in Latin America is surprisingly high; however,
BMI does not inuence the outcome of ART performed in
these women.
Keywords: ART, BMI, obesity, clinical pregnancy, live
birth, miscarriage
JBRA Assisted Reproduction 2017;21(2):79-83
doi: 10.5935/1518-0557.20170020
The prevalence of overweight and obesity, dened
by World Health Organization (WHO) as a body mass
index (BMI) of 25-30kg/m2 and ≥30kg/m2 (WHO, 2004),
respectively, is increasing worldwide as an epidemic, and
has become a serious health problem. Rivera et al. (2014)
reported that nearly 30% of the Latin American population
is obese. If current trends continue, it is estimated that by
the year 2030 up to 80% of the Latin American and the
Caribbean adult population could be overweight or obese
(Kelly et al., 2008).
It has been demonstrated that the time required
to achieve a spontaneous pregnancy is longer in obese
women (Gesink Law et al., 2007) and the probability of
pregnancy is reduced by 5% per unit of BMI exceeding
29kg/m2 (van der Steeg et al., 2008). Jungheim & Moley
(2010) suggested that obesity in women increases the
risk of infertility by impairing ovulation, oocyte quality,
fertilization, embryo quality and implantation. Due to
the relationship between higher BMI and infertility, many
overweight and obese women must undergo treatment
by assisted reproductive technologies (ART). Luke et al.
(2011) reported that 23.4% of the women undergoing
ART in the United States of America (USA) during 2007
were overweight and 16.5% were obese, and Provost
et al. (2016) showed a similar prevalence of overweight
(22.9%) and obesity (17.8%) within patients needing ART
in USA from 2008 to 2010.
The available evidence about the eects of BMI on the
outcome of ART is conicting. It has been suggested that
obese patients require higher doses of gonadotropins, have
a lower response to ovarian stimulation, higher cancellation
rates, reduced number of oocytes retrieved, poorer oocyte
quality, lower fertilization rates, less number of mature
oocytes and poorer embryo quality (Pandey et al., 2010).
DeUgarte et al. (2010) also showed that women with a BMI
35kg/m2 have lower implantation, pregnancy and live
birth rates than women with BMI < 35kg/m2. Moreover,
Luke et al. (2011) found reduced pregnancy rates with
autologous but not with donor oocytes in obese women,
suggesting impaired oocytes and poor embryo quality.
A recent report based on data from the Society for
Assisted Reproductive Technology Registry (SART) showed
that the prevalence of overweight and obesity was 22.9%
and 17.8%, respectively, and pregnancy outcomes were
more favorable in women with normal BMI, and it worsens
as BMI increases (Provost et al., 2016).
There are no studies regarding the prevalence of
overweight and obesity among women undergoing ART
in Latin America and its consequences on treatment
outcomes. The main objective of this study was to obtain
this missing evidence.
Data was obtained from the Latin American Registry
of ART (RLA). The RLA collects information from centers
in fteen Latin American countries. Patients admitted for
autologous in vitro fertilization (IVF) and intra-cytoplasmic
sperm injection (ICSI) with fresh embryo transfer started
between January 1st, 2010 and December 31st, 2014, and
babies born up to September of 2015, were included in
this study.
As part of the accreditation process, all participating
institutions agreed to have their data registered and
published by the RLA (Zegers-Hochschild et al., 2016).
Data used for the current study were women´s ages,
weights and heights, cancellation rates, numbers of
oocytes retrieved, numbers of embryos transferred, clinical
pregnancy rates and live birth rates per initiated cycle,
and miscarriage rates (following RLA rules, there was no
missing information). We used the terminology published
by the International Committee Monitoring Assisted
Reproductive Technologies (ICMART) and the WHO 2009
glossary (Zegers-Hochschild et al., 2009).
Original Article
JBRA Assist. Reprod. | v.21 | no2| Apr-May-Jun/ 2017
BMI was calculated by dividing body mass (weight
in kilograms) by the square of body height in meters.
We stratied BMI in four categories, according to the
WHO classication (WHO, 2004): BMI 18.4kg/m2
(underweight), 18.5-24.9 kg/m2 (normal weight), BMI 25-
30kg/m2 (overweight) and BMI ≥ 30kg/m2 (obese).
The parametric data was described as means and
standard deviation, and non-parametric data by median
and ranges. To compare dierences in groups we used the
Chi square test and the Mann-Whitney-u test for categorical
and non-parametric variables, respectively.
We performed a multivariable analysis to determine the
eects of BMI on cancellation, number of oocytes retrieved,
pregnancy, live birth and miscarriage rates, adjusting
for age, number of embryos transferred and embryo
developmental stage upon embryo transfer (embryos at
cleavage stage or blastocysts), when appropriate. Results
from women with normal BMI were used as the reference
group. A p-value below 0.01 was considered statistically
We analyzed a total of 107.313 patients admitted
for autologous IVF and ICSI, who underwent ovulation
induction for ART in Latin America during the study period.
All patients with initiated cycles were included in the study,
therefore some of them were cancelled previous oocyte
retrieval, other cancelled because lack of fertilization
or embryo development and the vast majority of them
reached fresh embryo transfer, either of cleavage stage
embryos or blastocysts (no frozen embryo transfers were
included). Their mean age (±SD) was 36.4±4.6 years
old and their prevalence rates regarding overweight and
obesity were 16.1% and 42.4%, respectively.
Table 1 shows the women´s ages, cancellation
rates, numbers of oocytes and the numbers of embryos
transferred in each BMI category. No signicant dierence
was found in age and number of embryos transferred
between the categories. Clinical pregnancy rates and live
birth rates per initiated cycle and miscarriage rates in each
BMI category are shown on table 2. If no adjustments are
made for women´s ages, numbers of embryos transferred
and the stages of embryo development at transfer, the
pregnancy and live birth rates become statistically lower in
obese patients when compared with women having normal
BMIs. Miscarriage rates varied from 15.9% to 18.4%,
without dierences according to BMI category.
