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

The details matter: personalized prediction of live birth after in vitro fertilization in women with polycystic ovary syndrome

OBJECTIVE

To derive and internally validate a clinical prediction model for live birth (LB) in women with polycystic ovary syndrome (PCOS) undergoing in vitro fertilization (IVF).

DESIGN

Retrospective cohort study.

SETTING

Four academic reproductive endocrinology clinics.

PATIENTS

A total of 207 women with PCOS confirmed using Rotterdam criteria undergoing their first fresh IVF cycle.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The primary outcome was cumulative LB per IVF cycle start. This included any LB that resulted from either fresh embryo transfer or any subsequent frozen embryo transfer from embryos obtained at the index oocyte retrieval. A prediction model was derived using multivariable logistic regression. Covariates considered for inclusion in the prediction model included demographic characteristics, medical history, and prior fertility treatment. Predicted probabilities for LB were calculated using the prediction model which included the 90% shrinkage factor for each adjusted odds ratio.

RESULTS

The final model, on the basis of maximization of the area under the receiver operating characteristic curve, included age < 35 years, White race, presence of polycystic ovaries on ultrasound (polycystic ovary morphology), normal body mass index (<25 kg/m2), being metabolically healthy (no metabolic risk factors), and being a nonresponder to ovulation induction agents including letrozole and clomiphene citrate. The area under the receiver operating characteristic curve score for the model was 0.68 (95% confidence interval [CI]: 0.60, 0.77). Predicted probabilities of LB ranged from 8.1% (95% CI: 2.8, 21.5) for a woman who had no favorable predictors to 74.2% (95% CI: 59.5, 84.9) for a woman who had all favorable predictors.

CONCLUSION

Our study demonstrated that, in addition to anovulation, the underlying pathophysiology and associated comorbidities alter the likelihood of a successful pregnancy in women with PCOS undergoing IVF. Further validation of this model is needed before it can serve as a tool to personalize prediction estimates for the probability of LB in women with PCOS.

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

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN, SIZE, DURATION

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

PARTICIPANTS/MATERIALS, SETTING, METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS, REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by a grant from ZonMw, the Dutch Organization for Health Research and Development (50-50110-96-518). The Department of Obstetrics and Gynecology of the UMCG received an unrestricted educational grant from Ferring Pharmaceuticals BV, The Netherlands. A.H. reports consultancy for the development and implementation of a lifestyle App MyFertiCoach developed by Ferring Pharmaceutical Company. All other authors have no conflicts to declare.

TRIAL REGISTRATION NUMBER

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

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.

AI, Borges Jr. E. Beetroot, watermelon and ginger juice supplementation may increase the clinical outcomes of Intracytoplasmic Sperm Injection cycles

OBJECTIVE

To prove the hypothesis that beetroot, watermelon and ginger juice supplementation improves the endometrial receptivity and clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles.

METHODS

This prospective randomized study enrolled 436 female patients undergoing ICSI cycles from January/2018 to June/2021, in a private university-affiliated IVF center. Female patients were randomized in a 1:3 ratio to either Control (n=109) or Supplementation Group (n=327). All patients received nutritional orientation before the beginning of the treatment. Participants in the Supplementation Group were instructed to intake a daily dose of homemade juice, prepared with fresh beetroot, watermelon and ginger, from the day of embryo transfer until the day of pregnancy test, while patients in Control Group did not follow the juice protocol. Generalized Linear Models, adjusted for potential confounders (female age, body mass index - BMI, endometrial thickness upon embryo transfer, and number of transferred embryos), followed by Bonferroni post hoc test for the comparison of means between groups, were used to investigate the impact of juice supplementation on the clinical outcomes of ICSI.

RESULTS

Patients and cycles characteristics were equally distributed among Supplementation and Control groups. Implantation rate (25.2% vs. 20.5%, p<0.001) and clinical pregnancy rate (41.0% vs. 22.0%, p=0.039) were significantly higher in the Supplementation compared to the Control group.

CONCLUSIONS

The use of beetroot, watermelon and ginger juice may be considered a promising strategy for improving clinical outcomes in assisted reproductive technology (ART), without any side effects.

