Overweight and obesity determined by body mass index criteria for Asian populations adversely affect assisted reproductive outcomes among Chinese women with polycystic ovary syndrome

Overweight and obesity determined by body mass index criteria for Asian populations adversely affect assisted reproductive outcomes among Chinese women with polycystic ovary syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Article Overweight and obesity determined by body mass index criteria for Asian populations adversely affect assisted reproductive outcomes among Chinese women with polycystic ovary syndrome Yinghui Ye, Ruimin Zhao, Xinyun Yang, Long Cui, Lefeng Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2834297/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Dec, 2023 Read the published version in International Journal of Obesity → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Obesity is a common feature in women with polycystic ovary syndrome (PCOS) and associated with multiple adverse reproductive outcomes. However, the impact of overweight and obesity on reproductive outcome of PCOS women underwent the in vitro fertilization-embryo transfer (IVF-ET) is currently controversial. Since appropriate body mass index (BMI) levels differ across ethnic groups, this study was performed to investigate the effects of BMI on IVF outcomes among women with PCOS using BMI cut-off values proposed by the World Health Organization for Asian populations.  Method(s): This was a retrospective study including 1066 women with PCOS receiving IVF treatment at our institution between January 2018 and June 2021, among whom 960 underwent their first fresh or frozen embryo transfer. Participants were categorized according to their BMI as follows: patients with normal weight (BMI < 23 kg/m 2 ), patients with overweight (BMI: 23–24.9 kg/m 2 ), and patients with obesity (BMI ≥ 25 kg/m 2 ). The effect of BMI on IVF outcomes (the numbers of oocytes, two pronuclear zygotes, and good-quality embryos; the rates of implantation, miscarriage, clinical pregnancy and live birth) was evaluated by descriptive statistics and logistic regression models with confounders adjusted. Interventions: no Result(s): High BMI was associated with significantly lower numbers of total oocytes retrieved, mature oocytes, two pronuclear zygotes, and good-quality embryos among women with PCOS. PCOS patients with a BMI ≥ 23 kg/m 2 had significantly lower live birth rates (41.9% vs. 49.1%; adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.57–0.97) and implantation rates (35.8% vs. 43.9%; aOR, 0.76; 95% CI, 0.61–0.93) than those with normal BMI. Conclusion(s): PCOS patients with a BMI ≥ 23 kg/m 2 have lower live birth rates than those with a BMI < 23 kg/m 2 . Defining obesity and overweight with ethnicity-specific BMI cut-offs may help to improve IVF outcomes among PCOS patients. Health sciences/Endocrinology/Endocrine system and metabolic diseases/Obesity Health sciences/Diseases/Endocrine system and metabolic diseases/Obesity polycystic ovary syndrome body mass index in vitro fertilization live birth race Figures Figure 1 1. Introduction Polycystic ovary syndrome (PCOS) is a complex endocrine and metabolic disorder with a variable prevalence ranging from 4–21% among women of reproductive age ( 1 – 3 ). This syndrome is often accompanied by insulin resistance, obesity, dyslipidemia, and type 2 diabetes ( 4 , 5 ). Obesity, especially abdominal obesity, is seen in approximately 50% of all women with PCOS ( 6 ). Various Reproductive disruptions have been identified among women with overweight or obesity, including anovulation and a higher risk of pregnancy loss ( 7 , 8 ). Infertile women with obesity receiving in vitro fertilization (IVF)–embryo transfer treatment have poorer clinical outcomes, especially if they have also been diagnosed with PCOS ( 8 , 9 ). However, studies exploring the potential effects of high body mass index (BMI) on IVF outcomes among women with PCOS have presented conflicting results. Multiple studies have demonstrated that higher BMI is associated with the need for higher doses of gonadotropin, lower observed levels of estradiol and human chorionic gonadotropin (hCG), and fewer oocytes retrieved ( 10 – 15 ), but the effect of overweight and obesity on the IVF outcomes of PCOS is still not well established. In 2014, Bailey et al. found that women with a BMI ≥ 30 kg/m 2 had 77% lower odds of clinical pregnancy and live birth per embryo transfer than lean (BMI < 25 kg/m 2 ) women with PCOS ( 16 ). Several studies have demonstrated that although for women with obesity who underwent IVF clinical pregnancy rates were similar to those with normal weight, women with PCOS with obesity had relatively higher miscarriage rates ( 12 – 14 ). However, a multicenter prospective study suggested that BMI had little impact on IVF outcomes among PCOS patients, given that women with higher BMI had lower clinical pregnancy rates than, but similar ongoing pregnancy rates to, women with normal BMI ( 17 ). Limited impact of BMI on IVF outcomes was further suggested in another retrospective case–control study that found no differences in fertilization, embryonic development, pregnancy, implantation, and live birth among women with PCOS and varying BMI who underwent IVF ( 15 ). The varied findings among the studies may be attributable to differences in race, case definitions, and study design. Differences among women from different regions and races should be considered when drawing research conclusions or enacting clinical guidance for PCOS given the complexity of this disease. Compared with Whites and African Americans, Asians tend to have lower BMI and milder PCOS symptoms with lower levels of testosterone and insulin resistance ( 18 ). Most studies investigating the effect of overweight and obesity on reproductive outcomes in PCOS are based on World Health Organization (WHO) BMI cut-off points derived primarily from European populations (e.g., overweight: 25.0 kg/m 2 ≤ BMI < 30.0 kg/m 2 ; obesity: ≥ 30 kg/m 2 ). However, emerging evidence demonstrates that Asians have a greater tendency toward abdominal obesity than non-Asian populations and have high risks of developing metabolic syndromes, such as diabetes, hypertension, and dyslipidemia, even with a BMI < 25 kg/m 2 ( 19 , 20 ). In consideration of the underestimation of obesity-related risks among Asians with the application of its standard BMI cut-off points, the WHO redefined obesity as a BMI ≥ 25 kg/m 2 and overweight as a BMI ≥ 23 kg/m 2 for Asia–Pacific populations in 2000 ( 21 ). A previous study also found that the prevalence of metabolic disorders increased significantly among individuals with BMI ≥ 23 kg/m 2 , confirming the validity of this value as an appropriate BMI “trigger point” in identifying individuals at high risks of developing metabolic disorders, including among Chinese women with PCOS ( 22 ). The impact of overweight and obesity on IVF outcomes among women with PCOS using BMI cut-off values for Asians has not been explored. This study was designed to determine the association between BMI classes (patients with normal weight [BMI < 23 kg/m 2 ], patients with overweight [BMI: 23–24.9 kg/m 2 ], and patients with obesity [BMI ≥ 25 kg/m 2 ]) and IVF embryonic and clinical outcomes among PCOS women using the WHO BMI classification for Asia–Pacific populations. 