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 3538 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
(4143 hours) and on day 3 (6567 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 2024 kg/m2, n = 50);
group 3 (overweight, BMI 2529 kg/m2, n = 24),
group 4 (obese, BMI 3034 kg/m2, n = 12)
group 5 (morbidly obese, BMI 35 kg/m2, n = 13).
MATERIALS AND METHODS
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.
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
2024 kg/m2,
n =50)
group 3
(overweight,
BMI 2529
kg/m2, n=24)

group 4
(obese, BMI
3034 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 patients 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
Population
Women with PCOS
Intervention
In 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 2 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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