Assessing the Impact of High Body Mass Index (BMI) on the Efficacy of Assisted Reproductive Technologies (ART) in Saudi Women: A Cross-Sectional Study Examining Ovarian Reserve and Treatment Outcomes

Introduction: The global surge in high body mass index (BMI) and obesity has led to various health complications. While numerous studies have shown that obesity disrupts female fertility, the specific effects of obesity on the success rate of assisted reproductive technology (ART) treatments in Saudi women have been less explored. This study aimed to delve into this gap, especially focusing on the correlation between BMI, ovarian reserve parameters, and ART outcomes among Saudi women. Methods: A cross-sectional study was carried out from January to August 2023, concentrating on Saudi women aged 18 and above who underwent ART treatments for infertility. A total of 1071 women participated, with 155 completing an online survey and 916 responding through a hard copy from several Saudi hospitals. The data encompassed demographics, medical history, anthropometric details, ovarian reserve parameters, and ART results. For the analysis, Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 28.0, Armonk, NY) was utilized, applying descriptive statistics, the Chi-square test, and a linear regression model to discern connections between BMI, participant characteristics, and ART outcomes. A p-value of less than 0.05 was considered statistically significant. Results: Most participants were aged 25-34 (406) years and held a bachelor's degree (707). Over half (560) received fertility treatments in the past, with 37.9% (406) having polycystic ovary syndrome (PCOS) and 23.5% (252) with other fertility-impacting medical conditions. Interestingly, 62.1% (665) had not undergone any ART cycles. Of those who did, 51.6% (553) had clinical pregnancies leading to live births. About 23.8% (308) of those with clinical pregnancies faced miscarriages without successful live births. Furthermore, 17.6% (189) reported complications or side effects from past ART procedures, and 31.4% (336) were on ART-related medications or supplements. The linear regression highlighted that individuals with normal weight tended to undergo more ART cycles. However, those with a higher BMI exhibited increased chances of achieving clinical pregnancies and live births. Conclusion: The study underscores the crucial relationship between BMI and ART efficacy in Saudi women. The data reveals that BMI can significantly influence ART treatment outcomes, especially concerning the number of cycles, clinical pregnancies, and live births. Consequently, BMI should be an essential consideration when evaluating and optimizing the success rates of ART procedures.


Introduction
Obesity and its implications on health have emerged as significant concerns globally, and Saudi Arabia is no exception.Obesity is known to adversely affect reproductive health, primarily causing infertility through mechanisms such as hormonal imbalances, insulin resistance, chronic inflammation, and compromised ovarian function [1,2].Assisted reproductive technologies (ART), which encompass revolutionary reproductive medical procedures like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), present a beacon of hope for infertile couples [3][4][5].However, the efficacy of these procedures hinges on several determinants, including the patient's weight, gamete quality, and endometrial receptivity [6].A stark representation of obesity can be observed in the World Health Organization's (WHO) definitions, categorizing individuals with a body mass index (BMI) of 25 or above as overweight and those with a BMI exceeding 30 as obese [7].Alarmingly, recent research by Wahabi et al. disclosed that a staggering almost two-thirds of Saudi women, encompassing all age groups and regions, grapple with obesity [8].This trend warrants grave concern, especially given the known association between obesity and reproductive issues, including menstrual anomalies, anovulation, polycystic ovary syndrome (PCOS), and hindered embryo implantation [9,10].
While several studies have ventured into examining the association between high BMI and ART outcomes, there remains a conspicuous research void concerning Saudi women over the past half-decade.Given the distinct genetic and cultural backdrop of this group, discerning how obesity impinges upon ART success rates becomes pivotal.Grasping this dynamic can pave the way for interventions and strategic planning, refining reproductive outcomes tailored for Saudi women -a move that could resonate profoundly with healthcare professionals and policy framers.This underscores the urgency for more expansive research on this topic, ultimately bolstering reproductive healthcare standards in the region.
In light of the aforementioned premises, this research pivots on a couple of central hypotheses, which will be rigorously evaluated using statistical tools such as correlation analyses, regression, and chi-square tests.Firstly, it is hypothesized that an uptick in BMI might correlate with a downturn in ovarian reserve markers, suggesting the probable adverse influence of high BMI on the volume and caliber of oocytes earmarked for ART [1][2][3].Secondly, it's anticipated that women with elevated BMI might record lower clinical pregnancy rates, diminished live birth figures, and escalated miscarriage numbers when juxtaposed against their normal BMI counterparts.This hypothesis insinuates that soaring BMI could potentially attenuate the effectiveness of ART procedures, culminating in suboptimal success rates coupled with augmented obstetric complications [1,2].
Guided by these hypotheses, the primary objective of this cross-sectional exploration is to gauge the impact of heightened BMI on the effectiveness of ART in Saudi women.Delving deeper, the study specifically aspires to discern the correlation between BMI and ovarian reserve metrics in Saudi women and to analyze the nexus between BMI and treatment outcomes -spanning clinical pregnancy rates, live birth statistics, and miscarriage rates-among Saudi women navigating through ART [1][2][3].

