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LETTER TO THE EDITOR
Year : 2012  |  Volume : 11  |  Issue : 4  |  Page : 247-249  

Consequences of increasing obesity burden on infertility treatment in the developing countries


Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication24-Oct-2012

Correspondence Address:
Adebiyi G Adesiyun
P.O.Box 204, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-3519.102859

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How to cite this article:
Adesiyun AG. Consequences of increasing obesity burden on infertility treatment in the developing countries. Ann Afr Med 2012;11:247-9

How to cite this URL:
Adesiyun AG. Consequences of increasing obesity burden on infertility treatment in the developing countries. Ann Afr Med [serial online] 2012 [cited 2020 Dec 3];11:247-9. Available from: https://www.annalsafrmed.org/text.asp?2012/11/4/247/102859

Sir,

In the developing world, a rapidly increasing prevalence of obesity have been reported and the burden of obesity is shifting toward the poor. [1],[2] Reported prevalence of obesity in Nigeria is in the range of 20.7% and 22%. [3],[4] In the United States and most European countries, 30% of women are obese and 6% are morbidly obese. [5] World Health Organization definition of obesity includes individuals with body mass index of 30 kg/m 2 and above. The increasing prevalence of obesity worldwide is the result of a combination of reduced exercise, changes in dietary composition, and increased calorie intake resulting in high energy intake and reduced expenditure. However, remote causes of obesity may be due to hormonal, endocrine, genetic, and psychological factors. Use of prescription drugs like steroids, contraceptives, and antidepressants may also cause obesity. A recent study reported that an estimated 22% of women with mean age of 24-28 years in United Kingdom would be obese in 2010, which is in sharp contrast to 16% reported in 2004. [6] This figure directly translates to increase obesity level among women of childbearing age who may be potential candidates for infertility treatment. Similar trend is also likely in the developing world. [1]

Obese women have been reported to be three times more likely as nonobese women to be at risk of infertility. [7] A delayed spontaneous conception has been reported in obese women, mainly caused by ovulatory factor. [8] The probability of pregnancy is reduced by 5% for every unit of body mass index (BMI) that exceeds 29 kg/m 2 . [8] An ovulatory infertility is reported to be three times more common in obese women. [9] Prevalence of polycystic ovary syndrome (PCOS) appears to be rising due to current epidemic of obesity and at least 35-63% of women with PCOS are obese and they are more prone to insulin resistance. [10] Female obesity is related to impaired fertility in both natural and assisted conception cycles. [11],[12] This may be related to absorption and distribution of the administered drugs, effect of hyperinsulinemia, hyperandrogenism on ovarian response, follicular growth, oocyte maturation, and endometrial maturation.

For obese infertile women who would need assisted reproductive technology (ART) treatment, the concerns of the ART unit are that of difficulty with ovarian stimulation and follicular monitoring, impairment in the outcomes of ovarian stimulation, and embryo transfer. [5] Obese women undergoing ovarian stimulation in ART treatment cycle were found to require higher dose and longer period of ovarian stimulation with gonadotrophins (GNT) due to lower follicular response, thus highlighting a state of GNT resistance. [5] A meta-analysis of 13 studies found a weighted mean difference of 771 International Unit of GNT needed more in obese women. [13] Although some study did not find deleterious effect of obesity on ovarian response in in vitro fertilization (IVF) treatment. [14],[15] However, more importantly, the combination of obesity with insulin resistance appears to affect the outcome of ovulation induction therapy. [16]

Outcomes of ovarian stimulation in obese women is usually characterized by fewer growing follicles, lower intra follicular human chorionic gonadotrophins concentration, lower peak estradiol level, lower number of matured oocytes , fewer oocyte retrieval, higher cancellation rate, impaired oocyte quality, lower fertilization rate, poorer embryo quality, lower incidence of embryo transfer, and lower mean number of transferred embryo. [5],[10] These consequences impacts on the patient and the health sector in terms of financial burden and psychological affectation. Some studies have failed to demonstrate association with impaired oocyte and embryo quality. [5],[17],[18] Studies that reported impairment in oocyte and embryo quality do not agree on the specific alteration that affects the quality. Metawally et al. further related the embryo quality in obese women to maternal age. [19] In furtherance to the outcome of ART treatment in obese women, a study of first cycle recipient of ovum donation without risk factors for miscarriage reported a significantly lower ongoing pregnancy rate in obese than in the normal control, pointing out that the endometrium may also play a role in the poor reproductive outcome. [20] This is further corroborated by a study that reported lower implantation rate and pregnancy rate among surrogate obese women in third party reproduction. [21] It is equally important to bare in mind that obese women are harder to monitor for follicular maturation accurately by trans vaginal sonography. It has been shown that they are at greater risk of over response. [22] Outcomes of embryo transfer in obese women is associated with higher incidences of low implantation rate, low pregnancy rate, high preclinical, and clinical miscarriage, increased complications during pregnancy to mother and fetus (which include gestation diabetes mellitus, pre-eclampsia, macrosomia, congenital fetal abnormalities, and intra uterine death) and low live birth rate. [16]

