Optimizing reproductive health in women with obesity and infertility

Building Healthy Babies: A Mixed-Methods Needs Assessment for a Pre-Conception Program in Ontario

OBJECTIVES

The objective of this study was to gather Ontario clinicians' and public members' views on the design of a pre-conception patient education program.

METHODS

In this mixed-methods study, online surveys comprised of rank order, multiple choice, and short answer questions were completed by clinicians and public members. Semi-structured focus groups consisting of 2-6 participants each were then held via videoconference. Demographic variables and survey responses were analyzed quantitatively using descriptive and summary statistics. Descriptive thematic qualitative analysis using the constant comparative method of grounded theory was completed on each transcript to generate themes.

RESULTS

A total of 168 public members and 43 clinicians in Ontario completed surveys, while 11 clinicians and 11 public members participated in the focus groups. A pre-conception program in Ontario was felt to be important. An individual appointment with a primary care provider was the favoured program format per survey responses, whereas a virtual format with an interactive component was preferred among focus group participants. Important topics to include were pre-conception health (infertility, genetic screening, folic acid), prenatal and postpartum counselling (diet, activity, substance use, prenatal care, postpartum course), and medical optimization in pregnancy (high-risk medical conditions, medications, mental health). Both groups emphasized the need to consider accommodations for marginalized populations and various cultures and languages.

CONCLUSION

A standardized pre-conception patient education program is felt to be of high value by Ontario clinicians and public members. A pre-conception program may help improve obstetrical outcomes and decrease rates of major congenital anomalies in Ontario.

The Involvement of the microRNAs miR-466c and miR-340 in the Palmitate-Mediated Dysregulation of Gonadotropin-Releasing Hormone Gene Expression

Diets high in saturated fatty acids are associated with obesity and infertility. Palmitate, the most prevalent circulating saturated fatty acid, is sensed by hypothalamic neurons, contributing to homeostatic dysregulation. Notably, palmitate elevates the mRNA levels of gonadotropin-releasing hormone (Gnrh) mRNA and its activating transcription factor, GATA binding protein 4 (Gata4). GATA4 is essential for basal Gnrh expression by binding to its enhancer region, with Oct-1 (Oct1) and CEBP-β (Cebpb) playing regulatory roles. The pre- and post-transcriptional control of Gnrh by palmitate have not been investigated. Given the ability of palmitate to alter microRNAs (miRNAs), we hypothesized that palmitate-mediated dysregulation of Gnrh mRNA involves specific miRNAs. In the mHypoA-GnRH/GFP neurons, palmitate significantly downregulated six miRNAs (miR-125a, miR-181b, miR-340, miR-351, miR-466c and miR-503), and the repression was attenuated by co-treatment with 100 μM of oleate. Subsequent mimic transfections revealed that miR-466c significantly downregulates Gnrh, Gata4, and Chop mRNA and increases Per2, whereas miR-340 upregulates Gnrh, Gata4, Oct1, Cebpb, and Per2 mRNA. Our findings suggest that palmitate may indirectly regulate Gnrh at both the pre- and post-transcriptional levels by altering miR-466c and miR-340, which in turn regulate transcription factor expression levels. In summary, palmitate-mediated dysregulation of Gnrh and, consequently, reproductive function involves parallel transcriptional mechanisms.

Pathophysiology of obesity-related infertility and its prevention and treatment by potential phytotherapeutics

BACKGROUND

Obesity is a complex multifactorial disease in which the accumulation of excess body fat has adverse health effects, as it can increase the risk of several problems, including infertility, in both men and women. Obesity and infertility have risen together in recent years. Against this background, the present review aims to highlight the impact of obesity on infertility and the underlying pathophysiology of obesity-related infertility (ORI) in men and women, and to provide readers with knowledge of current trends in the effective development of phytotherapeutics for its treatment.

METHODS

We thoroughly searched in PubMed, MEDLINE, Scopus, EMBASE, and Google Scholar to find all relevant papers on ORI and the therapeutic effects of phytotherapeutics on ORI in men and women.

RESULTS

The extensive search of the available literature revealed that obesity affects reproductive function through several complex mechanisms such as hyperlipidaemia, hyperinsulinaemia, hyperandrogenism, increased body mass index, disruption of the hormonal milieu, systemic inflammation, oxidative stress, alterations in epigenetics and dysbiosis. On the other hand, several studies reported that phytotherapeutics has a broad therapeutic spectrum of action by improving sex hormone homeostasis, ovarian dysfunction, menstrual cycle and inhibiting ovarian hyperplasia, as well as down-regulating ovarian apoptosis, inflammation and oxidative stress, and controlling metabolic dysfunction in obese women. Male infertility is also addressed by phytotherapeutics by suppressing lipogenesis, increasing testosterone, 3β-HSD and 17β-HSD levels, improving sperm parameters and attenuating testicular dyslipidaemia, oxidative stress, inflammation and germ cell apoptosis.