2. Methods And Materials 2.1 Study design and participants This was a retrospective cohort study investigating the effect of BMI on IVF treatment among women with PCOS and was conducted in the university-affiliated Women’s Hospital located in the south of China, between January 2018 and June 2021. The need for consent was exempted considering the retrospective design of the study. The study was approved by the Medical Ethics Committee of Women’s Hospital. Female patients with PCOS who underwent their first IVF cycle were included. PCOS was diagnosed based on the criteria defined by the 2003 Rotterdam Consensus ( 23 ). The exclusion criteria were as follows: age > 40; being diagnosed with premature ovarian insufficiency, thyroid dysfunction, or immunological disorders; being diagnosed or having a partner diagnosed with a genetic disorder requiring preimplantation genetic testing; having recurrent spontaneous abortions (defined as three or more previous spontaneous pregnancy losses); or having structural abnormalities of the reproductive system. BMI was calculated as weight in kilograms divided by height in meters squared. The participants were classified into the following BMI categories based on the WHO classification for Asia–Pacific populations: women with normal weight (BMI < 23 kg/m 2 ), women with overweight (BMI: 23–24.9 kg/m 2 ), and women with obesity (BMI ≥ 25 kg/m 2 ) ( 21 ). 2.2 IVF procedures Most patients (62.9%) enrolled in our study underwent ovarian stimulation for IVF through an antagonist controlled ovarian hyperstimulation (COH) protocol, while 25.8% received a long agonist protocol, and 11.3% underwent the progestin-primed ovarian stimulation scheme or other protocols. The COH protocol has been described in previous studies ( 24 – 26 ). Oocyte maturation was induced by the injection of hCG when two or more follicles reached 18 mm in diameter. Oocyte retrieval was carried out via transvaginal ultrasound-guided aspiration 36 hours after hCG administration. Retrieved oocytes were cultured in supplemented G-IVF medium (Vitrolife, Sweden) at 37°C in an incubator with 6% carbon dioxide and fertilized via conventional IVF, intracytoplasmic sperm injection (ICSI), or half IVF/half ICSI (IVF/ICSI). A fertilization check was carried out 16 to 20 hours after insemination, and normally fertilized two pronuclear (2PN) zygotes were transferred into drops of G-1 medium (Vitrolife, Sweden). The assessment of day 3 embryos was performed as previously described ( 27 ). An embryo was assessed to have good quality if it had 6–10 cells, < 25% fragmentation, and equally sized mononucleated blastomeres. Day 3 embryos were transferred and frozen by vitrification or cultured for an extended period in G-2 medium (Vitrolife, Sweden) until they reached the blastocyst stage. Good-quality blastocysts (grade 4BC or higher) were vitrified on day 5 or 6. For frozen-thawed embryo transfer, the endometrium was prepared by hormonal replacement therapy or a mild stimulation cycle. Embryo transfer was performed using cleavage-stage embryos or blastocysts, and no more than two embryos were transferred. 2.3 Outcomes The primary outcome was live birth, which was defined as the delivery of at least one infant born alive at 28 weeks of gestation or later via the first fresh/frozen embryo transfer cycle. Pregnancy-related secondary outcomes were the hCG positive rate, clinical pregnancy rate, implantation rate, and miscarriage rate. Ovarian stimulation and embryological measurements included the total dose of gonadotropins, number of oocytes retrieved, number of metaphase II (MII) oocytes, number of 2PN zygotes, and number of good-quality embryos. 2.4 Statistical analysis All statistical analyses were conducted using Statistical Package for Social Sciences version 26.0 (SPSS, Chicago, IL, USA) with a P-value ≤ 0.05 being considered statistically significant and followed by the Bonferroni test for post hoc analysis. The chi-square and Fisher’s exact tests were performed to compare nominal variables. Normally distributed (as determined with the Kolmogorov–Smirnov test) parametric variables were analyzed through the ANOVA test, while non-normally distributed metric variables were compared using the Kruskal–Wallis test. The results are summarized as median (interquartile range) for non-normally distributed continuous variables and as mean ± standard deviation for normally distributed continuous variables. Categorical variables are presented as absolute and relative frequencies. Multivariate regression was used to evaluate the association between BMI and various pregnancy outcomes while adjusting for known potential covariates that may bias the effects of overweight and obesity. These confounding factors included age, the basal follicle-stimulating hormone (FSH) level, the number of transferred embryos, and the type of embryo transfer. 3. Results 3.1 Baseline characteristics according to BMI in PCOS patients A total of 1,389 patients were enrolled into the study. Among these, 323 patients were excluded due to duplication or fulfillment of exclusion criteria. A total of 1,066 women with PCOS who underwent their first IVF/ICSI cycles met the inclusion criteria for this study and were categorized into three groups according to their BMI. Most women (n = 630; 59.1%) had normal BMI. A total of 241 women (22.6%) had overweight and 195 (18.3%) had obesity (Fig. 1). Baseline characteristics of patients are shown in Table 1. Patients in the normal BMI group had a shorter duration of infertility and higher education levels than those with overweight and obesity. No differences in the cause of infertility and the percentage of patients diagnosed with primary infertility were observed between the BMI groups. Women with obesity had higher basal serum FSH levels than normal BMI participants, but had lower levels of luteinizing hormone (LH) than participants in the other two groups. Anti-Müllerian hormone (AMH) levels significantly decreased as BMI increased. 3.2 Ovarian stimulation response and embryological outcomes No differences were observed in the proportion of ovarian stimulation protocols used among the three BMI groups. The majority (62.8%) of the PCOS patients received an antagonist scheme. The total dose of the gonadotropin used and the number of days for stimulation increased significantly with increasing BMI, while the estradiol levels on the day of hCG administration decreased with increasing BMI (Table 2). Furthermore, the number of oocytes retrieved and the number of MII oocytes decreased significantly with increasing BMI (p < 0.001 and p = 0.024, respectively), but no difference was observed in the maturation rates among the BMI groups. Moreover, higher BMI was associated with lower fertilization rates (p = 0.023), fewer 2PN zygotes (p < 0.001), and fewer good-quality embryos (p = 0.010). The proportions of embryos that were of good quality were comparable among the three groups (Table 2). Women with overweight or obesity had fewer oocytes retrieved (p < 0.001 and p = 0.001, respectively) and fewer 2PN zygotes (p < 0.001 and p < 0.001, respectively) than the normal BMI group. Although the difference was not significant (p = 0.055), the mean number of good-quality