Effects of different body mass indices on in vitro maturation in women with

polycystic ovaries

Shalom-Paz E; Marzal A; Wiser A; Almog B; Reinblatt S; Tulandi T; Holzer H.; Effects of different body mass indices on in vitro maturation in women with polycystic ovaries, Fertility and Sterility 2011 Aug;96(2):336-9

Introduction

• PCOS affects 5-10% of women of childbearing age & contributes to 10% of infertility, also responsible for approximately 70% of cases of anovulatory infertility

• There are two types of women with PCOS: – the ‘‘lean’’ type– the ‘‘obese’’ type.

• In obese women, excess body fat is associated with – chronic oligo anovulation– infertility due to hyperinsulinemia and ovarian

hyperandrogenemia.– higher miscarriage rates – higher prevalence of gestational diabetes– pregnancy induced hypertension

Introduction• However, results of studies evaluating the influence of BMI on

the outcome of IVF have been conflicting• The purpose of this study was to evaluate the effects of BMI

on in vitro maturation (IVM) in women with polycystic ovaries

MATERIALS AND METHODS

• This study retrospectively evaluated all IVM cycles that were performed for women with PCOS between the years 2004 and 2008 (total 116 cycles in 113 patients)

• PCOS was defined according to the Rotterdam criteria

• This study excluded women who underwent IVM for indications other than current infertility, including those for oocyte cryopreservation and oocyte donation.

MATERIALS AND METHODS• In vivo maturation was conducted as follows:

– first ultrasound scan on day 3 of the cycle follicles were counted and the endometrium measured.

– A second scan was scheduled between days 7 and 9 of the cycle. – Human chorionic gonadotropin was administered when the largest

follicle was ≤ 12 mm– Oocytes were collected 35–38 hours after hCG injection.– The number and measurement of follicles diameter was calculated on

the day of hCG administration.– Collection started with the largest follicle followed by examination of

oocyte maturity– The oocytes collected were assessed for nuclear maturity under the

dissecting microscope– Mature oocytes on the collection day were inseminated on the same

day and the immature oocytes were cultured in IVM medium

MATERIALS AND METHODS

• In vivo maturation was conducted as follows (continue):– Matured oocytes were inseminated by

intracytoplasmic sperm injection (ICSI)– The zygotes were cultured in Embryo Maintenance

Medium– Embryonic development was assessed on day 2 (41–

43 hours) and on day 3 (65–67 hours) after insemination according to • the regularity of blastomeres, • percentage and pattern of anucleate fragments• all dysmorphic characteristics of the embryos

MATERIALS AND METHODS

• In vivo maturation was conducted as follows (continue):– good quality embryos defined as

• if they had at least three cells on day 2 and six cells on day 3• contained < 20% anucleate fragments• exhibited no apparent morphologic abnormalities

– Low quality embryos define as• Embryos showing blastomere multinucleation• poor cell adhesion• uneven cell division• cytoplasmic abnormalities

– best-quality embryos were transferred on day 2 or 3 after ICSI

MATERIALS AND METHODS• The protocol was approved by the Institutional Research

Ethics Board of the McGill University Health Center, and all patients provided written informed consent.

• Demographic data recorded included – Age– BMI– basal hormonal levels– number of follicles– endometrial thickness– number of oocytes retrieved.

MATERIALS AND METHODS• Data that the study evaluated are:– the number of oocytes matured in vivo– maturation rate in vitro– fertilization and cleavage rates– number of embryos transferred– implantation rates– pregnancy rates– delivery rates.

MATERIALS AND METHODS• Patients were divided into subgroups according to BMI: – group 1 (underweight, BMI <20 kg/m2, n = 17), – group 2 (normal weight, BMI 20–24 kg/m2, n = 50); – group 3 (overweight, BMI 25–29 kg/m2, n = 24), – group 4 (obese, BMI 30–34 kg/m2, n = 12)– group 5 (morbidly obese, BMI ≥ 35 kg/m2, n = 13).

MATERIALS AND METHODSStatistical Analysis• Statistical analysis was performed using the SPSS software• Differences between parameters among the groups were

evaluated using t test or Mann-Whitney test, as appropriate. • Differences between proportions were evaluated using the c2

or Fisher exact test. • P value of <.05 was considered statistically significant.

Flow chart

Statistical Analysis• Statistical analysis was performed using the SPSS software• Differences between parameters among the groups were evaluated using t test or Mann-Whitney test, as appropriate. • Differences between proportions were evaluated using the c2 or Fisher exact test. • P value of <.05 was considered statistically significant.

all IVM cycles that were performed in Department of Obstetrics and Gynecology McGill University, Montreal, Quebec, Canada for women with PCOS between the years 2004 - 2008

(total 116 cycles in 113 patients)

women who underwent IVM for indications other than current infertility are excluded

group 1(underweight,

BMI <20 kg/m2, n =17)

group 2(normal

weight, BMI 20–24 kg/m2,

n =50)

group 3(overweight, BMI 25–29

kg/m2, n=24)

group 4(obese, BMI

30–34 kg/m2, n=12)

group 5(morbidly

obese, BMI ≥ 35 kg/m2,

n=13)

RESULTS

• Table 1 shows comparable baseline profiles of women with different BMIs.

