Association between periconceptional weight loss and maternal and neonatal outcomes in obese infertile women

Association between relative fat mass and female infertility among reproductive-aged women from NHANES 2013-2020

Female infertility is a prevalent condition closely linked with obesity. Current evaluation metrics like body mass index (BMI) and waist circumference (WC) have limitations. Relative fat mass (RFM) is a newer, more accurate obesity metric, but its relationship with infertility lacks research. Data from 3489 female participants aged 18-45 years from the NHANES 2013-2020 cycles were extracted and analyzed. Infertility was assessed based on participants' pregnancy attempts and medical consultations. The primary exposure variables were BMI, WC, and RFM. Survey-weighted logistic regression models were conducted to compare their associations with infertility, expressed as odds ratios (ORs). RFM was further categorized into quartiles for additional regression analysis. Subgroup analyses were conducted to evaluate whether the association between RFM and infertility differs across key demographic and clinical factors, including age, race, PIR, education level, BMI, smoking status, DM, hypertension, age at menarche, and history of pelvic inflammatory disease (PID). Restricted cubic splines (RCS) were employed for robustness and linearity assessments. Our results showed an infertility prevalence of 13.41%, with affected women being older and having higher BMI. The OR (1.039, 95% CI: 1.010, 1.068) for RFM in regression analysis of fully adjusted Model was higher than for BMI (1.020, 95% CI: 1.002, 1.039) and WC (1.014, 95% CI: 1.006, 1.022), indicating that each unit increase in RFM correlates with a higher risk of infertility. Similarly, quartile analysis of fully adjusted Model indicated increased infertility risk with higher RFM quartiles (Q2: OR = 1.66, 95% CI: 1.05, 2.64; Q3: OR = 1.79, 95% CI: 1.16, 2.74; Q4: OR = 2.23, 95% CI: 1.38, 3.60). Additionally, results were consistent in the supplementary subgroup analysis without interaction, and RCS confirmed a linear relationship. Our findings demonstrate a significant association between RFM and female infertility in a population-based sample, supporting the hypothesis that excess adiposity may play a role in reproductive health. Further research is needed to explore the mechanisms and broader applications of RFM in female reproductive health.

Evaluation of the MyFertiCoach Lifestyle App for Subfertile Couples: Single-Center Evaluation of Augmented Standard Care

BACKGROUND

Many couples undergoing fertility treatment face multiple lifestyle risk factors that lower their chances of achieving pregnancy. The MyFertiCoach (MFC) app was designed as an integrated lifestyle program featuring modules on healthy weight management, nutrition, exercise, quitting smoking, reducing alcohol and drug use, and managing stress. We hypothesized that supplementing standard care with the MFC app would improve lifestyle outcomes.

OBJECTIVE

This study aims to assess the impact of the MFC app on changing multiple lifestyle habits in women seeking fertility treatment. The primary outcome is the change in the total risk score (TRS) at 3- and six-month follow-ups. The TRS is calculated for each individual as the sum of all risk scores per behavior (eg, vegetable/fruit/folic acid intake, smoking, and alcohol use) at 3 and 6 months. A higher TRS indicates unhealthier nutrition and lifestyle habits and a lower likelihood of achieving pregnancy. The secondary endpoints include changes in BMI, activity score, preconception dietary risk score, distress score (eg, perceived burden), smoking habits, alcohol intake, and program adherence.

METHODS

This retrospective, observational, single-center evaluation included patients between January 1, 2022, and December 31, 2023. Subfertile female patients aged 18-43 years and their partners, who were referred to a gynecologist, were invited to participate in online lifestyle coaching via the MFC app. The gynecologist selected relevant lifestyle modules based on the results of integrated screening questionnaires. We used (hierarchical) linear mixed models (LMMs) to estimate changes in outcomes. For missing data patterns deemed missing not at random, joint modeling was applied. Statistical significance was set at P≤.05, with methods in place to maintain the same false-positive rate.

RESULTS

A total of 1805 patients were invited to participate in the evaluation, with an average of 737 (40.83%) completing the screening questionnaire at baseline. For the TRS, 798 (44.21%) patients were included at baseline, of whom 517 (64.8%) involved their partner. On average, 282 of 744 (37.9%) patients submitted at least one follow-up questionnaire. Patients rated the app above average (n=137, median score of 7 on a 1-10 scale) on days 7 and 14. The TRS decreased by an average of 1.5 points (P<.001) at T3 and T6 compared with baseline, a clinically meaningful improvement. All secondary outcomes showed statistically significant positive changes for patients who used a relevant lifestyle module (P<.001). Most improvements were achieved by 3 months and remained significant at 6 months (P<.001), except for alcohol intake (P<.53). These findings were consistent across both LMMs and joint models.