Obesity: A Doorway to a Molecular Path Leading to Infertility

The dramatic rise in obesity has recently made it a global health issue. About 1.9 billion were overweight, and 650 million global populations were obese in 2016. Obese women suffer longer conception time, lowered fertility rates, and greater rates of miscarriage. Obesity alters hormones such as adiponectin and leptin, affecting all levels within the hypothalamic-pituitary-gonadal axis. Advanced glycation end products (AGEs) and monocyte chemotactic protein-1 (MCP-1) are inflammatory cytokines that may play an important role in the pathophysiology of ovarian dysfunction in obesity. In obese males, there are altered sperm parameters, reduced testosterone, increased estradiol, hypogonadism, and epigenetic modifications transmitted to offspring. The focus of this article is on the possible adverse effects on reproductive health resulting from obesity and sheds light on different molecular pathways linking obesity with infertility in both female and male subjects. Electronic databases such as Google Scholar, Embase, Science Direct, PubMed, and Google Search Engine were utilized to find obesity and infertility-related papers. The search strategy is detailed in the method section. Even though multiple research work has shown that obesity impacts fertility in both male and female negatively, it is significant to perform extensive research on the molecular mechanisms that link obesity to infertility. This is to find therapeutics that may be developed aiming at these mechanisms to manage and prevent the negative effects of obesity on the reproductive system.

Worth the wait? Preconception weight reduction in women and men with obesity and infertility: a narrative review

Short and long-term weight reduction interventions are considered in the preconception period for women and men with obesity and infertility as obesity is associated with poorer reproductive outcomes. Short-term weight loss achieved with diet, exercise, and medications does not improve per cycle conception or live birth rates in women undergoing ovulation induction, intrauterine insemination, or in vitro fertilization (IVF), but may increase the rate of natural conception. Long-term weight loss achieved through surgical interventions may increase spontaneous conceptions, particularly among women with polycystic ovary syndrome, and may increase the live birth rate from IVF, though these findings are limited by recent evidence. There is a clear need for additional treatment options and well-designed weight loss intervention trials that address the heterogeneous causes of obesity among women and men with infertility and include fertility outcomes and perinatal morbidity as outcome measures.

Effectiveness of a 6-Month Lifestyle Intervention on Diet, Physical Activity, Quality of Life, and Markers of Cardiometabolic Health in Women with PCOS and Obesity and Non-PCOS Obese Controls: One Size Fits All?

Little is known about the difference in effectiveness of lifestyle intervention between women with PCOS and non-PCOS women. In a post hoc longitudinal analysis of a randomized, controlled trial, we aimed to investigate whether infertile women with PCOS and obesity (N = 87) responded differently to a 6-month lifestyle intervention program than infertile non-PCOS obese controls (N = 172). We evaluated several aspects of the intervention such as changes in diet, physical activity, and dropout rate, as well as the effect on weight, quality of life (QoL), and cardiometabolic outcomes. Multilevel analyses were used, and analyses were adjusted for baseline characteristics such as age, education, and smoking. Although BMI in both groups significantly decreased at 3 months and 6 months, there were no significant differences between the groups at 3 months (adjusted B: −0.3, 95% CI: −0.9 to 0.3, p = 0.35) and 6 months (adjusted B: 0.5, 95% CI: −0.4 to 1.4, p = 0.29). Women with PCOS and non-PCOS women had similar compliance with the lifestyle intervention in terms of actual change in diet and physical activity. Mental QoL scores were not different at either 3 or 6 months. Physical QoL scores were lower in women with PCOS compared with non-PCOS women at 3 months (adjusted B: −2.4, 95% CI: −4.8 to −0.06, p = 0.045) but not at 6 months. Cardiometabolic parameters did not differ between the groups. Our results showed that infertile women with PCOS and obesity and non-PCOS obese controls responded largely similarly to our lifestyle intervention and achieved the same level of improvement in markers of cardiometabolic health.

Preconception lifestyle advice for people with infertility

BACKGROUND

Infertility is a prevalent problem that has significant consequences for individuals, families, and the community. Modifiable lifestyle factors may affect the chance of people with infertility having a baby. However, no guideline is available about what preconception advice should be offered. It is important to determine what preconception advice should be given to people with infertility and to evaluate whether this advice helps them make positive behavioural changes to improve their lifestyle and their chances of conceiving.

