Semin Reprod Med 2012; 30(06): 507-516
DOI: 10.1055/s-0032-1328879
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Female Obesity and Assisted Reproductive Technologies

Banu Kumbak
1   IVF Unit, Department of Obstetrics and Gynecology, Fırat University Medical School, Elazig, Turkey
,
Engin Oral
2   Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey
,
Orhan Bukulmez
3   Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
› Author Affiliations
Further Information

Publication History

Publication Date:
16 October 2012 (online)

Abstract

Obesity has grown to epidemic proportions, and currently nearly half of the reproductive-age women are overweight or obese. Risks, success rates, and economic aspects of infertility treatments in obese women have been extensively investigated. Unfavorable ovarian stimulation characteristics like increased gonadotropin consumption, fewer selected follicles, and lower number of retrieved oocytes have been observed in obese women undergoing assisted reproductive technologies (ART). There seems to be a strong association between increased body mass index and lower pregnancy and live-birth rates and increased miscarriage rate. Coexisting factors like age and polycystic ovary syndrome status have also been blamed for these adverse effects. The mechanisms underlying those adverse outcomes, whether ovarian or endometrial, still remain to be fully elucidated. Moreover, maternal, perinatal, and neonatal complications have also been reported to be higher in obese pregnant women. Hence in some countries strict restrictions exist for access to elective fertility treatment in obese women. However, it is controversial if these policies are socially and ethically acceptable. Furthermore, because weight reduction is not an easy task, it may lead to the decreased probability of conception due to the advancing reproductive age for many obese women. Thus weight reduction should be encouraged and patients counseled accordingly, but whether restriction for fertility treatment is implemented in obese women remains a matter of debate. There remains much to be known regarding the association between obesity and ART.

 
  • References

  • 1 Balen AH, Anderson RA ; Policy & Practice Committee of the BFS. Impact of obesity on female reproductive health: British Fertility Society, Policy and Practice Guidelines. Hum Fertil (Camb) 2007; 10 (4) 195-206
  • 2 Maheshwari A, Scotland G, Bell J, McTavish A, Hamilton M, Bhattacharya S. The direct health services costs of providing assisted reproduction services in overweight or obese women: a retrospective cross-sectional analysis. Hum Reprod 2009; 24 (3) 633-639
  • 3 Koning AM, Kuchenbecker WK, Groen H , et al. Economic consequences of overweight and obesity in infertility: a framework for evaluating the costs and outcomes of fertility care. Hum Reprod Update 2010; 16 (3) 246-254
  • 4 Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894: i-xii , 1–253
  • 5 Metwally M, Ong KJ, Ledger WL, Li TC. Does high body mass index increase the risk of miscarriage after spontaneous and assisted conception? A meta-analysis of the evidence. Fertil Steril 2008; 90 (3) 714-726
  • 6 Zaadstra BM, Seidell JC, Van Noord PA , et al. Fat and female fecundity: prospective study of effect of body fat distribution on conception rates. BMJ 1993; 306 (6876) 484-487
  • 7 Wass P, Waldenström U, Rössner S, Hellberg D. An android body fat distribution in females impairs the pregnancy rate of in-vitro fertilization-embryo transfer. Hum Reprod 1997; 12 (9) 2057-2060
  • 8 Abrams B, Parker J. Overweight and pregnancy complications. Int J Obes 1988; 12 (4) 293-303