embryos among women with overweight (3 (1-5)) was also lower compared with women with normal BMI (4 (2-6)). However, the number of oocytes retrieved, 2PN zygotes, and good-quality embryos were comparable between women with overweight and those with obesity (Table 2). These results suggest that both obesity and overweight have potentially adverse impacts on oocyte number and quality in women with PCOS. 3.3 Pregnancy outcomes Among 1,066 IVF/ICSI cycles, fresh/frozen embryo transfer was performed in 960 cycles, and only the first transfer cycles were included. Participants were categorized into three groups according to BMI: normal BMI (n = 566; 59.0%), overweight (n = 221; 23.0%), and obesity (n = 173; 18.0%). The overall clinical outcomes are summarized in Table 3. PCOS patients with a BMI ≥ 23 kg/m 2 showed a significantly lower live birth rate (41.9% vs. 49.1%; adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.57–0.97) and implantation rate (35.8% vs. 43.9%; aOR, 0.76; 95% CI, 0.61–0.93) than the normal BMI group. The clinical pregnancy and early miscarriage rates were comparable among the three groups. Logistic regression analysis showed that the participants with obesity had a significantly lower implantation rate than the normal BMI group (33.9% vs. 43.9%; aOR, 0.71; 95% CI, 0.54–0.93). The implantation rate of women with overweight (37.5%) was also lower than that of women with normal BMI (43.9%), but the difference was not statistically significant. Compared to women with normal BMI, women with overweight or obesity had lower live birth rates (49.1%, 41.2%, and 42.8%, respectively), and the difference between women with normal BMI and those with overweight was statistically significant after adjusting for covariance (aOR, 0.71; 95% CI, 0.52–0.98; Table 3). 4. Discussion We investigated the IVF outcomes of women with PCOS who were classified into normal BMI, overweight, and obesity according to the WHO criteria for Asia–Pacific populations. We found that higher BMI was associated with lower numbers of oocytes retrieved, 2PN zygotes, and good-quality embryos. Moreover, live birth rates and implantation rates were significantly lower among PCOS patients with a BMI ≥ 23 kg/m 2 . Our results suggest that obesity and overweight have adverse impacts on oocyte number and quality and on pregnancy outcomes in PCOS patients undergoing IVF. To the best of our knowledge, this is the first study investigating the relationship between overweight and obesity with IVF outcomes among women with PCOS using the BMI classification criteria for Asian populations. PCOS is a well-recognized endocrine disorder affecting fertility in women of reproductive age. Obesity also has a negative effect on reproductive potential. The relationship between PCOS and obesity exacerbates metabolic disorders and adversely affects reproductive function among women ( 28 ). IVF is commonly used to treat infertility due to PCOS and/or obesity. Women with PCOS who undergo IVF have comparable pregnancy and live birth rates to, but lower fertilization rates and higher risks of miscarriage and ovarian hyperstimulation syndrome than, women without PCOS ( 29 ). However, the negative impact of female obesity on IVF clinical outcomes has been demonstrated by a large cohort study with 239,127 autologous cycles ( 30 ). Moreover, IVF outcomes are worse among women with PCOS with obesity ( 8 , 30 ). Although the impact of elevated BMI on IVF clinical outcomes of PCOS women has been widely explore, the results were controversial ( 10 – 15 ). Cohort studies performed in USA showed that the rates of implantation, pregnancy, pregnancy loss and live birth, decreased with increasing BMI, especially in patients with BMI ≥ 30 kg/m 2 ( 16 , 30 ). However, a Chinese multicenter, prospective study including 800 PCOS women suggested limited impact of BMI on IVF outcomes based on the findings that elevated BMI was associated with reduced clinical pregnancy rate but similar miscarriage rate and ongoing pregnancy rate. They defined BMI category as: normal (BMI, 19-23.9 kg/m 2 ); overweight (BMI, 24-27.9 kg/m 2 ); obesity (BMI ≥ 28kg/m 2 ) ( 17 ). Another Chinese retrospective cohort study involving 3079 patients undergoing IVF with freeze-all strategy showed that clinical pregnancy rates were similar among different BMI groups, women with obesity (BMI ≥ 30 kg/m 2 ) had a higher risk of miscarriage and lower live birth rate ( 14 ). Due to the difference in clinical outcomes among previous studies, the effect of ethnic difference and obesity/overweight classification is worthy of further investigation. BMI can be used to determine health risks, but appropriate classification differs across ethnic groups. Asian populations have a higher percentage of body fat than European populations with the same BMI ( 31 ). Thus, the current WHO criteria for obesity and overweight may not accurately reflect the risk for metabolic disorders among Asians. Race also likely contributes to differences in the clinical manifestation of PCOS ( 32 ). It has been reported that a BMI of 23 kg/m 2 or higher is associated with higher risks of metabolic disorders among women with PCOS from Southern China ( 22 ). Therefore, we used appropriate BMI categories for Asia–Pacific populations in the investigation of the impact of high BMI on IVF outcomes and focused on outcomes among PCOS women with a BMI of 23–24.9 kg/m 2 . In this study, PCOS women with a BMI ≥ 23 kg/m 2 had significantly lower live birth rates (41.9% vs. 49.1%, p = 0.030) and implantation rates (35.8% vs. 43.9%, p = 0.009) than normal BMI patients (BMI < 23 kg/m 2 ), suggesting that having BMI ≥ 23 kg/m 2 has negative effects on live birth and implantation among women with PCOS undergoing IVF. Moreover, the live birth rate was significantly reduced in patients with overweight (BMI: 23–24.9 kg/m 2 ). Although the differences were not significant, the clinical pregnancy rate and implantation rate among women with overweight (52.9% and 37.5%, respectively) were also lower than that of women with normal BMI (58.1% and 43.9%, respectively). While the live birth and clinical pregnancy rates in patients with overweight (41.2% and 52.9%, respectively) were very close to those with obesity (42.8% and 51.4%, respectively). Our results demonstrate that BMIs of 23–24.9 kg/m 2 were associated with adverse IVF outcomes in PCOS women. These findings indicate that in some Asian populations, the appropriate BMI target for women with PCOS who will undergo IVF treatment should be below 23 kg/m 2 . Obesity exerts negative effects on oocyte quality and endometrial receptivity among women with PCOS undergoing IVF. Women with obesity, especially those with PCOS, have shown alterations in endometrial gene expression during the window of implantation ( 33 ). However, IVF outcomes among women with obesity receiving donor oocytes vary. Several studies have shown associations between obesity and negative clinical outcomes of IVF procedures using donor oocytes ( 8 , 34 , 35 ), suggesting that obesity has specific effects on endometrial receptivity rather than on oocyte quality. However, other studies have found that obesity does not affect IVF outcomes in women receiving donor oocytes, suggesting that oocyte quality rather than endometrial receptivity may