CONCLUSIONS

In the present review, we discussed the effects of obesity on reproductive dysfunction in men and women and the underlying pathophysiology of ORI. In addition, the therapeutic effect of phytotherapeutics against ORI was highlighted.

Challenges in diagnosis and health care in polycystic ovary syndrome in Canada: a patient view to improve health care

BACKGROUND

Polycystic Ovary Syndrome (PCOS) is the most common endocrine-metabolic disorder affecting health and quality of life of those affected across the lifespan. We currently have limited evidence-based data on the experience of those living with PCOS in the health care system including diagnosis, health concerns and disease management. The aim of this study was to assess the perceptions of health status, health care experience and disease management support in those affected by PCOS in Alberta, Canada.

METHODS

An online questionnaire was completed via REDCap by individuals self-reporting a diagnosis of PCOS. Question categories included demographics, symptoms of PCOS and time to confirm a diagnosis, follow-up care, health concerns, and information resources. Descriptive statistics were used and thematic analyses was applied to open-response questions.

RESULTS

Responses from 194 participants living in Canada (93% in Alberta) were included. The average age was 34 ± 8 years and BMI was 35 ± 9. Menstrual irregularity was identified in 84% of respondents as the first symptom noticed and the primary reason for seeking a medical consultation. A PCOS diagnosis occurred on average 4.3 years following awareness of first symptoms and required consultation with more than one primary care provider for 57% of respondents. Half (53%) of respondents reported not receiving a referral to specialists for follow-up care and 70% were not informed about long-term health morbidity such as diabetes or cardiovascular disease. Most respondents (82%) did their own research about PCOS using on-line sources, academic literature and advice from peer support. The participant themes from open questions for improving health care included more resources and support, increased and reliable information, better education and training for clinicians, timely diagnosis, prompt referrals to specialists, and generally more compassion and empathy to the challenges faced by those managing their disease.

CONCLUSION

Our findings highlight the health concerns and challenges in health care for those with PCOS. In Alberta, Canada we have identified major gaps in health care including a timely diagnosis, follow up care and supports, and multidisciplinary care. This evidence-based data can be used to inform development of pathways to improve the health care experience in those affected by PCOS.

Endocrine factors associated with infertility in women: an updated review

INTRODUCTION

Infertility is defined as the inability to conceive after unprotected sexual intercourse for at least 12 consecutive months. Our objective is to present an updated narrative review on the endocrine causes of infertility in women.

AREAS COVERED

A comprehensive review was conducted using Scielo, Scopus, and EMBASE databases, comprising 245 articles. The pathophysiology of infertility in women was described, including endocrinopathies such as hypothalamic amenorrhea, hyperprolactinemia, polycystic ovary syndrome, primary ovarian insufficiency, obesity, thyroid dysfunction, and adrenal disorders. The diagnostic approach was outlined, emphasizing the necessity of hormonal studies and ovarian response assessments. Additionally, the treatment plan was presented, commencing with non-pharmacological interventions, encompassing the adoption of a Mediterranean diet, vitamin supplementation, moderate exercise, and maintaining a healthy weight. Subsequently, pharmacological treatment was discussed, focusing on the management of associated endocrine disorders and ovulatory dysfunction.

EXPERT OPINION

This comprehensive review highlights the impact of endocrine disorders on fertility in women, providing diagnostic and therapeutic algorithms. Despite remaining knowledge gaps that hinder more effective treatments, ongoing research and advancements show promise for improved fertility success rates within the next five years. Enhanced comprehension of the pathophysiology behind endocrine causes and the progress in genetic research will facilitate the delivery of personalized treatments, thus enhancing fertility rates.

