Gynecological Endocrinology

ISSN: 0951-3590 (Print) 1473-0766 (Online) Journal homepage: http://www.tandfonline.com/loi/igye20

Should high BMI be a reason for IVF treatment

denial?

S. Friedler, O. Cohen, G. Liberty, B. Saar-Ryss, S. Meltzer & T. Lazer

To cite this article: S. Friedler, O. Cohen, G. Liberty, B. Saar-Ryss, S. Meltzer & T. Lazer (2017):
Should high BMI be a reason for IVF treatment denial?, Gynecological Endocrinology, DOI:
10.1080/09513590.2017.1327042

To link to this article: http://dx.doi.org/10.1080/09513590.2017.1327042

Published online: 20 May 2017.

Submit your article to this journal

Article views: 1

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=igye20

Download by: [The UC San Diego Library] Date: 23 May 2017, At: 01:01
GYNECOLOGICAL ENDOCRINOLOGY, 2017
https://doi.org/10.1080/09513590.2017.1327042

ORIGINAL ARTICLE

Should high BMI be a reason for IVF treatment denial?

S. Friedlera,b, O. Cohenc, G. Libertya,b, B. Saar-Ryssa,b, S. Meltzera,b and T. Lazera,b
a
Infertility and IVF Unit, Barzilai University Medical Center, Ashkelon, Israel; bFaculty of Health Sciences, Ben Gurion University of the Negev,
Beer-Sheva, Israel; cResearch & Development Authority, Barzilai University Medical Center, Ashkelon, Israel

ABSTRACT ARTICLE HISTORY

Our aim was to examine the influence of BMI on the live-birth rate following IVF/ICSI and evaluate its spe- Received 28 November 2016
cific contribution among other factors thus enabling accurate reproductive policy development. All Accepted 2 May 2017
patients that underwent IVF/ICSI at our center during January 2012–July 2015 were included in this retro- Published online 17 May
spective study. A total of 1654 ICSI cycles were divided into four groups according to the patient’s BMI 2017
(kg/m2): group I (normal weight): <25 (943 cycles); group II (overweight): 25–30 (403 cycles); group III KEYWORDS
(obese): 30–35 (212 cycles); group IV (morbid obesity): >35 (96 cycles). Comparing the four groups of BMI, Body mass index;
mean age and number of previous ART cycles was significantly lower in group I compared to groups II, III intracytoplasmic sperm
and IV. Length of treatment was significantly shorter in group I compared to groups II, III and IV. Ovarian injection; in vitro
response to COH was comparable in terms of mean estradiol and progesterone levels on the day of hCG fertilization; live birth rate;
administration mean number of oocytes retrieved, fertilized and number of embryos transferred. obesity
Endometrial thickness was significantly lower in group IV. Outcome measures, such as implantation rate,
clinical pregnancy rate (CPR) per cycle and per ET, as well as live-birth rates did not differ significantly
between the groups, although in group IV LBR per cycle and per ET was lower. Multivariate logistic
regression stepwise analysis found a significant correlation between age and BMI but did not find correl-
ation between BMI and clinical pregnancy (p ¼ 0.436) or LB (p ¼ 0.206). The results of our relatively large
retrospective study did not demonstrate a significant impact of BMI on the ART cycle outcome. Therefore,
BMI should not be a basis for IVF treatment denial.

