Women, weight, and fertility: the effect of body mass index on the outcome of superovulation/intrauterine insemination cycles

Intra-patient analysis of individual weight gain or loss between IVF cycles: cycle now and transfer later

STUDY QUESTION

What is the impact of clinically significant weight change on outcomes related to IVF cycle performance?

SUMMARY ANSWER

While individual weight loss did not significantly impact ovarian response to stimulation or other cycle outcome parameters in our study, some positive associations were found for individual weight gain.

WHAT IS KNOWN ALREADY

The role of weight-change in patients undergoing IVF has been largely studied by comparing weight loss in different cohorts of patients stratified by a static BMI. Specifically, obesity has been extensively studied in relation to its negative effects on assisted or unassisted conception outcomes and ovulatory function. Previous research has shown conflicting results, while BMI, which is commonly used as a marker of obesity, may not accurately reflect the underlying factors affecting fertility in obese patients.

STUDY DESIGN, SIZE, DURATION

This study utilized a retrospective within-patient repeated measurement analysis design to assess the impact of weight change on IVF outcomes in cycles where all embryos were cryopreserved at the blastocyst stage for transfer at a later date.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at an academically affiliated fertility center. The data included 961 women who underwent at least two IVF cycles between December 2014 and June 2020, with documented short-term weight gain (n = 607) or weight loss (n = 354) within 1 year from their initial IVF cycle. Multivariable generalized estimating equations (GEE) and generalized linear mixed models (GLMM) were employed to assess associations between weight change and outcomes across cycles.

MAIN RESULTS AND THE ROLE OF CHANCE

The multivariable models indicated that weight loss did not show any significant associations with the numbers of oocytes retrieved, or mature oocytes, the fertilization rate or the blastulation rate. However, weight gain demonstrated a minor positive association with the number of oocytes retrieved in both GEE models (coefficient: 0.01, 95% CI: 0.00-0.01) and GLMM models (0.01, 95% CI: 0.01-0.00). There was also a potential increase in the fertilization rate with weight gain, as indicated by a positive coefficient in both GEE models (coefficient: 0.01, 95% CI: 0.00-0.02) and GLMM models (coefficient: 0.01, 95% CI: 0.00-0.01). However, the association between weight gain and the embryo blastulation rate was not statistically significant in any model.

LIMITATIONS, REASONS FOR CAUTION

This study focused on cycle performance parameters instead of reproductive outcomes, which restricted our ability to evaluate the impact of weight change on cumulative live birth rates. Additionally, the study did not account for variables such as stimulation protocols, potentially introducing confounding factors and limiting the generalizability of the results.

WIDER IMPLICATIONS OF THE FINDINGS

Although obesity is associated with adverse obstetrical risks, there is less evidence of adverse reproductive outcomes in IVF cycles. We therefore recommend that an IVF cycle should not be delayed due to weight, so that the patient is not adversely affected by increasing age. The IVF cycle should aim to freeze all embryos, so that embryo transfer can then occur after weight loss, so as to limit the recognized obstetrical risks.

STUDY FUNDING/COMPETING INTEREST(S)

The study was not funded and there were no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Effect of female body mass index on intrauterine insemination outcomes: a systematic review and meta-analysis

The prevalence of women with a raised body mass index (BMI) seeking assisted conception treatment is increasing. Findings of existing studies evaluating the effect of female BMI on intrauterine insemination (IUI) treatment outcomes remain inconsistent. This systematic review and meta-analysis evaluate the effect of female BMI on IUI treatment outcomes. Two authors independently conducted data extraction and assessed study quality. Risk ratios (RR) and 95% confidence intervals were calculated using the Mantel-Haenszel approach for dichotomous outcomes. 11 studies involving 23,145 IUI treatment events, comprising 21,211 cycles from 8 studies, and 1,934 participants in three studies, met the inclusion criteria for the meta-analysis. Two cohorts of women undergoing IUI treatment were compared - women with normal BMI < 25 kg/m2 were compared with a second cohort of women with a BMI category ≥ 25 kg/m2. There was no statistically significant difference in live birth rate (LBR) (RR 1.06, 95% CI 0.86-1.307); clinical pregnancy rate (CPR) (RR 0.94, 95% CI 0.78-1.13); miscarriage (RR 0.92, 95% CI 0.31-2.74) or ectopic pregnancy rate (RR 2.20, 95% CI 0.78-6.23). Our meta-analysis showed that a raised female BMI did not affect IUI treatment outcomes. Nevertheless, weight loss counselling should be offered to women with a raised BMI undergoing IUI, to reduce the associated obstetric morbidity.

Analysis of controlled ovarian hyperstimulation protocols in women over 35 years old with poor ovarian response: a real-world study

The objective of this study was to investigate the optimal controlled ovarian hyperstimulation (COH) protocol for patients aged 35 and above with poor ovarian response (POR), utilizing real-world data. This retrospective cohort study examined clinical information from a total of 4256 patients between January 2017 and November 2022. The patients were categorized into three groups: modified GnRH agonist protocol (2116 patients), GnRH antagonist protocol (1628 patients), and Mild stimulation protocol (512 patients). Comparative analysis was conducted on clinical variables and pregnancy outcomes across the three groups. The GnRH agonist protocol was associated with a higher number of oocyte number (4.02 ± 2.25 vs. 3.15 ± 1.52 vs. 2.40 ± 1.26, p < 0.001), higher number of transferable embryos (1.73 ± 1.02 vs. 1.35 ± 1.22 vs. 1.10 ± 0.86, p = 0.016), higher cumulative live birth rate 28.50(603/2116) vs. 24.94(406/1628) vs. 20.51(105/512), p < 0.001) than GnRH antagonist protocol and Mild stimulation protocol, the Mild stimulation protocol was associated with a higher miscarriage rates 16.27(62/381) vs. 16.61(48/289) vs. 32.22(29/90), p = 0.001) than the other two groups. Therefore, it can be concluded that all three protocols can be used in patients over 35 years old with poor ovarian response. However, if patients require more frozen-thawed embryo transfers to achieve better cumulative live birth rates, the modified GnRH agonist protocol may be the preferable option.

A prediction model for high ovarian response in the GnRH antagonist protocol

Backgrounds

The present study was designed to establish and validate a prediction model for high ovarian response (HOR) in the GnRH antagonist protocol.

Methods

In this retrospective study, the data of 4160 cycles were analyzed following the in vitro fertilization (IVF) at our reproductive medical center from June 2018 to May 2022. The cycles were divided into a training cohort (n=3121) and a validation cohort (n=1039) using a random sampling method. Univariate and multivariate logistic regression analyses were used to screen out the risk factors for HOR, and the nomogram was established based on the regression coefficient of the relevant variables. The area under the receiver operating characteristic curve (AUC), the calibration curve, and the decision curve analysis were used to evaluate the performance of the prediction model.

Results

Multivariate logistic regression analysis revealed that age, body mass index (BMI), follicle-stimulating hormone (FSH), antral follicle count (AFC), and anti-mullerian hormone (AMH) were independent risk factors for HOR (all P< 0.05). The prediction model for HOR was constructed based on these factors. The AUC of the training cohort was 0.884 (95% CI: 0.869-0.899), and the AUC of the validation cohort was 0.884 (95% CI:0.863-0.905).

Conclusion

The prediction model can predict the probability of high ovarian response prior to IVF treatment, enabling clinicians to better predict the risk of HOR and guide treatment strategies.

Pre-pregnancy obesity is not associated with poor outcomes in fresh transfer in vitro fertilization cycles: a retrospective study

PURPOSE

The impact of body mass index (BMI) on in vitro fertilization (IVF) has been well acknowledged; however, the reported conclusions are still incongruent. This study aimed to investigate the effect of BMI on IVF embryos and fresh transfer clinical outcomes.

METHODS

This retrospective cohort analysis included patients who underwent IVF/ICSI treatment and fresh embryo transfer from 2014 to March 2022. Patients were divided into the underweight group: BMI < 18.5 kg/m2; normal group: 18.5 ≤ BMI < 24 kg/m2; overweight group: 24 ≤ BMI < 28 kg/m2; and obesity group: BMI ≥ 28 kg/m2. A generalized linear model was used to analyze the impact of BMI on each IVF outcome used as a continuous variable.