OBJECTIVES

To assess the safety and effectiveness of preconception lifestyle advice on fertility outcomes and lifestyle behavioural changes for people with infertility.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, CINAHL, trial registers, Google Scholar, and Epistemonikos in January 2021; we checked references and contacted field experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), randomised cross-over studies, and cluster-randomised studies that compared at least one form of preconception lifestyle advice with routine care or attention control for people with infertility.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Primary effectiveness outcomes were live birth and ongoing pregnancy. Primary safety outcomes were adverse events and miscarriage. Secondary outcomes included reported behavioural changes in lifestyle, birth weight, gestational age, clinical pregnancy, time to pregnancy, quality of life, and male factor infertility outcomes. We assessed the overall quality of evidence using GRADE criteria.

MAIN RESULTS

We included in the review seven RCTs involving 2130 participants. Only one RCT included male partners. Three studies compared preconception lifestyle advice on a combination of topics with routine care or attention control. Four studies compared preconception lifestyle advice on one topic (weight, alcohol intake, or smoking) with routine care for women with infertility and specific lifestyle characteristics. The evidence was of low to very low-quality. The main limitations of the included studies were serious risk of bias due to lack of blinding, serious imprecision, and poor reporting of outcome measures. Preconception lifestyle advice on a combination of topics versus routine care or attention control Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.79 to 1.10; 1 RCT, 626 participants), but the quality of evidence was low. No studies reported on adverse events or miscarriage. Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice on a combination of topics affects lifestyle behavioural changes: body mass index (BMI) (mean difference (MD) -1.06 kg/m², 95% CI -2.33 to 0.21; 1 RCT, 180 participants), vegetable intake (MD 12.50 grams/d, 95% CI -8.43 to 33.43; 1 RCT, 264 participants), alcohol abstinence in men (RR 1.08, 95% CI 0.74 to 1.58; 1 RCT, 210 participants), or smoking cessation in men (RR 1.01, 95% CI 0.91 to 1.12; 1 RCT, 212 participants). Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of women with adequate folic acid supplement use (RR 0.98, 95% CI 0.95 to 1.01; 2 RCTs, 850 participants; I² = 4%), alcohol abstinence (RR 1.07, 95% CI 0.99 to 1.17; 1 RCT, 607 participants), and smoking cessation (RR 1.01, 95% CI 0.98 to 1.04; 1 RCT, 606 participants), on low quality evidence. No studies reported on other behavioural changes. Preconception lifestyle advice on weight versus routine care Studies on preconception lifestyle advice on weight were identified only in women with infertility and obesity. Compared to routine care, we are uncertain whether preconception lifestyle advice on weight affects the number of live births (RR 0.94, 95% CI 0.62 to 1.43; 2 RCTs, 707 participants; I² = 68%; very low-quality evidence), adverse events including gestational diabetes (RR 0.78, 95% CI 0.48 to 1.26; 1 RCT, 317 participants; very low-quality evidence), hypertension (RR 1.07, 95% CI 0.66 to 1.75; 1 RCT, 317 participants; very low-quality evidence), or miscarriage (RR 1.50, 95% CI 0.95 to 2.37; 1 RCT, 577 participants; very low-quality evidence). Regarding lifestyle behavioural changes for women with infertility and obesity, preconception lifestyle advice on weight may slightly reduce BMI (MD -1.30 kg/m², 95% CI -1.58 to -1.02; 1 RCT, 574 participants; low-quality evidence). Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice affects the percentage of weight loss, vegetable and fruit intake, alcohol abstinence, or physical activity. No studies reported on other behavioural changes. Preconception lifestyle advice on alcohol intake versus routine care Studies on preconception lifestyle advice on alcohol intake were identified only in at-risk drinking women with infertility. We are uncertain whether preconception lifestyle advice on alcohol intake affects the number of live births (RR 1.15, 95% CI 0.53 to 2.50; 1 RCT, 37 participants; very low-quality evidence) or miscarriages (RR 1.31, 95% CI 0.21 to 8.34; 1 RCT, 37 participants; very low-quality evidence). One study reported on behavioural changes for alcohol consumption but not as defined in the review methods. No studies reported on adverse events or other behavioural changes. Preconception lifestyle advice on smoking versus routine care Studies on preconception lifestyle advice on smoking were identified only in smoking women with infertility. No studies reported on live birth, ongoing pregnancy, adverse events, or miscarriage. One study reported on behavioural changes for smoking but not as defined in the review methods.