Introduction indicated endometrial dysregulation among obese patients com-

Obesity is a well-documented epidemic globally with high mor-
bidity and even mortality rates imposing major social and eco-
nomic burden on our society [1]. The impact of overweight and
obesity in women are manifested throughout the span of repro-
ductive life, from puberty to pregnancy and delivery. Overweight
and obesity are associated with ovulatory disorders, dysfunctional
uterine bleeding, reduced conception rates, increased early mis-
carriage rates, pregnancy complications, such as hypertension,
preeclampsia, diabetes, failure of labor induction, operative deliv-
ery, post-partum hemorrhage and fetal macrosomia [2,3].
The impact of obesity on the outcome of in vitro fertilization
(IVF) is controversial. Whereas several studies suggested that an
increased BMI had no adverse effects on IVF clinical outcomes
[4–13] large cohort and cross-sectional studies of obese women
using their own oocytes did demonstrate inferior ART outcome
in overweight and obese patients, including those with PCOS
[14–23]. The various parameters that may explain the inferior
ART outcome include lower ovarian response requiring higher
doses of gonadotropins [11,24], impairment of the oocyte quality
leading to inferior embryo quality leading to lower implantation
rates and higher rates of early miscarriages [6,12,13,17,
19,21,25,26]. Still, despite the numerous studies in this area the
impact of overweight and obesity on IVF outcomes is
inconclusive.
Poor reproductive outcomes among obese women may also be
associated with lower endometrial receptivity [27–30]. Gene
expression analysis during the window of implantation has
pared to controls with normal weight [31]. Reproductive policy
makers confront the fact that no exact BMI threshold level was
established above which IVF should be denied.
The aim of this study was to examine the influence of BMI
on the live-birth rate following IVF/ICSI and embryo transfer
(ET) and evaluate its specific contribution among other factors.
Materials and methods
This study was designed as a retrospective study on all patients
that were treated at the IVF unit of Barzilai University Medical
Center during the period of January 2012 and July 2015. The
study was reviewed and approved by our IRB. After reviewing
their medical files, demographic data, such as BMI, age, baseline
FSH, gravidity, parity, number of previous treatment cycles, indi-
cation for ART, were collected and evaluated. Various parameters
evaluated patients ovarian response including serum estradiol lev-
els on day of HCG, serum progesterone levels on day of HCG,
number of oocytes retrieved, number of oocytes with 2PN and
endometrial thickness. Treatment cycle clinical outcomes were
assessed by fertilization rate; number of embryos transferred per
cycle, implantation rate, number of sacs, clinical pregnancy rate
(CPR) and live birth rate (LBR).
Controlled ovarian hyperstimulation (COH) was performed
using either the routine long protocol of pituitary suppression
followed by ovarian stimulation or the multiple dose antagonist
protocol. Oocytes were retrieved by vaginal ultrasound-guided

CONTACT Shevach Friedler shevachf@bmc.gov.il, prof.friedler.s@gmail.com Infertility and IVF Unit, Barzilai University Medical Center, Ashkelon, Israel
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 S. FRIEDLER ET AL.

