The psychosocial impact of exercise as an intervention for persons living with obesity and female infertility: A rapid scoping review and pilot study.

Infertility is defined as the inability to conceive after a year of sexual intercourse without contraception [ 1 ]. Infertility rates have doubled since the 1980s and currently affect approximately one in six Canadian couples [ 2 ]. The experience of infertility can have psychosocial consequences, such as elevated levels of stress and anxiety and the experience of symptoms of depression and feelings of hopelessness [ 3 – 6 ]. Women experiencing infertility are more likely to experience higher levels of anxiety [ 7 ], depression [ 8 ], and psychological distress [ 9 ] compared to women not experiencing infertility. Furthermore, there is evidence to suggest that increased stress could negatively impact unassisted conception rates and fertility treatment outcomes [ 10 – 12 ]. Unfortunately, it appears the relationship between reproductive health and psychosocial factors is bidirectional, meaning these factors often increase and further impact fertility following an infertility diagnosis [ 7 – 10 ]. The severe psychological impact of infertility is emphasised in a study where women with infertility reported anxiety and depression levels similar to those of women with cancer, heart attacks, and HIV [ 13 ]. Thus, there is an important need to measure and monitor the psychological well-being of patients being treated for infertility. Individuals diagnosed with infertility who live with obesity face distinct psychological challenges during reproductive care. Due to the connection between excess adiposity and dysfunction in processes related to fertility, patients with obesity are often counselled by healthcare providers to reduce their body weight [ 14 ]. However, there is limited research that examines the psychosocial impacts on persons with obesity and infertility who have been prescribed lifestyle interventions [ 15 ]. A recent study explored the experiences of Canadian adults who live with two or more chronic diseases with healthcare providers incorporating obesity treatment guidelines in chronic disease management [ 16 ]. The study found that more than half of respondents who received a diagnosis of infertility perceived the obesity management support they received as “not very helpful” or “not at all helpful” [ 16 ]. The impact of advising patients to lose weight (often a considerable amount) without adequate support can lead to adverse health outcomes such as medication nonadherence, mistrust of their healthcare provider and avoidance of medical care [ 17 , 18 ]. To improve adoption and adherence to programs focused on behavioural change and minimize the negative consequences, there is a critical need to examine psychosocial outcomes for persons with female infertility and obesity during reproductive care. Independent of weight loss, physical activity and exercise are critical components of a lifestyle intervention for improved cardiometabolic health in preconception and pregnancy [ 19 ]. The primary objective of the present study is to determine the psychosocial effect of exercise as an intervention, or a component of an intervention, for persons of reproductive age (ages 18–40) living with obesity (BMI> or equal to 30 kg/m^2) and female infertility. Our research question is assessed in two ways. First, through a rapid scoping review describing the methods and psychosocial effects of exercise-based lifestyle interventions in persons with obesity and experiencing infertility. And second, through the results of a pre-experimental study examining self-reported measures of anxiety, depression, hopelessness, infertility-related stress, and perceived social support before and after a 12-week virtual exercise intervention in persons living with obesity and experiencing female infertility. Based on our review of the literature, we expected improvements in all measured psychosocial parameters. However, this pilot feasibility study did not have statistical power for hypothesis testing. We chose to combine a rapid scoping review with a pilot study as a strategic approach to effectively explore an under-researched area [ 20 ]. The rapid review aimed to identify gaps in the literature to inform our research objectives and our pilot study focused on exploring psychosocial measures and identifying challenges in implementing an exercise-based intervention for individuals with obesity and infertility, providing real-world context to theoretical insights. Together, the rapid scoping review and pilot study provide insights into the psychosocial effects of undergoing an exercise-based lifestyle intervention when living with obesity and infertility.