CONCLUSIONS

Our evaluation of a mobile health app integrated into standard care demonstrates immediate and clinically meaningful improvements in key lifestyle parameters among women seeking to become pregnant. Additional scientific research is needed to identify the causal pathways leading to sustained effectiveness. To maintain and enhance these outcomes, further tailoring of patient-specific programs is essential.

Prepregnancy dieting and obstetrical and neonatal outcomes: Findings from a national surveillance project in the United States

PROBLEM AND BACKGROUND

Women with overweight or obesity are recommended to lose weight before pregnancy. Dieting is one of the most used weight control strategies. However, the health implications of dieting before pregnancy remain unclear.

AIM

To evaluate the associations of dieting during the year before pregnancy with obstetrical and neonatal outcomes, including gestational weight gain (GWG), gestational diabetes, low birthweight, macrosomia, small-for-gestational-age infants (SGA), large-for-gestational-age infants (LGA), and preterm birth.

METHODS

This study analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS), which is a surveillance project in the United States that collects data on maternal health before, during, and after pregnancy. Women who participated in PRAMS phase 7 with a prepregnancy body mass index ≥25 kg/m2 and a singleton birth were eligible. Statistical analyses included logistic regressions and post-hoc mediation analysis (Sobel Test).

FINDINGS

A total number of 51,399 women were included in the analysis. Women who self-reported prepregnancy dieting (42.8 %) had lower odds of SGA (adjusted odds ratio [aOR]: 0.87; 95 % CI: 0.79-0.97), and higher odds of excessive GWG vs adequate GWG (aOR: 1.42; 95 % CI: 1.32-1.52), gestational diabetes (aOR: 1.12; 95 % CI: 1.02-1.22), and LGA (aOR: 1.18; 95 % CI: 1.08-1.28). Furthermore, the association between prepregnancy dieting and LGA was mediated by excessive GWG (Sobel Test z-value = 5.72, p < 0.01).

DISCUSSION AND CONCLUSION

This analysis revealed that prepregnancy dieting was associated with several adverse consequences, including excessive GWG, gestational diabetes, and LGA infants. Findings contribute to an improved understanding of the perinatal implications of prepregnancy dieting.

A high-fat eucaloric diet induces reprometabolic syndrome of obesity in normal weight women

We examined the effects of 1 month of a eucaloric, high-fat (48% of calories) diet (HFD) on gonadotropin secretion in normal-weight women to interrogate the role of free fatty acids and insulin in mediating the relative hypogonadotropic hypogonadism of obesity. Eighteen eumenorrheic women (body mass index [BMI] 18-25 kg/m2) were studied in the early follicular phase of the menstrual cycle before and after exposure to an HFD with frequent blood sampling for luteinizing hormone (LH) and follicle-stimulating hormone (FSH), followed by an assessment of pituitary sensitivity to gonadotropin-releasing hormone (GnRH). Mass spectrometry-based plasma metabolomic analysis was also performed. Paired testing and time-series analysis were performed as appropriate. Mean endogenous LH (unstimulated) was significantly decreased after the HFD (4.3 ± 1.0 vs. 3.8 ± 1.0, P < 0.01); mean unstimulated FSH was not changed. Both LH (10.1 ± 1.0 vs. 7.2 ± 1.0, P < 0.01) and FSH (9.5 ± 1.0 vs. 8.8 ± 1.0, P < 0.01) responses to 75 ng/kg of GnRH were reduced after the HFD. Mean LH pulse amplitude and LH interpulse interval were unaffected by the dietary exposure. Eucaloric HFD exposure did not cause weight change. Plasma metabolomics confirmed adherence with elevation of fasting free fatty acids (especially long-chain mono-, poly-, and highly unsaturated fatty acids) by the last day of the HFD. One-month exposure to an HFD successfully induced key reproductive and metabolic features of reprometabolic syndrome in normal-weight women. These data suggest that dietary factors may underlie the gonadotrope compromise seen in obesity-related subfertility and therapeutic dietary interventions, independent of weight loss, may be possible.

Higher waist circumference is associated with increased likelihood of female infertility: NHANES 2017-2020 results

Background

Waist circumference can be used as an anthropometric measure to assess central obesity and is easier and more convenient than the waist-to-hip ratio in identifying the risk of obesity and medical problems. Most studies showing an association between obesity and infertility in women have used BMI to measure obesity. Our goal was to examine any potential association between waist circumference and infertility.