Table 3 shows the outcomes of the multivariable
analyses. Correcting for age of the female partner,
overweight and obesity were associated to an increase in
the likelihood of cancellation and to a lower mean number
of oocytes retrieved, when compared to those with normal
BMIs. On the other hand, after adjusting for confounding
variables such as age, number of embryos transferred and
stage of embryo development upon transfer, we found that
the BMI category was not associated with changes in the
likelihoods of pregnancy, live birth and miscarriage.
We found that the proportion of overweight and
obese women treated with ART in Latin America between
2010 and 2014 reached 16.1% and 42.4%, respectively.
Intentionally, we decided to assess results per women
with initiated cycles, because such analysis oers better
epidemiological information for healthcare providers who
must counsel their patients. Consequently, we found
that an increase in BMI was associated to an increase in
cancellation and a reduced number of retrieved oocytes,
but did not aect the odds of clinical pregnancy, live birth
and miscarriage.
The main strength of our study is the large number
of cases and the thoroughness of the RLA database that
allows adjustment for the most relevant confounding
variables. It also represents results from dierent centers
located in dierent countries, thus conferring external
validity. However, potential limitations of the current study
are that we did not consider the possible eect of the male
partner and polycystic ovary syndrome, more commonly
diagnosed among obese women, on ART outcomes;
although Provost et al. (2016) recently suggested that it is
the BMI itself, rather than the underlying pathologies, that
contributes to the outcomes.
The prevalence of obese patients among Latin American
women undergoing ART is surprisingly higher than in any
other report published so far. Indeed, in the other large
multicentric studies, undertaken in the USA, only 16.5%
and 17.8% of patients undergoing ART were obese (Luke
et al., 2011; Provost et al., 2016). This issue could be
explained because of the rapid epidemiological changes
in most developing countries over the last decades, with
a nutritional transition, which impacts on the quality of
food, resulting in a declining of malnutrition rates, but an
increase in overweight and obesity (Rivera et al., 2004),
due to a change in dietary intake and energy expenditure,
inuenced by demographic, environmental, economic,
psychosocial and cultural factors (Barria & Amigo,
2006). Sedentary behavior and highly caloric diets, with
an increase intake of processed foods containing large
amounts of rened sugars and saturated fats, have been
described as the main causes of obesity in Latin America
and other developing countries (Pearson et al., 2014;
Popkin et al., 2012).
The group of overweight and obese women in our study
had signicantly more cycles cancelled. They also had
signicantly less oocytes retrieved, if compared with women
with normal BMI, and correcting by age, although this is of
little clinical signicance. Cancellation rates were four-fold
higher in obese patients than in women with a BMI < 30kg/
m2; however, this was much lower than cancellation rates
reported by Provost et al. (2016). Pinborg et al. (2011) also
showed an increase in the likelihood of cycle cancellation,
after adjusting for age. Moreover, Pinborg et al. (2011)
and Zander-Fox et al. (2012) also reported a signicantly
lower number of oocytes retrieved in obese patients.
In our study, after adjusting for known confounding
factors (age, number of embryos transferred and stage
of embryo development upon transfer), overweight and
obesity were not associated with a decrease in the odds
of pregnancy and live birth or an increase in the odds of
miscarriage. Several studies have reported that women
with overweight and obesity undergoing ART have lower
pregnancy and/or live birth rates, when compared with
patients with normal BMI (Tamer Erel & Senturk, 2009;
Orvieto et al., 2009; Bellver et al., 2010; Rittenberg et al.,
2011; Singh et al., 2012; Chavarro et al., 2012; Provost
et al., 2016). Moreover, the meta-analysis performed by
Rittenberg et al. (2011) also showed increased miscarriage
rates in obese patients undergoing ART. On the other
hand, other authors have reported no changes in ART
outcomes within dierent BMI categories (Sathya et al.,
2010; Vilarino et al., 2011; Zander-Fox et al., 2012).
However, none of these studies adjusted results for
known confounding factors, i.e. woman´s age, number
of embryos transferred and stage of embryo development
upon transfer. If the results from the current study are
analyzed without considering these variables, it also shows
a signicant dierence between women with normal weight
and obese patients, but this dierence disappears when
a multivariable analysis is performed to adjust results for
confounding variables.
Women´s BMI and ART - MacKenna, A.
JBRA Assist. Reprod. | v.21 | no2| Apr-May-Jun/ 2017
BMI ≤18.4 18.5-24.9 25.0-29.9 ≥30.0
Nº cycles 1.436 43.130 17.247 45.500
Age (years) * 35.0±4.6 35.8±4.5 36.0±4.6 36.0±4.6 §
Cancellation rates (%) 2.14 2.08 (A) 2.51 5.7 (B)
Nº oocytes retrieved 9.1 (0-58) 8.9 (0-80) (C) 9.0 (0-70) 8.1 (0-73) (D)
Nº embryos transferred 2.1 (1-6) 2.1 (1-6) 2.1 (1-5) 2.1 (1-6) §
* Means±SD. (A) vs (B) p<0.0001; Per initiated cycle.(C) vs (D) p<0.0001; Medians (ranges). § NS.
Table 1. Age, cancellation rates, number of oocytes retrieved and number of embryos transferred in women undergoing
107.313 cycles of autologous FIV/ICSI, according to BMI
BMI ≤18.4 18.5-24.9 25.0-29.9 ≥30
Nº cycles 1.436 43.130 17.247 45.500
Pregnancy rates (%) * 25.83 25.52 (A) 26.53 23.27 (B)
Live birth rates (%) * 21.24 20.55 (C) 21.32 18.68 (D)
Miscarriage rates (%) 15.90 17.98 18.40 18.33
Table 2. Clinical pregnancy, live birth and miscarriage rates in women undergoing 107.313 cycles of autologous FIV/ICSI,
according to BMI
* Per initiated cycle; (A) vs (B) p<0.0001; NS.; (C) vs (D) p<0.0001.