In the initial search, 838 studies were identified through database searching and were imported to Covidence. After duplicates were removed, the remaining 662 articles were selected for title and abstract screening. Of these articles, 18 were uploaded to full-text screening for assessment of review eligibility. Ultimately, nine articles were reviewed in the rapid scoping review ( Fig 1 ). There were no articles added to the rapid review search through citation searing or grey literature searching. The nine articles reviewed discussed a total of four different intervention protocols. Relevant information about study samples, interventions and results are summarised in Table 1 . Three of the articles provide only the study intervention protocol information [ 36 – 38 ]. The remaining six articles report on results from the selected studies [ 15 , 39 – 43 ]. All studies investigated the psychosocial effects of exercise-based interventions for women with obesity and experiencing infertility. The selected studies were based in Australia [ 39 , 40 ], the Netherlands [ 15 , 37 , 38 , 41 , 43 ], Spain [ 36 ], and the United-States of America [ 42 ]. Study characteristics of nine articles were reviewed and are presented. Three of the articles reviewed presented study protocols only. The lack of available outcome data is indicated by *. QoL = Quality of Life. Of the completed studies reviewed, there was one cohort study [ 39 , 40 ], two multi-centre randomized control trials [ 15 , 37 , 38 , 41 – 43 ]. The interventions of included studies varied in duration and in concept. The intervention duration of included studies varied between 12 and 24 weeks. The intervention concepts also varied. In Galletly et al’s 1996 study there was a weekly session with a psychiatry, dietetics, or reproductive medicine specialist to discuss the effects of lifestyle changes on pregnancy outcomes alongside their exercise intervention [ 39 , 40 ]. The FIT-PLESE intervention included a calorie restriction and anti-obesity medication component alongside their exercise component [ 42 ]. Last, the LIFEstyle study intervention included dietary change and behaviour modification components alongside their exercise component [ 15 , 37 , 38 , 41 , 43 ]. Further, the exercise component of the respective interventions also differed. For example, Galletly et al’s study included a weekly, hour-long, group exercise component while the FIT-PLESE and LIFEstyle studies had exercise interventions more focused on obtaining weekly or daily step counts. The outcomes measured in these completed studies varied as well. Galletly et al’s study measured anxiety, depression and self esteem while the FIT-PLESE and LIFEstyle studies focused more on quality of life. Galletly et al found statistically significant reductions in anxiety and depression symptoms, statistically significant improvements in self-esteem, and statistically significant reductions in general health scores immediately following the intervention program [ 39 , 40 ]. A low score in the General Health questionnaire used in this study indicates a favourable psychological state [ 44 , 45 ]. The FIT-PLESE study found statistically insignificant decreases in fertility QoL in both groups after the intervention [ 42 ]. The LIFEstyle study found statistically significant reductions in physical QoL immediately after the intervention in the intervention group and no difference in mental QoL between intervention and control groups [ 41 ]. In a follow up study, found no significant difference in any of QoL, anxiety, depression, sleep quality, and perceived stress measures between intervention or control groups at 5 years post randomization [ 15 ]. Further, between PCOS and non-PCOS participants, they found no significant difference in mental QoL score change but slightly lower physical QoL scores at the 3-month measurement during the intervention [ 43 ]. In general, the research to date suggests that exercise-based interventions may improve psychological measures such as anxiety, depression, perceived stress, self-esteem, general health and physical quality of life (QoL) in the short term. However, positive psychological effects have not been observed past immediate, end-of-study assessments, as documented in Van Dammen’s 2019 5-year post-randomization follow-up study [ 15 ]. Further, there is no evidence of improvement in mental QoL after engaging in exercise-based interventions for women with obesity and infertility [ 41 ]. Exercise interventions may have less effects on physical QoL in participants with PCOS [ 43 ]. Protocols for two prospective studies have been published to investigate the psychosocial effects of exercise-based interventions [ 36 , 38 ]. The table in S2 Text . summarises the risk of bias assessment outcomes for studies included in this rapid review. Two studies had a “high” risk of bias due to self-reporting