RESULTS

A total of 3465 IVF/ICSI cycles in the embryo part; and 1698 fresh embryo transplanted cycles from the clinical part were included. Available embryos rate (61.59% vs. 57.32%, p = 0.007) and blastocyst development rates (77.98% vs. 66.27%, p < 0.001) were higher in the obesity group compared to the normal BMI group. Also, the fertilization rate of IVF cycles in the obesity group was significantly decreased vs. normal BMI group (normal: 62.95% vs. 66.63% p = 0.006; abnormal: 5.43% vs. 7.04%, p = 0.037), while there was no difference in ICSI cycles. The clinical outcomes of overweight and obesity groups were comparable to the normal group. The gestational age of the obesity group was lower compared to the normal group (38.08 ± 1.95 vs. 38.95 ± 1.55, p = 0.011). The adjusted OR (AOR) of BMI for the preterm birth rate of singletons was 1.134 [(95% CI 1.037-1.240), p = 0.006]. BMI was significantly associated with live birth rate after excluded the PCOS patients [AOR: 1.042 (95% CI 1.007-1.078), p = 0.018]. In young age (≤ 35 years), clinical pregnancy rate and live birth rate were positively correlated with BMI, AOR was 1.038 [95% CI (1.001-1.076), p = 0.045] and 1.037 [95% CI (1.002-1.074) p = 0.038] respectively.

CONCLUSION

Being overweight and obese was not associated with poor IVF outcomes but could affect blastocyst formation. ICSI could help to avoid low fertilization in obese patients. Also, obesity was associated with increased rates of premature singleton births.

Association between obesity and fecundity in patients undergoing intrauterine insemination

Objective

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

Design

Retrospective cohort study.

Setting

Academic-based fertility clinic.

Patients

Patients undergoing IUI July 2007 to May 2012.

Interventions

None.

Main Outcome Measures

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

Results

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

Conclusions

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

Obesity and In Vitro Fertilization

Obesity is a highly prevalent chronic disease with a significant effect on reproductive-age women. The clinical implications of obesity on fertility and pregnancy are well studied citing ovulatory dysfunction, hormonal imbalances, higher miscarriage rates, and increased maternal and neonatal risks. For this reason, many patients with obesity seek reproductive specialists to help build their families. Despite this literature base, the effect of weight loss interventions prior to assisted reproductive technology (ART) is lacking. This review aims to outline the impact of obesity on ART, specifically in vitro fertilization (IVF). Response differences to treatment protocols compared with normal weight counterparts, limitations of access to care, and the mixed results of weight-reduction strategies prior to fertility treatment will be addressed. The known data surrounding benefits of lifestyle modification, pharmacologic therapies, and surgical interventions for obesity prior to IVF are outlined and found to emphasize a need for further research to determine the optimal approach for infertility patients with obesity.

Navigating the Role of Anti-Obesity Agents Prior to Pregnancy: A Narrative Review

Utilization of anti-obesity agents is rising in reproductive-age females with some planning for future pregnancy. Lifestyle-induced weight loss has been shown to increase spontaneous conception rate, improve rates of fertility intervention complications, and decrease pregnancy comorbidities. However, the definitive role of assisting weight loss with medication prior to pregnancy remains to be established. The implications of anti-obesity agent used prior to pregnancy are explored in this narrative review, considering benefits of weight loss as well as available evidence for use and risks of anti-obesity agents prior to pregnancy.

The impact of cryopreserved sperm on intrauterine insemination outcomes: is frozen as good as fresh?

Introduction

Frozen sperm utilization might negatively impact cycle outcomes in animals, implicating cryopreservation-induced sperm damage. However, in vitro fertilization and intrauterine insemination (IUI) in human studies are inconclusive.

Methods

This study is a retrospective review of 5,335 IUI [± ovarian stimulation (OS)] cycles from a large academic fertility center. Cycles were stratified based on the utilization of frozen (FROZEN, n = 1,871) instead of fresh ejaculated sperm (FRESH, n = 3,464). Main outcomes included human chorionic gonadotropin (HCG) positivity, clinical pregnancy (CP), and spontaneous abortion (SAB) rates. Secondary outcome was live birth (LB) rate. Odds ratios (OR) for all outcomes were calculated utilizing logistic regression and adjusted (adjOR) for maternal age, day-3 FSH, and OS regimen. Stratified analysis was performed based on OS subtype [gonadotropins; oral medications (OM): clomiphene citrate and letrozole; and unstimulated/natural]. Time to pregnancy and cumulative pregnancy rates were also calculated. Further subanalyses were performed limited to either the first cycle only or to the partner's sperm only, after excluding female factor infertility, and after stratification by female age (<30, 30-35, and >35 years old).

Results

Overall, HCG positivity and CP were lower in the FROZEN compared to the FRESH group (12.2% vs. 15.6%, p < 0.001; 9.4% vs. 13.0%, p < 0.001, respectively), which persisted only among OM cycles after stratification (9.9% vs. 14.2% HCG positivity, p = 0.030; 8.1% vs. 11.8% CP, p = 0.041). Among all cycles, adjOR (95% CI) for HCG positivity and CP were 0.75 (0.56-1.02) and 0.77 (0.57-1.03), respectively, ref: FRESH. In OM cycles, adjOR (95% CI) for HCG positivity [0.55 (0.30-0.99)] and CP [0.49 (0.25-0.95), ref.: FRESH] favored the FRESH group but showed no differences among gonadotropin and natural cycles. SAB odds did not differ between groups among OM and natural cycles but were lower in the FROZEN group among gonadotropin cycles [adjOR (95% CI): 0.13 (0.02-0.98), ref.: FRESH]. There were no differences in CP and SAB in the performed subanalyses (limited to first cycles or partner's sperm only, after excluding female factors, or after stratification according to female age). Nevertheless, time to conception was slightly longer in the FROZEN compared to the FRESH group (3.84 vs. 2.58 cycles, p < 0.001). No significant differences were present in LB and cumulative pregnancy results, other than in the subgroup of natural cycles, where higher LB odds [adjOR (95% CI): 1.08 (1.05-1.12)] and higher cumulative pregnancy rate (34% vs. 15%, p = 0.002) were noted in the FROZEN compared to the FRESH group.

Conclusion

Overall, clinical outcomes did not differ significantly between frozen and fresh sperm IUI cycles, although specific subgroups might benefit from fresh sperm utilization.

An Algorithm to Predict the Lack of Pregnancy after Intrauterine Insemination in Infertile Patients

Increasing intrauterine insemination (IUI) success rates is essential to improve the quality of care for infertile couples. Additionally, straight referral of couples with less probability of achieving a pregnancy through IUI to more complex methods such as in vitro fertilization is important to reduce costs and the time to pregnancy. The aim of the present study is to prospectively evaluate the threshold values for different parameters related to success in intrauterine insemination in order to provide better reproductive counseling to infertile couples, moreover, to generate an algorithm based on male and female parameters to predict whether the couple is suitable for achieving pregnancy using IUI. For that, one hundred ninety-seven infertile couples undergoing 409 consecutive cycles of intrauterine insemination during a two-year period were included. The first year served as a definition of the parameters and thresholds related to pregnancy achievement, while the second year was used to validate the consistency of these parameters. Subsequently, those parameters that remained consistent throughout two years were included in a generalized estimating equation model (GEE) to determine their significance in predicting pregnancy achievement. Parameters significantly associated with the lack of pregnancy through IUI and included in the GEE were (p < 0.05): (i) male age > 41 years; (ii) ejaculate sperm count < 51.79 x 10⁶ sperm; (iii) swim-up alkaline Comet > 59%; (iv) female body mass index > 45 kg/m²; (v) duration of infertility (>84 months), and (vi) basal LH levels > 27.28 mUI/mL. The application of these limits could provide a pregnancy prognosis to couples before undergoing intrauterine insemination, therefore avoiding it in couples with low chances of success. The retrospective application of these parameters to the same cohort of patients would have increased the pregnancy rate by up to 30%.

The impact of anti-Müllerian hormone on endometrial thickness in gonadotropin stimulation/intrauterine insemination cycles: is there an effect on pregnancy outcomes?

PURPOSE

To study the association, if any, between anti-Müllerian hormone (AMH) and pre-ovulatory endometrial thickness (ET) in gonadotropin/intrauterine insemination (IUI) cycles.

METHODS

This retrospective cohort study included a total of 964 patients undergoing 1926 gonadotropin/IUI cycles at an academic fertility center. Primary outcome measure was the association between serum AMH and measured ET on the day of and the day before human chorionic gonadotropin hormone (hCG) ovulation trigger. The effect of a model combining AMH and ET on early pregnancy outcomes was a secondary measure.

RESULTS

In 52.8% of cycles, ET was last assessed and recorded on the day of hCG administration, while in the remaining 47.2% on the day prior to trigger. In unadjusted regression models, AMH was weakly correlated with ET on hCG trigger day [bAMH (95%CI) = 0.032 (- 0.008, 0.070), p = 0.015]. When adjusting for potential confounders, the positive correlation became significant [0.051 (0.006, 0.102), p = 0.047]. Similar findings were observed when assessing the correlation between AMH and ET on the day prior to hCG trigger. ET was non-significantly associated with the odds of clinical pregnancy, when adjusting for potential confounders, except for when restricting the analysis to couples with idiopathic infertility [OR (95%CI), p-value: 0.787 (0.623, 0.993), 0.044].