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births. Evidence was insufficient to allow conclusions on the effects of preconception lifestyle advice on adverse events and miscarriage and on safety, as no studies were found that looked at these outcomes, or the studies were of very low quality. This review does not provide clear guidance for clinical practice in this area. However, it does highlight the need for high-quality RCTs to investigate preconception lifestyle advice on a combination of topics and to assess relevant effectiveness and safety outcomes in men and women with infertility.

Pharmacological and non-pharmacological strategies for obese women with subfertility

BACKGROUND

Clinicians primarily recommend weight loss for obese women seeking pregnancy. The effectiveness of interventions aimed at weight loss in obese women with subfertility is unclear.

OBJECTIVES

To assess the effectiveness and safety of pharmacological and non-pharmacological strategies compared with each other, placebo, or no treatment for achieving weight loss in obese women with subfertility.

SEARCH METHODS

We searched the CGF Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED from inception to 18 August 2020. We also checked reference lists and contacted experts in the field for additional relevant papers.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials in which weight loss was the main goal of the intervention. Our primary effectiveness outcomes were live birth or ongoing pregnancy and primary safety outcomes were miscarriage and adverse events. Secondary outcomes included clinical pregnancy, weight change, quality of life, and mental health outcome.

DATA COLLECTION AND ANALYSIS

Review authors followed standard Cochrane methodology.

MAIN RESULTS

This review includes 10 trials. Evidence was of very low to low quality: the main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision. Non-pharmacological intervention versus no intervention or placebo Evidence is insufficient to determine whether a diet or lifestyle intervention compared to no intervention affects live birth (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.65 to 1.11; 918 women, 3 studies; I² = 78%; low-quality evidence). This suggests that if the chance of live birth following no intervention is assumed to be 43%, the chance following diet or lifestyle changes would be 33% to 46%. We are uncertain if lifestyle change compared with no intervention affects miscarriage rate (OR 1.54, 95% CI 0.99 to 2.39; 917 women, 3 studies; I² = 0%; very low-quality evidence). Evidence is insufficient to determine whether lifestyle change compared with no intervention affects clinical pregnancy (OR 1.06, 95% CI 0.81 to 1.40; 917 women, 3 studies; I² = 73%; low-quality evidence). Lifestyle intervention resulted in a decrease in body mass index (BMI), but data were not pooled due to heterogeneity in effect (mean difference (MD) -3.70, 95% CI -4.10 to -3.30; 305 women, 1 study; low-quality evidence; and MD -1.80, 95% CI -2.67 to -0.93; 43 women, 1 study; very low-quality evidence). Non-pharmacological versus non-pharmacological intervention We are uncertain whether intensive weight loss interventions compared to standard care nutrition counselling affects live birth (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low-quality evidence), clinical pregnancy (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low-quality evidence), BMI (MD -3.00, 95% CI -5.37 to -0.63; 11 women, 1 study; very low-quality evidence), weight change (MD -9.00, 95% CI -15.50 to -2.50; 11 women, 1 study; very low-quality evidence), quality of life (MD 0.06, 95% CI -0.03 to 0.15; 11 women, 1 study; very low-quality evidence), or mental health (MD -7.00, 95% CI -13.92 to -0.08; 11 women, 1 study; very low-quality evidence). No study reported on adverse events . Pharmacological versus pharmacological intervention For metformin plus liraglutide compared to metformin we are uncertain of an effect on the adverse events nausea (OR 7.22, 95% CI 0.72 to 72.7; 28 women, 1 study; very low-quality evidence), diarrhoea (OR 0.31, 95% CI 0.01 to 8.3; 28 women, 1 study; very low-quality evidence), and headache (OR 5.80, 95% CI 0.25 to 133; 28 women, 1 study; very low-quality evidence). We are uncertain if a combination of metformin plus liraglutide vs metformin affects BMI (MD 2.1, 95% CI -0.42 to 2.62; 28 women, 1 study; very low-quality evidence) and total body fat (MD -0.50, 95% CI -4.65 to 3.65; 28 women, 1 study; very low-quality evidence). For metformin, clomiphene, and L-carnitine versus metformin, clomiphene, and placebo, we are uncertain of an effect on miscarriage (OR 3.58, 95% CI 0.73 to 17.55; 274 women, 1 study; very low-quality evidence), clinical pregnancy (OR 5.56, 95% CI 2.57 to 12.02; 274 women, 1 study; very low-quality evidence) or BMI (MD -0.3, 95% CI 1.17 to 0.57, 274 women, 1 study, very low-quality evidence). We are uncertain if dexfenfluramine versus placebo affects weight loss in kilograms (MD -0.10, 95% CI -2.77 to 2.57; 21 women, 1 study; very low-quality evidence). No study reported on live birth, quality of life, or mental health outcomes. Pharmacological intervention versus no intervention or placebo We are uncertain if metformin compared with placebo affects live birth (OR 1.57, 95% CI 0.44 to 5.57; 65 women, 1 study; very low-quality evidence). This suggests that if the chance of live birth following placebo is assumed to be 15%, the chance following metformin would be 7% to 50%. We are uncertain if metformin compared with placebo affects gastrointestinal adverse events (OR 0.91, 95% CI 0.32 to 2.57; 65 women, 1 study; very low-quality evidence) or miscarriage (OR 0.50, 95% CI 0.04 to 5.80; 65 women, 1 study; very low-quality evidence) or clinical pregnancy (OR 2.67, 95% CI 0.90 to 7.93; 96 women, 2 studies; I² = 48%; very low-quality evidence). We are also uncertain if diet combined with metformin versus diet and placebo affects BMI (MD -0.30, 95% CI -2.16 to 1.56; 143 women, 1 study; very low-quality evidence) or waist-to-hip ratio (WHR) (MD 2.00, 95% CI -2.21 to 6.21; 143 women, 1 study; very low-quality evidence). Pharmacological versus non-pharmacological intervention No study undertook this comparison.