  • 9 Bhattacharya S, Campbell DM, Liston WA, Bhattacharya S. Effect of body mass index on pregnancy outcomes in nulliparous women delivering singleton babies. BMC Public Health 2007; 7: 168
  • 10 Siega-Riz AM, King JC ; American Dietetic Association; American Society of Nutrition. Position of the American Dietetic Association and American Society for Nutrition: obesity, reproduction, and pregnancy outcomes. J Am Diet Assoc 2009; 109 (5) 918-927
  • 11 Clark AM, Thornley B, Tomlinson L, Galletley C, Norman RJ. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 1998; 13 (6) 1502-1505
  • 12 Norman RJ, Noakes M, Wu R, Davies MJ, Moran L, Wang JX. Improving reproductive performance in overweight/obese women with effective weight management. Hum Reprod Update 2004; 10 (3) 267-280
  • 13 Rich-Edwards JW, Goldman MB, Willett WC , et al. Adolescent body mass index and infertility caused by ovulatory disorder. Am J Obstet Gynecol 1994; 171 (1) 171-177
  • 14 Clark AM, Ledger W, Galletly C , et al. Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod 1995; 10 (10) 2705-2712
  • 15 Rajkhowa M, Bicknell J, Jones M, Clayton RN. Insulin sensitivity in women with polycystic ovary syndrome: relationship to hyperandrogenemia. Fertil Steril 1994; 61 (4) 605-612
  • 16 Hsueh AJ, Billig H, Tsafriri A. Ovarian follicle atresia: a hormonally controlled apoptotic process. Endocr Rev 1994; 15 (6) 707-724
  • 17 Levens ED, Skarulis MC. Assessing the role of endometrial alteration among obese patients undergoing assisted reproduction. Fertil Steril 2008; 89 (6) 1606-1608
  • 18 Pasquali R, Gambineri A. Metabolic effects of obesity on reproduction. Reprod Biomed Online 2006; 12 (5) 542-551
  • 19 Robker RL, Akison LK, Bennett BD , et al. Obese women exhibit differences in ovarian metabolites, hormones, and gene expression compared with moderate-weight women. J Clin Endocrinol Metab 2009; 94 (5) 1533-1540
  • 20 Mutsaerts MA, Groen H, ter Bogt NC , et al. The LIFESTYLE study: costs and effects of a structured lifestyle program in overweight and obese subfertile women to reduce the need for fertility treatment and improve reproductive outcome. A randomised controlled trial. BMC Womens Health 2010; 10: 22
  • 21 van der Steeg JW, Steures P, Eijkemans MJ , et al. Obesity affects spontaneous pregnancy chances in subfertile, ovulatory women. Hum Reprod 2008; 23 (2) 324-328
  • 22 Polson DW, Kiddy DS, Mason HD, Franks S. Induction of ovulation with clomiphene citrate in women with polycystic ovary syndrome: the difference between responders and nonresponders. Fertil Steril 1989; 51 (1) 30-34
  • 23 Hamilton-Fairley D, Kiddy D, Watson H, Paterson C, Franks S. Association of moderate obesity with a poor pregnancy outcome in women with polycystic ovary syndrome treated with low dose gonadotrophin. Br J Obstet Gynaecol 1992; 99 (2) 128-131
  • 24 Nyboe Andersen A, Balen A, Platteau P, Devroey P, Helmgaard L, Arce JC ; Bravelle Ovulation Induction (BOI) Study Group. Predicting the FSH threshold dose in women with WHO Group II anovulatory infertility failing to ovulate or conceive on clomiphene citrate. Hum Reprod 2008; 23 (6) 1424-1430
  • 25 Orvieto R, Meltcer S, Nahum R, Rabinson J, Anteby EY, Ashkenazi J. The influence of body mass index on in vitro fertilization outcome. Int J Gynaecol Obstet 2009; 104 (1) 53-55
  • 26 Gosman GG, Katcher HI, Legro RS. Obesity and the role of gut and adipose hormones in female reproduction. Hum Reprod Update 2006; 12 (5) 585-601
  • 27 Bellver J, Rossal LP, Bosch E , et al. Obesity and the risk of spontaneous abortion after oocyte donation. Fertil Steril 2003; 79 (5) 1136-1140
  • 28 Bellver J, Melo MA, Bosch E, Serra V, Remohí J, Pellicer A. Obesity and poor reproductive outcome: the potential role of the endometrium. Fertil Steril 2007; 88 (2) 446-451