CONCLUSION

Our findings support an effect of serum AMH on endometrial development in gonadotropin induced cycles, even when adjusting for the diagnosis of PCOS. ET was not associated with the odds of achieving a clinical pregnancy, except for couples with idiopathic infertility.

Low BMI is associated with poor IUI outcomes: a retrospective study in 13,745 cycles

PURPOSE

To evaluate the association between body mass index (BMI) and pregnancy outcomes in women receiving intrauterine insemination (IUI) treatment.

METHODS

The study included 6407 women undergoing 13,745 IUI cycles stratified by BMI. Cox regression was used to analyze the association between BMI and cumulative live births across multiple IUI cycles. A generalized estimating equation (GEE) was used to analyze the live birth rate per cycle.

RESULTS

Compared with normal-weight women (n = 4563), underweight women (n = 990) had a lower cumulative pregnancy and live birth rate (20.71% vs 25.93% and17.17% vs 21.61%, respectively), while overweight women (n = 854) had a higher cumulative pregnancy and live birth rate (31.97%, 26.58%). Adjusted for confounders, the hazard ratio (HR) for achieving live birth following up to a maximum of four IUI cycles was 0.80 (95% CI: 0.67-0.95), comparing underweight with normal weight. In the GEE analyses, low BMI was also associated with a lower per-cycle birth rate (OR 0.79, 95% CI: 0.66-0.95), with adjustment for cycle-specific parameters, including ovarian stimulation, endometrial thickness, and follicular diameter.

CONCLUSION

Low BMI is associated with poor IUI outcomes.

Obesity-related alterations in protein expression in human follicular fluid from women undergoing in vitro fertilization

OBJECTIVE

To compare the proteomic composition of follicular fluid from women with normal weight vs. women with obesity but without a history of polycystic ovary syndrome or known ovarian dysfunction undergoing in vitro fertilization.

DESIGN

Cross-sectional.

SETTING

Academic medical center.

PATIENT(S)

Eight women with normal weight and 8 women with obesity undergoing in vitro fertilization and without a history of polycystic ovary syndrome, ovulatory dysfunction, diminished ovarian reserve, or known endometriosis were included in the analysis.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Proteomic assessment using liquid chromatography-mass spectrometry analysis.

RESULT(S)

The mean age of women with normal weight was similar to that of women with obesity (32.9 vs. 32.6 years, not significant). The mean body mass index of women with normal weight was 21.2 kg/m² compared with a body mass index of 37.1 kg/m² in women with obesity. A total of 1,174 proteins were identified with ≥2 peptides present. Twenty-five proteins were found to be significantly altered in the follicular fluid from women with obesity. Of these 25 proteins, 19 were up-regulated and 6 were down-regulated. Notably, C-reactive protein was 11-fold higher in the follicular fluid from women with obesity than in the follicular fluid from women with normal weight.

CONCLUSION(S)

Obesity is associated with dysregulation at the level of the follicle, including alterations in proteins related to inflammation and metabolism. These include proteins with emerging roles in energy homeostasis and follicular regulation.

Effect of ovulation before or after intrauterine insemination on pregnancy outcome in patients with unexplained infertility or polycystic ovarian syndrome

OBJECTIVE

To investigate the relationship between ovulation and pregnancy outcomes in patients undergoing intrauterine insemination (IUI).

METHODS

The clinical data from 784 patients, diagnosed with polycystic ovarian syndrome (PCOS) or unexplained infertility, underwent 1624 IUI cycles were analyzed retrospectively. Ovulation was observed by transvaginal ultrasonography on the day of IUI. The clinical pregnancy rate (CPR), abortion rate (AR), and live birth rate (LBR) were analyzed.

RESULTS

The study included 1031 pre-ovulation IUI cycles (63.49%) and 593 post-ovulation IUI cycles (36.51%). The CPR was 13.05%, the AR was 15.57%, and the LBR was 11.02%. Ovulation before or after IUI affected the CPR (11.06% VS 16.53%, p = .002) and LBR (9.41% VS 13.83%, p = .006) per cycle, but did not affect the AR (14.91% VS 16.33%, p = .149). The sex ratio of children was not related to ovulation (p = .948). After adjusting for baseline characteristics and logistic regression, the CPR (OR = 1.931, 95% CI 1.062-1.931, p = .019) and LBR (OR = 1.389, 95% CI 1.007-1.916, p = .045) of post-ovulation insemination were higher than those of pre-ovulation insemination significantly.

CONCLUSION

Pregnancy outcomes were affected by ovulation on the day of IUI in patients with unexplained infertility or PCOS. Post-ovulation insemination may improve the CPR of IUI.

Body Size, Fertility, and Reproductive Justice: Examining the Complex Interplay between BMI, Reproductive Health, and Access to Care

The relationship between obesity and reproduction is highly complex. While there are clear obstetrical and fertility risks associated with elevated BMI, it is less clear how weight loss impacts these outcomes. Increasingly, patients considered obese according to BMI are being denied access to fertility care, thus leaving them without treatment options for their disease (infertility). Notably, BMI cutoffs disproportionately affect historically marginalized populations in the United States and people of lower socioeconomic status (SES). This paper uses a reproductive justice framework to discuss access to reproductive healthcare based on BMI. In doing so, we connect obesity to larger systems of structural inequalities. We conclude that rather than strict BMI cutoffs, a more holistically patient-centered approach is appropriate taking into account the overall health of the individual, available scientific data, clinical capabilities, and the patient’s value system. This will ultimately make reproductive medicine more accessible to all patients.

The effect of semen collection at home on intrauterine insemination outcomes

BACKGROUND

The WHO 2010 guidelines recognize at-home semen collection as an acceptable alternative to standard collection at the clinic in "exceptional circumstances". There is lack of sufficient data to determine the need for revisiting these recommendations for treatment purposes.

OBJECTIVES

To determine whether at home semen collection has any effect on intrauterine insemination (IUI) cycle outcomes.

MATERIALS AND METHODS

This is a retrospective cohort study of 729 IUI treatment cycles (382 patients) performed at an academic fertility center from 9/19/2019 to 12/31/2020. Semen collected at the "clinic" was used for 343 cycles before the Coronavirus Disease 2019 (COVID-19) pandemic (09/19/2019-3/21/2020), and "at-home" collected specimens were used for 386 cycles following revised protocols with COVID-19 driven changes (5/30/2020-12/31/2020). Logistic regression models were performed to evaluate the effect of "at-home" semen collection on achieving a positive pregnancy test (PPT) and a clinical pregnancy (CP).

RESULTS

Male and female partners' age, ovarian reserve biomarkers, and stimulation regimens used were similar in the "clinic" and "at-home" groups. In unadjusted models, "at-home" collection had no significant effect on the odds for a PPT [OR (95%CI): 0.733(0.503-1.069)] or CP [0.816(0.543-1.226)]. These results persisted even when adjusting for maternal age and anti-Müllerian Hormone: PPT [0.739(0.505-1.081)] and CP [0.826(0.547-1.248)]. Of the semen analysis parameters under evaluation, only motility appeared to significantly impact the odds of achieving a PPT [1.014(1.004-1.025)] and a CP [1.017(1.006-1.029)]. This effect was slightly attenuated for samples collected "at-home" [1.012(0.997-1.027) and 1.015(0.999-1.031), respectively for PPT and CP].

DISCUSSION

This study adds important information to the limited literature regarding the effect of at-home semen collection on IUI outcomes. Under adequate protocols, at-home semen collection should be considered a safe alternative. Additional research is needed to optimize such protocols.

CONCLUSION

Our data suggest that at-home semen collection does not negatively impact IUI pregnancy outcomes. This article is protected by copyright. All rights reserved.

Dietary patterns are associated with improved ovarian reserve in overweight and obese women: a cross-sectional study of the Lifestyle and Ovarian Reserve (LORe) cohort

BACKGROUND

Growing evidence suggests that adherence to certain dietary patterns is associated with improved fecundity and reproductive outcomes in the general population and infertile couples assisted reproductive treatments. The objective of this study was to assess if dietary patterns are associated with ovarian reserve in reproductive age women without a history of infertility.