Study design and participants
This cross-sectional study was executed from January to August 2023, targeting Saudi women aged 18 years and above who have sought ART procedures, such as IVF or ICSI, for addressing infertility.Of the total of 1071 participants, 155 engaged via an online survey, while 916 responded through hard copy surveys sourced from diverse hospitals in Saudi Arabia.

Ethical approval
The study obtained approval from the Institutional Review Board of King Faisal University, with approval number KFU-REC-2023-AUG-ETHICS1138.

Data collection
All participants completed a comprehensive questionnaire capturing demographic details, medical histories, anthropometric data, ovarian reserve metrics, and treatment results.The data entry process leveraged Google online forms, with the resultant data, subsequently migrated to Microsoft Excel for subsequent analytical processing.

Characteristics of study participants
The study comprised a total of 1072 Saudi women who underwent ART.The participants were distributed across different age groups, with the majority falling between 25 and 34 years 406 (37.9%).A significant proportion of participants held a bachelor's degree 707 (66.0%) and were unemployed 560 (52.3%

Outcomes for ART and ovarian reserve parameters
In evaluating the outcomes of ART and ovarian reserve parameters, a comprehensive analysis of participant experiences was conducted (Table 4).Among the participants, a significant proportion of 665 (62.1%) had not undergone any ART cycles, while 161 (15.0%) had undergone three or more cycles, indicating varying degrees of engagement with the treatment.

TABLE 6: Association between BMI and participant's characteristics
Data in the table is represented as N (count) and % (percentage).A p-value of <0.05 was considered statistically significant.

BMI: body mass index
Table 7 shows the relationship between BMI and ovarian reserve parameters was explored.A significant association was found between BMI and the number of ART cycles undergone (p < 0.001), where participants with higher BMI tended to have undergone fewer cycles.Similarly, BMI was significantly associated with the achievement of clinical pregnancy (p < 0.001) and live births resulting from clinical pregnancies (p < 0.001), with higher BMI associated with lower rates of success.Moreover, the occurrence of miscarriages was also significantly associated with BMI (p < 0.001).

Linear regression model between BMI and ovarian reserve parameters
Table 8 represents a linear regression model that was constructed to further investigate the relationship between BMI and ovarian reserve parameters.After controlling for potential confounders, the odds of undergoing a greater number of ART cycles were significantly higher in normal-weight participants (Exp[B] = 1.004, 95% CI = 1.000-1.113,p = 0.007).Similarly, the odds of achieving clinical pregnancy increased with higher BMI (Exp[B] = 1.034, 95% CI = 1.000-1.302,p = 0.010).Participants with higher BMI also had increased odds of a clinical pregnancy resulting in a live birth (Exp[B] = 1.015, 95% CI = 1.000-1.151,p = 0.030).Notably, the odds of experiencing a miscarriage were significantly higher for participants with underweight BMI (Exp[B] = 1.910, 95% CI = 1.000-13.719,p = 0.020).

Predictors Exp(B), 95% CI P-value
How many ART cycles have you undergone so far?

Discussion
This research delves into the intricate relationship between BMI and the efficacy of ART in Saudi women, an area underscoring the broader implications of obesity on reproductive health as introduced previously [1].Rooted in a methodological approach that segmented participants based on BMI -high BMI (≥30 kg/m²) and normal BMI (18.5-24.9kg/m²) -the outcomes produced from this study lend credence to existing literature and provide fresh avenues for clinical and research applications.
A significant proportion of participants belonged to the age bracket of 20-40 years, and the majority underwent ART interventions, including IVF or ICSI, to combat infertility.Data extraction methodologies involved both on-site and electronic self-administered questionnaires, ensuring a comprehensive approach [2].This method was justified as it offered a holistic understanding of demographic nuances, medical antecedents, ovarian metrics, and treatment results.
In assessing the study's outcomes, a pronounced relationship between BMI and varying ovarian reserve markers was identified [3].This directly emphasizes that BMI is instrumental in forecasting the success rate of ART endeavors.Notably, a rise in BMI correlated with fewer ART cycles, diminished instances of clinical pregnancies and live births, and a heightened probability of miscarriages.These observations resonate with extant research that documented the detrimental consequences of elevated weight on fertility [4,5].
Contrarily, a surprising outcome noted higher likelihoods of clinical pregnancies culminating in live births amongst high BMI participants.This seemingly counteractive result might be attributed to the intricate balance between BMI, hormonal shifts, and reproductive dynamics in individuals with obesity.Enhanced estrogen synthesis by fat tissues might facilitate better implantation probabilities and subsequent pregnancy outcomes [6,7].Yet, the exact mechanisms necessitate deeper probing in subsequent studies.
Equally worth noting is the established link between underweight BMI categorizations and escalated miscarriage rates, reaffirming previous literature insights [8,9].Hormonal irregularities and diminished ovarian functionality in individuals with lower weight might be potential causatives for the increased miscarriage predisposition.These results underscore the significance of a balanced BMI for optimal fertility outcomes.
While this research didn't discern evident links between BMI and demographic attributes, it remains paramount to underline that factors like age, academic qualifications, and economic standing could modulate both BMI and reproductive wellness [10][11][12][13].
In conclusion, this study's findings accentuate the clinical ramifications of BMI on ART.Medical practitioners should be apprised of BMI's salience when evaluating patients for ART [14].Advising patients on BMI's conceivable influence on treatment results and championing a balanced lifestyle, inclusive of weight management, could augment the likelihood of triumphant ART outcomes.However, the study is not without its limitations.The potential influence of socio-demographic variables on the relationship between BMI and ART outcomes warrants a deeper dive in subsequent research.