  • 29 Wattanakumtornkul S, Damario MA, Stevens Hall SA, Thornhill AR, Tummon IS. Body mass index and uterine receptivity in the oocyte donation model. Fertil Steril 2003; 80 (2) 336-340
  • 30 Styne-Gross A, Elkind-Hirsch K, Scott Jr RT. Obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation. Fertil Steril 2005; 83 (6) 1629-1634
  • 31 McClamrock HD. The great weight debate: do elevations in body mass index (BMI) exert a negative extraovarian effect on in vitro fertilization outcome?. Fertil Steril 2008; 89 (6) 1609-1610
  • 32 Budak E, Fernández Sánchez M, Bellver J, Cerveró A, Simón C, Pellicer A. Interactions of the hormones leptin, ghrelin, adiponectin, resistin, and PYY3-36 with the reproductive system. Fertil Steril 2006; 85 (6) 1563-1581
  • 33 Maheshwari A, Stofberg L, Bhattacharya S. Effect of overweight and obesity on assisted reproductive technology—a systematic review. Hum Reprod Update 2007; 13 (5) 433-444
  • 34 Luke B, Brown MB, Stern JE, Missmer SA, Fujimoto VY, Leach R ; SART Writing Group. Female obesity adversely affects assisted reproductive technology (ART) pregnancy and live birth rates. Hum Reprod 2011; 26 (1) 245-252
  • 35 Luke B, Brown MB, Missmer SA, Bukulmez O, Leach R, Stern JE ; Society for Assisted Reproductive Technology writing group. The effect of increasing obesity on the response to and outcome of assisted reproductive technology: a national study. Fertil Steril 2011; 96 (4) 820-825
  • 36 Al-Azemi M, Omu FE, Omu AE. The effect of obesity on the outcome of infertility management in women with polycystic ovary syndrome. Arch Gynecol Obstet 2004; 270 (4) 205-210
  • 37 Pasquali R, Patton L, Gambineri A. Obesity and infertility. Curr Opin Endocrinol Diabetes Obes 2007; 14 (6) 482-487
  • 38 Jungheim ES, Lanzendorf SE, Odem RR, Moley KH, Chang AS, Ratts VS. Morbid obesity is associated with lower clinical pregnancy rates after in vitro fertilization in women with polycystic ovary syndrome. Fertil Steril 2009; 92 (1) 256-261
  • 39 Tian L, Shen H, Lu Q, Norman RJ, Wang J. Insulin resistance increases the risk of spontaneous abortion after assisted reproduction technology treatment. J Clin Endocrinol Metab 2007; 92 (4) 1430-1433
  • 40 Wang JX, Davies M, Norman RJ. Body mass and probability of pregnancy during assisted reproduction treatment: retrospective study. BMJ 2000; 321 (7272) 1320-1321
  • 41 Homburg R. Pregnancy complications in PCOS. Best Pract Res Clin Endocrinol Metab 2006; 20 (2) 281-292
  • 42 Boomsma CM, Fauser BC, Macklon NS. Pregnancy complications in women with polycystic ovary syndrome. Semin Reprod Med 2008; 26 (1) 72-84
  • 43 Ozgun MT, Uludag S, Oner G, Batukan C, Aygen EM, Sahin Y. The influence of obesity on ICSI outcomes in women with polycystic ovary syndrome. J Obstet Gynaecol 2011; 31 (3) 245-249
  • 44 McCormick B, Thomas M, Maxwell R, Williams D, Aubuchon M. Effects of polycystic ovarian syndrome on in vitro fertilization-embryo transfer outcomes are influenced by body mass index. Fertil Steril 2008; 90 (6) 2304-2309
  • 45 Winter E, Wang J, Davies MJ, Norman R. Early pregnancy loss following assisted reproductive technology treatment. Hum Reprod 2002; 17 (12) 3220-3223
  • 46 Carrington B, Sacks G, Regan L. Recurrent miscarriage: pathophysiology and outcome. Curr Opin Obstet Gynecol 2005; 17 (6) 591-597
  • 47 Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev 2010; (1) CD003053
  • 48 Tso LO, Costello MF, Albuquerque LE, Andriolo RB, Freitas V. Metformin treatment before and during IVF or ICSI in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2009; (2) CD006105
  • 49 Bates GW, Whitworth NS. Effect of body weight reduction on plasma androgens in obese, infertile women. Fertil Steril 1982; 38 (4) 406-409