methods and missing outcome data [ 39 , 40 ]. Three studies had “some concerns” of bias due to self-reporting methods for outcome measurement [ 15 , 41 , 43 ]. Two studies had a low risk of bias, though both studies were missing information to fully characterise the risk of bias in all domains [ 36 , 42 ]. One study had inadequate information to fully characterise the risk of bias [ 37 ]. Further, articles 1, 5, and 9, describe protocol information only and do not comment on the results of the study [ 36 – 38 ]. As a result, the risk of bias could not fully be assessed in these studies. Eleven participants were enrolled in the exercise intervention study. Pre-intervention, nine participants completed all of the questionnaires, while two participants completed some questionnaires. Post-intervention, seven participants completed all post-intervention questionnaires. Four participants did not complete the 12-week exercise intervention and dropped out of the study and thus, did not complete the post-intervention questionnaires. The participants ranged from 28 to 42 years of age, with an average of 34 ± 3.7 at the time of enrolment. Self-reported anthropometric measures (e.g., height and weight) were collected using a survey pre-intervention and after the completion of the intervention. BMI (kg/m 2 ) was calculated before and after the intervention. Pre-intervention participants’ (n = 11) average BMI was 40.3 kg/m 2  ± 4.5 After completing the exercise program, the average BMI of participants (n = 7) was reduced to 38.9 kg/m 2  ± 5.8. Measures of age, height, weight and BMI at pre-intervention and post-intervention are reported in Table 2 . Obesity is defined as having a BMI (kg/m 2) equal to or above 30, while severe or morbid obesity is defined as having a BMI (kg/m 2) greater than or equal to 40 kg/m 2 . BMI (kg/m 2 )was calculated by the research team using self-reported measures of weight and height. * No Data. Five surveys were administered to participants to characterize the cohort’s psychosocial profiles. Results from pre-intervention and post-intervention survey administration are summarized in Table 3 . *No Data. Pre and post-intervention measures of anxiety, depression, hopelessness, perceived social support, quality of life, and fertility-related stress for each participant are captured in Table 3 . The validated questionnaires used to obtain these measurements were HADS, Beck Hopelessness Scale, Multidimensional scale of perceived social support, SF-12(V2), and FPI. Individual scores for depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS). Pre-intervention (n = 11), participant scores for depression and anxiety averaged to be 8.4 ± 3.5 for depression and 4.3 ± 2.2 for anxiety, respectively. Seven participants (63.6%) reported having considerable symptoms of depression, and one participant (9.1%) reported considerable symptoms of anxiety. Post-intervention (n = 7), the average score for depression decreased 2.1 points from pre-intervention to 6.3 ± 3.0. Scores for anxiety rather increased from pre-intervention to 4.9 ± 2.5. After the intervention, the proportion of those experiencing considerable symptoms of depression decreased to 42.9% while the proportion of those experiencing considerable symptoms of anxiety increased to 28.6%. Figs 2 and 3 depict the baseline and post-intervention scores from each participant. Scores range from 0-21. Total subscale scores for depression and anxiety equal to or above eight represent considerable symptoms of depression. Scores range from 0-21. Total subscale scores for depression and anxiety equal to or above eight represent considerable symptoms of depression. Health-Related QoL was measured using the SF-12v2. Pre-intervention, the sample average pre-intervention for mental and physical components scores was within normal ranges. After the intervention, a general increase was observed in the physical component score to 55.7 (± 6.1) from 51.4 (± 4.3) pre-intervention. All the while, a decrease was observed in the mental component score to 32.8 (± 8.5) from 43.0 (± 8.7) pre-intervention. There was some variability in post-intervention QoL score changes amongst participants. Physical component scores increased post-intervention in four of seven participants, while one remained consistent, and two decreased. Alternatively, mental component scores decreased in four of seven participants, while one remained consistent and two increased. Of note, one participant’s mental component score decreased by over 20 points post-intervention. Table 4 describes the baseline and post-intervention Health-Related QoL scores. The physical and mental component scores are summary scores based on 8 domains, scores range between 0–100. The summary scores are based on the national average whereby 50 represents an average score for each summary score. A physical component score 50 or less has been