Conclusions
The interplay between BMI and the success rates of ART in Saudi women is both intricate and profound.This study reinforces the pivotal role BMI plays in determining the efficacy of ART treatments, with both higher and lower BMIs showcasing potential impacts on fertility outcomes.The counterintuitive finding of increased successful pregnancies in women with higher BMIs signals the need for further research to unravel the underlying mechanisms.Moreover, the importance of maintaining an optimal BMI for enhanced reproductive success cannot be overstated.Medical professionals should be cognizant of this relationship, ensuring that patient assessments and counseling incorporate weight management and its ramifications on ART.Future studies might also delve deeper into the socio-demographic factors and their potential influence on this BMI-ART relationship to provide a holistic perspective and guide clinical decisions.

Appendices
Table 9 displays the questionnaire used in the research.

3 :
How would you rate the severity of the pediatric traumatic brain injury you have encountered?were utilized for the evaluation of pediatric traumatic brain injury?(Select all that apply) a) Computed Tomography (CT) scan b) Magnetic Resonance Imaging (MRI) c) Other (Please specify: ________________) Were the imaging findings consistent with the clinical presentation?imaging findings influence the clinical decision-making process?a) They confirmed the diagnosis and guided treatment decisions.b) They provided additional information but did not significantly impact the clinical management.c) They were inconclusive or did not correlate with the clinical presentation.Were surgical interventions required based on the imaging findings?you with the diagnostic accuracy of the imaging techniques used?a) Very satisfied b) Moderately satisfied c) Not satisfied Did the imaging techniques provide valuable prognostic information?a) Yes b) No c) Not sure 2023 Aleid et al.Cureus 15(10): e46706.DOI 10.7759/cureus.46706How frequently do you encounter challenges related to the availability of MRI for pediatric TBI cases?about the radiation exposure associated with CT scans in pediatric patients?a) Yes, I am very concerned.b) Somewhat concerned.c) No, I am not concerned.Do you believe that there is a need for evidence-based guidelines regarding the appropriate use of imaging techniques in pediatric TBI? a) Yes.b) Maybe it could be helpful.c) No, I don't think it is necessary.Section 2: Hypothesis 1 -Association between abnormal CT scan findings and the presence of pediatric TBI Did the CT scan findings reveal any abnormal intracranial findings suggestive of pediatric TBI? findings were present on the CT scan, what was the nature of the injury?(Select all that apply) (Please specify: ________________) Were there any discrepancies between the CT scan findings and the clinical presentation?Did the presence of abnormal CT scan findings correlate with the severity of pediatric TBI? a) Yes, strongly correlated b) Yes, moderately correlated c) No correlation was observed 2023 Aleid et al.Cureus 15(10): e46706.DOI 10.7759/cureus.4670613 of 17 Did the abnormal CT scan findings impact the choice of treatment options for pediatric TBI? applicable Were any further confirmatory tests or additional imaging studies performed after the initial CT scan?you in the accuracy of the CT scan findings?a) Very confident b) Moderately confident c) Not confident Did the CT scan findings significantly contribute to the clinical management decisions?a) Yes, significantly b) Yes, to some extent c) No, they had minimal impact Were there any cases where the CT scan findings did not align with the clinical outcomes?sure In your experience, what is the overall reliability of CT scans in detecting pediatric TBI? Hypothesis 2 -Correlation between specific MRI characteristics and the severity of pediatric TBI Did the MRI findings reveal any specific characteristics indicative of pediatric TBI? a) Yes b) No c) Not sure If specific characteristics were present on the MRI, what was observed?(Select all that apply) 2023 Aleid et al.Cureus 15(10): e46706.DOI 10.7759/cureus.46706a) Diffuse axonal injury b) Intracranial hemorrhage c) Contusion(s) d) Edema e) Other (Please specify: ________________) Were the MRI findings consistent with the severity of pediatric TBI? a) Yes, strongly consistent b) Yes, moderately consistent c) No consistency observed Did the specific MRI characteristics influence the choice of treatment options for pediatric TBI? a) Yes b) No c) Not applicable Did the presence and extent of specific MRI characteristics correlate with the prognosis of pediatric TBI? a) Yes, strongly correlated b) Yes, moderately correlated c) No correlation was observed Were there any discrepancies between the MRI findings and the clinical presentation?sure Did the MRI findings contribute to a better understanding of the anatomical involvement in pediatric TBI cases?a) Yes, significantly b) Yes, to some extent c) No, they had minimal impact How confident were you in the accuracy of the MRI findings?a) Very confident b) Moderately confident c) Not confident Were there any cases where the MRI findings did not align with the clinical outcomes?a) Yes b) No c) Not sure 2023 Aleid et al.Cureus 15(10): e46706.DOI 10.7759/cureus.4670615 of 17 In your experience, what is the overall reliability of MRI in detecting and characterizing pediatric TBI?