Cancellation* Nº oocytes
retrieved Pregnancy Live birth Miscarriage
Underweight BMI
OR 1.00 (0.68 to
1.46) p=0.995
β -0.27 (-0.62 to
0.08) p=0.695
OR 1.03 (0.91 to
1.18) p=0.629
OR 1.04 (0.91 to
1.20) p=0.552
OR 0.94 (0.79 to
1.26) p=0.695
Overweight BMI
OR 1.18 (1.05 to
1.32 p=0.005
β 0.20 (0.08 to
0.31) p=0.001
OR 1.00 (0.96 to
1.05) p=0.811
OR 1.0 (0.95 to
1.05) p=0.927
OR 1.0 (0.92 to
1.10) p=0.881
Obesity BMI
OR 2.78 (2.58 to
3.01) p<0.0001
β -0.79 (-0.88 to
0.70) p<0.0001
OR 0.96 (0.93 to
1.00) p=0.025
OR 0.96 (0.93 to
0.99) p=0.039
OR 1.01 (0.95 to
1.09) p=0.693
* Results are adjusted for age and presented as odd ratios (95% condence interval) and p-value. † Results are adjusted
for age and presented as coecient β of medians (95% condence interval) and p-value. ‡ Results are adjusted for age,
number of embryos transferred and embryo stage at embryo transfer and presented as odd ratios (95% condence interval)
and p-value.
Table 3. Multivariable analysis adjusting for age, number of embryos transferred and stage of embryo development upon
transfer on predictors of ART outcome, according to abnormal BMI categories in women undergoing 107.313 cycles of
autologous FIV/ICSI
Some authors have used multivariable analyses to
adjust results for confounding variables: Sneed et al.
(2008) adjusted results for age and showed that BMI did not
have a major eect on ART outcome; Pinborg et al. (2011)
corrected results for age, social class, diagnosis and duration
of infertility, demonstrating that pregnancy and live birth
rates were signicantly lower in obese women undergoing
their rst ART cycle; Petersen et al. (2013) adjusted results
for age and smoking, reporting reduced live birth rates as
BMI increased; and Schliep et al. (2015) corrected results
for age and parity, showing no dierences in ART success
among dierent BMI categories. Moreover, Veleva et al.
(2008) adjusting results for age, diagnosis and history
of miscarriage, reported an increased risk of miscarriage
in women with overweight and obesity. However, none of
these authors adjusted results for woman´s age, number
of embryos transferred and stage of embryo development
upon transfer together, as we did in our study.
Furthermore, Luke et al. (2011), Provost et al. (2016)
and Moragianni et al. (2012) used multivariable analyses to
correct results for several confounding variables including
age, number of embryos transferred and day of embryo
transfer. The rst two authors used data from the SART
registry and showed that an increased BMI was associated
with signicantly greater odds of failure to achieve clinical
intrauterine pregnancy and live birth. Provost et al. (2016)
also reported signicantly higher miscarriage rates with
increasing BMI categories. Using data from a single center,
Moragianni et al. (2012) showed that the odds of clinical
pregnancy and live births were lower and the odds of
miscarriage were higher in women with BMI 30kg/m2.
These authors concluded that higher BMI is associated
with a signicant impairment on ART outcomes. We could
not reach the same conclusions, which may be due to a
possible role of ethnicity on ART results. All these studies
were performed in the USA and Luke et al. (2011), the
only author reporting ethnicity, had 6% of Hispanic women
among their subjects, against most Hispanic women in our
study, which was not registered, for demographic reasons,
but expected. In a recent systematic review, performed
by Humphries et al. (2016), the authors concluded that
there are signicant disparities in pregnancy and live
birth rates after ART by ethnicity; however, most available
studies are limited by sample size, selection bias (dierent
denitions of race and ethnicity), extensive missing data
and inadequate adjustment for confounding variables.
Original Article
JBRA Assist. Reprod. | v.21 | no2| Apr-May-Jun/ 2017
On the other hand, given the high prevalence of obesity
among women undergoing ART in Latin America, patients
have to be aware of the maternal and neonatal risks derived
from obesity and should be advised to lose weight before
undergoing ART. Recently, a large cohort study showed
that relative risks of gestational diabetes, preeclampsia,
fetal macrosomia, cesarean delivery, blood loss, neonatal
hypoglycemia and respiratory distress syndrome increase
as BMI increases over 25kg/m2 (Schuster et al., 2016).
Moreover, Koning et al. (2010) suggested that overweight
and obesity in ovulatory infertile women leads to a 44%
and 70% increase in costs due to pregnancy complications,
respectively. A recently published study by Kaye et al.
(2016) suggested how relevant it is to develop reasonable
standards of care for obese patients, to encourage them
to lose weight before undergoing fertility treatment, giving
priority to safety and overall health status, although
patient’s autonomy must be balanced with non-malecence
and the avoidance of interventions that may be unsafe
both immediately and in the long run.
In summary, we found that BMI does not inuence the
outcomes of ART performed in Latin American women,
nevertheless, considering maternal and neonatal risks,
overweight and obese patients should be advised to
lose weight before undergoing ART. Future studies are
needed to assess the role of ethnicity on ART results and
the underlying causes of trans-ethnical dierences on
outcomes between women having similar BMI.
Thanks to Carolina Musri, the RLA administrator, and
all members of centers reporting to RLA for their eorts,
which enabled this study.