RESULTS

• The number and quality of oocytes among women with different BMIs were also similar, as demonstrated in Table 2

RESULTS

• There was no significant difference in the endometrial thickness and rates of implantation, pregnancy, and delivery among women with different BMIs.

RESULTS

• The pregnancy rate in underweight women was 50%, normal weight 47.9%, overweight 29.1%, obese 27.2%, and in morbidly obese women was 30.7%.

• The miscarriage and delivery rates were also similar• These results were comparable to those of underweight,

normal weight, and overweight women.

DISCUSSION

• Several investigators have reported the effects of different BMIs on the outcome of IVF.

• It seems that obesity: – lengthens the duration of stimulation– increases the gonadotropin doses required– decreases peak E2 levels, number of mature

follicles, and number of oocytes retrieved– increases the cycle cancellation rate– obese patient’s habitus can sometimes interfere

with oocyte retrieval and ET

DISCUSSION

• This study was the first study evaluating the effects of BMI on IVM.

• One of the differences between IVM and conventional IVF is that gonadotropin stimulation is not used.

• The study demonstrated that there was no correlation between different BMI and IVM outcome obesity did not impair the ability to perform oocyte retrieval or ET

DISCUSSION• Reports on the effects of obesity on oocyte and

embryo quality have been conflicting, and few studies have looked at the association of BMI and IVF outcome

• Metwally et al. reported that obesity adversely affected embryo quality in young women (<35 years) undergoing IVF/ICSI, whereas oocyte quality was not affected the study could not demonstrate the relationship between obesity and oocyte or embryo quality.

DISCUSSION• Report by Jungheim et al. and in agreement with

Vilarino et al. that morbid obesity impairs implantation rates in IVF the study did not find any differences in implantation rates among the different BMI subgroups treated with IVM.

DISCUSSION• There have been many reports associating obesity

with increased miscarriage rate, regardless of the methods of conception in the study the rate of miscarriages was 25% in normal and overweight women there was a trend toward higher miscarriage rates in underweight and in women with BMI >30 kg/m2.

DISCUSSION

• Regardless of the findings, the study recommend lifestyle changes for patients who are not within the normal weight range.

• Despite not having an impact on pregnancy rates per se, it is well established that obesity predisposes women to several general and obstetric complications, such as pre-eclampsia, gestational diabetes, and birth defects, as well as requiring a cesarean section

• In addition, low BMI is also associated with poor obstetric outcome, such as intrauterine growth restriction and preterm labor.

CONCLUSION

• The study suggests that the results of treatment with IVM are independent of BMI.

• Large, prospective studies are needed to confirm these findings.

Critical appraisal

• What is the study type?a Retrospective, cohort study

• PopulationWomen with PCOS

• InterventionIn Vitro Maturation on PCOS women, divided into 5 BMI groups.

• Comparison Body Mass Index

• Outcomes BMI effects on the number of oocytes matured in vivo, maturation rate in vitro, fertilization and cleavage rates, number of embryos transferred, implantation rates, pregnancy rates & delivery rates in women with PCOS that having IVM procedure.

• What is the study type? Is the study type appropriate to the research question?The study type retrospective, cohort study. Yes, the study type appropriate to the research question.

• What is the reference/target population?– all IVM cycles that were performed in Department of Obstetrics and

Gynecology McGill University, Montreal, Quebec, Canada for women with PCOS between the years 2004 - 2008 (total 116 cycles in 113 patients)

– excluded women who underwent IVM for indications other than current infertility, including those for oocyte cryopreservation and oocyte donation.

Critical appraisal

• What are the study factors?The study factors are the number of oocytes matured in vivo, maturation rate in vitro, fertilization and cleavage rates, number of embryos transferred, implantation rates, pregnancy rates, and delivery rates.

• Are the aims clearly stated?Yes they are.The Objective is To evaluate the effect of body mass index (BMI) on in vitro maturation (IVM) outcomes in women with polycystic ovaries

• Is the design appropriate to the stated aim?Yes, it is

• Was the sample size justified?Yes, it was

• Do the numbers add up? No, they did not. There were no number add up

• Were the basic data adequately described?Yes, we can see it in the table 1

• Was the statistical significance assesed?Yes ,by p< 0,05

• Are statistical methods described? – Yes. The statistical analysis was performed using the SPSS software

package – Differences between parameters among the groups were evaluated

using t test or Mann-Whitney test– Differences between proportions were evaluated using the χ2 or

Fisher exact test

• Are sample measurement likely to be valid and reliable?Yes they are

• How do the result compare with the previous reports?Reports on the effects of obesity on oocyte and embryo quality have been conflicting to previous report

• What implication does the study have for your practice?This study give an information, that the results of treatment with IVM are independent of BMI.

• What conclusion did the authors reach about the research question?The conclusion suggests that the results of treatment with IVM are independent of BMI

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