AUTHORS' CONCLUSIONS

Evidence is insufficient to support the use of pharmacological and non-pharmacological strategies for obese women with subfertility. No data are available for the comparison of pharmacological versus non-pharmacological strategies. We are uncertain whether pharmacological or non-pharmacological strategies effect live birth, ongoing pregnancy, adverse events, clinical pregnancy, quality of life, or mental heath outcomes. However, for obese women with subfertility, a lifestyle intervention may reduce BMI. Future studies should compare a combination of pharmacological and lifestyle interventions for obese women with subfertility.

Pre-Conception Interventions for Subfertile Couples Undergoing Assisted Reproductive Technology Treatment: Modeling Analysis

Background

Approximately 1 in 7 couples experience subfertility, many of whom have lifestyles that negatively affect fertility, such as poor nutrition, low physical activity, obesity, smoking, or alcohol consumption. Reducing lifestyle risk factors prior to pregnancy or assisted reproductive technology treatment contributes to the improvement of reproductive health, but cost-implications are unknown.

Objective

The goal of this study was to evaluate reproductive, maternal pregnancy, and birth outcomes, as well as the costs of pre-conception lifestyle intervention programs in subfertile couples and obese women undergoing assisted reproductive technology.

Methods

Using a hypothetical model based on quantitative parameters from published literature and expert opinion, we evaluated the following lifestyle intervention programs: (1) Smarter Pregnancy, an online tool; (2) LIFEstyle, which provides outpatient support for obese women; (3) concurrent use of both Smarter Pregnancy and LIFEstyle for obese women; (4) smoking cessation in men; and (5) a mindfulness mental health support program using group therapy sessions. The model population was based on data from the Netherlands.