Perceptions and Beliefs About Preconceptional Care Among Primary Healthcare Workers in Jeddah City, Saudi Arabia: An Analytical Cross-Sectional Study

Introduction Preconception care (PCC) is one of the important aspects of reproductive health and family planning, from the preventive aspect as primordial prevention for future offspring and primary prevention for females before pregnancy. However, there is no written protocol about PCC and it is not routinely practiced in Saudi Arabia. This study aimed to assess the perceptions and beliefs among care workers regarding PCC. Methods A cross-sectional study was conducted on general practitioners (GP), family physicians (FP), practitioner nurses (PN), and midwives (MW) in primary healthcare centers (PHC) in Jeddah City using a validated questionnaire that assesses their preconception practices, perceptions, and beliefs. Results This study included 201 participants, of whom 98.5% were Saudi nationals and 80.1% were female. Most (64.7%) were 30-39 years old, followed by 40-49 years old (21.9%). The majority (67.7%) were married and had one or two children (37.3%). Most (36%) were practitioner nurses, followed by family physicians (31%), and had 11-15 years of experience (32%), followed by six to 10 years of experience. The majority (44%) reported providing PCC one to five times last month. Of all participants, 72.63% agreed that PCC affected pregnancy outcomes, and 83% agreed that PCC is important. However, 51.7% agreed there is not enough time to provide PCC services. The service rated as the highest priority was providing advice regarding smoking cessation (82.1%), alcohol cessation (84.6%), control of chronic diseases (85.1%), and information about drug use (86.6%). Most participants rated rubella screening as highly important (89.9%), followed by hepatitis screening (88.6%). Family physicians and practitioner nurses perceived PCC as more important than general practitioners and midwives (p=0.026) and were more likely to perceive hospitals as the optimal setting for PCC (p=0.015). General practitioners were more likely to believe in the insufficient evidence base for PCC (p < 0.001). Conclusion The study found that healthcare workers had good perceptions, knowledge, and attitudes toward the PCC, but their practice was poor. Most lacked formal training and had differing perspectives on PCC, depending on their professions. The findings could inform strategies and measures to improve PCC practice among healthcare workers and raise awareness as well as capacity building by enhancing the training of healthcare workers.

Obesity and menstrual disorders

Obesity is a growing public health concern and is associated with a range of menstrual disorders, including heavy menstrual bleeding, oligomenorrhea, dysmenorrhea, and endometrial pathology. Investigations may be more logistically challenging in those in the population with obesity, and because of the heightened risk of endometrial malignancy, there should be a low threshold for biopsy to exclude endometrial hyperplasia. Although treatment modalities for women with obesity are broadly similar to those with a normal BMI, additional consideration must be given to the risks associated with estrogen in obesity. Outpatient management of heavy menstrual bleeding is a developing field and outpatient treatment modalities are preferable in the population with obesity to avoid the morbidity associated with anesthetics.

L-carnitine enhances developmental potential of bovine oocytes matured under high lipid concentrations in vitro

Maternal obesity elevates non-esterified fatty acids (NEFA) follicular concentrations. Bovine cumulus-oocyte complexes (COCs) matured in vitro under high NEFA have altered metabolism and reduced quality. Systemically, obesity promotes altered mitochondrial metabolism linked to L-carnitine insufficiency. We hypothesized that L-carnitine supplementation during IVM of bovine COCs in the presence of high NEFA would lessen the negative effects of exposure to excessive lipids on embryonic development and oxidative stress. COCs were collected from abattoir ovaries and matured in four groups: CON (control), LC (3 mM L-carnitine), HN (high NEFA: 200uM oleic, 150uM palmitic and 75uM stearic acid), and HNLC (HN and LC). Mature oocytes were assayed for aerobic and anaerobic metabolism utilizing oxygen and pH microsensors or fertilized in vitro (D0). Cleavage (D3) and blastocyst (D7, D8) rates were assessed. D3 embryos with ≥ 4 cells were stained for cytosolic and mitochondrial ROS. D8 blastocysts were assayed for gene transcript abundance of metabolic enzymes. Oocyte metabolism was not affected by IVM treatment. D3 formation of embryos with ≥ 4 cells were lower in LC or HN than CON or HNLC; blastocyst rates were greater for CON and lower for HN than LC and HNLC. D3 embryo mitochondrial and cytosolic ROS were reduced in HNLC when compared to other groups. IVM in HN altered blastocyst gene transcript abundance when compared to CON, but not LC or HNLC. In conclusion, supplementation with L-carnitine protects oocytes exposed to high NEFA during IVM and improves their developmental competence, suggesting that high lipid exposure may lead to L-carnitine insufficiency in bovine oocytes.

Does the Ketogenic Diet Improve the Quality of Ovarian Function in Obese Women?

