The combined effect of BMI and age on ART outcomes
Authors: Rafael Filipa , Rodrigues Maria Dias , Bellver Jose , Canelas-Pais Mariana , Garrido Nicolas , Garcia-Velasco Juan A , Soares Sérgio Reis , Santos-Ribeiro Samuel 
Published: March 2023

Abstract

STUDY QUESTION
For a woman with infertility and overweight/obesity, can infertility treatment be postponed to first promote weight loss?

SUMMARY ANSWER
Advice regarding a delay in IVF treatment to optimize female weight should consider female age, particularly in women over 38 years for whom only substantial weight loss in a short period of time (3 months) seems to provide any benefit.

WHAT IS KNOWN ALREADY
Body weight excess and advanced age are both common findings in infertile patients, creating the dilemma of whether to promote weight loss first or proceed to fertility treatment immediately. Despite their known impact on fertility, studies assessing the combined effect of female age and BMI on cumulative live birth rates (CLBRs) are still scarce and conflicting.

STUDY DESIGN, SIZE, DURATION
We performed a multicentre retrospective cohort study including 14 213 patients undergoing their first IVF/ICSI cycle with autologous oocytes and subsequent embryo transfers, between January 2013 and February 2018 in 18 centres of a multinational private fertility clinic. BMI was subdivided into the following subgroups: underweight (&lt;18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obesity (≥30.0 kg/m2).

PARTICIPANTS/MATERIALS, SETTING, METHODS
The primary outcome was CLBR. The secondary outcome was time to pregnancy. To assess the influence of female age and BMI on CLBR, two multivariable regression models were developed with BMI being added in the models as either an ordinal categorical variable (Model 1) or a continuous variable (Model 2) using the best-fitting fractional polynomials. CLBR was estimated over 1-year periods (Model 1) and shorter timeframes of 3 months (Model 2). We then compared the predicted CLBRs according to BMI and age.

MAIN RESULTS AND THE ROLE OF CHANCE
When compared to normal weight, CLBRs were lower in women who were overweight (adjusted odds ratio (aOR) 0.86, 95% CI 0.77–0.96) and obese (aOR 0.74, 95% CI 0.62–0.87). A reduction of BMI within 1 year, from obesity to overweight or overweight to normal weight would be potentially beneficial up to 35 years old, while only a substantial reduction (i.e. from obesity to normal BMI) would be potentially beneficial in women aged 36–38 years. Above 38 years of age, even considerable weight loss did not compensate for the effect of age over a 1-year span but may be beneficial in shorter time frames. In a timeframe of 3 months, there is a potential benefit in CLBR if there is a loss of 1 kg/m2 in BMI for women up to 33.25 years and 2 kg/m2 in women aged 33.50–35.50 years. Older women would require more challenging weight loss to achieve clinical benefit, specifically 3 kg/m2 in women aged 35.75–37.25 years old, 4 kg/m2 in women aged 37.50–39.00 years old, and 5 kg/m2 or more in women over 39.25 years old.

LIMITATIONS, REASONS FOR CAUTION
This study is limited by its retrospective design and lower number of women in the extreme BMI categories. The actual effect of individual weight loss on patient outcomes was also not evaluated, as this was a retrospective interpatient comparison to estimate the combined effect of weight loss and ageing in a fixed period on CLBR.

WIDER IMPLICATIONS OF THE FINDINGS
Our findings suggest that there is potential benefit in weight loss strategies within 1 year prior to ART, particularly in women under 35 years with BMI ≥25 kg/m2. For those over 35 years of age, weight loss should be considerable or occur in a shorter timeframe to avoid the negative effect of advancing female age on CLBR. A tailored approach for weight loss, according to age, might be the best course of action.

STUDY FUNDING/COMPETING INTEREST(S)
No specific funding was obtained for this study. All authors have no conflicts to declare.

TRIAL REGISTRATION NUMBER
N/A.