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obesity and fertility implications

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The increasing incidence of obesity if affecting fertiliyu . Can we do something as health care personnel ?

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obesity and fertility implications

  1. 1. OBESE ADOLESCENT AND FERTILITY IMPLICATIONS DR PRANAY PHUKAN MD FICOG ASSOCIATE PROFESSOR DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY ASSAM MEDICAL COLLEGE
  2. 2. OBESITY  A new world wide health problem  The greatest epidemic ever experienced by humans  Resulting from increasing population increasing lifespan Urbanization Plentiful food Physical inactivity  Rate of obesity has doubled over the past decade
  3. 3. Obesity  Fertility implications both genders  Pregnancy Complications  Metabolic syndrome  Malignancy  Economic burden Adolescent obesity is associated with three fold increase in nulliparity and four fold increase in nulligravidity People of such constitution cannot be Prolific. .fatness and flabbiness are to blame The womb is unable to receive the semen And they menstruate infrequently and little Hippocrates (Lloyd et al 1978)
  4. 4. Focus  Pathophysiology of obesity and infertility  Influence of obesity on PCOS  Benefits of weight loss on reproduction
  5. 5. Measuring Obesity (BMI) Some Asian populations have a genetically higher percent body fat than Caucasians resulting in greater risk of complications at a lower BMI of 23 to 25 (ASRM 2015) Overweight 25 -29.9 increased disease risk Class I obesity 30 – 34,9high disease risk Class II Obesity 35 – 39.9very high disease risk Class III obesity > 40 extremely high disease risk
  6. 6. Genetic factor  Heritability (40 to 70 % )  Genes for Leptin  Suppressor of Cytokine signalling 3  Genes for glucose transporter Genetic Behaviour Environment Causes
  7. 7. Decreased Physical activity  Excess TV; computer, & play station time  Children are home alone (dual income parents)  Decreased physical activity at school & at home  Transportation by car or school bus  Neighbourhood safety ?  Few public parks, sidewalks, swimming pools ..etc An imperfect body reflects an imperfect person
  8. 8. Changing Dietary Habits  Increased intake of caloric sweeteners & edible oil  Increased intake of processed foods, refined carbohydrates & salty high fat snacks  Reduced intake of fruits and vegetables  Increased global beverage due to:  increased accessibility,  lower price,  income dynamics and marketing
  9. 9. Development of obesity From Traditional to Modern Leisure and food
  10. 10. Obesity In Developing Countries  The burden of obesity & its complications is shifting rapidly towards the poor.  Simultaneous malnutrition & overweight exist.  Obesity is now 4X more common than malnutrition in some developing countries.  Evidence from Brazil & China points to a clear shift in obesity and overweight from middle class to the poor.  These observations are replicated across many countries in Asia, Africa & Latin America.
  11. 11. CHILDHOOD OBESITY IS INCREASING EVEN IN THE POOR COUNTRIES.
  12. 12. Lipotoxicity  Ectopic lipid accumulation in non adipose cells  When energy intake exceeds the capacity of normal adipose tissue to safely store fat  Excess free fatty acids accumulates in abnormal locations such as muscle liver etc  Oxidative stress develops in these tissues  Insulin resistance and inflammation (ASRM 2015) Lipotoxicity affects granulosa cells and leads to impaired oocyte maturation and poor oocyte quality
  13. 13. Possible mechanisms (Adipokines abnormalities) Abnormalities of adipokines cause inflammation and abnormal cell signalling which leads to impaired cellular function and metabolism
  14. 14. Reproductive concerns  Menstrual cycle abnormalities  Ovulatory dysfunction  Altered ovarian responsiveness  Poor Oocyte quality  Miscarriage  Adverse maternal fetal environment  Male infertility Obesity’s reproductive targets CNS Ovary ovarian follicles and oocytes The embryo The Endometrium Semen
  15. 15. Obesity and the Menstrual Cycle Affects HPO axis  Amenorrhoea, Anovulation : Adipokines inhibit ovulation  Long cycle length (usually defined as >35 days)  Even childhood obesity has been shown to be associated with menstrual difficulties in later life (Lake et al. 1997 ) .  The menstrual disturbances may be further aggravated in the presence of PCOS
  16. 16. Increased risk of miscarriage  Impaired folliculogenesis and poor oocyte quality  Endometrial receptivity is impaired  Higher prevalence of PCOS among overweight and obese women  British Fertility Society guidance suggests that fertility treatment should be deferred until BMI is less than 35 kg/m 2  ART can help to select healthy embryo
  17. 17. Obesity and psychosocial and psychobiological factors  Comparative reduction in sexual frequency  Due to decreased dopamine activity and increased serotonoin levels in the brain secondary to overeating  Obesity: more sexual dysfunction (Brody 2004)