Background: Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, the prevalence of which ranges from 8 to 13%. It is characterized by metabolic, reproductive, and psychological alterations. PCOS prevalence is related to body mass index (BMI). Women with BMI < 25 kg/m2 have a prevalence of 4.3%, whereas women with BMI > 30 kg/m2 have a prevalence of 14%. Moreover, women with PCOS have a risk of type 2 diabetes mellitus (T2DM) two-fold higher than controls, independently of BMI. Both PCOS and T2DM are also consequences of lower serum sex-hormone-binding globulin (SHBG) levels, which is currently considered a biomarker of metabolic disorders, in particular T2DM. Aim: To evaluate the effect of the very-low-calorie ketogenic diet (VLCKD) on markers suggested to be predictive of metabolic and ovulatory dysfunction. These comprehend SHBG, anti-Mullerian hormone (AMH), and progesterone levels on day 21 of the menstrual cycle in a cohort of obese non-diabetic women with PCOS and regular menses. Methods: Twenty-five patients (mean age 25.4 ± 3.44 years) with obesity and PCOS underwent VLCKD for 12 weeks. Each of them underwent measurements of anthropometric parameters (body weight, height, and waist circumference) and blood testing to evaluate serum levels of SHBG, AMH, and progesterone before and after 12 weeks of VLCKD. Results: At enrollment, all patients had high BMI, WC, and AMH, whereas SHBG and progesterone levels were low. After VLCKD, the patients showed a significant reduction in BMI, WC, and HOMA index. In particular, 76% of patients (19/25) switched from obesity to overweight, and the HOMA index normalized, reaching values lower than 2.5 in 96% (24/25) of patients. In addition, serum AMH levels significantly decreased, and progesterone and SHBG significantly increased after VLCKD. Conclusions: This is the first study documenting the effects of VLCKD on ovarian reserve and luteal function in women with PCOS. VLCKD could be used to improve metabolic and ovulatory dysfunction in women with PCOS. Further studies are needed to understand the reasons for the AMH reduction.

The impact of the ileoanal pouch on female fertility in ulcerative colitis: A systematic review and meta-analysis

AIM

Ileal pouch-anal anastomosis is a restorative option for patients with ulcerative colitis (UC) requiring surgery. The primary outcome of this study was the relative risk of infertility in women with UC undergoing restorative proctocolectomy (RPC) compared to the same patients before undergoing RPC. Infertility was defined as the inability to conceive after 1 year of regular sexual intercourse without contraception.

METHODS

A systematic review and meta-analysis were performed to include all relevant articles from 1946 from MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Studies included reported on the fertility rate of a cohort with UC and also reported the rate after RPC in those within the cohort who underwent surgery. This study was registered on PROSPERO (CRD42021259745).

RESULTS

Thirteen studies met the inclusion criteria and accounted for 793 patients pre-pouch and 802 post-pouch. The mean and median age of the patients at analysis was 36.8 and 32.7 years respectively; and the median duration of follow-up following ileal pouch-anal anastomosis was 110.4 (68-139) months. Our results highlight that following RPC the relative risk of infertility is 4.17 (95% CI 1.99, 8.74) compared with patients before RPC who had UC.

CONCLUSIONS

The findings of this meta-analysis provide an update on a previous meta-analysis published over a decade ago and results remain congruent. This suggests that despite advancements in surgical techniques the risk to fertility remains similar to a decade ago. However, further high quality studies are needed to try and decipher independent risk factors associated with a decrease in infertility.

Female obesity and infertility: outcomes and regulatory guidance

Obesity has been associated with reduced fertility, although the dynamics and mechanisms which link excess weight to reduced fertility are not yet fully clarified. Obese women, especially those with central obesity, are less likely to conceive per cycle. Obese women suffer from perturbations of the hypothalamus-pituitary-ovary axis, disturbances of the menstrual cycle and are up to three times more likely to suffer from oligo/anovulation. A delicate hormonal balance regulates follicular development and the maturation of oocytes and it has been observed that obesity can alter the hormonal environment: adipocytes, in fact, are responsible for the production of a hormone called leptin (present in high quantities in obese women) which has been associated with reduced fecundity. In addition to compromising ovulation, obesity negatively affects the development and implantation of the endometrium. The expression of polycystic ovary syndrome (PCOS) is regulated, in part, by weight, so obese women with PCOS often have a more severe phenotype and higher subfertility rates. Furthermore, obesity impairs women's response to medically assisted procreation (MAP) treatments. The authors have set out to delineate a broad-ranging overview of obesity's impact on female fertility, by drawing upon sources spanning the 1994-2022 period. Assisted reproductive technology (ART) procedures are also discussed as they relate to obese patients. In addition the dynamics by which maternal obesity reportedly affects fetal, neonatal and child development have also been briefly enunciated.