METHODS

This was a cross-sectional study of 185 women in the Lifestyle and Ovarian Reserve (LORe) cohort. Women aged 18-44 without a history of infertility were recruited from the local community at an academic medical center. Subjects completed validated food frequency and physical activity questionnaires to assess patterns over the year prior to presentation. Dietary patterns including a Western (including meat, refined carbohydrates, high-calorie drinks), prudent (including fruits, vegetables, olive oil and nuts), fertility (lower intake of trans fat with higher intake of monounsaturated fatty acids, increased intake of plant based protein, high-fat dairy, lower glycemic load carbohydrates and supplemental iron) and profertility diet (PFD) (characterize by whole grains, soy and seafood, low pesticide residue produce, supplemental folic acid, B12 and vitamin D) were identified through principal component analysis. Main outcome measures were serum antimullerian hormone concentration (AMH) (ng/mL) and antral follicle count (AFC) obtained by transvaginal ultrasound.

RESULTS

After stratifying by BMI, adjusting for age, smoking and physical activity, dietary patterns were not associated with ovarian reserve in normal weight women. Increased adherence to a profertility diet in overweight and obese women (BMI ≥ 25 kg/m²) was associated with a significantly higher AMH. Women in the third and fourth quartiles of PFD adherence had a mean AMH concentration of 1.45 ng/mL (95%CI 0.33-2.56, p = 0.01) and 1.67 ng/mL (95%CI 0.60-2.74, p = 0.003) higher than women in the lowest quartile respectively. The highest adherence to PFD was also associated with a higher AFC in women with a BMI ≥ 25 kg/m² (β = 7.8, 95%CI 0.003-15.34, p < 0.05). Other common dietary patterns were not significantly associated with ovarian reserve.

CONCLUSIONS

Increased adherence to a profertility diet is associated with improved markers of ovarian reserve in overweight and obese women. These findings provide novel insight on potential modifiable lifestyle factors associated with ovarian reserve.

The pregnancy outcomes of infertile women with polycystic ovary syndrome undergoing intrauterine insemination with different attempts of previous ovulation induction

BACKGROUND

Polycystic ovary syndrome (PCOS) is one of the most common reasons for infertility. The consensus of the treatment of infertile women with PCOS is ovulation induction (OI) for six to nine attempts before in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Nowadays, more attention was paid to a rising, noninvasive treatment, intrauterine insemination (IUI), as some experts claimed IUI could benefit PCOS patients with infertility. Our study means to investigate the outcomes of IUI for PCOS patients and if patients' previous OI cycles can be a predictive factor for IUI outcomes.

METHODS

A total of 1,086 PCOS patients was included and 1,868 IUI cycles were performed between January 2007 and July 2021 in the department of assisted reproduction in Shanghai Ninth People's Hospital. All included patients underwent IUI treatments with letrozole+human menopausal gonadotropin (LE+hMG) for ovarian stimulation.

RESULTS

The pregnancy outcomes were not associated with the attempts of failed OI cycles previously. Specifically, the clinical pregnancy rate was 21.14% for PCOS patients without previous OI cycles, 21.95% for PCOS patients with 1-2 previous OI cycles and 23.64% for PCOS patients with 3 or more previous OI cycles (p=0.507). The corresponding live birth rate was 16.64%, 18.06%, and 18.68%, respectively, of which the difference was not statistically significant (p=0.627). The cumulative rate per patient was 38.59% for clinical pregnancy and 31.03% for live birth, and approximately 98% of the pregnancies occurred in the first 3 cycles of IUI.

CONCLUSION

PCOS women with different attempts of OI cycles had similar pregnancy outcomes after IUI, thus a history of repeated failures of OI treatments was not a predictive factor for the pregnancy outcomes in IUI cycles. Most pregnancies occurred in the first three cycles of IUI, so we strongly recommended three attempts of IUI for PCOS women before they switched to IVF/ICSI. Generally, IUI might be an assist for infertile women with PCOS before IVF/ICSI and might accelerate pregnancy for target women without invasive manipulations.

Obesity and reproduction: a committee opinion

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

Overweight and obesity significantly reduce pregnancy, implantation, and live birth rates in women undergoing In Vitro Fertilization procedures

OBJECTIVE

The objective of this study was to evaluate the effects of overweight and obesity on fertility outcomes in IVF procedures.

METHODS

This was a retrospective and nonrandomized study that included 191 IVF/ICSI cycles using non-donor oocytes performed between July 2016 and December 2018 that were allocated according to Body Mass Index (BMI) in three groups: Normal group: 18.5-24.9 (n=67 women), Overweight group: 25.0-29.9 (n=86 women) and Obesity group: ≥30.0 (n=38 women). We compared fertilization rates, embryo quality at day 3, development and quality of blastocyst, pregnancy rates, implantation rates, and live birth rates.

RESULTS

Patients from all groups had similar stimulation days, but those women with overweight and obesity used more hormones compared to women with normal weight (p<0.05). Fertilization rates, zygotes that underwent cleavage and good-quality embryos at Day 3 were similar between the three evaluated groups. The groups of overweight and obesity had embryos at Day 3 with significantly less cells, compared to those from the normal group (p<0.05). The blastocyst development rate was significantly lower in women with overweight and obesity compared to women with normal BMI (p<0.05); but, the percentages of good blastocysts were similar in all studied patients. Pregnancy, implantation and live birth rates were significantly lower in the group of women with overweight and obesity, compared to those women with normal weight (p<0.05). Obese women had significantly more miscarriages compared to those in the other groups (p<0.05).

CONCLUSIONS

Our data shows that an increased BMI affects embryo development and significantly reduces the pregnancy, implantation and live birth rates.

The diagnosis of Gestational Diabetes Mellitus and its impact on In Vitro Fertilization pregnancies. A pilot study

BACKGROUND

In Vitro Fertilization (IVF) is increasingly becoming a necessary mode of reproduction. This high risk group is prone to Gestational Diabetes Mellitus (GDM) which further exposes these pregnancies to an increased risk of adverse outcomes. In light of the limited data in the current literature, further investigation is needed regarding the time of GDM diagnosis in IVF pregnancies as well as the outcome of IVF pregnancies complicated by GDM.

METHODS

In this three center pilot cross sectional study, the data of 101 singleton IVF pregnancies complicated by GDM were analyzed. Prompt GDM diagnosis in IVF pregnancies was accomplished by self-blood glucose monitoring (SMBG) from the first antenatal visit and confirmed by an OGTT. To evaluate pregnancy outcome, maternal and fetal complications in the 101 GDM IVF group was compared to 101 IVF as well as 101 spontaneous conceptions (SC). The three groups were matched by age. The effect of demographic and glycemic parameters on the outcome of GDM IVF pregnancies was investigated.

RESULTS

GDM diagnosis was made before the 24th week in 37.6% of the GDM IVF group. The week of delivery was earlier for the GDM IVF group (37 ± 1.7) relative to the IVF (37.9 ± 0.9, p < 0.001) and the SC group (38.1 ± 0.8, p < 0.001). GDM IVF pregnancies exhibited greater preeclampsia rates and 84.8% underwent caesarian section. No significant difference regarding LGA and SGA birth weights was found. Complications of GDM IVF pregnancies were associated with the 1-h postprandial BG (r = 0.267, p = 0.007).

CONCLUSION

GDM screening in IVF pregnancies may be considered earlier than the 24th week. IVF pregnancies affected by GDM are prone to increased maternal and fetal complications which are associated with 1-h postprandial BG.

Predictors of pregnancy after intrauterine insemination in women with polycystic ovary syndrome

Objective

To evaluate the effects of body mass index (BMI) in patients with polycystic ovary syndrome (PCOS) undergoing controlled ovarian stimulation (COS) with intrauterine insemination (IUI).

Methods

This retrospective study evaluated couples with PCOS undergoing COS and IUI. The relationship between cumulative IUI pregnancy outcomes and BMI, treatment cycles, treatment schemes, number of dominant follicles, endometrial thickness, infertility duration and type of infertility was analysed.

Results

The study evaluated 831 IUI cycles in 451 couples with PCOS. Compared with normoweight women, overweight and obese women required more human menopausal gonadotropin (hMG) doses and more days of COS. Gestational diabetes mellitus occurred more frequently in the obese group than in the other BMI groups. The clinical pregnancy and live birth rates in the hMG, clomiphene citrate (CC) + hMG and letrozole (LE) + hMG groups were significantly higher than those in the CC and LE groups. The clinical pregnancy rate was higher in the secondary infertility group compared with the primary infertility group.

Conclusion

Obese women might require more hMG doses and more days of COS to overcome the effects of weight. As BMI increases, the incidence of gestational diabetes might also increase. The number of cycles and type of infertility may have a predictive value for pregnancy outcomes.

Response to ovulation induction treatments in women with polycystic ovary syndrome as a function of serum anti-Müllerian hormone levels

PURPOSE

To assess whether anti-Müllerian hormone (AMH) can predict response to ovulation induction (OI) with clomiphene citrate (CC), letrozole (LET), or follicle-stimulating hormone (FSH) in women with polycystic ovary syndrome (PCOS) undergoing OI/intrauterine inseminations (IUI).