The authors have no conict of interests to report.
Corresponding author:
Antonio MacKenna
Unit of Reproductive Medicine,
Clinica Las Condes
Santiago, Chile
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... Consistent with previous studies, infertility duration [19], method of insemination [18], bFSH [19], BMI [18,19,32], infertility type [19], number of oocytes retrieved [19], duration of Gn (days) [19], and age [18,19] were not found to be risk factors for EP, although one study [20] suggested that age and BMI could independently influence the occurrence of EP. However, unlike the findings of a previous study [19], the current study found a higher Gn dosage to be a protective factor against EP. ...
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Background The study investigated whether specific ultrasonographically observed endometrial features (including endometrium type and thickness) were linked to ectopic pregnancy after stimulated cycles with fresh embryo transfer. Method Of 6246 pregnancy cycles after fresh embryo transfer, 6076 resulted in intrauterine pregnancy and 170 in ectopic pregnancy. The primary outcome of the study was ectopic pregnancy, with the main variables being endometrium type and endometrial thickness. Univariate and subsequent multiple-stepwise logistic regression analyses were used to identify the risk factors of ectopic pregnancy. Results 1. Compared with patients with an endometrial thickness ≥ 8 mm, the adjusted odds ratio for those with an endometrial thickness < 8 mm was 3.368 (P < 0.001). The adjusted odds ratio for women with a type-C endometrium was 1.897 (P = 0.019) compared with non-type C. 2. A larger dose of gonadotropin used during controlled ovarian hyperstimulation was a protective factor against ectopic pregnancy (P = 0.008). 3. The GnRH antagonist protocol (P = 0.007) was a risk factor for ectopic pregnancy, compared with the use of GnRH agonists. Conclusion (1) An endometrial thickness < 8 mm coupled with a type C endometrium significantly increased the risk of ectopic pregnancy after fresh embryo transfer. (2) A thin endometrial thickness and a type C endometrium could be further related to an abnormal endometrial receptivity/peristaltic wave. (3) Patients at a high risk of ectopic pregnancy should therefore be given special attention, with early diagnosis during the peri-transplantation period may assist in the prevention of ectopic pregnancy.
... Luke et al. (11) additionally detail a decrease in fecundity, length of gestation, and LBR as BMI increased in patients undergoing IVF, compounded by increasing age and BMI. Although a few studies have not found an association between high BMI and IVF success (26,27), these appear to be outliers as confirmed by a recent meta-analysis on this subject (12). ...
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Objective To determine if an association exists between body mass index (BMI) and fecundity after intrauterine insemination (IUI). Design Retrospective cohort study. Setting Academic-based fertility clinic. Patient(s) Patients undergoing IUI July 2007 to May 2012. Intervention(s) None. Main Outcome Measure(s) Primary outcome: live-birth rate (LBR) per IUI cycle; secondary outcomes: positive pregnancy test and clinical pregnancy rates (CPRs). Result(s) A total of 1959 cycles were performed on 661 women (mean age, 31.9 ± 4.9 years). When examined by obesity class, LBR and CPR were similar for women with class I, II, and III obesity when compared with women with normal BMI. However, class III obese women (adjusted risk ratio [aRR], 1.70; 95% confidence interval [CI], 1.12–2.59) had increased pregnancy rates compared with normal BMI, but no differences in pregnancy rates were observed for women with class I or II obesity. In addition, pregnancy rates (aRR, 1.50; 95% CI, 1.12–2.02) and CPR (aRR, 1.51; 95% CI, 1.07–2.14) were higher in overweight women relative to normal BMI. Notably, among patients with ovulatory dysfunction, CPRs after IUI were reduced by 43% in obese women (aRR, 0.57; 95% CI, 0.37–1.07), whereas women without ovulatory dysfunction were twice as likely to achieve a clinical pregnancy when they were obese (aRR, 1.96; 95% CI, 1.19–3.24). The CIs for the obesity risk ratios in each stratum of ovulatory function exhibited no overlap, suggesting evidence of potential effect modification by ovulatory function. Conclusion(s) LBRs after IUI were similar across BMI subgroups. This is in contrast to research of in vitro fertilization treatments showing lower LBR with increasing BMI. However, obesity may adversely affect IUI CPR in those with ovulatory dysfunction in particular. The reason for this discrepancy is unclear and warrants further study.
... 6 Therefore, assisted reproductive technologies are more common among women with obesity and also a poorer outcome has been reported among these women. 7,8 Based on our hypothesis, the possible increased risk of multiple pregnancies might be caused by disorders in hormonal activity due to obesity. 9 In obese women, spontaneous multiple pregnancies are suggested to be related to the increased levels of follicle-stimulating hormone. ...
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Objective To investigate the effects of increased pre-pregnancy body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) on the risk of having spontaneous multiple pregnancies using a nationwide register-based study sample. Methods Data from the National Medical Birth Register (MBR) (2004–2018) were used to evaluate the effects of a higher pre-pregnancy BMI on the risk of multiple pregnancies. Lower and higher pre-pregnancy BMI classes, using the WHO classification, were compared with a normal weight class. A logistic regression model was used to assess the primary outcomes. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) between the groups were compared. The model was adjusted by maternal age, maternal height, and maternal smoking status. Results The odds of multiple pregnancies were higher among women in the overweight group (aOR 1.07, 95% CI 1.02–1.12), obesity class I group (aOR 1.11, 95% CI 1.04–1.18), and obesity class II group (aOR 1.15, 95% CI 1.03–1.28) compared with women in the non-overweight BMI class. Women in the underweight group had lower odds for multiple pregnancies (aOR 0.82, 95% CI 0.73–0.93). Conclusion The odds of multiple pregnancies slightly increase with pre-pregnancy obesity, and this should be acknowledged as a minor risk factor for multiple pregnancies.