recommended as a cut-off to determine a physical condition. While a mental score equal to or below 42 may be indicative of “clinical depression”. *No Data. Fertility-related stress was measured by using the Fertility Problem Inventory (FPI) [ 26 ]. Individual scores for each domain and overall fertility-related stress values are reported in Table 5 . Pre-intervention (n = 9), scores for fertility-related stress ranged from 138 to 176, with an average score of 158.9 ± 12.8. Post-intervention (n = 7) fertility-related stress scores ranged from 138 to 164, and the average score reduced to 153.1 ± 10.3. The pre and post-intervention changes measured by the FPI varied by domain. Compared to pre-intervention measures, post-intervention social concern reduced in six out of seven participants (85.7%) and sexual concern decreased in four of seven participants (57.1%). Rejection of a childfree lifestyle increased in four of seven participants (57.1%). Relationship concern remained the same or approximately the same or nearly the same in four of the seven participants (57.1%). Last, for the need for parenthood domain, three of seven (42.9%) reported a need for parenthood. Ultimately, the fertility-related stress scores decreased in five of seven participants (71.4%) post-intervention. *No Data. Hopelessness was measured using the Beck Hopelessness Scale (BHS) [ 22 ]. Ten of eleven participants completed the questionnaire pre-intervention, and seven completed the questionnaire post-intervention. Of the ten participants pre-intervention, only two participants (18.2%) reported mild hopelessness, with the remaining eight participants scoring (72.7%) in the normal range. Post-intervention, three of seven participant scores (42.9%) remained constant, while four participants (57.1%) reported decreases (a reduction) in hopelessness. The baseline and post-intervention BHS scores are reported in Table 3 . The Multidimensional Scale of Perceived Social Support (MSPSS) was used to measure perceived social support [ 27 ]. Pre-intervention, ten of eleven participants completed the questionnaires and post-intervention, seven of seven completed the questionnaire. All participants reported scores signifying high levels of perceived social support before and after the intervention. Post-intervention, five of the seven participants reported decreases in their scores compared to pre-intervention, and two scores remained constant. Individual data for both time points are displayed in Table 3 . Three themes emerged from the open-ended responses on the weekly satisfaction survey that highlighted satisfaction with the program and areas where modifications could be made to enhance participant experience. These themes were: (1) external motivation, (2) taking charge and control of adherence, and (3) the need for resources to overcome barriers. Please see Fig 4 , which illustrates the themes and sub-themes for participants’ attitudes towards the exercise intervention. Several participants expressed positive feedback about the instructor and how the instructor motivated them during the intervention. The theme of external motivation emerged as crucial for maintaining adherence to the program, but it also emphasized the potential need to foster intrinsic motivation. The next theme that emerged from the data was taking charge and control of adherence. For example, after periods of missing sessions, participants noted a desire to get back on track with the program and reach their goals. Having adherence goals set, specific session times and a Facebook group likely provided encouragement to continue with the program after setbacks. The last theme was the need for resources to overcome obstacles. There were multiple quotes from participants that identified resources in place to help participants overcome obstacles, such as advice on injuries and providing adequate recovery time but also highlighted where alternative arrangements could be made, such as considering the time of year and weather conditions.

Findings from this rapid review and pilot study suggest that while exercise-based interventions can have a positive impact on certain psychosocial outcomes, exercise alone may not fully address the psychological needs of individuals with obesity and infertility. To maximize the benefits of exercise programs, evidence from the current study suggests that clinicians should incorporate additional support mechanisms, particularly to manage anxiety and improve mental quality of life. Furthermore, our study offers new insights by examining the effects of exercise on hopelessness, perceived social support, and infertility-related stress, all of which showed favourable outcomes. In conclusion, future research should focus on integrating psychological support within exercise interventions and exploring other factors that contribute to the psychosocial well-being of this population.