METHODS

A total of 738 OI/IUI cycles from 242 patients at an academic center were stratified in three groups by medication: CC (n = 295), LET (n = 180), and FSH (n = 263), in a retrospective fashion. Ovarian response to treatment (RT, development of at least one dominant follicle) was assessed using mixed effects logistic regression models.

RESULTS

Overall, RT cycles had lower AMH levels compared to no-RT cycles (p < 0.001). This finding persisted when analysis was limited to oral agents but attenuated in FSH cycles. For CC and LET cycles, the predicted probability (PProb) for RT decreased as AMH levels increased (PProb (95%CI): 97% (93-100), 79% (70-88), and 75% (61-89); 85% (78-93), 75% (67-83), and 73% (63-86) for AMH pct.: ≤ 25th, ≥ 50th, and ≥ 75th, for CC and LET, respectively)). However, RT was noted in 98.5% of FSH/IUI cycles regardless of AMH. For CC cycles, those with AMH ≥ 75th pct. had lower odds for RT over cycles with AMH < 75th pct. (OR 0.2, 95%CI 0.04-0.8, p = 0.02). Similarly, lower odds for RT were observed in LET cycles with AMH ≥ 75th pct. (0.6, 0.3-1.4, p = 0.25).

CONCLUSION

In PCOS, increasing serum AMH levels are associated with lower probability of RT to oral agents. Our findings constitute a valuable tool for the clinician when counseling PCOS patients and designing a personalized ovulation induction treatment strategy.

Revisiting the Impact of Local Leptin Signaling in Folliculogenesis and Oocyte Maturation in Obese Mothers

The complex nature of folliculogenesis regulation accounts for its susceptibility to maternal physiological fitness. In obese mothers, progressive expansion of adipose tissue culminates with severe hyperestrogenism and hyperleptinemia with detrimental effects for ovarian performance. Indeed, maternal obesity is associated with the establishment of ovarian leptin resistance. This review summarizes current knowledge on potential effects of impaired leptin signaling throughout folliculogenesis and oocyte developmental competence in mice and women.

Pretreatment antimüllerian hormone levels and outcomes of ovarian stimulation with gonadotropins/intrauterine insemination cycles

OBJECTIVE

To evaluate the association, if any, between serum antimüllerian hormone (AMH) levels and probability of clinical pregnancy and spontaneous abortion (SAB) in the infertility setting.

DESIGN

Retrospective cohort study.

SETTING

Academic fertility center.

PATIENT(S)

A total of 1,861 gonadotropin stimulation/intrauterine insemination cycles stratified by AMH levels into 3 groups: Low, <25th percentile (<0.7 ng/mL); Middle, ≥25th and <75th percentile (0.7-4.4 ng/mL); and High, ≥75th percentile (≥4.5 ng/mL).

INTERVENTION(S)

Intrauterine insemination after stimulation with gonadotropins.

MAIN OUTCOME MEASURE(S)

Cumulative probability of clinical pregnancy over a maximum of 3 and/or 6 cycles and SAB incidence risk rate (IRR). The Kaplan-Meier failure function (log rank test), Cox proportional hazards models, and multilevel mixed-effects Poisson regression models were performed to compare outcomes among the AMH groups.

RESULT(S)

Overall, in both unadjusted and adjusted models, the probability of achieving a clinical pregnancy was higher in the Middle and High AMH groups compared with that in the Low AMH group, both over 3 (hazard ratios [95% confidence interval], 1.55 [1.05-2.29] and 1.85 [1.22-2.81], respectively) and 6 (1.71 [1.17-2.48] and 2.12 [1.42-3.16], respectively) cycles. In the unadjusted models, the SAB IRR was higher among the Low AMH group (IRR [95% confidence interval], 2.17 (1.11-4.24]), with the relationship persisting after adjusting for age (1.83 [0.93-3.60]). When the SAB IRR were calculated separately for the subpopulations with and without polycystic ovary syndrome, a similar relationship was noted among the latter in the unadjusted (1.94 [0.97-3.88]) and adjusted (1.74 [0.86-3.49]) analyses.

CONCLUSION(S)

In women undergoing gonadotropin stimulation/intrauterine insemination, AMH appears to affect the probability of achieving a clinical pregnancy. A possible negative impact, independent of age, on the risk of SAB was also suggested.

DNA Fragmentation in Human Spermatozoa and Pregnancy Rates after Intrauterine Insemination. Should the DFI Threshold Be Lowered?

Sperm DNA fragmentation index (DFI) can be analyzed by a flow cytometric assay after treatment with acid and acridine orange. In this prospective, cohort study, the value of DFI was determined in a semen analysis collected before fertility treatment (baselineDFI) in 146 couples and during 1–3 intrauterine inseminations (IUI) in 211 couples (511 cycles). The pregnancy rate (PR)/cycle was 9.9% if baselineDFI was >10 and 21.7% if baselineDFI was ≤10, (p < 0.005). The live birth rate (LBR)/cycle was 5% if baselineDFI was >10 and 14.2% if baselineDFI was ≤10 (p < 0.005). PR/patient was 23.1% if baselineDFI was >10 and 45.5% if baselineDFI was ≤10 (p < 0.005). LBR/patient was 12.4% if baselineDFI was >10 and 34% if baselineDFI was ≤10 (p < 0.005). When isolating non-stimulated IUI cycles and couples with female age < 35, a significant difference in PR and LBR between couples with high DFI and low DFI was seen. Results suggest that DFI > 10 could advice against timed coitus and non-stimulated IUI cycles. Analysis for DFI performed before treatment provides information about PR and LBR after IUI.

Clarifying the relationship between total motile sperm counts and intrauterine insemination pregnancy rates

OBJECTIVE

To study the relationship between postwash total motile sperm count (TMSC) and intrauterine insemination (IUI) outcomes.

DESIGN

Retrospective review SETTING: Large fertility clinic PATIENT(S): A total of 92,471 insemination cycles from 37,553 patients were included in this study.

INTERVENTION(S)

All stimulated clomiphene citrate, letrozole, and/or injectable gonadotropin IUI cycles performed at a single institution from 2002 through 2018 were reviewed. Generalized estimating equations (GEE) analysis was used to account for multiple cycles by individual patients and to adjust for female partner age, body mass index, and stimulation protocol.

MAIN OUTCOME MEASURE(S)

Successful clinical pregnancy was defined as ultrasound confirmation of an intrauterine gestational sac with fetal cardiac activity.

RESULT(S)

A total of 92,471 insemination cycles were available to evaluate the relationship between postwash TMSC and clinical pregnancy. Pregnancy rates were highest with TMSC of ≥9 × 10⁶ and declined gradually as TMSC decreased. Complete data for the adjusted GEE analysis were available for 62,758 cycles. Adjusted GEE analysis among cycles with TMSC of ≥9 × 10⁶ (n = 46,557) confirmed that TMSC in this range was unrelated to pregnancy. Conversely, TMSC was highly predictive of pregnancy (Wald χ² = 39.85) in adjusted GEE analysis among cycles with TMSC of <9 × 10⁶ (n = 16,201), with a statistically significant decline.

CONCLUSIONS

IUI pregnancy is optimized with TMSC of ≥9 × 10⁶, below which the rates gradually decline. Although rare, pregnancies were achieved with TMSC of <0.25 × 10⁶. Since the decline in pregnancy is gradual and continuous, there is no specific threshold above which IUI should be recommended. Rather, these more specific quantitative predictions can be used to provide personalized counseling and guide clinical decision making.

Predictive factors for intrauterine insemination outcomes: a review

PURPOSE

Intrauterine insemination (IUI) is a frequently utilized method of assisted reproduction for patients with mild male factor infertility, anovulation, endometriosis, and unexplained infertility. The purpose of this review is to discuss factors that affect IUI outcomes, including infertility diagnosis, semen parameters, and stimulation regimens.

METHODS

We reviewed the published literature to evaluate how patient and cycle specific factors affect IUI outcomes, specifically clinical pregnancy rate, live birth rate, spontaneous abortion rate and multiple pregnancy rate.

RESULTS

Most data support IUI for men with a total motile count > 5 million and post-wash sperm count > 1 million. High sperm DNA fragmentation does not consistently affect pregnancy rates in IUI cycles. Advancing maternal and paternal age negatively impact pregnancy rates. Paternal obesity contributes to infertility while elevated maternal BMI increases medication requirements without impacting pregnancy outcomes. For ovulation induction, letrozole and clomiphene citrate result in similar pregnancy outcomes and are recommended over gonadotropins given increased risk for multiple pregnancies with gonadotropins. Letrozole is preferred for obese women with polycystic ovary syndrome. IUI is most effective for women with ovulatory dysfunction and unexplained infertility, and least effective for women with tubal factor and stage III-IV endometriosis. Outcomes are similar when IUI is performed with ovulation trigger or spontaneous ovulatory surge, and ovulation may be monitored by urine or serum. Most pregnancies occur within the first four IUI cycles, after which in vitro fertilization should be considered.