... The association of BMI with pregnancy outcomes following ART and IUI have been previously studied with mixed results. While there is literature that demonstrates lower pregnancy and live birth rates among obese patients following IVF cycles [22][23][24][25], other studies have suggested that BMI does not affect pregnancy outcomes [26][27][28]. Most of this research was conducted using analysis of non-donor sperm cycles, and our study contributes further data on the impact of BMI on fertility treatment outcomes in the context of donor sperm cycles. ...
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PurposeTo report fertility treatment use and outcomes among patients who use donor sperm for intrauterine insemination (IUI), in vitro fertilization (IVF), and reciprocal IVF (co-IVF).Methods This is a retrospective review of patients who used donor sperm at an urban, southeastern academic reproductive center between 2014 and 2020.ResultsAmong the 374 patients presenting for care, 88 (23.5%) were single, 188 (50.3%) were in a same-sex female partnership, and 98 (26.2%) had a male partner with a diagnosis of male factor infertility. Most patients did not have infertility (73.2%). A total of 1106 cycles were completed, of which there were 931 IUI cycles, 146 traditional IVF cycles, and 31 co-IVF cycles. Live birth rates per cycle were 11% in IUI, 42% in IVF, and 61% in co-IVF. Of all resulting pregnancies, hypertensive disorders were most commonly experienced (18.0%), followed by preterm delivery (15.3%), neonatal complications (9.5%), gestational diabetes (4.8%), and fetal growth restriction (4.8%). Of the 198 infants born, fifteen (8.3%) required admission to the neonatal intensive care unit and three (1.7%) demised. Pregnancy and neonatal complications were more likely to occur in older patients and patients with elevated body mass index.Conclusion The use of donor sperm for fertility treatment is increasing. These data show reassuring live birth rates; however, they also highlight the risks of subsequent pregnancy complications. With the expansion of fertility treatment options for patients, these data assist provider counseling of patients regarding anticipated cycle success rates and possible pregnancy complications.
... In reproductively older women (i.e., ~35 to 44 years old but premenopausal) or those deemed "nonresponders," the ovaries produce few oocytes even when the presence of healthy follicles is predicted by anti-Mullerian hormone levels and high doses of gonadotropins are given (61)(62)(63). Similarly, obese women have high rates of IVF cycle cancellation due to failed follicle growth responses to hormones (64,65). Our preclinical studies indicate that improving mitochondrial bioenergetics and reducing collagen deposition within the underlying ovarian stroma will be beneficial toward facilitating follicle growth and maturation in women seeking pregnancy. ...
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The female ovary contains a finite number of oocytes, and their release at ovulation becomes sporadic and disordered with aging and with obesity, leading to loss of fertility. Understanding the molecular defects underpinning this pathology is essential as age of childbearing and obesity rates increase globally. We identify that fibrosis within the ovarian stromal compartment is an underlying mechanism responsible for impaired oocyte release, which is initiated by mitochondrial dysfunction leading to diminished bioenergetics, oxidative damage, inflammation, and collagen deposition. Furthermore, antifibrosis drugs (pirfenidone and BGP-15) eliminate fibrotic collagen and restore ovulation in reproductively old and obese mice, in association with dampened M2 macrophage polarization and up-regulated MMP13 protease. This is the first evidence that ovarian fibrosis is reversible and indicates that drugs targeting mitochondrial metabolism may be a viable therapeutic strategy for women with metabolic disorders or advancing age to maintain ovarian function and extend fertility.
... A large study using the Latin American Registry of ART investigated the effect of obesity on pregnancy outcomes in more than 107,000 patients undergoing autologous IVF/ICSI treatments. It noted that BMI was not associated with the percentage of pregnancy, live birth and miscarriage (MacKenna et al., 2017). Similar findings were described in a systematic review published by Jungheim and co-workers, indicating that obesity has no adverse effect on IVF outcomes in patients undergoing oocyte-donation programmes (Jungheim et al., 2010). ...
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Increasing evidence has demonstrated that obesity impairs female fertility and negatively affects human reproductive outcome following medically assisted reproduction (MAR) treatment. In the United States, 36.5% of women of reproductive age are obese. Obesity results not only in metabolic disorders including type II diabetes and cardiovascular disease, but might also be responsible for chronic inflammation and oxidative stress. Several studies have demonstrated that inflammation and reactive oxygen species (ROS) in the ovary modify steroidogenesis and might induce anovulation, as well as affecting oocyte meiotic maturation, leading to impaired oocyte quality and embryo developmental competence. Although the adverse effect of female obesity on human reproduction has been an object of debate in the past, there is growing evidence showing a link between female obesity and increased risk of infertility. However, further studies need to clarify some gaps in knowledge. We reviewed the recent evidence on the association between female obesity and infertility. In particular, we highlight the association between fat distribution and reproductive outcome, and how the inflammation and oxidative stress mechanisms might reduce ovarian function and oocyte quality. Finally, we evaluate the connection between female obesity and endometrial receptivity.
... Similarly, gonadotropin responses are altered with obesity. Obese women require higher doses of gonadotrophins and longer treatment courses to support follicular development in IVF [93,94], yet they also have a higher rate of cycle cancellation due to poor ovarian response [94][95][96]. This altered response to gonadotropin stimulation has been linked to a reduced expression of FSHR in the granulosa cells of overweight and obese women [97]. ...