Table 2
6%) had undergone weight loss interventions.A substantial number of 427 (39.9%) were taking medications or supplements that might influence fertility.Most participants 672 (62.7%) had not undergone any ART cycles, and 553 (51.6%) had experienced clinical pregnancies resulting in live births.Count % How long have you been trying to conceive?

TABLE 2 : General information
Data in the table is represented as N (count) and % (percentage).ART: assisted reproductive technology

Table 3
illustrates the majority of participants had not been diagnosed with hormonal disorders related to fertility 896 (83.7%) or undergone tests to assess ovarian reserve 931 (86.9%).Many participants 882 (82.4%) had not received information about the impact of BMI on ovarian reserve.Additionally, a considerable number of participants 350 (32.7%) experienced irregular menstrual cycles, and 441 (41.2%) had been diagnosed with polycystic ovaries.Symptoms related to hormonal imbalances were reported by 385 (35.9%) of participants, while 294 (27.5%) had thyroid disorders.

TABLE 3 : Gynecological history
Data in the table is represented as N (count) and % (percentage).
Importantly, 259 (24.2%) of participants had been informed by healthcare providers about the potential influence of BMI on treatment outcomes, showcasing the relevance of BMI in reproductive health conversations.Additionally, 217 (20.3%) of participants received counseling or support concerning weight management during their ART treatment, underscoring the holistic nature of fertility care.How many ART cycles have you undergone so far?
In terms of clinical pregnancies, 280 (26.1%) of participants achieved this milestone, whereas 756 (70.6%) did not.Further scrutinizing clinical pregnancies, it was observed that 294 (27.5%) of these cases resulted in live births, with the remaining 672 (62.7%) not culminating in successful live births.In instances where clinical pregnancies did not lead to live births, 308 (23.8%) reported experiencing miscarriages, pointing to the complexities of reproductive outcomes.Notably, a subset of participants 189 (17.6%) encountered complications or side effects arising from previous ART treatments, highlighting the multifaceted nature of these interventions.Moreover, a distinct group of 196 (18.3%) underwent supplementary procedures during their ART journey.In terms of medication intake, 336 (31.4%) of participants were actively taking medications or supplements tailored to their ART regimen.

TABLE 4 : Outcomes for ART and ovarian reserve parameters Data
in the table is represented as N (count) and % (percentage).ART: assisted reproductive technologyBMI

Table 5
within the context of BMI and its associations, a meticulous examination of BMI distribution and its implications on ART outcomes was performed.The majority of participants fell within the normal weight range of 752 (70.2%), while 187 (17.5%) were classified as overweight, and 132 (12.3%) were underweight.

TABLE 5 : Body mass index
Data in the table is represented as N (count) and % (percentage).

Table 6
dives into the connection between participants' BMI and their demographic characteristics.The distribution of BMI categories, including normal, overweight, and underweight, is examined across various participant attributes.While no significant associations were detected between BMI and these characteristics, this analysis provides valuable insight into the interplay between BMI and demographics, highlighting the complexity of factors influencing reproductive health.

TABLE 7 : Association between BMI and ovarian reserve parameters
Data in the table is represented as N (count) and % (percentage).A p-value of <0.05 was considered statistically significant.ART: assisted reproductive technology, BMI: body mass index