We utilized a dual methodological approach by combining a rapid scoping review and a pilot study to strengthen our validity of our findings while addressing unmet needs in the literature. Of note, this study used patient-oriented research methods, informing the design of the pilot study to ensure the study’s objectives and methodology were meaningful to our patient population [ 21 ]. This study received ethics approval from the provincial health research ethics authority (HREA # 2019.214). This rapid scoping review was started on June 14th, 2023, with the search being repeated in December 2023 to review any recently published articles. This rapid scoping review aimed to: (1) explore existing studies which evaluated exercise-based interventions for participants with obesity and experiencing infertility, and (2) to understand the psychosocial effects of these interventions on the target population. Search components and terms were discussed amongst the team, with a final search being developed by a health sciences librarian (AF) using Mesh and keywords in Ovid Medline. The search was tested to ensure key articles were discovered. The search was then performed in Ovid Medline, Embase.com, and CINAHL (Ebsco). The search strategy for Medline sets out the search approach in more detail ( S1 Text ). Results were imported into and duplicates were removed using Covidence software. Articles were screened by one author (JM). Articles identified through the initial search were first screened based on title and abstract. Articles not fulfilling at least one inclusion criteria were excluded at this stage. Next, articles were screened through full text review. Articles were included in the review based on the following inclusion criteria: (1) participants were experiencing female-factor infertility; (2) participant BMIs were greater than or equal to 30 kg/m^2; (3) participants were seeking fertility services; (4) interventions included an exercise component; and (5) the reported outcomes included psychosocial measures such as anxiety, depression, quality of life, fertility related stress, and hopelessness. Articles not meeting all inclusion criteria, not published in the english, or not available in full text form were excluded. were excluded. Predetermined details from each study were then extracted from each study. JM and KW completed the Cochrane Risk of Bias assessment of each study using need to the following five domains: (1) bias arising from the randomization process; (2) bias due to deviations from intended intervention; (3) bias due to missing outcome data; (4) bias in the measurement of the outcome; (5) bias in the selection of the reported result. Judgement of each study was based on the following rating system: high, some concerns, low and no information. KW acted as the second reviewer and verified all judgments. This review’s risk of bias assessment is available in ( S2 Text ). The data extracted from the articles in this review included population data (age, sample size, BMI, and cause of infertility); intervention data; and outcome data (psychosocial outcomes measured and associated results). Data was extracted and charted by one author (JM). The PRISMA Scoping Review Checklist for this review is available as a supplementary file ( S1 Checklist ). A feasibility assessment of this pilot study is reported in our previously published work on the same cohort [ 22 ]. This study used a patient-oriented research approach, which involved including people with lived experience (PWLE) as collaborating research partners, in the development of this study’s objectives and methodology. The study methodology was informed by four PWLE collaborators who have lived experience of obesity and infertility. Two patient engagement sessions were held to elicit patient-partner input. During the first session, the researchers consulted the PWLE collaborators on the research topic to engage in an exchange of information to connect the PWLE collaborators’ experience with the researchers’ knowledge. Based on patient partner responses to the researcher’s questions, the study protocol was modified to include questionnaires to measure psychosocial variables. During the second patient engagement session, PWLE collaborators reviewed the developed methodology. Researchers documented the PWLE collaborators’ feedback and revised the methods based on their recommendations. During discussion group sessions with PWLE collaborators, several key emotional and psychological experiences were shared, including anxiety, depression, hopelessness, infertility-related stress, and perceived social support. From these discussions, the researchers selected validated questionnaires to measure the constructs identified by the patients. The questionnaire package included six validated tools: (1) Leisure Time Physical Activity