CONCLUSIONS

Providers recommending IUI for treatment of infertility should take into account all of these factors when evaluating patients and making treatment recommendations.

A patient-specific model combining antimüllerian hormone and body mass index as a predictor of polycystic ovary syndrome and other oligo-anovulation disorders

OBJECTIVE

To determine whether a patient-specific predictive model combining antimüllerian hormone (AMH) levels and body mass index (BMI) can aid in the diagnosis of polycystic ovary syndrome (PCOS) and other ovulatory dysfunction disorders (OVDYS) among infertile women.

DESIGN

Retrospective cohort study.

SETTING

Academic fertility center.

PATIENT(S)

One thousand and ten infertile women undergoing 3,160 intrauterine insemination (IUI) cycles, stratified by diagnosis in three groups: PCOS, OVDYS, and other etiologies.

INTERVENTION(S)

Ovulation induction followed by IUI or ultrasound-monitored natural cycles.

MAIN OUTCOME MEASURE(S)

The probability of either PCOS or OVDYS diagnosis based on AMH levels alone and a patient-specific predictive model that combines serum AMH and patient's BMI.

RESULT(S)

Median and interquartile range (IQR) for the serum AMH levels (ng/mL) were the highest in women with PCOS, and lowest in those with other infertility causes. Overall, for every 1 ng/mL increase in AMH, the odds of PCOS and OVDYS versus other causes increased by 55% and 24%, respectively. Postestimation from multivariate logistic regression models showed that PCOS diagnosis can be predicted with lower AMH values in women with a higher BMI compared with the AMH values predicting PCOS in normal-weight or underweight patients. The receiver operating characteristic curves reinforced these findings, and the best cutoffs for PCOS diagnosis were 7.5, 4.4, and 4.1 ng/mL for women belonging to the BMI groups 18.5-24.9, 25.0-29.9, and ≥30.0 kg/m², respectively.

CONCLUSION(S)

Taking into account AMH and BMI, we developed a model that predicts the probability of an oligo-anovulation diagnosis, thus facilitating patient-specific counseling in the infertility setting.

Effect of body mass index on intrauterine insemination cycle success

OBJECTIVE

To determine whether body mass index (BMI) affects intrauterine insemination treatment success.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

A total of 3,217 intrauterine insemination treatment cycles in 1,306 patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary outcome was live birth rate stratified by BMI. Secondary outcomes included rates of clinical pregnancy (defined as an intrauterine pregnancy with a heartbeat present on ultrasound), multiple gestation, biochemical pregnancy, missed abortion, ectopic, and spontaneous abortion.

RESULT(S)

Women with BMI 25 to 29.99 kg/m² or ≥30 kg/m² were equally likely to have a live birth as women of normal BMI. Women with BMI ≥30 kg/m² did have a higher likelihood of biochemical pregnancy than women with normal BMI.

CONCLUSION(S)

A BMI between 25 and 29.99 kg/m² or ≥30 kg/m² does not appear to have a negative effect on live birth after intrauterine insemination. Obesity may be associated with a higher risk of biochemical pregnancy after intrauterine insemination.

Effects of a high-fat diet on the lipid profile of oocytes in mice

Существуют предпосылки того, что у женщин с ожирением возможно снижение качества ооцитов. При этом остается неясным, как связано это изменение с ожирением: опосредованно или напрямую, че- рез изменение содержания и/или состава липидов в ооцитах. Целью настоящей работы было изучение на мышах влияния богатой жирами диеты, применяемой к самкам-донорам, на качественный состав и общее количество липидов в незрелых и созревших in vivo ооцитах. Установлено, что диета, богатая липидами, при- водит к увеличению массы тела самок мышей по сравнению с контролем ( p < 0.001; 44.77 ± 1.46 и 35.22 ± 1.57 соответственно), а также уровня холестерина ( p < 0.05; 2.06 ± 0.10 и 1.78 ± 0.10 соответственно) и триглицери- дов ( p < 0.05; 2.13 ± 0.23 и 1.49 ± 0.21 соответственно) в крови этих животных. Эта диета не повлияла на степень ненасыщенности внутриклеточных липидов незрелых (0.207 ± 0.004 в эксперименте и 0.206 ± 0.002 в контроле) и зрелых ооцитов (0.212 ± 0.005 в эксперименте и 0.211 ± 0.003 в контроле). При созревании ооцитов in vivo на- блюдалось возрастание содержания внутриклеточных липидов. В зрелых ооцитах количество липидов было больше в экспериментальной группе по сравнению с контролем ( p < 0.01; 8.15 ± 0.37 и 5.83 ± 0.14 соответствен- но). Выявлено увеличение количества внутриклеточных липидов при созревании ооцитов как после стан- дартной диеты ( p < 0.05; 4.72 ± 0.48 и 5.83 ± 0.14 соответственно), так и после диеты, богатой жирами ( p < 0.001; 3.45 ± 0.62 и 8.15 ± 0.37 соответственно). Таким образом, при созревании ооцитов мышей in vivo возрастает со- держание внутриклеточных липидов, богатая жирами диета приводит к повышенному содержанию липидов в зрелых ооцитах.

Effects of twice daily compared with split-time estrous detection on pregnancy percentage in recipient beef cows

Objectives were to compare pregnancy percentages per embryo transfer (P/ET) in recipient beef cows following twice daily compared with split-time estrous detection and to determine associations of dominant follicle diameter, CL volume and progesterone concentrations. All cows (n = 695) were treated to synchronize time of estrus among cows using a CIDR + Select-Synch treatment regimen and randomly assigned to twice-daily or split-time estrous detection (CS-DEET or CS-SEET, respectively). Cows in the CS-DEET group were observed twice daily (eight times) for estrus until 96 h after the time of PGF2α administration, whereas cows in the CS-SEET group were observed twice (64 and 84 h after PGF2α). In 280 recipient cows, blood sampling (for progesterone) and ultrasonographic assessment of dominant follicle diameter were conducted 48 h after the time of PGF2α administration. At 7 d after estrus, the CL was imaged and there was transfer of a frozen-thawed embryo into cows with a CL ≥ 1.5 cm. There were positive correlations between follicle diameter and CL volume (r_s = 0.827; P < 0.001) and CL volume and progesterone concentration (r_s = 0.680; P < 0.001). Progesterone and CL volume differed between cows in CS-SEET and CS-DEET groups P < 0.05), however, percentage P/ET for cows in the CS-SEET and CS-DEET groups did not differ (P > 0.1). Dominant follicle diameter, CL volume and progesterone concentrations were greater in pregnant compared with nonpregnant cows. In conclusion, percentage P/ET did not differ when there was twice daily and split-time estrous detection highlighting the value of this approach in beef enterprises.

Fertility preservation outcomes in women with gliomas: a retrospective case-control study

PURPOSE

With advances in cancer therapy, reproductive-aged women can look forward to a life post-malignancy. Fortunately, fertility preservation (FP) may provide relief from potential infertility caused by cancer or associated caustic treatments. Outcomes of FP in pre-treatment reproductive-aged women with gliomas have not been previously characterized.

METHODS

Between 2007 and 2018, 10 patients undergoing FP prior to chemotherapy and/or radiation treatment for gliomas were identified at Brigham and Women's Hospital. They were matched 3:1 to male-factor infertility patients by age ± 1 year.

RESULTS

Patients with gliomas had significantly lower baseline anti-Müllerian hormone levels than male-factor infertility controls (2.37 vs 5.16 ng/mL, p = 0.002, log transformed). Despite higher starting (350 vs. 240 IU, p = 0.004) and total gonadotropin doses (4270 vs. 2270 IU, p < 0.001) over a similar stimulation duration (12.1 vs. 11.1 days, p = 0.219), cancer patients had lower peak estradiol levels (1420 vs. 2245 pg/mL, p = 0.003). The total number of follicles on the day of trigger (14.1 vs. 15.6, p = 0.284), the number of oocytes retrieved (18.4 vs. 20.5, p = 0.618), and the percentage of mature oocytes (69.9 vs. 73.8%, p = 0.076) were similar between cases and controls. One patient returned for a cryopreserved embryo transfer and delivered a healthy child.

CONCLUSIONS

Patients undergoing FP prior to chemotherapy and/or radiation for a glioma achieve satisfactory FP outcomes and should be appropriately counseled regarding the opportunity to family-build after treatment.