Role of Occupational Therapy in Primary Care

The American Occupational Therapy Association (AOTA) affirms that occupational therapy practitioners1 are well prepared to contribute to interprofessional collaborative care teams addressing the primary care needs of individuals across the life course. Because of an increased focus on preventive population health and social determinants of health by health care organizations, synergy between primary care and occupational therapy is growing, with support for client-centered,2 comprehensive whole-person care, health promotion and prevention, disease self-management, and quality of life (Halle et al., 2018). Occupational therapy practitioners’ distinct knowledge of the significant impact that roles, habits, and routines have on health and wellness makes their contribution to primary care valuable (AOTA, 2020b). Occupational therapy’s focus on meaningful engagement in occupations is relevant and vital to participation in individual, family, and community life (AOTA, 2020c). In addition, occupational therapy practitioners’ holistic and population perspectives allow them to be effective both as interprofessional health care team members and as direct care providers to support client, family, and community needs in primary care delivery models (Leland et al., 2017). The purposes of this position paper are to define primary care and to describe occupational therapy’s evolving and advancing role in primary care, including expansion of services into specialty primary care areas such as pediatric primary care and obstetrics and gynecology (AOTA, 2018).

Fetal and Placental Weight in Pre-Gestational Maternal Obesity (PGMO) vs. Excessive Gestational Weight Gain (EGWG)-A Preliminary Approach to the Perinatal Outcomes in Diet-Controlled Gestational Diabetes Mellitus

Both pre-gestational maternal obesity (PGMO) and excessive gestational weight gain (EGWG) increase the risk of gestational diabetes mellitus (GDM). Here, we conducted a retrospective study to comparatively examine the relation between fetal birth weight (FW) and placental weight (PW) in PGMO (n = 100) compared to EGWG (n = 100) with respect to perinatal outcomes in diet-controlled GDM. The control group was made up of 100 healthy pregnancies. The mean FW and the mean PW in EGWG were correlated with lowered fetal weight/placental weight ratio (FW/PW ratio). The percentage of births completed by cesarean section accounted for 47%, 32%, and 18% of all deliveries (EGWG, PGMO, and controls, respectively), with the predominance of FW-related indications for cesarean section. Extended postpartum hospital stays due to neonate were more frequent in EGWG, especially due to neonatal jaundice (p < 0.05). The results indicate the higher perinatal risk in mothers with EGWG compared to PGMO during GDM-complicated pregnancy. Further in-depth comparative studies involving larger patient pools are needed to validate these findings, the intent of which is to formulate guidelines for GDM patients in respect to management of PGMO and EGWG.

Potential Adverse Effects of Female and Male Obesity on Fertility: A Narrative Review

CONTEXT

Despite several studies documenting that obesity affects female and male fertility and leads to multiple adverse reproductive outcomes, the mechanisms involved are not elucidated. We aimed to summarize the potential adverse effects of female and male obesity, as well as the impact of weight loss on their fertility status.

EVIDENCE ACQUISITION

This review summarizes papers investigating the potential adverse effects of female and male obesity and the impact of weight-loss interventions on fertility among reproductive age populations. PubMed, Scopus, Web of Science, and Google Scholar databases were searched for retrieving studies published up to November 2019 on obesity/overweight among reproductive age populations.

RESULTS

The review of 68 studies revealed that female and male obesity/overweight increases the risk of sub-fecundity and infertility. The destructive effects of female obesity on reproduction are attributed to a variety of ovarian and extra-ovarian factors. In women with overweight or obesity, the time taken to conceive is longer, and they have a decreased fertility rate, increased requirement for gonadotropins, and higher miscarriage rate when compared to those with normal weight. Male obesity may lead to subfertility, mainly because of the disruption of the hypothalamus-pituitary-gonadal (HPG) axis, increased testicular temperature, impairment of the physical and molecular structure of sperm, decreased sperm quality, and erectile dysfunction due to peripheral vascular disease. Most studies recommend lifestyle interventions as first-line therapy in the general population of women and men with obesity and infertility.

CONCLUSIONS

This study shows the negative effects of female and male overweight and obesity on fertility. Therefore, educational interventions on the adverse effects of obesity and the benefits of weight reduction, such as increasing pregnancy rate, should be considered for couples seeking fertility.