  • 50 Ladson G, Dodson WC, Sweet SD , et al. The effects of metformin with lifestyle therapy in polycystic ovary syndrome: a randomized double-blind study. Fertil Steril 2011; 95 (3) 1059-1066 ; e1–e7
  • 51 Guzick DS, Wing R, Smith D, Berga SL, Winters SJ. Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertil Steril 1994; 61 (4) 598-604
  • 52 Shah DK, Ginsburg ES. Bariatric surgery and fertility. Curr Opin Obstet Gynecol 2010; 22 (3) 248-254
  • 53 Pandey S, Maheshwari A, Bhattacharya S. Should access to fertility treatment be determined by female body mass index?. Hum Reprod 2010; 25 (4) 815-820
  • 54 Fedorcsák P, Dale PO, Storeng R , et al. Impact of overweight and underweight on assisted reproduction treatment. Hum Reprod 2004; 19 (11) 2523-2528
  • 55 Balen AH, Platteau P, Andersen AN , et al. The influence of body weight on response to ovulation induction with gonadotrophins in 335 women with World Health Organization group II anovulatory infertility. BJOG 2006; 113 (10) 1195-1202
  • 56 Wang JX, Davies MJ, Norman RJ. Obesity increases the risk of spontaneous abortion during infertility treatment. Obes Res 2002; 10 (6) 551-554
  • 57 Thum MY, El-Sheikhah A, Faris R , et al. The influence of body mass index to in-vitro fertilisation treatment outcome, risk of miscarriage and pregnancy outcome. J Obstet Gynaecol 2007; 27 (7) 699-702
  • 58 Ramsay JE, Greer I, Sattar N. ABC of obesity. Obesity and reproduction. BMJ 2006; 333 (7579) 1159-1162
  • 59 Yu CK, Teoh TG, Robinson S. Obesity in pregnancy. BJOG 2006; 113 (10) 1117-1125
  • 60 Practice Committee of American Society for Reproductive Medicine. Obesity and reproduction: an educational bulletin. Fertil Steril 2008; 90 (5, Suppl) S21-S29
  • 61 Farquhar CM, Gillett WR. Prioritising for fertility treatments—should a high BMI exclude treatment?. BJOG 2006; 113 (10) 1107-1109
  • 62 Gillett WR, Putt T, Farquhar CM. Prioritising for fertility treatments—the effect of excluding women with a high body mass index. BJOG 2006; 113 (10) 1218-1221
  • 63 Zachariah M, Fleming R, Acharya U. Management of obese women in assisted conception units: a UK survey. Hum Fertil (Camb) 2006; 9 (2) 101-105
  • 64 Kennedy R, Kingsland C, Rutherford A, Hamilton M, Ledger W ; British Fertility Society. Implementation of the NICE guideline—recommendations from the British Fertility Society for national criteria for NHS funding of assisted conception. Hum Fertil (Camb) 2006; 9 (3) 181-189
  • 65 Fassino S, Pierò A, Boggio S, Piccioni V, Garzaro L. Anxiety, depression and anger suppression in infertile couples: a controlled study. Hum Reprod 2002; 17 (11) 2986-2994
  • 66 Puhl RM, Moss-Racusin CA, Schwartz MB, Brownell KD. Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Educ Res 2008; 23 (2) 347-358
  • 67 Loh S, Wang JX, Matthews CD. The influence of body mass index, basal FSH and age on the response to gonadotrophin stimulation in non-polycystic ovarian syndrome patients. Hum Reprod 2002; 17 (5) 1207-1211
  • 68 Dechaud H, Anahory T, Reyftmann L, Loup V, Hamamah S, Hedon B. Obesity does not adversely affect results in patients who are undergoing in vitro fertilization and embryo transfer. Eur J Obstet Gynecol Reprod Biol 2006; 127 (1) 88-93
  • 69 van Swieten EC, van der Leeuw-Harmsen L, Badings EA, van der Linden PJ. Obesity and Clomiphene Challenge Test as predictors of outcome of in vitro fertilization and intracytoplasmic sperm injection. Gynecol Obstet Invest 2005; 59 (4) 220-224
  • 70 Al-Inany HG, Abou-Setta AM, Aboulghar M. Gonadotrophin-releasing hormone antagonists for assisted conception. Cochrane Database Syst Rev 2006; 3 (3) CD001750