follicular puncture, fertilization was assessed 16–18 h after routine
insemination or ICSI under an inverted microscope and consid-
ered normal when two clearly distinct PN containing nucleoli
were present. Cleavage was assessed 24 and 48 h later. ET was
performed on day 2/3 or 5 after oocyte retrieval. The best
embryos were selected for transfer. Supernumerary top quality
embryos were frozen and the remainders were followed for
blastocyst formation. After ET, all patients received luteal sup-
port, including 800 mg of vaginally administered micronized P
(Utrogestan; Laboratories Piette International S.A., Brussels,
Belgium) or IM injections of 50 mg/d of progesterone in oil.
Serum hCG levels were measured 14 d after embryo transfer.
Implantation rate was determined by dividing the number of ges-
tational sacs by the number of embryos transferred. Clinical
pregnancy was defined as a visible sac and the presence of fetal
heartbeat on the 7th gestational week.
A total of 1654 IVF/ICSI cycles were divided into four groups
according to the patient’s BMI (kg/m2): group I (normal
weight): <25 (943 cycles); group II (overweight): 25–30 (403
cycles); group III (obese): 30–35 (212 cycles); group IV (morbid
obesity): >35 (96 cycles).
Statistical analysis
The demographic background, parameters of the ovarian
response and parameters of the laboratory and clinical outcomes
were compared between the four groups. Our primary outcome
was the LBR per cycle initiated and per ET and secondary out-
comes were 2PN fertilization rate, embryo implantation rate (IR);
CPR per cycle initiated and per ET. Given a two-sided signifi-
cance level of 0.05 and a difference of 5% in the live birthrate
between the groups, the group size needed for 80% statistical
power was 80 cycles in each of the four groups.
Quantitative statistics gave descriptive parameters, such as
mean ± SD and frequencies, presented as percentage. Statistical
analysis was performed using the v2 test for comparison of the
groups’ outcome variables and other categorical variables, and
Student’s two-sided t test regarding continuous variables.
ANOVA was used where appropriate to estimate differences of
means between the groups. Multivariate logistic regression ana-
lysis was used to examine the correlation of BMI to live-birth.
Table 1. Patient’s characteristics.
BMI group <25 kg I 25–30 kg II 30–35 kg III
N ¼ 1654 943 (57%) 403 (24%) 212 (13%)
Age 32.85 ± 5.9 34.08 ± 5.9 35.10 ± 6
Gravidity 1.15 ± 1.2 1.29 ± 1.3 1.31 ± 1.4
Parity 0.5 ± 0.75 0.62 ± 0.9 0.5 ± 0.7
FSH (IU/L) 7.54 ± 3 6.35 ± 2.7 6.67 ± 2.9
Previous cycles 3.58 ± 6.8 3.54 ± 2.8 6.07 ± 11.4
a
¼ I versus II, III, IV, p ¼ 0.001;
b
¼ III, IV versus I, II, p ¼ 0. 001.
A p value of <0.05 was considered statistically significant. The
data was analyzed using SPSS version 21 (SPSS, Inc., Chicago, IL).
Results
Patient’s characteristics according to BMI groups are presented
in Table 1.
Comparing the four groups of BMI, mean age and number of
previous ART cycles was significantly lower in group I compared
to groups II, III and IV. Mean baseline FSH was lower in all
study groups compared to the control. Gravidity and parity were
comparable among the groups.
Patients’ ovarian response to COH according to the BMI
groups is presented in Table 2. The length of treatment was lon-
ger in the groups II, III and IV compared to group I (p < 0.001).
The parameters of the ovarian response including mean serum
estradiol and progesterone levels on the day of hCG administra-
tion, mean number of oocytes retrieved, fertilized and number of
embryos transferred were comparable. Endometrial thickness was
significantly lower in group IV compared to groups I, II and III.
Parameters of the treatment cycle clinical outcome are pre-
sented in Table 3. Outcome measures, such as implantation rate,
clinical pregnancy as well as live-birth rates rate per cycle and
per ET, did not differ significantly between the groups.
Logistic regression stepwise analysis found a significant
correlation between age and BMI but did not find correlation
between BMI and clinical pregnancy (r ¼ 0.44, p ¼ 0.436) or LB
(r¼ 0.072, p ¼ 0.206).
Discussion
Obesity is a worldwide problem with potential impact on the
reproductive system. However, despite the numerous studies in
this area the impact of overweight and obesity on ART outcomes
is inconclusive due to conflicting results in the literature. Several
studies suggested that an increased BMI had no adverse effects
on IVF clinical outcomes [4–13]. The results of our study concur
with these reports main finding. For instance in a recent and
large study, comparing 1602 Italian women who underwent their
first IVF cycle, after adjusting for maternal age and other con-
founders, odds for ongoing pregnancy rate showed no differences
across different BMI categories. No statistical difference was
found among BMI groups in total FSH doses, number of oocytes
>35 kg IV p value retrieved and quality of embryos obtained [13]. In our study,
96 (6%) overweight and obese women had basal serum level of FSH con-
34.27 ± 6.01 0.001a centration significantly lower than women with normal BMI cor-
1.2 ± 1.3 0.176
0.43 ± 0.7 0.099 roborating some previous observations [13,32,33]. Vitamin D
6.92 ± 2.4 0.001a concentration was not measured in our study.
5.34 ± 5.5 0.001b The observation of slower ovarian response of the overweight
and obese patients requiring longer stimulation in our study is in
line with other reports [15,18,34]. Still, the number of oocytes

Table 2. Patient’s ovarian response.

BMI Group <25 kg I 25–30 kg II 30–35 kg III >35 kg IV p value
Length of treatment (days) 10 ± 3.2 10.8 ± 5.5 11.2 ± 5.1 10.8 ± 3.6 0.001a
Progesterone on hCG day (ng/ml) 0.637 ± 0.41 0.606 ± 0.43 0.550 ± 0.41 0.609 ± 0.41 0.055
Estradiol on hCG day (pg/ml) 1609 ± 1091 1525 ± 1026 1527 ± 1205 1436 ± 1241 0.307
# of oocytes retrieved 8.16 ± 6.3 7.6 ± 5.9 7.5 ± 6.6 7.2 ± 6.6 0.219
# of oocytes fertilized (2PN) 5.08 ± 3.6 4.63 ± 3.4 5.23 ± 4.2 4.61 ± 4.1 0.147
# of embryos transferred 2.01 ± 0.7 2.07 ± 0.8 2.04 ± 0.8 1.97 ± 0.7 0.065
Endometrial thickness (mm) 10.36 ± 2.20 10.57 ± 2.21 10.3 ± 2.14 9.85 ± 2.3 0.034c
a
¼ I versus II, III, IV, p ¼ 0.001;
c
¼ IV versus I, II, IIII p ¼ 0. 001.
 GYNECOLOGICAL ENDOCRINOLOGY 3

Table 3. Clinical outcome-descriptive statistics.