Questionnaire, (2) Hospital Anxiety and Depression Scale (HADS), (3) Short Form-12 Version 2 (SF-12v2), (4) Beck Hopelessness Scale (BHS), (5) Fertility Problem Inventory (FPI), and (6) Multidimensional Scale of Perceived Social Support (MSPSS) [ 22 – 27 ]. This paper reports on results from questionnaires 2–6, as the results from questionnaire 1 are reported elsewhere [ 22 ]. Scores for depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS) [ 24 ]. The HADS has been validated for patients and the general public [ 28 ]. The HADS questionnaire has seven items each for depression and anxiety. Scoring for each item ranges from zero to three, with three denoting the highest levels of anxiety or depression. Total scores range from 0-21, with higher scores representing more severe levels of depression and anxiety. Total subscale scores for depression and anxiety equal to or above eight represent considerable symptoms of depression and anxiety. Health-Related QoL was measured using the SF-12v2. The SF-12v2 is a health-related quality-of-life questionnaire consisting of twelve questions that measure eight domains of health that assess physical and mental health. The SF-12v2, a shortened version of the SF-36 is a valid assessment of the same domains with fewer questions to reduce the respondent burden amongst participants [ 29 ]. Based on survey questions of eight domains, physical and mental component scores can be calculated with scores ranging from 0-100 and 50 (±10), indicating normative scores for the general population. Fertility-related stress was measured by using the Fertility Problem Inventory (FPI) [ 26 ]. The FPI has demonstrated validity in women experiencing infertility [ 30 ]. The 46-item questionnaire uses a Likert scale from 1 to 5 to measure the following five domains: 1) sexual concern, 2) social concern, 3) relationship concern, 4) need for parenthood, and 5) rejection of a childfree lifestyle. Using the FPI domain scores, a measure of global stress can be calculated by summing the individual scores of the five domains. For global fertility-related stress, the scores can range from 46 to 276. Higher scores signify higher levels of fertility-related global stress. Hopelessness was measured using the Beck Hopelessness Scale (BHS) [ 22 ]. The BHS is a 20-item self-reported questionnaire designed to quantify three significant aspects of hopelessness in outpatients: feelings about the future, loss of motivation, and expectations. BHS has high predictive and internal validity [ 31 ]. Scores range from 0 to 20. Scores from 0-3 are considered in the normal range, those from 4-8 equate to mild hopelessness, and scores between 9–14 represent moderate hopelessness. Scores above 14 identify severe hopelessness. The Multidimensional Scale of Perceived Social Support (MSPSS) was developed to obtain subjective measures of perceived social support from three sources: family, friends, and significant others [ 27 ]. The MSPSS has been validated for use in various populations [ 32 ]. The MSPSS includes 12 items scored on a Likert scale from 1-5 [ 27 ]. Scores range from 12-84, the higher the score, the higher the perceived social support. Scores from 12-35 signify low levels, 36–60 medium levels and 60–84 high levels of social support. Participants were recruited primarily through physicians at a local fertility clinic. Potential patients were identified by physicians: (1) as new patients to the NL Fertility Services clinic for their initial assessment or (2) following a review of current patients’ medical records by a physician in their circle of care. Social media platforms (local Facebook Support Groups, such as “Faces of Fertility” and “Newfoundland and Labrador Infertility Support”) were used as an additional means of recruitment using a recruitment poster. A total of 32 persons with female infertility were referred to the research team to discuss the details of the study. A research team member called and emailed all potential participants to introduce the study. After initial referral, 21 of the contacted persons decided not to participate for one of the following reasons: (1) not interested at this time, (2) do not have enough time to commit during the week, (3) do not want to potentially delay fertility treatment to participate, (4) starting their weight-loss program (Some patients decided not to participate as they had already begun a weight-loss program, independently), or (5) lack of confidence. Participants were recruited based on the following inclusion and exclusion criteria. The inclusion criteria for the present study were: (1) between the ages of 18 and 45 experiencing infertility (i.e., inability to conceive after twelve months of trying) through either self-report or physician referral, (2) with a BMI > 30 kg/m 2 , (3) who were not meeting the Canadian Physical Activity Guidelines for