be the driving factor behind adverse outcomes related to obesity ( 36 , 37 ). Our results showed that high BMI was associated with reduced numbers of oocytes, 2PN zygotes, and good-quality embryos among women with PCOS, which is consistent with previous reports ( 12 – 14 ). We found that fertilization rates decreased as BMI increased, suggesting that obesity not only affects the number of oocytes but also adversely impacts oocyte development among women with PCOS. Previous studies have not clearly identified the association between the fertilization rate and BMI among women with PCOS ( 12 , 13 ), and one study even reported higher fertilization rates among women with higher BMI ( 14 ). In an obese mouse model, oocyte examination revealed disorganized meiotic spindles and disrupted mitochondrial architecture. The potential mechanism for compromised oocyte quality may be through lipotoxicity, high levels of leptin, and a chronic inflammatory state ( 28 ). Further studies are needed to determine the impact of obesity on oocyte quality in PCOS. Our study is unique in that we defined normal weight, overweight, and obesity using the WHO BMI cut-off points for Asia–Pacific populations. We also recruited a large cohort of women with PCOS who underwent their first IVF cycle, and we obtained detailed information on their ovarian stimulation results, embryological data, and pregnancy outcomes, which were used for analysis. This study has several limitations. First, our study participants were recruited from only one assisted reproductive technology clinic at a tertiary care hospital in Hangzhou, a city located in southeast China. The prevalence of obesity among women with PCOS varies across different Asian countries and even across different regions of China. Whether our findings can be applied to other Asian populations needs to be validated. Second, this was a retrospective observational study. Although we adjusted for several confounding factors, large multicenter prospective studies are required to verify our results. In conclusion, we found that a BMI ≥ 23 kg/m 2 was associated with adverse IVF outcomes among women with PCOS. Women with PCOS and a BMI of 23–24.9 kg/m 2 are considered to have normal BMI when using the standard WHO BMI cut-off values. In our study, nearly 40% of women had a BMI ≥ 23 kg/m 2 . These PCOS patients with a BMI ≥ 23 kg/m 2 may have obtained better IVF outcomes if they had received appropriate advice for BMI reduction from clinicians before IVF treatment. The actual effect of individual weight loss on IVF outcomes among Chinese women with polycystic ovary syndrome needs to be verified by a large prospective study. Declarations Funding Statement National Key R&D Program of China (2021YFC2700100)， National Natural Science Foundation of China (81974228), and Key R&D Program of Zhejiang (2021C03G2013079) Acknowledgments The authors thank all the Department of Assisted Reproduction of Women's Hospital staff for their support and cooperation. Authorship contribution statement Yinghui Ye was responsible for conceptualization, funding acquisition, project administration, and editing. Ruimin Zhao was responsible for data curation, investigation, and writing-Original draft preparation. Xinyun Yang contributed to extracting and analyzing data and validation of results. 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Best Pract Res Clin Obstet Gynaecol. 2016;37:46-55. Bellver J, Martínez-Conejero JA, Labarta E, Alamá P, Melo MA, Remohí J, 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(7):2335-41, 41.e1-8. Bellver J, Pellicer A, García-Velasco JA, Ballesteros A, Remohí J, Meseguer M. Obesity reduces uterine receptivity: clinical experience from 9,587 first cycles of ovum donation with normal weight donors. Fertil Steril. 2013;100(4):1050-8. Provost MP, Acharya KS, Acharya CR, Yeh JS, Steward RG, Eaton JL, et al. Pregnancy outcomes decline with increasing recipient body mass index: an analysis of 22,317 fresh donor/recipient cycles from the 2008-2010 Society for Assisted Reproductive Technology Clinic Outcome Reporting System registry. Fertil Steril. 2016;105(2):364-8. Jungheim ES, Schon SB, Schulte MB, DeUgarte DA, Fowler SA, Tuuli MG. IVF outcomes in obese donor oocyte recipients: a systematic review and meta-analysis. Human Reprod. 2013;28(10):2720-7. Styne-Gross A, Elkind-Hirsch K, Scott RT, Jr. Obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation. Fertil Steril. 2005;83(6):1629-34. Tables Table 1. Baseline characteristics according to BMI in PCOS patients.  BMI (kg/m 2 ) Characteristic < 23 (n=630) 23-24.9 (n=241) ≥ 25 (n=195) p value Age (y) 29 (27-31) a 30 (27-32) b 29 (27-31) a 0.034 BMI (kg/m 2 ) 20.8 (19.5-22.0) a 24.0 (3.4-24.5) b 26.4 (25.6-27.6) c <0.001 Duration of infertility (y) 3(2-4) a 3 (2-5) b 3 (2-5) b 0.001 Education background <0.001 High school and below 382 (60.6) a 182 (75.5) b 155 (79.5) b Bachelor degree and above 248 (39.4) 59 (24.5) 40 (20.5) Indication combined with PCOS 0.454  PCOS only 340 (54) 112 (46.5) 99 (50.8) PCOS + Tubal factor 137 (21.7) 58 (24.1) 51 (26.2) PCOS + Male factor 44 (7.0) 22 (9.1) 13 (6.7) PCOS + other 109 (17.3) 49 (20.3) 32 (16.4) Infertility type 0.651 Primary infertility 423 (67.1) 157 (65.1) 127 (65.1) Secondary infertility 207 (32.9) 84 (34.9) 68 (34.9) Basal FSH level (IU/L) 6.0 ± 1.5 a 6.0 ± 1.4 a 5.6 ± 1.5 b 0.024 Basal LH level (IU/L) 9.1 (6.0-15) a 9.0 (5.2-13.3) a 7.3 (4.4-11.6) b <0.001 LH/FSH 1.5 (1.0-2.4) a 1.4 (1.0-2.1) b 1.3 (0.8-2.1) c 0.001 Basal prolactin (IU/L) level 15.9 (18-22.5) 15.2 (11.2-22.0) 15.0 (10.3-22.1) 0.402 Basal testosterone (ng/mL) level 1.2 (0.8-1.6) 1.3(0.9-1.7) 1.2 (0.9-1.7) 0.659 Basal AMH (pmol/mL) level, 9.4 ± 4.3 a 8.4 ± 4.0 b 7.5 ± 3.9 c <0.001 Basal E2 (pg/mL) level 142.3 ± 157.3 120.2 ± 51.7 139 ± 152.3 0.119 The number of patients with 566 221 173 embryo transferred, N The number of transferred 2 (1-2) a 2 (1-2) a 2 (2-2) b 0.001 embryos (n) Single embryo transfer 211 (37.3) a 66 (29.9) b 39 (22.5) c 0.001 Fresh embryo transfer 191 (33.7） 90 (40.7） 72 (41.9) 0.066 Day 3 embryo transfer 441 (77.9) a 196 (88.7) b 156 (90.2) c <0.001 Note: Data are presented as mean ± standard deviation (SD) for continuous variables with normal distribution or as median (IQR) for continuous variables that did not show a normal distribution, and categorical variables are reported as no. (%). Superscript letters indicate between-group differences (for example, groups with the same superscript did not significantly differ from one another, while different superscripts indicate a statistical difference) BMI = body mass index; PCOS = polycystic ovary syndrome; FSH = follicle-stimulating hormone; LH = luteinizing hormone; E2 = estradiol; AMH = antimullerian hormone. Table 2. Ovarian stimulation outcomes and embryological data. BMI (kg/m 2 ) Characteristic < 23 (n=630) 23-24.9 (n=241) ≥ 25 (n=195) p value Stimulation protocol 0.082 Agonist-based 170 (27) 59 (24.5) 46 (23.6) Antagonist-based 392 (62.2) 154 (63.9) 124 (63.6) PPOS and others 68 (10.8) 28 (11.6) 25 (12.8) Total gonadotropin dose (IU) 1162.5 (1125-1875) a 1800 (1350-2250) b 2150 (1650-2625) c <0.001 Stimulation days (d) 10 (9-11) a 10 (9-12) b 11 (10-13) c <0.001 E2 on the day of trigerring (pg/mL) 19954 (11476.4) a 16260.9 (11246.3) b 14911.7 (11710.1) b <0.001 Fertilization method 0.914 IVF 357 (56.7) 129 (53.5) 112 (57.4) ICSI 168 (26.7) 70 (29.0) 50 (25.6) IVF + ICSI 105 (16.7) 42 (17.4) 33 (16.9) Total oocytes retrieved, n 18.1 ± 8.9 a 15.9 ± 7.9 b 15.3 ± 9.1 b <0.001 MII oocytes, n 10.7 ± 7.4 a 8.9 ± 7.4 ab 7.7 ± 6.9 b 0.024 MII oocytes rate, % 55.5 ± 26.5 50.3 ± 28.8 48.7 ± 28.1 0.197 2PN zygotes, n 9 (5-13) a 7 (4-11) b 7 (3-10) b <0.001 2PN rate, % 59.2 ± 25.6 a 54.5 ± 25 b 55.0 ± 27.1 ab 0.023 Good-quality embryos, n 4 (2-6) a 3 (1-5) ab 2 (1-5) b 0.010 Good-quality embryos rate per 2PN, % 45.6 (25-66.7) 50 (25-79.6) 50 (20-72.2) 0.533 Note: Data are presented as mean ± standard deviation (SD) for continuous variables with normal distribution or median (IQR) for continuous variables that did not show a normal distribution, and categorical variables are reported as no. (%). Superscript letters indicate between-group differences (for example, groups with the same superscript are not significantly different from one another, while different superscripts indicate a statistical difference). BMI = body mass index; PPOS = Progestin Primed Ovary Stimulation; E2 = estradiol; IVF = in vitro fertilization; ICSI = intracytoplasmic sperm injection; MII = metaphase II; 2PN = two pronuclear. Table 3. Logistic regression on clinical outcomes according to female BMI. BMI (kg/m 2 ) Characteristic < 23 (n=566) ≥ 23 (n=394) 23-24.9 (n=221) ≥ 25 (n=173) Implantation rate, % a 43.9 35.8 37.5 33.9 Crude OR (95%CI) Reference 0.79 (0.65-0.97) 0.82(0.60-1.11) 0.84 (0.60-1.18) Adjusted OR (95%CI) Reference 0.76 (0.61-0.93) 0.80 (0.63-1.03) 0.71 (0.54-0.93) P value 0.009 0.085 0.014 hCG positive rate, % a 64.3 57.1 57.9 56.1 Crude OR (95%CI) Reference 0.74 (0.60-0.90) 0.77 (0.56-1.06) 0.71 (0.50-1.00) Adjusted OR (95%CI) Reference 0.75 (0.57-0.98) 0.79 (0.57-1.10) 0.70 (0.49-0.99) P value 0.037 0.164 0.045 Clinical pregnancy rate, % a 58.1 52.3 52.9 51.4 Crude OR (95%CI) Reference 0.77 (0.64-0.95) 0.82 (0.60-1.12) 0.77 (0.54-1.08) Adjusted OR (95%CI) Reference 0.81 (0.62-1.06) 0.85 (0.62-1.17) 0.76 (0.54-1.09) P value 0.127 0.325 0.136 Live birth rate, % a 49.1 41.9 41.2 42.8 Crude OR (95%CI) Reference 0.73 (0.60-0.90) 0.74 (0.54-1.0） 0.77 (0.55-1.10) Adjusted OR (95%CI) Reference 0.75 (0.57-0.97) 0.71 (0.52-0.98) 0.78 (0.55-1.11) P value 0.030 0.037 0.167 Early miscarriage rate, % a 9.7 10.7 13.7 9.0 Crude OR (95%CI) Reference 1.10 (0.72-1.69) 1.29 (0.70-2.41) 0.81 (0.37-1.79) Adjusted OR (95%CI) Reference 1.18 (0.67-2.08) 1.04 (0.95-1.14) 0.84 (0.37-1.91) P value 0.564 0.230 0.674 Note: After controlling for confounding factors, adjusted values are presented as aOR with 95% CI. 95%CI =95% confidential intervals; aOR=adjusted odds ratio. Bold numbers indicate differences with statistical significance compared with the reference group. a, Models were adjusted for age, basal FSH level, the number of transferred embryos, and the type of embryo transfer. Additional Declarations There is NO conflict of interest to disclose Cite Share Download PDF Status: Published Journal Publication published 08 Dec, 2023 Read the published version in International Journal of Obesity → Version 1 posted Editorial decision: revise 31 May, 2023 Review # 2 received at journal 28 May, 2023 Reviewer # 2 agreed at journal 14 May, 2023 Review # 1 received at journal 08 May, 2023 Reviewer # 1 agreed at journal 25 Apr, 2023 Reviewers invited by journal 24 Apr, 2023 Submission checks completed at journal 19 Apr, 2023 Editor assigned by journal 18 Apr, 2023 First submitted to journal 18 Apr, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2834297","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":194705526,"identity":"d00ff2e4-bbfd-426d-a3ff-4b5f1a2f6b8f","order_by":0,"name":"Yinghui Ye","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYHACNoaEChs5fgaGBCCHmUgtD86kGUs2kKKF8WHb4cQNB8AcIrQYHO8xe5AI1LL5/IFnEgwV1okN7GcP4Ndy5oy5QcK5dONtBw6kSTCcSU9s4MlLwK/lRo6ZREKZtey2gw1pEoxA6xokeAzwa7n/BqiFjZlxczMDUMs/YrTc4AFqaXNW3MAG0tJAhBbJM2llEgnAQJY4w5BskXAs3biNJwe/Fr7jh7dJ/gBFZf+ZxBsfaqxl+9nP4NeicIADpoAnARyZbHjVA4F8A/sDKJP9ACHFo2AUjIJRMEIBALEtSaORvw0eAAAAAElFTkSuQmCC","orcid":"","institution":"Women's Hospital, Zhejiang University School of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yinghui","middleName":"","lastName":"Ye","suffix":""},{"id":194705527,"identity":"57aa1082-b045-47fa-9773-e8768828b11c","order_by":1,"name":"Ruimin Zhao","email":"","orcid":"","institution":"Women's Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ruimin","middleName":"","lastName":"Zhao","suffix":""},{"id":194705528,"identity":"c42b9fd8-0885-4b63-9521-c2dab66b3c24","order_by":2,"name":"Xinyun Yang","email":"","orcid":"","institution":"Women's Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xinyun","middleName":"","lastName":"Yang","suffix":""},{"id":194705529,"identity":"fb458186-a262-48e2-b1b9-9af0e486774a","order_by":3,"name":"Long Cui","email":"","orcid":"","institution":"Women's Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Long","middleName":"","lastName":"Cui","suffix":""},{"id":194705530,"identity":"514c6221-d870-4651-9841-3642c75ca828","order_by":4,"name":"Lefeng Wang","email":"","orcid":"","institution":"Women's Hospital, Zhejiang University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lefeng","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2023-04-19 02:30:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2834297/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2834297/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41366-023-01430-1","type":"published","date":"2023-12-08T05:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":36346137,"identity":"02f11910-b8c9-4f04-a55a-2160a87cab94","added_by":"auto","created_at":"2023-04-26 20:13:56","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":671964,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart\u003c/p\u003e","description":"","filename":"Fig1flowchart.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2834297/v1/7a6e60d683f9a1292006a31a.jpg"},{"id":47896941,"identity":"607391c5-bfeb-4195-a0c0-257f1dd27ae6","added_by":"auto","created_at":"2023-12-09 08:32:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":505750,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2834297/v1/7d7c8571-bc96-454b-95f1-816ff1f38fe9.