Methods

This cross-sectional study, which formed part of the National Health and Nutrition Examination Survey (NHANES), comprised women ages 18 to 45 between 2017 and 2020. Participants without waist circumference data or information on infertility were removed from the study. The independent relationship between waist circumference and infertility was investigated using weighted binary logistic regression and subgroup analysis.

Results

We investigated 1509 participants and discovered that the prevalence of infertility rose as the WC trisection rose. (tertile 1, 7.55%; tertile 2, 10.56%; tertile 3, 15.28%; trend < 0.001). Multivariate logistic regression showed that after total adjustment, higher WC levels were associated with an increased likelihood of infertility in women (OR1.02; 95% CI 1.01-1.03), and There was a 2% rise in the incidence of infertility for every unit (cm) increased WC. Subgroup analysis and interaction tests showed no significant dependence of the effects of marital status, diabetes, hypertension, and high cholesterol on the association between WC and infertility (p for all interaction tests > 0.05). The inflection point of the positive non-linear relationship between WC and infertility was 116.6 cm.

Conclusion

Excessive waist circumference assessment may increase the probability of infertility, and more attention should be paid to the management of waist circumference should be given more attention.

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.

How effective are lifestyle interventions for overweight women trying to conceive?

PURPOSE OF REVIEW

To summarize and critically review the current knowledge on the effectiveness of lifestyle modifications for overweight women trying to conceive.

RECENT FINDINGS

Overweight is associated with a wide spectrum of disorders, which may directly or indirectly affect fertility [from menstrual cycle irregularities to a lower chance of live birth after assisted reproductive technology (ART) treatment]. Weight loss through nonpharmaceutical lifestyle interventions is achievable. Weight loss can normalize menstrual cycle irregularities and can increase fecundability. Pregnancy-associated risks, such as gestational diabetes can be decreased by preconception weight reduction.

SUMMARY

Weight loss through lifestyle changes (i.e., lower caloric intake and increased physical activity), may increase fecundability and may have a positive impact on the course of pregnancy, delivery, and neonatal outcomes. Accordingly, women should be motivated to reduce their weight before conception. However, the effectiveness of life-style intervention programs for women actively seeking medical support in achieving pregnancy has not convincingly been demonstrated. In the few randomized controlled trials (RCTs), selection bias for trial participation by patient motivation may have been present, yet participant attrition was still high and mean effects were small, casting doubts on the utility of such programs in routine care. Pharmacological and surgical intervention may be more effective or necessary complements to lifestyle intervention programs.

The Effect of an eHealth Coaching Program (Smarter Pregnancy) on Attitudes and Practices Toward Periconception Lifestyle Behaviors in Women Attempting Pregnancy: Prospective Study

BACKGROUND

Lifestyle behaviors during the periconception period contribute to achievement of a successful pregnancy. Assessment of attitudes and practices toward these modifiable behaviors can aid in identifying gaps in unhealthy lifestyle behaviors with impact on intervention effectiveness.

OBJECTIVE

This study investigates the effectiveness of coaching by the eHealth program Smarter Pregnancy during the periconception period on improvement of attitudes and practices toward fruit and vegetable intake and smoking in women attempting pregnancy through assisted reproductive technology (ART) or natural conception.

METHODS

Women attempting pregnancy through ART (n=1060) or natural conception (n=631) were selected during the periconception period. The intervention groups, conceived through ART or naturally, received Smarter Pregnancy coaching for 24 weeks, whereas the control group conceived through ART and did not receive coaching. Attitudes and practices at baseline and follow-up periods were obtained from self-administered online questionnaire provided by the program. Attitudes were assessed in women with unhealthy behaviors as their intention to increase their fruit and vegetable intake and to quit smoking using a yes/no question. Outcomes on practices, suggesting effectiveness, included daily fruit (pieces) and vegetable (grams) intake, and if women smoked (yes/no). Changes in attitudes and practices were compared at 12 and 24 weeks with baseline between the ART intervention and ART control groups, and within the intervention groups between ART and natural conception. Changes in practices at 12 and 24 weeks were also compared with baseline between women with negative attitude and positive attitude within the intervention groups: ART and natural conception. Analysis was performed using linear and logistic regression models adjusted for maternal confounders and baseline attitudes and practices.