(Mean ± SD) # cycles <25 kg 943 25–30 kg 403 30–35 kg 212 <35 kg 96 Total 1654 p value
Fertilization rate 64 ± 9 58.4 ± 26.2 64 ± 25 61 ± 26 0.619
Total Embryos transferred 1561 691 354 157 2763
Total Sacs 275 120 49 26 470
Implantation rate (%) (sacs/ET’d) 17.6% 17.4% 13.8% 16.6% 17.0% 0.213
Cycles with no ET 134 60 41 19 254
Cycles with ET (n) 809 343 171 77 1400
Pregnancies (n) 222 90 42 20 374
CPR/cycle (%) 27.44% 26.24% 24.56% 25.97% 26.71% 0.213
CPR/ET 26.71% 25.97% 24.56% 26.24% 26.7% 0.213
Life birth (n) 237 11 27 54 145
LBR/Cycle 14.33% 13.40% 12.74% 11.46% 14.33% 0.213
LBR/ET 17.92% 15.74% 15.79% 14.29% 16.93% 0.213

retrieved, fertilized and the number of embryos transferred as
well as the clinical outcome including LBR in our study were
comparable among the various BMI groups evaluated, corrobo-
rating some previous reports [4,7,8] but conflicting other obser-
vations of obesity associated with a lower number of oocytes
retrieved per cycle [4,5,6,35–38] and lower rate of fertilization
[11,19,22,24,39,40].
In contrast with our major finding, large cohort and cross-
sectional studies of obese women using their own oocytes did
demonstrate inferior ART outcome in overweight and obese
patients, including those with PCOS [14–23]. Several meta-analy-
ses and systematic reviews on this topic have concurred
[6,41–43], showing that overweight women (BMI >25) under-
going IVF have a 10% lower live birth rate than normal weight
women (BMI <25) [43].
However, the statistical association reported in the various
studies is significantly influenced by the various prevalence of
obesity in the populations included reflected in the size of the
groups with overweight, obesity and morbid obesity in each
study.
Some studies have focused exclusively on pregnancy loss as a
primary outcome in obese patients undergoing IVF and found
pregnancy loss rates to be higher with increasing BMI
[12,13,17,19,21,25,26]. In our study, CPR as well as LBR did not
differ significantly among the various BMI groups.
Another possible explanation of the detrimental effect of obes-
ity on reproduction is through a negative impact on endometrial
receptivity [27–31]. Indeed in our study, the endometrial thick-
ness was significantly lower in the group of patients with morbid
obesity. In contrast, Nichols et al. (2003) [44] noted that the
mean endometrial thickness on the day of retrieval was increased
in obese women (BMI 28 kg/m2), with a significant reduction
in pregnancy rate compared to underweight (BMI <20 kg/m2) or
normal-weight women (BMI 20–27.9 kg/m2) [44] whereas others
reported comparable endometrial thickness in different BMI sub-
groups [34,40,45].
A systematic review and meta-analysis of outcomes in obese
recipients of donated oocytes found no association between obes-
ity and chance of implantation, pregnancy or live birth and noted
that oocyte quality rather than endometrial receptivity may be
the overriding factor influencing IVF outcomes in obese women
using autologous oocytes [46]. Conversely, three consecutive
studies by Bellver et al., including 2656 first-cycles of ovum
donation [28] then 6500 cycles [18] and finally 9587 first cycles
of ovum donation recipients using normal-weight donors [29],
found no differences in laboratory or embryo quality parameters
among the four BMI groups but reproductive outcome, such as
implantation, pregnancy, clinical pregnancy, twin pregnancy and
live-birth rates were significantly reduced as the recipients BMI
increased.
It seems that the impact of obesity is gradual, is more signifi-
cant in the severe obese and still pregnancy rates are comparable
to those achieved in patients with elevated age or diminished
ovarian reserve [23].
Therefore, advice about the possible negative impact of obesity
is warranted in this group of patients but denial of access to
treatment is not justified.
Disclosure of interest