The prevalence of obesity in adults worldwide, and specifically in women of reproductive age, is concerning given the risks to fertility posed by the increased risk of type 2 diabetes, metabolic syndrome and other non-communicable diseases. Obesity has a multi-systemic impact in female physiology that is characterized by the presence of oxidative stress, lipotoxicity, and the activation of pro-inflammatory pathways, inducing tissue-specific insulin resistance and ultimately conducive to abnormal ovarian function. A higher body mass is linked to Polycystic Ovary Syndrome, dysregulated menstrual cycles, anovulation, and longer time to pregnancy, even in ovulatory women. In the context of ART, compared to women of normal BMI, obese women have worse outcomes in every step of their journey, resulting in reduced success measured as live birth rate. Even after pregnancy is achieved, obese women have a higher chance of miscarriage, gestational diabetes, pregnancy complications, birth defects, and most worryingly, a higher risk of stillbirth and neonatal death. The potential for compounding effects of ART on pregnancy complications and infant morbidities in obese women has not been studied. There is still much debate in the field on whether these poorer outcomes are mainly driven by defects in oocyte quality, abnormal embryo development or an unaccommodating uterine environment, however the clinical evidence to date suggests a combination of all three are responsible. Animal models of maternal obesity shed light on the mechanisms underlaying the effects of obesity on the peri-conception environment, with recent findings pointing to lipotoxicity in the ovarian environment as a key driver of defects in oocytes that have not only reduced developmental competence but long-lasting effects in offspring health.
... Obesity is also present in 20-70% of women with PCOS, depending on geographic region (Li et al., 2018;Lim et al., 2012;Pandey et al., 2010;Silvestris et al., 2018). Obese women exhibit reduced fecundity, even after several ART treatment cycles (Khairy and Rajkhowa, 2017;MacKenna et al., 2017). ...
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Metabolic risk factors such as obesity are considered major obstacles to female fertility. Chronic infertility imposes psychological and social burdens on women because infertility violates societal gender roles. Although the prevalence of obesity among women is expected to increase in the future, the relevance of metabolic status for fertility is still underestimated. However, the assessment of metabolic risk factors is highly relevant for understanding fertility disorders and improving infertility treatment. This narrative review discusses the associations of metabolic risk factors (e.g. obesity, female athlete triad, oxidative stress) with significant infertility. An electronic search was conducted for studies published between 2006 and 2020 in Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, PubMed, Scopus, Google Scholar and related databases. In total, this search identified 19,309 results for polycystic ovary syndrome, 28,969 results for endometriosis, and only 1611 results for idiopathic and/or unknown infertility. For the present narrative review, 50 relevant studies were included: 19 studies were on obesity, 24 studies investigated the female athlete triad, and seven studies addressed other risk factors, including reactive oxygen species. This narrative review confirms the direct impact of obesity on female infertility, while the effect of other risk factors needs to be confirmed by large-scale population studies.
... Body mass index (BMI) is usually used as an important factor to calculate the dosage of gonadotropins during the controlled ovarian stimulation (COH). e available evidence about the effects of BMI on the outcome of assisted reproductive technology (ART) is conflicting [13]. Most studies agree that the increase in BMI is related to the increase amounts of gonadotropins used in the process of COH [14], but others found that there is no significant difference in the gonadotropin doses between different BMI groups [15]. ...
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Purpose: To assess whether body mass index (BMI) affects the outcome of in vitro fertilization (IVF) in progestin-primed ovarian stimulation (PPOS) protocol. Methods: A retrospective study was conducted in the Reproductive Medicine Center, Renmin Hospital of Wuhan University, from June 2016 to June 2017. 636 infertile women who received PPOS protocol in IVF treatment were divided into three groups according to BMI. The data of basic characteristics, embryological outcomes, and cycle characteristics of controlled ovarian stimulation of different groups were collected and studied. Result(s). There was no significant difference in almost all the basic characteristics, embryological outcomes of controlled ovarian stimulation, and cycle characteristics of controlled ovarian stimulation among the three groups. There was a tendency that the duration of infertility was decreased with the increase of patients' weight, although there was no significant difference (P=0.051). However, overweight patients had a higher fertilization rate than normal weight patients and underweight patients (70.3 vs. 67.7 vs. 66.8, P=0.008), but two-pronuclei (2PN) fertilization rate and cleavage rate showed no significant difference among the three groups. Conclusion(s). BMI showed no impact on the outcome of the ovarian stimulation outcome in PPOS protocol. PPOS protocol may benefit overweight patients, for it attains the same effect with normal patients and requires no increase in gonadotropin (Gn) dose and Gn duration.
Ovarian stimulation is the starting point of reproductive medicine but the procedure can result in adverse reactions particularly the dangerous ovarian hyperstimulation syndrome. Fully revised in line with modern practice of ovarian stimulation, this new edition is divided into six sections that cover mild forms, non-conventional forms, IVF, complications and their management, alternatives, and the practicalities of procedures. All aspects of ovarian stimulation are discussed including the different stimulation protocols from which to choose, the management of poor responders and hyper-responders, as well as stimulation in patients with PCOS. Comprehensively reviewing the modern approach to ovarian stimulation, the alternative procedures are also described, both in IVF and other methods of assisted reproduction. Written by leading experts on reproductive health and fertility, this book will assist infertility specialists, gynecologists, reproductive endocrinologists and radiologists in determining successful treatment for their patients.
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Physical activity and sedentary behaviour are associated with metabolic and mental health during childhood and adolescence. Understanding the inter-relationships between these behaviours will help to inform intervention design. This systematic review and meta-analysis synthesized evidence from observational studies describing the association between sedentary behaviour and physical activity in young people (<18 years). English-language publications up to August 2013 were located through electronic and manual searches. Included studies presented statistical associations between at least one measure of sedentary behaviour and one measure of physical activity. One hundred sixty-three papers were included in the meta-analysis, from which data on 254 independent samples was extracted. In the summary meta-analytic model (k = 230), a small, but significant, negative association between sedentary behaviour and physical activity was observed (r = −0.108, 95% confidence interval [CI] = −0.128, −0.087). In moderator analyses, studies that recruited smaller samples (n < 100, r = −0.193, 95% CI = −0.276, −0.109) employed objective methods of measurement (objectively measured physical activity; r = −0.233, 95% CI = −0.330, −0.137) or were assessed to be of higher methodological quality (r = −0.176, 95% CI = −0.215, −0.138) reported stronger associations, although effect sizes remained small. The association between sedentary behaviour and physical activity in young people is negative, but small, suggesting that these behaviours do not directly displace one another.