  • 71 Kumbak B, Akbas H, Sahin L, Karlikaya G, Karagozoglu H, Kahraman S. Ovarian stimulation in women with high and low body mass index: GnRH agonist versus GnRH antagonist. Reprod Biomed Online 2010; 20 (3) 314-319
  • 72 Spandorfer SD, Kump L, Goldschlag D, Brodkin T, Davis OK, Rosenwaks Z. Obesity and in vitro fertilization: negative influences on outcome. J Reprod Med 2004; 49 (12) 973-977
  • 73 Loveland JB, McClamrock HD, Malinow AM, Sharara FI. Increased body mass index has a deleterious effect on in vitro fertilization outcome. J Assist Reprod Genet 2001; 18 (7) 382-386
  • 74 Bellver J, Ayllón Y, Ferrando M , et al. Female obesity impairs in vitro fertilization outcome without affecting embryo quality. Fertil Steril 2010; 93 (2) 447-454
  • 75 Zhang D, Zhu Y, Gao H , et al. Overweight and obesity negatively affect the outcomes of ovarian stimulation and in vitro fertilisation: a cohort study of 2628 Chinese women. Gynecol Endocrinol 2010; 26 (5) 325-332
  • 76 Lashen H, Ledger W, Bernal AL, Barlow D. Extremes of body mass do not adversely affect the outcome of superovulation and in-vitro fertilization. Hum Reprod 1999; 14 (3) 712-715
  • 77 Metwally M, Cutting R, Tipton A, Skull J, Ledger WL, Li TC. Effect of increased body mass index on oocyte and embryo quality in IVF patients. Reprod Biomed Online 2007; 15 (5) 532-538
  • 78 Esinler I, Bozdag G, Yarali H. Impact of isolated obesity on ICSI outcome. Reprod Biomed Online 2008; 17 (4) 583-587
  • 79 Sneed ML, Uhler ML, Grotjan HE, Rapisarda JJ, Lederer KJ, Beltsos AN. Body mass index: impact on IVF success appears age-related. Hum Reprod 2008; 23 (8) 1835-1839
  • 80 Dokras A, Baredziak L, Blaine J, Syrop C, VanVoorhis BJ, Sparks A. Obstetric outcomes after in vitro fertilization in obese and morbidly obese women. Obstet Gynecol 2006; 108 (1) 61-69
  • 81 Egan B, Racowsky C, Hornstein MD, Martin R, Tsen LC. Anesthetic impact of body mass index in patients undergoing assisted reproductive technologies. J Clin Anesth 2008; 20 (5) 356-363
  • 82 Mitchell M, Bakos HW, Lane M. Paternal diet-induced obesity impairs embryo development and implantation in the mouse. Fertil Steril 2011; 95 (4) 1349-1353
  • 83 Martini AC, Tissera A, Estofán D , et al. Overweight and seminal quality: a study of 794 patients. Fertil Steril 2010; 94 (5) 1739-1743
  • 84 Vahratian A, Smith YR. Should access to fertility-related services be conditional on body mass index?. Hum Reprod 2009; 24 (7) 1532-1537
  • 85 Dondorp W, de Wert G, Pennings G , et al; ESHRE Task Force on Ethics and Law, including. Lifestyle-related factors and access to medically assisted reproduction. Hum Reprod 2010; 25 (3) 578-583
  • 86 Abenhaim HA, Kinch RA, Morin L, Benjamin A, Usher R. Effect of prepregnancy body mass index categories on obstetrical and neonatal outcomes. Arch Gynecol Obstet 2007; 275 (1) 39-43
  • 87 Usha Kiran TS, Hemmadi S, Bethel J, Evans J. Outcome of pregnancy in a woman with an increased body mass index. BJOG 2005; 112 (6) 768-772
  • 88 Linné Y. Effects of obesity on women's reproduction and complications during pregnancy. Obes Rev 2004; 5 (3) 137-143
  • 89 Weiss JL, Malone FD, Emig D , et al; FASTER Research Consortium. Obesity, obstetric complications and cesarean delivery rate—a population-based screening study. Am J Obstet Gynecol 2004; 190 (4) 1091-1097
  • 90 Kristensen J, Vestergaard M, Wisborg K, Kesmodel U, Secher NJ. Pre-pregnancy weight and the risk of stillbirth and neonatal death. BJOG 2005; 112 (4) 403-408
  • 91 O'Brien TE, Ray JG, Chan WS. Maternal body mass index and the risk of preeclampsia: a systematic overview. Epidemiology 2003; 14 (3) 368-374
  • 92 Krishnamoorthy U, Schram CM, Hill SR. Maternal obesity in pregnancy: is it time for meaningful research to inform preventive and management strategies?. BJOG 2006; 113 (10) 1134-1140