The authors report no conflicts of interest.
References
1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national
prevalence of overweight and obesity in children and adults during
1980–2013: a systematic analysis for the Global Burden of Disease
Study 2013. Lancet 2014;384:766–81.
2. ACOG Committee on Obstetric Practice. Obesity in pregnancy. ACOG
committee opinion. No. 549. Obstet Gynecol 2013;121:213–7.
3. Practice Committee of the American Society for Reproductive
Medicine. Obesity and reproduction: a committee opinion. Fertil Steril
2015;104:1116–26.
4. Dechaud H, Anahory T, Reyftmann L, et al. Obesity does not adversely
affect results in patients who are undergoing in vitro fertilization and
embryo transfer. Eur J Obstet Gynecol Reprod Biol 2006;127:88–93.
5. Dokras A, Baredziak L, Blaine J, et al. Obstetric outcomes after in vitro
fertilization in obese and morbidly obese women. Obstet Gynecol
2006;108:61–9.
6. Maheshwari A, Stofberg L, Bhattacharya S. Effect of overweight and
obesity on assisted reproductive technology-a systematic review. Hum
Reprod Update 2007;13:433–44.
7. Martinuzzi K, Ryan S, Luna M, Copperman AB. Elevated body mass
index (BMI) does not adversely affect in vitro fertilization outcome in
young women. J Assist Reprod Genet 2008;25:169–75.
8. Matalliotakis I, Cakmak H, Sakkas D, et al. Impact of body mass index
on IVF and ICSI outcome: a retrospective study. Reprod BioMed
Online 2008;16:778–83.
9. Vilarino FL, Bianco B, Christofolini DM, Barbosa CP. Impact of body
mass index on in vitro fertilization outcomes. Rev Bras Ginecol Obstet
2010;32:536–40.
10. Moragianni VA, Jones SML, Ryley DA. The effect of body mass index
on the outcomes of first assisted reproductive technology cycles. Fertil
Steril 2012;98:102–8.
11. Ozekinci M, Seven A, Olgan S, et al. Does obesity have detrimental
effects on IVF treatment outcomes? BMC Womens Health 2015;15:61.
12. Schliep KC, Mumford SL, Ahrens KA. Effect of male and female body
mass index on pregnancy and live birth success after in vitro fertiliza-
tion. Fertil Steril 2015;103:388–95.
13. Sarais V, Pagliardini L, Rebonato G, et al. A comprehensive analysis of
body mass index effect on in vitro fertilization outcomes. Nutrients
2016;8:109.
14. Jungheim ES, Lanzendorf SE, Odem RR, et al. Morbid obesity is asso-
ciated with lower clinical pregnancy rates after in vitro fertilization in
women with polycystic ovary syndrome. Fertil Steril 2009;92:256–61.
4 S. FRIEDLER ET AL.
15. Shah DK, Missmer SA, Berry KF, et al. Effect of obesity on oocyte and
embryo quality in women undergoing in vitro fertilization. Obstet
Gynecol 2011;118:63–70.
16. Luke B, Brown MB, Missmer SA, et al. The effect of increasing obesity
on the response to and outcome of assisted reproductive technology: a
national study. Fertil Steril 2011a;96:820–5.
17. Luke B, Brown MB, Stern JE, et al. Female obesity adversely affects
assisted reproductive technology (ART) pregnancy and live birth rates.
Hum Reprod 2011b;26:245–52.
18. Bellver J, Ayllon Y, Ferrando M, et al. Female obesity impairs in vitro
fertilization outcome without affecting embryo quality. Fertil Steril
2010;93:447–54.
19. Boots C, Stephenson MD. Does obesity increase the risk of miscarriage
in spontaneous conception: a systematic review. Semin Reprod Med
2011;29:507–13.
20. Bu Z, Dai W, Guo Y, et al. Overweight and obesity adversely affect
outcomes of assisted reproductive technologies in polycystic ovary syn-
drome patients. Int J Clin Exp Med 2013;6:991–5.
21. Boots CE, Bernardi LA, Stephenson MD. Frequency of euploid miscar-
riage is increased in obese women with recurrent early pregnancy loss.
Fertil Steril 2014;102:455–9.
22. Vural F, Vural B, Çak{roglu Y. The role of overweight and obesity in
in vitro fertilization outcomes of poor ovarian responders. Biomed Res
Int 2015;2015:781543.
23. Provost MP, Acharya KS, Acharya CR, et al. Pregnancy outcomes