Results

All model-based analyses of the lifestyle interventions showed a reduction in the number of in vitro fertilization, intracytoplasmic sperm injection, or intrauterine insemination treatments required to achieve pregnancy and successful birth for couples in the Netherlands. Smarter Pregnancy was modeled to have the largest increase in spontaneous pregnancy rate (13.0%) and the largest absolute reduction in potential assisted reproductive technology treatments. Among obese subfertile women, LIFEstyle was modeled to show a reduction in the occurrence of gestational diabetes, maternal hypertensive pregnancy complications, and preterm births by 4.4%, 3.8%, and 3.0%, respectively, per couple. Modeled cost savings per couple per year were €41 (US $48.66), €360 (US $427.23), €513 (US $608.80), €586 (US $695.43), and €1163 (US $1380.18) for smoking cessation, mindfulness, Smarter Pregnancy, combined Smarter Pregnancy AND LIFEstyle, and LIFEstyle interventions, respectively.

Conclusions

Although we modeled the potential impact on reproductive outcomes and costs of fertility treatment rather than collecting real-world data, our model suggests that of the lifestyle interventions for encouraging healthier behaviors, all are likely to be cost effective and appear to have positive effects on reproductive, maternal pregnancy, and birth outcomes. Further real-world data are required to determine the cost-effectiveness of pre-conception lifestyle interventions, including mobile apps and web-based tools that help improve lifestyle, and their effects on reproductive health. We believe that further implementation of the lifestyle app Smarter Pregnancy designed for subfertile couples seeking assistance to become pregnant is likely to be cost-effective and would allow reproductive health outcomes to be collected.

The effect of excess body fat on female and male reproduction

The dramatic increase in the prevalence of obesity coincides with a decline in reproductive health indices in both sexes. Energy excess mediates changes to the regulatory mechanisms of the reproductive system. Obese individuals exhibit increased estrogen concentrations, due to the overexpression of aromatase in the adipose tissue; via a negative feedback loop, men present with symptoms of hypogonadotropic hypogonadism. These hormonal changes, along with increased oxidative stress, lipotoxicity and disturbances in the concentrations of adipokines, directly affect the gonads, peripheral reproductive organs and the embryo. Clinical evidence is somewhat contradicting, with only some studies advocating worse semen parameters, increased incidence of erectile dysfunction, increased doses of ovulation induction medications, and worse live birth rates in assisted reproductive technology (ART) cycles in obese individuals compared with those of normal weight. Similar conclusions are drawn about patients with insulin resistance syndromes, namely polycystic ovary syndrome (PCOS). As far as treatment options are concerned, lifestyle changes, medical therapy and bariatric surgery may improve the reproductive outcome, although the evidence remains inconclusive. In this review, we summarize the evidence on the association of obesity and reproductive health on both the molecular and the clinical level, and the effect of weight-loss interventions on reproductive potential.

The Impact of Traditional Medicine-Based Lifestyle and Diet on Infertility Treatment in Women Undergoing Assisted Reproduction: A Randomized Controlled Trial

The problem of infertility is growing rapidly in the world. Traditional medicine with thousands of years of history has claimed that it can treat some kinds of infertility using nutritional and lifestyle modifications and interventions. The purpose of this study was to evaluate the effect of a traditional medicine-oriented diet and lifestyle on infertility treatment. Based on a clinical trial study, 180 infertile women who were 20-40 years old and candidates for in vitro fertilization (IVF) were randomly assigned to 2 groups: an intervention group and a control group. The intervention group used diet and lifestyle recommendations based on Iranian traditional medicine for at least 3 months. The number of ova, mature ovum number, embryo number, embryo quality, and fertilization rate were significantly higher in the intervention group than in the control group (for all items; p < 0.05). Overall pregnancy rate was significantly higher in the intervention group (35.2 vs. 12.4%; odds ratio [OR], 3.8; 95% CI, 1.8-8.3). The intervention group had a higher rate of getting spontaneous pregnancy than the control group (20.9 vs. 2.2%; OR, 11.5; 95% CI, 2.6-50.9). Chemical pregnancy was significantly higher in the intervention group (64 vs. 27.5%; OR, 4.7; 95% CI, 1.9-11.6). Diet and lifestyle modifications based on traditional medicine can contribute greatly to the infertility treatment. Thus, many infertility cases can be treated without the need to use advanced methods. In case of using assisted reproductive techniques, traditional medicine can enhance the efficiency of these methods.

The Risks Associated With Obesity in Pregnancy

BACKGROUND

Approximately one-third of all women of childbearing age are overweight or obese. For these women, pregnancy is associated with increased risks for both mother and child.