RESULTS

The ART intervention group showed higher vegetable intake and lower odds for negative attitudes toward vegetable intake after 12 weeks (β_adj=25.72 g, P<.001; adjusted odds ratio [OR_adj] 0.24, P<.001) and 24 weeks of coaching (β_adj=23.84 g, P<.001; OR_adj 0.28, P<.001) compared with ART controls. No statistically significant effect was observed on attitudes and practices toward fruit intake (12 weeks: P=.16 and .08, respectively; 24 weeks: P=.16 and .08, respectively) and smoking behavior (12 weeks: P=.87; 24 weeks: P=.92). No difference was observed for the studied attitudes and practices between the ART intervention and natural conception intervention groups. Women with persistent negative attitude toward fruit and vegetable intake at week 12 showed lower fruit and vegetable intake at week 24 compared with women with positive attitude (β_adj=-.49, P<.001; β_adj=-30.07, P<.001, respectively).

CONCLUSIONS

The eHealth Smarter Pregnancy program may improve vegetable intake-related attitudes and practices in women undergoing ART treatment. Women with no intention to increase fruit and vegetable intake had less improvement in their intakes. Despite small changes, this study demonstrates again that Smarter Pregnancy can be used to improve vegetable intake, which can complemented by blended care that combines face-to-face and online care to also improve fruit intake and smoking behavior.

Effects of preconception weight loss after lifestyle intervention on fertility outcomes and pregnancy complications

It is well documented that obesity decreases natural fertility among men and women as well as pregnancy chances after conventional infertility and assisted reproductive technology (ART)-based treatments. Moreover, pregnancy complications are increased in women with overweight and obesity. General guidelines on the treatment of obesity recommend lifestyle intervention, including diet and exercise as the first-line treatment, coupled with or without medical treatments, such as weight loss medication or bariatric surgery, to reduce complications of obesity in adults. In the context of infertility in various countries and infertility clinics, there is a body mass index limit for public refund of infertility treatment of women with obesity. In this respect, it is important to investigate the evidence of effects of lifestyle intervention preceding infertility treatment on reproductive outcomes. The combined results of 15 randomized controlled trials (RCTs) of the effectiveness of preconception lifestyle intervention on reproductive outcomes documented in the latest systemic review and meta-analysis, together with the most recent RCT performed in 2022 are discussed. The current evidence suggests that greater weight loss and increase in clinical pregnancy, live birth, and natural conception rates after lifestyle intervention compared with no intervention were observed, but it seems no beneficial effect of lifestyle intervention preceding ART was observed on these parameters. With respect to potential harm of lifestyle intervention, there is no significant increased risk of early pregnancy loss, although the most recent RCT (not included in the systematic review and meta-analysis) showed a trend toward an increased risk. Complications during pregnancy, such as early pregnancy loss and maternal as well as fetal and neonatal complications, are underreported in most studies and need further analysis in an individual participant data meta-analysis. Limitations of the studies as well as future perspectives and challenges in this field of research will be highlighted.

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.

Preconceptional maternal weight loss and hypertensive disorders in pregnancy: a systematic review and meta-analysis

BACKGROUND

Hypertensive disorders of pregnancy (HDP), including pregnancy-induced hypertension (PIH), Preeclampsia (PE), Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) and chronic hypertension, are leading causes of maternal and perinatal morbidity and mortality. Although the pathophysiology of HDP is complex, preconceptional weight reduction in obese women might reduce these complications. We conducted a systematic review and meta-analysis to investigate the effectiveness of preconceptional weight loss by lifestyle intervention or bariatric surgery in overweight and obese women and the reduction of the risk of HDP.

METHODS AND RESULTS

Databases are searched until September 2019 resulting in 2547 articles: 110 full-text analysis and 29 detailed analysis. Reduced risks were shown for HDP in seven articles (n = 4381) of weight loss after lifestyle intervention or bariatric surgery (OR range 0.10-0.64), for PIH in four articles (n = 46,976) (OR range 0.14-0.79), and for PE in seven articles (n = 169,734) (OR range 0.14-0.84). The stratified analysis of weight loss after lifestyle intervention and bariatric surgery shows comparable results. The meta-analysis of 20 studies of the effectiveness of lifestyle intervention and bariatric surgery revealed reduced risks of HDP (OR 0.45 (95% CI 0.32-0.63)), PIH (OR 0.61 (95%CI 0.44-0.85)) and PE (OR 0.67 (95%CI 0.51-0.88)).