physical activity, and (4) who are willing to commit to an online group exercise program three days a week for 12-weeks. Women were excluded from the study if they were < 18 or older than 45 years, had physical impairments limiting their ability to participate, or were unwilling to delay fertility treatment for 16-weeks. The exclusion criteria were selected to ensure clear, interpretable results focused on the effects of an exercise intervention on women with obesity (BMI > 30 kg/m 2 ). Participants who agreed to participate in the study were emailed a consent form, a Physical Activity Readiness Questionnaire for Everyone (PARQ+), and the Godin-Shephard Leisure-Time Physical Activity Questionnaire to determine eligibility. Upon revision of the PARQ+ responses, participants who indicated having specific comorbidities like asthma or high blood pressure were given a PARmed-X to obtain medical clearance from their healthcare provider. The Godin-Shephard Leisure-Time Physical Activity Questionnaire was used to determine whether participants met the eligibility criteria for physical activity while also being used as a validated tool for data collection mentioned below. After one month of recruitment, eleven participants were successfully enrolled in the study. The details of the exercise intervention are outlined in our previous publication, known as the PRO-FIT-CARE study [ 33 ]. The exercise intervention was designed for participants to exercise at a moderate-to-vigorous intensity level while completing low-impact, body-weighted exercise [ 33 ]. Due to the COVID-19 pandemic, the exercise intervention was in an online group setting environment using Zoom Software. The exercise sessions were delivered live by a registered Kinesiologist three days a week, each lasting 45 minutes and spanning 12 weeks. Live participation was encouraged; however, sessions were recorded for participants unable to attend to complete at a later time. A private Facebook page for participants to engage with one another was also created based on feedback from the patient partner discussion groups. On this Facebook page, members of the research team posted nutritional tips and recipes, motivational quotes, and, most importantly, links to the virtual exercise program. Participants completed a questionnaire package pre-intervention and after the 12-week intervention. Questionnaires were sent to participants’ emails or printed and delivered to their home addresses. Due to the virtual nature of the program, all questionnaires were completed by the participant and contained self-reported data. The following questionnaires were administered: 1) Godin-Shephard Leisure Time Physical Activity Questionnaire (GSLTPAQ); 2) Hospital Anxiety and Depression Scale (HADS); 3) Short Form Health Survey, version 2 (SF-12v2)); 4) Fertility Problem Inventory (FPI); 5) Beck Hopelessness Scale (BHS); 6) Multidimensional Scale of Perceived Social Support (MSPSS). In addition, information was gathered through a post-intervention semi-structured discussion group. Last, anthropometric measures (height and weight) were self-reported, year of birth, current medications, and comorbidities were collected. Data was collected using virtual and physical copies of the questionnaires. Individual scores were inputted into a Microsoft Excel spreadsheet, separated by the questionnaire used and variable measured. Due to the small sample size (n = 11), statistical analysis of pilot study data is limited to descriptive statistics. Confidence intervals and P-values for the results are not reliable due to the small sample size of the pilot study [ 34 ]. A student license was obtained from QualityMetric to analyze the SF-12v2 data. PRO CoRE scoring software was used to score SF-12v2 domains and to analyze means and standard deviations of the physical and mental component scores (PCS, MCS, respectively). To gather more information about patient’s satisfaction with exercise intervention, using Google forms, participants responded weekly to open-end questions regarding the program, instructors, how participants felt during the week and any other general comments. Impactful quotes from these responses underwent thematic analysis by two reviewers (CB, KW) and were categorized into subthemes and themes [ 35 ].

Detailed search strategy sample for rapid scoping review, as applied to Medline search. (DOCX) Cochrane risk of bias assessment figure for rapid scoping review [ 67 ]. Bias assessment judgments are summarized for articles included in the rapid scoping review through the Cochrane risk of bias assessment tool. Articles 1, 5, and 9 described study protocols only, hence many bias domains were not able to be assessed due to lack of information. (DOCX) The PRISMA scoping review checklist summarizes key procedural elements of the present rapid scoping review [ 68 ]. (PDF)