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Objective: To investigate the independent and combined associations between female and male body mass index (BMI) on the probability of achieving a live birth after treatments with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) under adjustment for relevant covariates. Design: Population-based cohort study. Setting: Danish national registers. Patient(s): Patients with permanent residence in Denmark receiving IVF or ICSI treatment with use of autologous oocytes from January 1, 2006, to September 30, 2010. Intervention(s): None. Main outcome measure(s): Live birth. Analyses were adjusted for age and smoking at treatment initiation and results stratified by BMI groups and presented by IVF/ICSI treatment. Result(s): In total, 12,566 women and their partners went through 25,191 IVF/ICSI cycles with 23.7% ending in a live birth. Overweight and obese women with regular ovulation had reduced odds of live birth (adjusted OR 0.88, 95% CI 0.79-0.99 and adjusted OR 0.75, 95% CI 0.63-0.90, respectively) compared with normal-weight women. IVF-treated couples with both partners having BMI ≥25 kg/m(2) had the lowest odds of live birth (adjusted OR 0.73, 95% CI 0.48-1.11) compared with couples with BMI <25 kg/m(2). BMI showed no significant effect on chance of live birth after ICSI. Conclusion(s): Increased female and male BMI, both independently and combined, negatively influenced live birth after IVF treatments. With ICSI, the association with BMI was less clear.
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Mexico and other Latin American countries are currently undergoing important demographic, epidemiologic and nutrition transitions. Noncom-municable chronic diseases such as obesity, type 2 diabetes mellitus, and high blood pressure are becoming public health problems as the population experiences an important reduction in physical activity and an increase in energy-dense diets. In contrast, the prevalence of undernutrition is declining in most countries, although several decades will be needed before the prevalence drops to acceptable values. The objective of this article is to discuss the characteristics of the nutrition transition with emphasis in data from Mexico, Brazil, and Chile
INTRODUCTION: This study investigates the relative risk of obstetric complications stratified by pre-pregnancy body mass index (BMI) and pregnancy weight gain. METHODS: This was a retrospective cohort study of 17,393 pregnant women with singleton births between January 2004 and May 2015. We stratified patients based on pre-pregnancy BMI category (as per the Institute of Medicine, IOM) and amount of weight gain (appropriate, less than or greater than recommended). Primary maternal outcomes included: gestational diabetes (GDM), preeclampsia, macrosomia, fetal growth restriction (FGR), and rates of cesarean delivery, shoulder dystocia, preterm delivery (PTD), blood loss and operative delivery. Primary neonatal outcomes included hypoglycemia, length of NICU stay, APGAR score at 5 minutes, and rate of respiratory distress syndrome (RDS). RESULTS: The relative risk of GDM, preeclampsia, fetal macrosomia, cesarean delivery, blood loss, neonatal hypoglycemia and RDS increased with each successive BMI category. The risk for FGR mostly decreased with increasing BMI. Risks of other obstetric and neonatal complications did not appear to be correlated with increasing BMI category. FGR risk decreased with increasing weight gain for non-obese patients. For all classes of obesity, patient's weight gain was positively correlated with a higher risk of cesarean delivery and inversely proportional to the risk of PTD. CONCLUSION: This large retrospective cohort study showed that as BMI category changed from I to II to III, there were significant increases in the rates of maternal and neonatal complications. In addition pregnancy complications are increased when weight gain does not conform to IOM recommendations.
Multinational data on assisted reproduction techniques undertaken in 2013 were collected from 158 institutions in 15 Latin American countries. Individualized cycle-based data included 57,456 initiated cycles. Treatments included autologous IVF and intracytoplasmic sperm injection (ICSI), frozen embryo transfers, oocyte donations. In autologous reproduction, 29.22% of women were younger than 35 years, 40.1% were 35–39 years and 30.6% were 40 years or older. Overall delivery rate per oocyte retrieval was 20.6% for ICSI and 25.4% for IVF. Multiple births included 20.7% for twins and 1.1% for triplets and over. In oocyte donations, twins reached 30% and triplets 1.4%. In singletons, pre-term births were 7.5%: 36.58% in twins and 65.52% in triplets. The relative risk for prematurity was 4.9 (95% CI 4.5 to 5.3) in twins and 8.7 (95% CI 7.6 to 10.0) in triplets and above. Perinatal mortality was 29.4 per 1000 in singletons, 39.9 per 1000 in twins and 71.6 per 1000 in high order multiples. Elective single embryo transfer represented only 2% of cycles, with delivery rate of 39.1% in women aged 34 years or less. Given the effect of multiple births and prematurity, it is mandatory to reduce the number of embryos transferred in the region.
Objective: To examine the effect of body mass index (BMI) on IVF outcomes in fresh autologous cycles. Design: Retrospective cohort study. Setting: Not applicable. Patient(s): A total of 239,127 fresh IVF cycles from the 2008-2010 Society for Assisted Reproductive Technology registry were stratified into cohorts based on World Health Organization BMI guidelines. Cycles reporting normal BMI (18.5-24.9 kg/m(2)) were used as the reference group (REF). Subanalyses were performed on cycles reporting purely polycystic ovary syndrome (PCOS)-related infertility and those with purely male-factor infertility (34,137 and 89,354 cycles, respectively). Intervention(s): None. Main outcome measure(s): Implantation rate, clinical pregnancy rate, pregnancy loss rate, and live birth rate. Result(s): Success rates and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for all pregnancy outcomes were most favorable in cohorts with low and normal BMIs and progressively worsened as BMI increased. Obesity also had a negative impact on IVF outcomes in cycles performed for PCOS and male-factor infertility, although it did not always reach statistical significance. Conclusion(s): Success rates in fresh autologous cycles, including those done for specifically PCOS or male-factor infertility, are highest in those with low and normal BMIs. Furthermore, there is a progressive and statistically significant worsening of outcomes in groups with higher BMIs. More research is needed to determine the causes and extent of the influence of BMI on IVF success rates in other patient populations.