The impact of male factor infertility on early and late morphokinetic parameters: a retrospective analysis of 4126 time-lapse monitored embryos

STUDY QUESTION

Is there an effect of male factor infertility (MFI) on either early or late morphokinetic parameters obtained during embryonic culture to blastocyst stage in a time-lapse imaging (TLI) incubator?

SUMMARY ANSWER

Neither mild nor severe MFI had an impact on overall time to blastocyst or duration of individual cleavage stages in the total embryo population.

WHAT IS KNOWN ALREADY

Prior studies have suggested that paternal DNA and sperm quality affect embryo morphokinetic parameters, but the impact of MFI is not fully understood.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study, at a major academic fertility centre, included 536 couples (women, ≤44 years of age) undergoing IVF between September 2013 and September 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data from 4126 embryos cultured to the blastocyst stage in a TLI-monitored incubator were retrospectively reviewed. Embryos derived from the sperm of men with MFI were compared with those derived from patients with other infertility diagnoses. Generalized fixed and random effects models, t-test and χ2 were used as appropriate.

MAIN RESULTS AND THE ROLE OF CHANCE

Couples with MFI had a higher rate of ICSI utilization and fewer usable embryos on average, and the men were older compared with couples with other diagnoses. Additionally, the women in MFI couples were younger and had higher antral follicle counts (AFCs) and higher anti-Müllerian hormone (AMH) levels compared with the other women undergoing IVF. When controlling for maternal and paternal ages, AMH and fertilization method (conventional IVF versus ICSI), neither mild nor severe MFI affected duration of individual cleavage stages or overall time to the blastocyst stage, when all or only usable embryos were examined (coefficient 0.44 hours in all embryos, P = 0.57; coefficient 0.39 hours in usable embryos, P = 0.60). Whether the sperm was surgically extracted similarly had no significant effect on embryo morphokinetic parameters. When the fertilization method was assessed independently, ICSI lengthened the overall time to blastocyst stage by 1.66 hours (P = 0.03) on average, primarily due to an increase in duration of the time from 5-cell embryo stage to early blastulation (P5SB).

LIMITATIONS, REASONS FOR CAUTION

This large cohort study avoided embryo selection bias due to random assignment of embryos to the TLI incubators. However, our findings may not be generalizable to groups under-represented in our clinic population. Future studies should also evaluate the impact of male hormonal status and detailed sperm morphology, such as head versus flagellum defects, on embryo morphokinetic development.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings suggest that the fertilization method rather than MFI per se impacts time to early blastulation. The clinical implications of this effect on embryo development warrant further investigation.

STUDY FUNDING/COMPETING INTEREST(S)

There were no sources of funding for this study. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A

Effects of Obesity and Thrombophilia on the Risk of Abortion in Women Undergoing In Vitro Fertilization

INTRODUCTION

Obesity is associated with a higher risk of abortion in women undergoing in vitro fertilization (IVF). Whether thrombophilia amplifies this risk is currently unclear. The aim of this study was to evaluate the effects of thrombophilia on the risk of abortion in obese women treated with IVF.

METHODS

Patient characteristics, presence of inherited or acquired thrombophilia, and comorbidities were prospectively collected before the procedure in consecutive women undergoing IVF. The primary outcome was the incidence of abortion among women who achieved a clinical pregnancy.

RESULTS

A total of 633 non-obese and 49 obese Caucasian women undergoing IVF were included. 204 (32%) women achieved clinical pregnancy, of whom six had an ectopic pregnancy and 63 experienced an abortion. The incidence of abortion was higher in obese women compared to non-obese women after adjusting for age (64.3% vs. 29.3%, odds ratio [OR] 4.41; 95% CI 1.41 to 13.81). Women with one or more thrombophilia were at increased risk of abortion relative to those without thrombophilia (OR 2.70; 95% CI 1.34 to 5.45), and the risk seemed to be higher with hereditary (OR 5.12; 95% CI 1.77 to 14.8) than acquired thrombophilia (OR 1.92; 95% CI 0.52 to 5.12; p for interaction 0.194). Among obese women, the presence of one or more thrombophilia seemed associated with a substantially increased risk of abortion (unadjusted OR 14.00; 95% CI 0.94 to 207.6).

CONCLUSIONS

Obese women undergoing IVF have a high risk of abortion which seems further amplified by the concomitant presence of thrombophilia.

Obesity and Reproduction

OBJECTIVE

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

OUTCOMES

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

EVIDENCE

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

VALUES

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

BENEFITS, HARMS, AND COSTS

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

VALIDATION

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

SPONSORS

Canadian Fertility & Andrology Society.

RECOMMENDATIONS

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

Vitamin D and Obesity: Two Interacting Players in the Field of Infertility

Obesity plays an important role in human fertility in both genders. The same is true for vitamin D, for which accumulating evidence from observational human studies suggests a key role for both male and female fertility. In the latter case, however, robust data from relevant interventional studies are currently lacking. It is also not clear whether obesity and vitamin D deficiency, besides their independent effect on human infertility, act in synergy. Several pathogenetic mechanisms may be proposed as a linkage between vitamin D deficiency and obesity, with respect to infertility. In any case, the independent contribution of vitamin D deficiency in obese infertile states needs to be proven in interventional studies focusing on either vitamin D supplementation in obese or weight loss strategies in vitamin D-deficient infertile patients.

PGR and PTX3 gene expression in cumulus cells from obese and normal weighting women after administration of long-acting recombinant follicle-stimulating hormone for controlled ovarian stimulation

PURPOSE

The present study aimed to determine clinical IVF parameters and gene expression in cumulus cells (CCs) in obese and normal weighting women after administration of 150 mcg of corifollitropin alfa for controlled ovarian hyperstimulation (COH).

METHODS

150 mcg of corifollitropin alfa and gonadotropin releasing hormone antagonist were used for COH. Analysis of CC gene expression was performed using quantitative real-time PCR.

RESULTS

We did not find significant differences in biochemical and clinical pregnancy rates between obese and normal weighting women. Obese women required twice as much of additional gonadotropins for ovarian stimulation and had a significantly lower proportion of good quality embryos on day 5 of IVF cycle. Expression of PGR and PTX3 was significantly higher in CCs of obese women.

CONCLUSION

Obese women require significantly larger amounts of gonadotropins to achieve similar IVF success rates as normal weighting women. Differences in CC gene expression and smaller proportion of good quality embryos may imply that oocytes derived from obese women are of lower quality. Further studies are needed to evaluate whether obesity itself or the higher amount of gonadotropins used in obese women causes this effect.

IUI: review and systematic assessment of the evidence that supports global recommendations

BACKGROUND

IUI with or without ovarian stimulation (OS) has become a first-line treatment option for many infertile couples, worldwide. The appropriate treatment modality for couples and their clinical management through IUI or IUI/OS cycles must consider maternal and perinatal outcomes, most notably the clinical complication of higher-order multiple pregnancies associated with IUI-OS. With a current global emphasis to continue to decrease maternal and perinatal mortality and morbidity, the World Health Organization (WHO) had established a multi-year project to review the evidence for the establishment of normative guidance for the implementation of IUI as a treatment to address fertility problems, and to consider its cost-effectiveness for lower resource settings.

OBJECTIVE AND RATIONALE

The objective of this review is to provide a review of the evidence of 13 prioritized questions that cover IUI with and without OS. We provide summary recommendations for the development of global, evidence-based guidelines based upon methodology established by the WHO.

SEARCH METHODS

We performed a comprehensive search using question-specific relevant search terms in May 2015. For each PICO (Population, Intervention, Comparison and Outcomes) drafted by WHO, specific search terms were used to find the available evidence in MEDLINE (1950 to May 2015) and The Cochrane Library (until May 2015). After presentation to an expert panel, a further hand search of references in relevant reviews was performed up to January 2017. Articles that were found to be relevant were read and analysed by two investigators and critically appraised using the Cochrane Collaboration's tool for assessing risk of bias, and AMSTAR in case of systematic reviews. The quality of the evidence was assessed using the GRADE system. An independent expert review process of our analysis was conducted in November 2016.

OUTCOMES

This review provides an assessment and synthesis of the evidence that covers 13 clinical questions including the indications for the use of IUI versus expectant management, the sperm parameters required, the best and optimal method of timing and number of inseminations per cycle, prevention strategies to decrease multiple gestational pregnancies, and the cost-effectiveness of IUI versus IVF. We provide an evidence-based formulation of 20 recommendations, as well as two best practice points that address the integration of methods for the prevention of infection in the IUI laboratory. The quality of the evidence ranges from very low to high, with evidence that may be decades old but of high quality, however, we further discuss where critical research gaps in the evidence remain.

WIDER IMPLICATIONS

This review presents an evidence synthesis assessment and includes recommendations that will assist health care providers worldwide with their decision-making when considering IUI treatments, with or without OS, for their patients presenting with fertility problems.