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose","formattedTitle":"Overweight and obesity determined by body mass index criteria for Asian populations adversely affect assisted reproductive outcomes among Chinese women with polycystic ovary syndrome","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePolycystic ovary syndrome (PCOS) is a complex endocrine and metabolic disorder with a variable prevalence ranging from 4\u0026ndash;21% among women of reproductive age (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This syndrome is often accompanied by insulin resistance, obesity, dyslipidemia, and type 2 diabetes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Obesity, especially abdominal obesity, is seen in approximately 50% of all women with PCOS (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVarious Reproductive disruptions have been identified among women with overweight or obesity, including anovulation and a higher risk of pregnancy loss (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Infertile women with obesity receiving in vitro fertilization (IVF)\u0026ndash;embryo transfer treatment have poorer clinical outcomes, especially if they have also been diagnosed with PCOS (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, studies exploring the potential effects of high body mass index (BMI) on IVF outcomes among women with PCOS have presented conflicting results. Multiple studies have demonstrated that higher BMI is associated with the need for higher doses of gonadotropin, lower observed levels of estradiol and human chorionic gonadotropin (hCG), and fewer oocytes retrieved (\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), but the effect of overweight and obesity on the IVF outcomes of PCOS is still not well established. In 2014, Bailey et al. found that women with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e had 77% lower odds of clinical pregnancy and live birth per embryo transfer than lean (BMI\u0026thinsp;\u0026lt;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e) women with PCOS (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Several studies have demonstrated that although for women with obesity who underwent IVF clinical pregnancy rates were similar to those with normal weight, women with PCOS with obesity had relatively higher miscarriage rates (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, a multicenter prospective study suggested that BMI had little impact on IVF outcomes among PCOS patients, given that women with higher BMI had lower clinical pregnancy rates than, but similar ongoing pregnancy rates to, women with normal BMI (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Limited impact of BMI on IVF outcomes was further suggested in another retrospective case\u0026ndash;control study that found no differences in fertilization, embryonic development, pregnancy, implantation, and live birth among women with PCOS and varying BMI who underwent IVF (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The varied findings among the studies may be attributable to differences in race, case definitions, and study design.\u003c/p\u003e \u003cp\u003eDifferences among women from different regions and races should be considered when drawing research conclusions or enacting clinical guidance for PCOS given the complexity of this disease. Compared with Whites and African Americans, Asians tend to have lower BMI and milder PCOS symptoms with lower levels of testosterone and insulin resistance (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Most studies investigating the effect of overweight and obesity on reproductive outcomes in PCOS are based on World Health Organization (WHO) BMI cut-off points derived primarily from European populations (e.g., overweight: 25.0 kg/m\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026le;\u0026thinsp;BMI\u0026thinsp;\u0026lt;\u0026thinsp;30.0 kg/m\u003csup\u003e2\u003c/sup\u003e; obesity: \u0026ge; 30 kg/m\u003csup\u003e2\u003c/sup\u003e). However, emerging evidence demonstrates that Asians have a greater tendency toward abdominal obesity than non-Asian populations and have high risks of developing metabolic syndromes, such as diabetes, hypertension, and dyslipidemia, even with a BMI\u0026thinsp;\u0026lt;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In consideration of the underestimation of obesity-related risks among Asians with the application of its standard BMI cut-off points, the WHO redefined obesity as a BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e and overweight as a BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e for Asia\u0026ndash;Pacific populations in 2000 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A previous study also found that the prevalence of metabolic disorders increased significantly among individuals with BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e, confirming the validity of this value as an appropriate BMI \u0026ldquo;trigger point\u0026rdquo; in identifying individuals at high risks of developing metabolic disorders, including among Chinese women with PCOS (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe impact of overweight and obesity on IVF outcomes among women with PCOS using BMI cut-off values for Asians has not been explored. This study was designed to determine the association between BMI classes (patients with normal weight [BMI\u0026thinsp;\u0026lt;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e], patients with overweight [BMI: 23\u0026ndash;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e], and patients with obesity [BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e]) and IVF embryonic and clinical outcomes among PCOS women using the WHO BMI classification for Asia\u0026ndash;Pacific populations.\u003c/p\u003e"},{"header":"2. Methods And Materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design and participants\u003c/h2\u003e \u003cp\u003eThis was a retrospective cohort study investigating the effect of BMI on IVF treatment among women with PCOS and was conducted in the university-affiliated Women\u0026rsquo;s Hospital located in the south of China, between January 2018 and June 2021. The need for consent was exempted considering the retrospective design of the study. The study was approved by the Medical Ethics Committee of Women\u0026rsquo;s Hospital. Female patients with PCOS who underwent their first IVF cycle were included. PCOS was diagnosed based on the criteria defined by the 2003 Rotterdam Consensus (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The exclusion criteria were as follows: age\u0026thinsp;\u0026gt;\u0026thinsp;40; being diagnosed with premature ovarian insufficiency, thyroid dysfunction, or immunological disorders; being diagnosed or having a partner diagnosed with a genetic disorder requiring preimplantation genetic testing; having recurrent spontaneous abortions (defined as three or more previous spontaneous pregnancy losses); or having structural abnormalities of the reproductive system.\u003c/p\u003e \u003cp\u003eBMI was calculated as weight in kilograms divided by height in meters squared. The participants were classified into the following BMI categories based on the WHO classification for Asia\u0026ndash;Pacific populations: women with normal weight (BMI\u0026thinsp;\u0026lt;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e), women with overweight (BMI: 23\u0026ndash;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e), and women with obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 IVF procedures\u003c/h2\u003e \u003cp\u003eMost patients (62.9%) enrolled in our study underwent ovarian stimulation for IVF through an antagonist controlled ovarian hyperstimulation (COH) protocol, while 25.8% received a long agonist protocol, and 11.3% underwent the progestin-primed ovarian stimulation scheme or other protocols. The COH protocol has been described in previous studies (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOocyte maturation was induced by the injection of hCG when two or more follicles reached 18 mm in diameter. Oocyte retrieval was carried out via transvaginal ultrasound-guided aspiration 36 hours after hCG administration. Retrieved oocytes were cultured in supplemented G-IVF medium (Vitrolife, Sweden) at 37\u0026deg;C in an incubator with 6% carbon dioxide and fertilized via conventional IVF, intracytoplasmic sperm injection (ICSI), or half IVF/half ICSI (IVF/ICSI). A fertilization check was carried out 16 to 20 hours after insemination, and normally fertilized two pronuclear (2PN) zygotes were transferred into drops of G-1 medium (Vitrolife, Sweden). The assessment of day 3 embryos was performed as previously described (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). An embryo was assessed to have good quality if it had 6\u0026ndash;10 cells, \u0026lt; 25% fragmentation, and equally sized mononucleated blastomeres. Day 3 embryos were transferred and frozen by vitrification or cultured for an extended period in G-2 medium (Vitrolife, Sweden) until they reached the blastocyst stage. Good-quality blastocysts (grade 4BC or higher) were vitrified on day 5 or 6. For frozen-thawed embryo transfer, the endometrium was prepared by hormonal replacement therapy or a mild stimulation cycle. Embryo transfer was performed using cleavage-stage embryos or blastocysts, and no more than two embryos were transferred.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Outcomes\u003c/h2\u003e \u003cp\u003eThe primary outcome was live birth, which was defined as the delivery of at least one infant born alive at 28 weeks of gestation or later via the first fresh/frozen embryo transfer cycle. Pregnancy-related secondary outcomes were the hCG positive rate, clinical pregnancy rate, implantation rate, and miscarriage rate. Ovarian stimulation and embryological measurements included the total dose of gonadotropins, number of oocytes retrieved, number of metaphase II (MII) oocytes, number of 2PN zygotes, and number of good-quality embryos.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e \u003cp\u003e All statistical analyses were conducted using Statistical Package for Social Sciences version 26.0 (SPSS, Chicago, IL, USA) with a P-value\u0026thinsp;\u0026le;\u0026thinsp;0.05 being considered statistically significant and followed by the Bonferroni test for post hoc analysis. The chi-square and Fisher\u0026rsquo;s exact tests were performed to compare nominal variables. Normally distributed (as determined with the Kolmogorov\u0026ndash;Smirnov test) parametric variables were analyzed through the ANOVA test, while non-normally distributed metric variables were compared using the Kruskal\u0026ndash;Wallis test. The results are summarized as median (interquartile range) for non-normally distributed continuous variables and as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for normally distributed continuous variables. Categorical variables are presented as absolute and relative frequencies.\u003c/p\u003e\u003cp\u003eMultivariate regression was used to evaluate the association between BMI and various pregnancy outcomes while adjusting for known potential covariates that may bias the effects of overweight and obesity. These confounding factors included age, the basal follicle-stimulating hormone (FSH) level, the number of transferred embryos, and the type of embryo transfer.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Baseline characteristics according to BMI in PCOS patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 1,389 patients were enrolled into the study. Among these, 323 patients were excluded due to duplication or fulfillment of exclusion criteria. A total of 1,066 women with PCOS who underwent their first IVF/ICSI cycles met the inclusion criteria for this study and were categorized into three groups according to their BMI. Most women (n = 630; 59.1%) had normal BMI. A total of 241 women (22.6%) had overweight and 195 (18.3%) had obesity (Fig. 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBaseline characteristics of patients are shown in Table 1. Patients in the normal BMI group had a shorter duration of infertility and higher education levels than those with overweight and obesity. No differences in the cause of infertility and the percentage of patients diagnosed with primary infertility were observed between the BMI groups. Women with obesity had higher basal serum FSH levels than normal BMI participants, but had lower levels of luteinizing hormone (LH) than participants in the other two groups. Anti-M\u0026uuml;llerian hormone (AMH) levels significantly decreased as BMI increased.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Ovarian stimulation response and embryological outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo differences were observed in the proportion of ovarian stimulation protocols used among the three BMI groups. The majority (62.8%) of the PCOS patients received an antagonist scheme. The total dose of the gonadotropin used and the number of days for stimulation increased significantly with increasing BMI, while\u0026nbsp;the estradiol levels on the day of hCG administration decreased with increasing BMI\u0026nbsp;\u0026nbsp;(Table 2).\u003c/p\u003e\n\u003cp\u003eFurthermore, the number of oocytes retrieved and the number of MII oocytes decreased significantly with increasing BMI (p \u0026lt; 0.001 and p = 0.024, respectively), but no difference was observed in the maturation rates among the BMI groups. Moreover, higher BMI was associated with lower fertilization rates (p = 0.023), fewer 2PN zygotes (p \u0026lt; 0.001), and fewer good-quality embryos (p = 0.010). The proportions of embryos that were of good quality were comparable among the three groups (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWomen with overweight or obesity had fewer oocytes retrieved (p \u0026lt; 0.001 and p\u003cem\u003e\u0026nbsp;\u003c/em\u003e= 0.001, respectively) and fewer 2PN zygotes (p\u0026nbsp;\u0026lt; 0.001\u0026nbsp;and p\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001, respectively) than the normal BMI group. Although the difference was not significant (p = 0.055), the mean number of good-quality embryos among women with overweight (3 (1-5)) was also lower compared with women with normal BMI (4 (2-6)). However, the number of oocytes retrieved, 2PN zygotes, and good-quality embryos were comparable between women with overweight and those with obesity (Table 2). These results suggest that both obesity and overweight have potentially adverse impacts on oocyte number and quality in women with PCOS. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Pregnancy outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 1,066 IVF/ICSI cycles, fresh/frozen embryo transfer was performed in 960 cycles, and only the first transfer cycles were included. Participants were categorized into three groups according to BMI: normal BMI (n = 566; 59.0%), overweight (n = 221; 23.0%), and obesity (n = 173; 18.0%).\u003c/p\u003e\n\u003cp\u003eThe overall clinical outcomes are summarized in\u0026nbsp;Table 3.\u0026nbsp;PCOS patients with a BMI\u0026nbsp;\u0026ge; 23 kg/m\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eshowed a significantly lower live birth rate (41.9% vs. 49.1%;\u0026nbsp;adjusted odds ratio [aOR],\u0026nbsp;0.75; 95% confidence interval [CI], 0.57\u0026ndash;0.97) and implantation rate (35.8% vs. 43.9%; aOR, 0.76; 95% CI, 0.61\u0026ndash;0.93) than the normal BMI group. The clinical pregnancy and early miscarriage rates were comparable among the three groups.