  18. 18. Impact of obesity on ART
  19. 19. Obstetric Complications in Obese Pregnant Women Early pregnancy  Spontaneous abortion  Recurrent miscarriage Congenital anomalies  Neural tube defects  Spina bifida  Congenital heart disease  Omphalocele Late pregnancy  Hypertensive disorder of pregnancy  Gestational nonproteinuric hypertension  Preeclampsia  Gestational diabetes mellitus  Preterm birth  Intrauterine fetal demise Peripartum Cesarean delivery Decreased VBAC success Operative morbidity Anesthesia complications Excessive blood loss Postpartum endometritis Wound infection/breakdown Postpartum thrombophlebitis Fetal/neonatal complications Fetal macrosomia ( Shoulder dystocia Birth weight < 4000 g Birth weight < 4500 g Childhood obesity
  20. 20. Maternal obesity and health risk of the offspring ‘Developmental over nutrition hypothesis' which proposes that the increased fuel supply to the foetus in maternal obesity or over nutrition leads to permanent changes in offspring metabolism, behaviour and appetite regulation with resultant obesity, metabolic and behavioural problems in adult life
  21. 21. Obesity and Male Reproduction Obese men (Not all)  Impaired erectile function  Sleep apnoea  Increasesed scrotal temperature  Poor semen quality Oligospermia Asthenospermia  Less sexual intercourse
  22. 22. Mechanism Altered Sperm function  Increased sperm DNA damage  Decreased sperm mitochondrial activity  Induces seminal oxidative stress  Impairs blastocyst development  Increases miscarriage  Failed ART
  23. 23. Male Obesity  Hyperinsulinemia  Suppression of SHBG  Increased androgen bioavailability  Oestrogen production  Reduced gonadotropin secretions  Decreased total and bioavailable testosterone  Diminishes LH pulse amplitude  Decreased Leydig cell testosterone secretion Hyperestrogenic Hypogonadotric hypogonadism
  24. 24. Fertility treatment should be deferred until BMI is less than 35 kg/m 2
  25. 25. Current recommendation for lifestyle modification  Weight loss of 7% of body weight  Increased physical activity (150 minutes/week)  A 500 to 1000 Kcal/day decrease from usual diet  1 to 2 pound weight loss per week  Low calorie diet of 1000 to 12000 Kcal/day  Achieving total 10 % decrease in total body weight over 6 months  Reductions in weight of 5–10% of initial body weight may reduce the levels of insulin and androgens Weight gain recurs when life style modifications are not sustained
  26. 26. Weight loss  Lifestyle modification, dietary restriction, physical activity  pharmacotherapy with varied results.  Dietary interventions are associated with increasing weight regain over time, although this can be minimized with continuing care  Only 15% of the subjects can sustain weight loss successfully over time  Rapid weight loss achieved by crash diets or excessive exercise is detrimental to reproductive outcomes during fertility treatments. Life style modification programs (especially diet programs) have been shown to be associated with poor levels of compliance
  27. 27.  Very low calorie diet resulting in rapid weight loss may have impact on oocyte quality and fertilization rates  Metformin, at a dose of 850 mg twice daily, have not been shown to affect menstrual frequency, body weight or insulin sensitivity, despite a fall in total testosterone and waist circumference.  Orlistat in obese PCOS showing a degree of effectiveness; however, there are no large randomized controlled trials in obese subfertile women.
  28. 28. Not the first line of treatment
  29. 29. The National Institute for Clinical Excellence (NICE) recommends  Lifestyle interventions, which encourage a nutritionally balanced diet with appropriate calorie content and which promote the benefits of regular exercise for individuals with a BMI ≥25,  The drug orlistat for those with a BMI ≥30 and  Bariatric surgery for those with a BMI of >50 (National Institute for Health and Clinical Excellence 2006);  There is little evidence that these recommendations are making an impact on the prevalence of obesity in the population.  Thus, it is likely that the ‘challenge’ of obesity will remain for reproductive biologists for some time to come.
  30. 30. Conclusion • Obesity in women has impacts on fertility and fertility treatment. • Increase in BMI reduces the chance of conception in ovulatory women and affects the outcome of ovulation induction treatment. • Obese women undergoing IVF require higher doses of gonadotrophins, respond poorly to ovarian stimulation and have fewer oocytes harvested. • Obesity is associated with lower fertilization rates, poor quality embryos and higher miscarriage rates. • Weight loss in these women improves their reproductive outcomes; however, in order for this to be effective it has to be gradual and sustained
  31. 31. Thank you

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