CONCLUSIONS

Preconceptional weight loss after lifestyle intervention or bariatric surgery is effective in reducing risks of HDP, PIH and PE, and emphasizes the need to optimize weight in overweight and obese women with a child wish. More research is recommended to investigate short-term and long-term beneficial and harmful side-effects of these interventions on maternal and offspring health.

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).

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.

Preconception Care to Reduce the Risks of Overweight and Obesity in Women of Reproductive Age: An Integrative Review

Despite adverse pregnancy outcomes for women with overweight or obesity, preconception guidelines for achieving optimal wellness for women contemplating pregnancy regarding the risks of overweight or obesity are varied based upon national affiliation. The aim of this study was to synthesize the best evidence related to preconception counseling and care focused on overweight or obesity provided to women of reproductive age. An integrative review of original studies was conducted. PubMed, Cumulative Index in Nursing and Allied Health Literature, Ovid, Scopus, Web of Science, and Embase were included. Full-text, data-based articles were searched from 2009 to 2018, with reviews and synthesis completed in 2019 and 2020. Of 8703 initial articles, 31 articles remained in the review. Quality assessment and level of evidence were evaluated based upon criteria from the Joanna Briggs Institute and the Johns Hopkins Nursing Evidence-Based Practice Quality Guide. The level of evidence for the majority of studies was non-experimental but they were of good quality with appropriate methods, samples and relevant results. Limited attention and interest in preconception counseling regarding risks of overweight or obesity by health care professionals were noted, which may contribute to women’s unawareness of these risks on preconception health.

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.

Reducing intergenerational obesity and diabetes risk

To address the intergenerational transmission of obesity and diabetes, strategies promoting the health of women of reproductive age appear to be urgently needed. In this narrative review, we summarise what has been learned from many prenatal clinical trials, discuss the emerging evidence from preconception clinical trials and highlight persistent gaps and critical future directions. Most trials tested prenatal interventions that resulted in a limited gestational weight gain of ~1 kg and reduced gestational diabetes by 20-30%. These interventions also reduced macrosomia by 20-40% but had little-to-no impact on other offspring outcomes at birth or beyond. Far fewer trials tested preconception interventions, with almost all designed to improve conception or live-birth rates in overweight or obese women with infertility rather than reduce intergenerational risks in diverse populations. Preconception trials have successfully reduced weight by 3-9 kg and improved markers of glucose homeostasis and insulin resistance by the end of the intervention but whether effects were sustained to conception is unclear. Very few studies have reported offspring outcomes at birth and beyond, with no evidence thus far of beneficial effects on offspring obesity or diabetes risks. Further efforts to develop effective and scalable strategies to reduce risk of obesity and diabetes before conception should be prioritised, especially for diverse and under-resourced populations at disparately high risk of obesity and diabetes. Future clinical trials should include interventions with high potential for dissemination, diverse populations, thorough maternal phenotyping from enrolment through to conception and pregnancy, and rigorous assessment of offspring obesity and diabetes risks from birth onwards, including into the third generation.

Effects of α-lipoic acid and myo-inositol supplementation on the oocyte environment of infertile obese women: A preliminary study

Obesity is becoming pandemic and is associated with impaired reproductive potential. Oxidative stress, low-grade chronic inflammation and mitochondrial dysfunctions, which characterize obesity, strongly affect oocyte environment and function. Supplementation with antioxidant and anti-inflammatory compounds has been suggested to improve fertility. Here we evaluated the effect of α-lipoic acid and myo-inositol supplementation on the oocyte environment of infertile obese women. Nineteen normal-weight and twenty-three obese women, infertile for non-ovarian reasons, were recruited. For two months before ovarian stimulation, all women received 400 μg/die folic acid, whereas 15 obese were additionally supplemented with 800 mg α-lipoic acid, 2 g myo-inositol/die. Antioxidant capacity was measured in follicular fluid by enzymatic assay; mitochondrial DNA (mtDNA) content and mRNA levels of two respiratory chain subunits were analyzed in granulosa cells by Real-time PCR. Pregnancy rate was similar between normal-weight and treated obese, and lower in untreated obese patients. Supplemented women showed significantly higher antioxidant levels in follicular fluid compared to the two groups taking only folic acid. Conversely, granulosa cells mtDNA content was decreased in treated and higher in untreated obese patients compared to normal-weight women, suggesting mtDNA increases to compensate for oxidative-stress damages. Reduced expression of respiratory subunits in untreated obese may confirm mitochondria impairment. Interestingly, mtDNA levels inversely correlated to both total and metaphase II oocyte number. In this preliminary study, combined supplementation of α-lipoic acid and myo-inositol in infertile obese women was associated with amelioration in the oxidative status of the oocyte environment, possibly contributing to a higher pregnancy rate.