The effect of day 2 versus day 3 embryo transfer on early pregnancy outcomes in women with a low yield of fertilized oocytes

PURPOSE

To evaluate the differences in implantation and pregnancy rates when embryo transfer occurs on D2 versus D3 in women with a low yield of fertilized oocytes.

METHODS

A total of 156 IVF/ICSI cycles from 141 women at an academic fertility center were analyzed in a retrospective fashion. Women with a low number of fertilized oocytes (≤ 2 two pronuclei (2PN) stage zygotes) who had their fresh embryo transfer on D2 or D3 were included in the study. Positive pregnancy test per IVF cycle (PPT), clinical pregnancy rate (CPR), spontaneous abortion rate (SABR), and implantation rate (IMPR) were the main outcome measures assessed. Mann-Whitney U test and χ² test were used as appropriate. A generalized linear mixed effect model adjusted for relevant covariates was conducted. P < 0.05 was considered significant.

RESULTS

Patients having their embryo transfer on D2, when compared to those who had a D3 embryo transfer, experienced similar PPT [30.8 vs. 28.2%, respectively; adjusted OR (95%CI): 0.49 (0.16, 1.52)], CPR [26.9 vs. 25.6%, respectively; adjusted OR (95%CI): 0.44 (0.12, 1.67)], and IMPR [17.3 vs. 16.7%, respectively; adjusted β (95%CI) - 5.6% (- 15.0, 3.9)].

CONCLUSION

Our findings suggest that transferring embryos on D2 versus D3 in women with a limited number of 2PN stage zygotes does not affect early pregnancy outcomes. These results indicate that there can be some flexibility in scheduling the day of transfer at the convenience of both the patient and the center.

The role of female obesity on in vitro fertilization outcomes

The aim of this review is to analyze the role of obesity on fertility outcome in women undergoing in vitro fertilization (IVF) with respect to clinical or live birth rates and pregnancy loss rates. Despite findings from several earlier and newer studies that obesity does not adversely affect pregnancy outcome in women attempting conception, numerous reports from mostly recent studies suggest that obesity undoubtedly impairs IVF outcomes. Obesity impairs ovarian responsiveness to gonadotrophin stimulation, requiring higher doses of medication, increased risk of cycle cancelation, pre-term delivery, low birth weight or miscarriage, and decreases implantation, clinical pregnancy or live birth rates compared to women of normal weight. The mechanisms underlying the adverse effects of female obesity on IVF outcome may be primarily explained by functional alterations to the hypothalamic-pituitary-ovarian axis. Additionally, obesity appears to affect deleteriously the number and quality of oocytes or embryos, and impairs endometrial decidualization which is necessary for uterine receptivity. Nevertheless, attaining normal body weight by the use of lifestyle modifications, including a healthy diet and exercise over time of several months before and during an IVF treatment, may be successful in achievement of gradual and sustainable weight loss with improvement of IVF outcome.

Should we continue to measure endometrial thickness in modern-day medicine? The effect on live birth rates and birth weight

The evaluation of endometrial thickness (EMT) is still part of standard cycle monitoring during IVF, despite the lack of robust evidence of any value of this measurement to predict little revalidation in contemporary medical practice; other tools, however, such as endocrine profile monitoring, have become increasingly popular. The aim of this study was to reassess whether EMT affects the outcome of a fresh embryo transfer in modern-day medicine, using a retrospective, single-centre cohort of 3350 IVF cycles (2827 women) carried out between 2010 and 2014. In the multivariate regression analysis, EMT was non-linearly associated with live birth, with live birth rates being the lowest with an EMT less than 7.0 mm (21.6%; P < 0.001) and then between 7.0 mm and 9.0 mm (30.2%; P = 0.008). An EMT less than 7.0 mm was also associated with a decrease in neonatal birthweight z-scores (-0.40; 95% CI -0.69 to -0.12). In conclusion, these results reaffirm the use of EMT as a potential prognostic tool for live birth rates and neonatal birthweight in contemporary IVF, namely when considered together with other ovarian stimulation monitoring methods, such as the late-follicular endocrine profile.

Effect of Gonadotropin Types and Indications on Homologous Intrauterine Insemination Success: A Study from 1251 Cycles and a Review of the Literature

Objective

To evaluate the IUI success factors relative to controlled ovarian stimulation (COS) and infertility type, this retrospective cohort study included 1251 couples undergoing homologous IUI.

Results

We achieved 13% clinical pregnancies and 11% live births. COS and infertility type do not have significant effect on IUI clinical outcomes with unstable intervention of various couples' parameters, including the female age, the IUI attempt rank, and the sperm quality.

Conclusion

Further, the COS used seemed a weak predictor for IUI success; therefore, the indications need more discussion, especially in unexplained infertility cases involving various factors. Indeed, the fourth IUI attempt, the female age over 40 years, and the total motile sperm count <5 × 10⁶ were critical in decreasing the positive clinical outcomes of IUI. Those parameter cut-offs necessitate a larger analysis to give infertile couples more chances through IUI before carrying out other ART techniques.

Deletion of Suppressor of Cytokine Signaling 3 from Forebrain Neurons Delays Infertility and Onset of Hypothalamic Leptin Resistance in Response to a High Caloric Diet

The cellular processes that cause high caloric diet (HCD)-induced infertility are poorly understood but may involve upregulation of suppressor of cytokine signaling (SOCS-3) proteins that are associated with hypothalamic leptin resistance. Deletion of SOCS-3 from brain cells is known to protect mice from diet-induced obesity, but the effects on HCD-induced infertility are unknown. We used neuron-specific SOCS3 knock-out mice to elucidate this and the effects on regional hypothalamic leptin resistance. As expected, male and female neuron-specific SOCS3 knock-out mice were protected from HCD-induced obesity. While female wild-type mice became infertile after 4 months of HCD feeding, infertility onset in knock-out females was delayed by 4 weeks. Similarly, knock-out mice had delayed leptin resistance development in the medial preoptic area and anteroventral periventricular nucleus, regions important for generation of the surge of GnRH and LH that induces ovulation. We therefore tested whether the suppressive effects of HCD on the estradiol-induced GnRH/LH surge were overcome by neuron-specific SOCS3 knock-out. Although only 20% of control HCD-mice experienced a preovulatory-like LH surge, LH surges could be induced in almost all neuron-specific SOCS3 knock-out mice on this diet. In contrast to females, HCD-fed male mice did not exhibit any fertility decline compared with low caloric diet-fed males despite their resistance to the satiety effects of leptin. These data show that deletion of SOCS3 delays the onset of leptin resistance and infertility in HCD-fed female mice, but given continued HCD feeding this state does eventually occur, presumably in response to other mechanisms inhibiting leptin signal transduction.

SIGNIFICANCE STATEMENT

Obesity is commonly associated with infertility in humans and other animals. Treatments for human infertility show a decreased success rate with increasing body mass index. A hallmark of obesity is an increase in circulating leptin levels; despite this, the brain responds as if there were low levels of leptin, leading to increased appetite and suppressed fertility. Here we show that leptin resistant infertility is caused in part by the leptin signaling molecule SOCS3. Deletion of SOCS3 from brain neurons delays the onset of diet-induced infertility.

EFFECT OF INSULIN RESISTANCE ON THE OCCURRENCE OF PREGNANCY IN WOMEN TREATED EMPIRICALLY FOR UNEXPLAINED INFERTILITY

Context

The detrimental effects of hyperinsulinemia on human ovaries during follicular development process have been shown in various studies, particularly in women with polycystic ovary syndrome. To our knowledge there is no study regarding the effect of insulin resistance (IR) on the intrauterine insemination (IUI) success in women with unexplained infertility (UEI).

Objective

To evaluate the effects of IR on the occurrence of pregnancy among infertile women undergoing ovulation induction (OI) with IUI for UEI.

Design

Prospective cohort study.

Subjects and Methods

173 patients who met the criteria for UEI and under the age of 35 were included in this study. All women underwent OI with IUI and, subsequently, they were divided into two groups based on the presence of pregnancy. Data reviewed for analysis were demographic, clinical, and laboratory features.

Results

There were 37 (21.4%) cycles with pregnancy and 136 (78.6%) cycles without pregnancy. Median infertility duration was significantly lower in the pregnant group when compared with non-pregnants (p=0.018). The mean number of previous cycles per patient was also lower in this group (p=0.028). No significant differences were found between the groups in terms of other variables. Levels of insulin, fasting glucose and HOMA-IR were also similar between the two groups.

Conclusions

IR calculated by using HOMA-IR index has no positive or negative effect on the occurrence of pregnancy in women undergoing OI therapy with IUI for UEI.