Obesity has equally been found to affect male infertility. A study of male partners of women attending infertility clinic found out that the incidence of obesity was three times more in men with male factor infertility compared with others. [23] Even though there is no consensus of opinion on how it affects the seminal fluid parameter, there are weighted evidence that obesity decreases sperm quality. [23],[24] Some authors have also demonstrated significant positive correlation between obesity, low sperm density, increased DNA fragmentation, impaired morphology, and motility. [25],[26] Multivariate analysis demonstrated low seminal fructose level and low neutral alpha glucosidase levels responsible for epididymal sperm maturation and motility acquisition. [27]

The highest rate of infertility is reported to be in Africa, mainly from preventable causes. [28] It is pertinent for gynecologist in the developing world to continue to re-evaluate and re-appraise the causes and trends of infertility toward finding evolving preventive etiologies and putting in place appropriate strategies to curb such etiologic factors. Obesity is one of such etiology that could be prevented.

Evidence abound that weight loss improves reproductive function. [16] Weight loss has been associated with increased frequency of ovulation and improve pregnancy rate. [16] Obesity can be managed by various strategies, which can be employed individually or in combinations, and these include: sensible and sustainable dietary habit, effective and sustainable physical activity, behavioral modification that may involve cessation of smoking and reduction of alcohol consumption, use of weight loss pharmacological agents to be employed when most necessary and where appropriate bariatric surgical procedures. [16]

 
   References Top

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2.Popkin BM, Gordon-Larsen P. The nutrition transition: Worldwide obesity dynamics and their determinants. Int J Obes Relat Metab Disord 2004;28 Suppl 3:S2-9.  Back to cited text no. 2
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5.Bellver J, Ayllón Y, Ferrando M, Melo M, Goyri E, Pellicer A, et al. Female obesity impairs in vitro fertilization outcome without affecting embryo quality. Fertil Steril 2010;93:447-54.  Back to cited text no. 5
    
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7.Rich-Edwards JW, Goldman MB, Willet WC, Hunter DJ, Stamfer MJ, Colditz GA, et al. Adolescent body mass index and infertility caused by ovulation disorders. Am J Obstet Gynecol 1994;171:171-7.  Back to cited text no. 7
    
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11.Zaadstra BM, Seidell JC, Van Noord PA, te Velde ER, Habbema JA, Vrieswijk B, et al. Fat and female fecundity: Prospective study of effect of body fat distribution on conception rates. BMJ 1993;306:484-7.  Back to cited text no. 11
    
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15.Lewis CG, Warness GM, Wang XJ, Matthews CD. Failure of body mass index or body weight to influence markedly the response to ovarian hyperstimulation in normal cycling women. Fertil Steril 1990;53:1097-9.  Back to cited text no. 15
    
16.Balen AH. Obesity and reproduction. In: Balen AH, editor. Infertility in practise. 3 rd ed. London: Informa; 2008. p. 40-51.  Back to cited text no. 16
    
17.Nichols JE, Crane MM, Higdon HL, Miller PB, Boone WR. Extremes of body mass index reduce in vitro fertilization pregnancy rates. Fertil Steril 2003;79:645- 7.  Back to cited text no. 17
    
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19.Metwally M, Tuckerman EM, Laird SM, Ledger WL, Li TC. Impact of high body mass index on endometrial morphology and function in the pre-implantation period in women with recurrent miscarriage. Reprod Biomed Online 2007;14:328-34.  Back to cited text no. 19
    
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22.Balen AH, Platteau P, Andersen AN, Devroey P, Sørensen P, Helmgaard L, et al. The influence of body weight on response to ovulation induction with gonadotrophins in335 women with World Healh Organisation group II anovulatory infertility. BJOG 2006;113:1195-202.  Back to cited text no. 22
    
23.Magnusdottir EV, Thorsteinsson T, Thorsteinsdottir S, Heimisdottir M, Olafsdottir K. Persistent oganochlorines, sedentary occupation, obesity and human male subfertility. Hum Reprod 2005;20:208-15.  Back to cited text no. 23
    
24.Hammoud AO, Wilde N, Gibson M, Parks A, Carrel DT, Meikle AW. Male obesity and alteration in sperm parameters. Fertil Steril 2008;90:2222-5.  Back to cited text no. 24
    
25.Stewart TM, Liu DY, Garre HC, Jørgensen N, Brown EH, Baker HW. Associations between andrological measures, hormones, and semen quality in fertile Australian men: Inverse relationship between obesity and sperm output. Hum Reprod 2009;24:1561-8.  Back to cited text no. 25
    
26.Hammoud AO, Gibson M, Peterson CM, Meikle AW, Carrell DT. Impact of male obesity on infertility: A critical review of current literature. Fertil Steril 2008;90:897-904.  Back to cited text no. 26
    
27.Martini AC, Tissera A, Estofán D, Molina RI, Mangeaud A, de Cunee MF, et al. Overweight and seminal quality: A study of 794 patients. Fertil Steril 2010;94:1739-43.  Back to cited text no. 27
    
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