METHODS

This review is based on pertinent publications retrieved by a selective search of PubMed, with special attention to current population-based cohort studies, systematic reviews, meta-analyses, and controlled trials.

RESULTS

Obesity in pregnancy is associated with unfavorable clinical outcomes for both mother and child. Many of the risks have been found to depend linearly on the body-mass index (BMI). The probability of conception declines linearly, starting from a BMI of 29 kg/m2, by 4% for each additional 1 kg/m2 of BMI (hazard ratio 0.96, 95% confidence interval: [0.91; 0.99]). A 10% increase of pregravid BMI increases the relative risk of gestational diabetes and that of preeclampsia by approximately 10% each. A 5 kg/m2 increase of BMI elevates the relative risk of intrauterine death to 1.24 [1.18; 1.30]. An estimated 11% of all neonatal deaths can be attributed to the consequences of maternal overweight and obesity. Nonetheless, in most randomized controlled trials, nutritional and lifestyle interventions did not bring about any clinically relevant reduction in the incidence of gestational diabetes and fetal macrosomia.

CONCLUSION

The risks associated with obesity in pregnancy cannot necessarily be influenced by intervention. Preventive measures aimed at normalizing body weight before a woman becomes pregnant are, therefore, all the more important.

Female subfertility

Subfertility is common and affects one in six couples, half of whom lack an explanation for their delay in conceiving. Developments in the diagnosis and treatment of subfertility over the past 50 years have been truly remarkable. Indeed, current generations of couples with subfertility are more fortunate than previous generations, as they have many more opportunities to become parents. The timely access to effective treatment for subfertility is important as many couples have a narrow window of opportunity before the age-related effects of subfertility limit the likelihood of success. Assisted reproduction can overcome the barriers to fertility caused by tubal disease and low sperm count, but little progress has been made in reducing the effect of increasing age on ovarian function. The next 5-10 years will likely see further increases in birth rates in women with subfertility, a greater awareness of lifestyle factors and a possible refinement of current assisted reproduction techniques and the development of new ones. Such progress will bring challenging questions regarding the potential benefits and harms of treatments involving germ cell manipulation, artificial gametes, genetic screening of embryos and gene editing of embryos. We hope to see a major increase in fertility awareness, access to safe and cost-effective fertility care in low-income countries and a reduction in the current disparity of access to fertility care.

Effects of maternal body mass index on pregnancy outcome after 8570 artificial insemination cycles with donor's sperm

Increased body mass index (BMI) might have an adverse effect on pregnancy. However, the influence of BMI on the pregnancy outcomes after artificial insemination with donor's sperm (AID) had been rarely reported. This study aimed to investigate the correlation between BMI and AID. The pregnancy outcome of 8570 AID cycles was retrospectively analyzed. BMI was categorized as underweight (<18.5 kg/m²; group A), normal weight (18.5-23.9 kg/m²; group B), overweight (24-27.9 kg/m²; group C), and obese (≥28 kg/m²; group D). The results showed that cumulative pregnancy rate and cumulative live birth rate in groups A, B, C and D tended to decrease as BMI increased; however, abortion rate, and ectopic pregnancy rate in groups A, B, C, and D exhibited a gradual increase in the tendency. Cesarean delivery rate also increased as BMI increased. Birth defect rate in the group D were significantly higher than that in the group A. Interestingly, the pregnancy rate was gradually decreased with increasing age in groups A, B, and C, but this was not observed in the group D. The findings suggested that BMI can affect the pregnancy outcomes after AID; it is important to achieve a normal BMI prior to AID treatments.

Assessment of the development of assisted reproductive technology in Liaoning province of China, from 2012 to 2016

BACKGROUND

The development of assisted reproduction techniques (ART) has resulted in rapid advances in the treatment of infertility. However, a systematic assessment of ART and its processes and outcomes in China has never been carried out. The goal of this study was to assess the features of ART status from 2012 to 2016 in clinics and in vitro fertilization (IVF) laboratories in Liaoning, the largest IVF province in the northeast of China.

METHODS

Data from Jan 1, 2012 to Dec 31, 2016 was retrieved from the assisted reproductive certificate registry of Liaoning province. We extracted data from: i) fresh and thawed cycles; ii) donor sperm and donor egg cycles; iii) intrauterine insemination with husband semen and donor semen (AIH and AID).