Objective: We conducted a systematic review to evaluate the influence of race and ethnicity on clinical pregnancy and live birth outcomes after in vitro fertilization. Data sources: We searched PubMed, EMBASE, Web of Science, CINAHL, POPLINE, and Cochrane Central, and hand-searched relevant articles published through July 22, 2015. Study appraisal and synthesis methods: Two reviewers independently evaluated abstracts to identify studies that compared clinical pregnancy rates and live birth rates for two or more racial and/or ethnic groups after non-donor IVF cycles. Results: Twenty-four studies were included. All five U.S. registry-based studies showed that black, Hispanic, and Asian women had lower clinical pregnancy rates and/or live birth rates after IVF, compared with white women. Similarly, most clinic-specific studies reported significant disparities in these primary outcomes, potentially attributable to differences in infertility diagnosis, spontaneous abortion, and obesity. Studies varied with respect to definitions of race/ethnicity, inclusion of first cycles vs. multiple cycles for individual women, and collected covariates. Most studies were limited by sample size, inadequate adjustment for confounding, selection bias, and extensive missing data. Conclusions: Although current evidence points to race and ethnicity, especially black race, as strong predictors of poorer outcomes after in vitro fertilization, the utility of results is constrained by the limitations described.
Objective: To determine what assisted reproductive technologies (ART) policies, if any, have been instituted in response to an increasingly overweight and obese patient population. Design: Cross-sectional survey. Setting: University-affiliated IVF clinic. Patient(s): Women in the overweight and obese body mass index (BMI) categories seeking ART treatments. Intervention(s): Anonymous survey sent to medical directors at 395 IVF centers listed in Society for Assisted Reproductive Technology database. Main outcome measure(s): Assessment of recommendations, policies, and restrictions for patients who are overweight/obese and who desire treatment for infertility, including in IVF, IUI, and donor egg cycles. Result(s): Seventy-seven anonymous responses were received (19.5% response rate): 64.9% of centers have a formal policy for obesity, and 84% of those have a maximum BMI at which they will perform IVF, while 38% of those have a maximum BMI for performing IUI; 64.6% of respondents reported anesthesia requirements/concerns as the primary criteria for patient exclusion. Other primary considerations included safety during ongoing pregnancy and ART outcomes. Conclusion(s): Centers that have policies regarding obesity and access to ART consider efficacy, procedural safety, safety in pregnancy, and overall health status. Policies vary widely. The patient's autonomy must be balanced with nonmaleficence and the avoidance of interventions that may be unsafe both immediately and long term.
To assess the effects of both male and female body mass index (BMI), individually and combined, on IVF outcomes. Prospective cohort study. University fertility center. All couples undergoing first fresh IVF cycles, 2005-2010, for whom male and female weight and height information were available (n = 721 couples). None. Embryologic parameters, clinical pregnancy, and live birth incidence. The average male BMI among the study population was 27.5 ± 4.8 kg/m(2) (range, 17.3-49.3 kg/m(2)), while the average female BMI (n = 721) was 25.2 ± 5.9 kg/m(2) (range, 16.2-50.7 kg/m(2)). Neither male nor female overweight (25-29.9 kg/m(2)), class I obese (30-34.9 kg/m(2)), or class II/III obese (≥35 kg/m(2)) status was significantly associated with fertilization rate, embryo score, or incidence of pregnancy or live birth compared with normal weight (18.5-24.9 kg/m(2)) status after adjusting for male and female age, partner BMI, and parity. Similar null findings were found between combined couple BMI categories and IVF success. Our findings support the notion that weight status does not influence fecundity among couples undergoing infertility treatment. Given the limited and conflicting research on BMI and pregnancy success among IVF couples, further research augmented to include other adiposity measures is needed. Copyright © 2014 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
The number of children and adolescents who are overweight or obese worldwide is alarming. We did a systematic review to estimate the prevalence of overweight and obesity in children aged 0-19 years in Latin America. We searched specialised databases and seven books for relevant studies that were done in Spanish-speaking and Portuguese-speaking Latin American and Caribbean countries and published in peer-reviewed journals between January 2008, and April 2013. Indicators used were BMI (kg/m(2)) in all age groups and weight-for-height in children younger than 5 years. We identified 692 publications and included 42. Estimated prevalence of overweight in children younger than 5 years in Latin America was 7·1% with the weight-for-height WHO 2006 classification method. National combined prevalences of overweight and obesity with the WHO 2007 classification method ranged from 18·9% to 36·9% in school-age children (5-11 years) and from 16·6% to 35·8% in adolescents (12-19 years). We estimated that 3·8 million children younger than 5 years, 22·2-25·9 million school-age children, and 16·5-21·1 million adolescents were overweight or obese. Overall, between 42·5 and 51·8 million children aged 0-19 years were affected-ie, about 20-25% of the population. Although undernutrition and obesity coexist in the region, policies in most countries favour prevention of undernutrition, and only a few countries have implemented national policies to prevent obesity. In view of the number of children who are overweight or obese, the associated detrimental effects on health, and the cost to health-care systems, implementation of programmes to monitor and prevent unhealthy weight gain in children and adolescents are urgently needed throughout Latin America.