decline with increasing body mass index: analysis of 239,127 fresh
autologous in vitro fertilization cycles from the 2008–2010 Society for
Assisted Reproductive Technology registry. Fertil Steril 2016;105:663–9.
24. Pinborg A, Gaarslev C, Hougaard CO, et al. Influence of female body-
weight on IVF outcome: a longitudinal multicentre cohort study of
487 infertile couples. Reprod Biomed Online 2011;23:490–9.
25. 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;27:699–702.
26. Veleva Z, Tiitinen A, Vilska S, et al. High and low BMI increase
the risk of miscarriage after IVF/ICSI and FET. Hum Reprod
2008;23:878–84.
27. Bellver J, Rossal L, Bosch E, et al. Obesity and the risk of spontaneous
abortion after oocyte donation. Fertil Steril 2003;79:1136–40.
28. Bellver J, Melo MA, Bosch E, et al. Obesity and poor reproductive out-
come: the potential role of the endometrium. Fertil Steril 2007;88:
446–51.
29. Bellver J, Pellicer A, Garcıa-Velasco JA, et al. Obesity reduces uterine
receptivity: clinical experience from 9587 first cycles of ovum donation
with normal weight donors. Fertil Steril 2013;100:1050–8.
30. DeUgarte DA, DeUgarte CM, Sahakian V. Surrogate obesity negatively
impacts pregnancy rates in third-party reproduction. Fertil Steril
2010;93:1008–10.
31. Bellver J, Martınez-Conejero JA, Labarta E, et al. Endometrial gene
expression in the window of implantation is altered in obese women
especially in association with polycystic ovary syndrome. Fertil Steril
2011;95:2335–41.
32. Vanni VS, Vigano P, Somigliana E, et al. Vitamin D and assisted
reproduction technologies: current concepts. Reprod Biol Endocrinol
2014;12:47.
33. De Pergola G, Maldera S, Tartagni M, et al. Inhibitory effect of obesity
on gonadotropin, estradiol, and inhibin B levels in fertile women.
Obesity (Silver Spring) 2006;14:1954–60.
34. Esinler I, Bozdag G, Yarali H. Impact of isolated obesity on ICSI out-
come. Reprod Biomed Online 2008;17:583–7.
35. Wittemer C, Ohl J, Bailly M, et al. Does body mass index of infertile
women have an impact on IVF procedure and outcome? J Assist
Reprod Genet 2000;17:547–52.
36. Fedorcsak P, Dale PO, Storeng R, et al. Impact of overweight and
underweight on assisted reproduction treatment. Hum Reprod 2004;19:
2523–8.
37. Orvieto R, Meltcer S, Nahum R, et al. The influence of body mass
index on in vitro fertilization outcome. Int J Gynaecol Obstet
2009;104:53–5.
38. 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:
325–32.
39. Li Y, Yang D, Zhang Q. Impact of overweight and underweight on
IVF treatment in Chinese women. Gynecol Endocrinol 2010;26:416–22.
40. Zeng X, Pang H, Li X, et al. Impact of obesity on endometrial blood
flow in women without polycystic ovarian syndrome during intracyto-
plasmic sperm injection. Reprod Biol Endocrinol 2013;11:57.
41. Metwally M, Ong KJ, Ledger WL, Li TC. Does high body mass index
increase the risk of miscarriage after spontaneous and assisted concep-
tion? A meta-analysis of the evidence. Fertil Steril 2008;90:714–26.
42. Rittenberg V, Seshadri S, Sunkara SK, et al. Effect of body mass index
on IVF treatment outcome: an updated systematic review and meta-
analysis. Reprod Biomed Online 2011;23:421–39.
43. Koning AM, Mutsaerts MA, Kuchenbecker WK, et al. Complications
and outcome of assisted reproduction technologies in overweight and
obese women. Hum Reprod 2012;27:457–67.
44. Nichols JE, Crane MM, Higdon HL, et al. Extremes of body mass
index reduce in vitro fertilization pregnancy rates. Fertil Steril
2003;79:645–7.
45. Ku SY, Kim SD, Jee BC, et al. Clinical efficacy of body mass index as
predictor of in vitro fertilization and embryo transfer outcomes.
J Korean Med Sci 2006;21:300–3.
46. Jungheim ES, Schon SB, Schulte MB, et al. IVF outcomes in obese
donor oocyte recipients: a systematic review and meta-analysis. Hum
Reprod 2013;28:2720–7.