RESULTS

We showed that: (i) there has been a significant increase in the number of IVF fresh and thawed cycles, and the proportion of cases of primary infertility and secondary infertility has decreased and increased, respectively; (ii) standard long GnRH agonist was the major ovarian stimulation protocol. During the observation period, increasing trends in the use of GnRH antagonists, mild stimulation, and natural cycles were observed; (iii) significant differences in the number of cycles, number of retrieved oocytes, fertilization rates, implantation rates, and sex ratio were noticed between conventional IVF and intracytoplasmic sperm injection; (iv) significant differences in age at treatment for infertility, number of cycles, and ectopic pregnancy rates were noticed between donor sperm cycles and donor egg cycles; (v) significant differences in number of thawed cycles, number of thawed embryos, embryo recovery rates, implantation rates, and clinical pregnancy rates were noticed between day 3 and day 5 embryos; (vi) significant differences in age at treatment for infertility, number of cycles, clinical pregnancy rates, ectopic pregnancy rates, and live birth ratio were noticed between AIH and AID.

CONCLUSIONS

ART in Liaoning province has undergone substantial development from 2012 to 2016 in clinics and IVF laboratories. This presentation of detailed ART data will provide researchers, policy makers, and potential ART users a rich source of information about IVF characteristics in the northeast of China.

Recent advances in understanding the relationship between long- and short-term weight change and fertility

The impact of excess body weight on fertility is well recognized among both women attempting to conceive spontaneously and those attempting to conceive with medical assistance. Although many leading societies of reproductive medicine have proposed weight loss as a means to counteract the negative consequences of obesity on fertility, there is limited research on this topic. In this review, we provide a brief overview of the recent advances in the literature focused on how long- and short-term weight change affects fertility among women. Overall, despite initial hope that weight loss may be beneficial for fertility, two large well-conducted randomized controlled trials have consistently shown that short-term weight loss among overweight and obese women undergoing infertility treatment does not improve a woman's probability of live birth. The observational evidence among women attempting to conceive without medical assistance also suggests limited benefits of weight loss on fecundity or pregnancy loss. In contrast, substantial weight gain between consecutive pregnancies, in the year prior to pregnancy attempt, and throughout adulthood appears to be harmful for not only time to pregnancy but also pregnancy maintenance. Future research focused on efforts to prevent weight gain during adulthood is needed to better understand whether these types of interventions may have beneficial effects on fertility.

Cost-effectiveness analysis of lifestyle intervention in obese infertile women

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN, SIZE, DURATION

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

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS, REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by a grant from ZonMw, the Dutch Organization for Health Research and Development (50-50110-96-518). The department of obstetrics and gynaecology of the UMCG received an unrestricted educational grant from Ferring pharmaceuticals BV, The Netherlands. B.W.J.M. is a consultant for ObsEva, Geneva.

TRIAL REGISTRATION NUMBER

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

Obstetric and perinatal outcomes in subfertile patients who conceived following low technology interventions for fertility enhancement: a comprehensive review

PURPOSE

Low technology interventions for fertility enhancement (LTIFE) are strategies that avoid retrieval, handling, and manipulation of female gametes. The definition of LTIFE is yet to be widely accepted and clarified, but they are commonly used in milder cases of infertility and subfertility. Based on these considerations, the aim of the present study was comprehensively to review and investigate the obstetric and perinatal outcomes in subfertile patients who underwent LTIFE.

METHODS

A literature search up to May 2017 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science, and Google Scholar. An evidence-based hierarchy was used according to The Oxford Centre for Evidence-Based Medicine to determine which articles to include and analyze, and to provide a level of evidence of each association between intervention and outcome.

RESULTS

This analysis identified preliminary and low-grade evidence on the influence of LTIFE on obstetric and perinatal outcomes in subfertile women.

CONCLUSIONS

LTIFE women should deserve major consideration from Clinicians/Researchers of Reproductive Medicine, because these treatments could be potentially responsible for mothers' and babies' complications. So far, the lack of well-designed and unbiased studies makes further conclusions difficult to be drawn.