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.

Impact of maternal obesity on the risk of preterm delivery: insights into pathogenic mechanisms

PURPOSE

Preterm delivery (PTD) represents the leading cause of neonatal death and disability. Among risk factors for PTD, maternal obesity (MO) is becoming an ever more relevant condition in developed countries, although the mechanisms relating this condition to higher risk of PTD is not clear. Aim of this narrative review is to summarize evidences from clinical and translational research showing how MO might negatively impact on pregnancy and neonatal outcomes, particularly, by increasing the risk of PTD.

METHODS

We performed comprehensive review of the literature in PubMed and Google Scholar databases for studies from 1998 to 2018 linking MO to PTD and inflammation.

RESULTS

Chronic inflammatory status associated to increased synthesis of adipokines and cytokines from fat tissue has been shown in obesity. Obese women have a higher risk of both spontaneous and medically induced PTD. In about 50% of cases of spontaneous PTD, an infection-induced chorion amnionitis can be detected while in the remaining 50% a sterile inflammatory response has been described. Activation of uterine innate immunity system in intra-amniotic cavity and in chorioamniotic membranes might represent the missing link between MO and the pathogenesis of PTD.

CONCLUSION

Tissue inflammation might represent the pathogenic link between MO and increased occurrence of PTD. The achievement of pre-pregnancy normal maternal weight and body mass index is a fundamental aim of public health to reduce the incidence of PTD and get optimal reproductive outcomes.

Effect of a Short Message Service Intervention on Excessive Gestational Weight Gain in a Low-Income Population: A Randomized Controlled Trial

Objectives: The objective of this trial was to investigate the effect of educational short message service (SMS), or text messages, on excessive gestational weight gain (GWG) in a low-income, predominantly overweight/obese population. Methods: Participants (n = 83) were mostly overweight/obese women recruited at Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics on the island of O’ahu, Hawai’i at 15–20 weeks gestational age. The intervention group received SMS on nutrition and physical activity during pregnancy designed to help them meet Institute of Medicine (IOM) guidelines for GWG and American College of Obstetricians and Gynecologists guidelines for exercise, respectively. The control group received SMS about general health topics during pregnancy, excluding nutrition and physical activity. Both groups received one text message per week for eighteen weeks. GWG was defined as the difference between the last self-reported weight taken before delivery and participants’ self-reported weight before pregnancy. Differences between study groups were examined using t-tests and Chi-square tests. Linear regression models were used to examine association of GWG with study group and other factors. Results: GWG was similar (p = 0.58) in the control group (14.1 ± 11.4 kg) and the intervention group (15.5 ± 11.6 kg). The percentage of participants exceeding IOM guidelines for GWG was similar (p = 0.51) in the control group (50.0%, n = 17) and the intervention group (60.5%, n = 23). Conclusions: GWG was not significantly different between intervention and control groups. Trials that begin earlier in pregnancy or before pregnancy with longer intervention durations and varying message frequency as well as personalized or interactive messages may be needed to produce significant improvements.

Effect of Maternal Obesity and Preconceptional Weight Loss on Male and Female Offspring Metabolism and Olfactory Performance in Mice

According to the “developmental origins of health and disease” (DOHaD) concept, maternal obesity predisposes the offspring to non-communicable diseases in adulthood. While a preconceptional weight loss (WL) is recommended for obese women, its benefits on the offspring have been poorly addressed. We evaluated whether preconceptional WL was able to reverse the adverse effects of maternal obesity in a mouse model, exhibiting a modification of foetal growth and of the expression of genes encoding epigenetic modifiers in liver and placenta. We tracked metabolic and olfactory behavioural trajectories of offspring born to control, obese or WL mothers. After weaning, the offspring were either put on a control diet (CD) or a high-fat (HFD). After only few weeks of HFD, the offspring developed obesity, metabolic alterations and olfactory impairments, independently of maternal context. However, male offspring born to obese mother gained even more weight under HFD than their counterparts born to lean mothers. Preconceptional WL normalized the offspring metabolic phenotypes but had unexpected effects on olfactory performance: a reduction in olfactory sensitivity, along with a lack of fasting-induced, olfactory-based motivation. Our results confirm the benefits of maternal preconceptional WL for male offspring metabolic health but highlight some possible adverse outcomes on olfactory-based behaviours.