\u003c/p\u003e\n\u003cp\u003eLogistic regression analysis showed that the participants with obesity had a significantly lower implantation rate than the normal BMI group (33.9% vs. 43.9%; aOR, 0.71; 95% CI, 0.54\u0026ndash;0.93). The implantation rate of women with overweight (37.5%) was also lower than that of women with normal BMI (43.9%), but the difference was not statistically significant. Compared to women with normal BMI, women with overweight or obesity had lower live birth rates (49.1%, 41.2%, and 42.8%, respectively), and the difference between women with normal BMI and those with overweight was statistically significant after adjusting for covariance (aOR, 0.71; 95% CI, 0.52\u0026ndash;0.98; Table 3).\u0026nbsp;\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eWe investigated the IVF outcomes of women with PCOS who were classified into normal BMI, overweight, and obesity according to the WHO criteria for Asia\u0026ndash;Pacific populations. We found that higher BMI was associated with lower numbers of oocytes retrieved, 2PN zygotes, and good-quality embryos. Moreover, live birth rates and implantation rates were significantly lower among PCOS patients with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e. Our results suggest that obesity and overweight have adverse impacts on oocyte number and quality and on pregnancy outcomes in PCOS patients undergoing IVF. To the best of our knowledge, this is the first study investigating the relationship between overweight and obesity with IVF outcomes among women with PCOS using the BMI classification criteria for Asian populations.\u003c/p\u003e \u003cp\u003ePCOS is a well-recognized endocrine disorder affecting fertility in women of reproductive age. Obesity also has a negative effect on reproductive potential. The relationship between PCOS and obesity exacerbates metabolic disorders and adversely affects reproductive function among women (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). IVF is commonly used to treat infertility due to PCOS and/or obesity. Women with PCOS who undergo IVF have comparable pregnancy and live birth rates to, but lower fertilization rates and higher risks of miscarriage and ovarian hyperstimulation syndrome than, women without PCOS (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). However, the negative impact of female obesity on IVF clinical outcomes has been demonstrated by a large cohort study with 239,127 autologous cycles (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Moreover, IVF outcomes are worse among women with PCOS with obesity (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough the impact of elevated BMI on IVF clinical outcomes of PCOS women has been widely explore, the results were controversial (\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Cohort studies performed in USA showed that the rates of implantation, pregnancy, pregnancy loss and live birth, decreased with increasing BMI, especially in patients with BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). However, a Chinese multicenter, prospective study including 800 PCOS women suggested limited impact of BMI on IVF outcomes based on the findings that elevated BMI was associated with reduced clinical pregnancy rate but similar miscarriage rate and ongoing pregnancy rate. They defined BMI category as: normal (BMI, 19-23.9 kg/m\u003csup\u003e2\u003c/sup\u003e); overweight (BMI, 24-27.9 kg/m\u003csup\u003e2\u003c/sup\u003e); obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;28kg/m\u003csup\u003e2\u003c/sup\u003e) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Another Chinese retrospective cohort study involving 3079 patients undergoing IVF with freeze-all strategy showed that clinical pregnancy rates were similar among different BMI groups, women with obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e) had a higher risk of miscarriage and lower live birth rate (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Due to the difference in clinical outcomes among previous studies, the effect of ethnic difference and obesity/overweight classification is worthy of further investigation.\u003c/p\u003e \u003cp\u003eBMI can be used to determine health risks, but appropriate classification differs across ethnic groups. Asian populations have a higher percentage of body fat than European populations with the same BMI (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Thus, the current WHO criteria for obesity and overweight may not accurately reflect the risk for metabolic disorders among Asians. Race also likely contributes to differences in the clinical manifestation of PCOS (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). It has been reported that a BMI of 23 kg/m\u003csup\u003e2\u003c/sup\u003e or higher is associated with higher risks of metabolic disorders among women with PCOS from Southern China (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Therefore, we used appropriate BMI categories for Asia\u0026ndash;Pacific populations in the investigation of the impact of high BMI on IVF outcomes and focused on outcomes among PCOS women with a BMI of 23\u0026ndash;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, PCOS women with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e had significantly lower live birth rates (41.9% vs. 49.1%, p\u0026thinsp;=\u0026thinsp;0.030) and implantation rates (35.8% vs. 43.9%, p\u0026thinsp;=\u0026thinsp;0.009) than normal BMI patients (BMI\u0026thinsp;\u0026lt;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e), suggesting that having BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e has negative effects on live birth and implantation among women with PCOS undergoing IVF. Moreover, the live birth rate was significantly reduced in patients with overweight (BMI: 23\u0026ndash;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e). Although the differences were not significant, the clinical pregnancy rate and implantation rate among women with overweight (52.9% and 37.5%, respectively) were also lower than that of women with normal BMI (58.1% and 43.9%, respectively). While the live birth and clinical pregnancy rates in patients with overweight (41.2% and 52.9%, respectively) were very close to those with obesity (42.8% and 51.4%, respectively). Our results demonstrate that BMIs of 23\u0026ndash;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e were associated with adverse IVF outcomes in PCOS women. These findings indicate that in some Asian populations, the appropriate BMI target for women with PCOS who will undergo IVF treatment should be below 23 kg/m\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eObesity exerts negative effects on oocyte quality and endometrial receptivity among women with PCOS undergoing IVF. Women with obesity, especially those with PCOS, have shown alterations in endometrial gene expression during the window of implantation (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). However, IVF outcomes among women with obesity receiving donor oocytes vary. Several studies have shown associations between obesity and negative clinical outcomes of IVF procedures using donor oocytes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), suggesting that obesity has specific effects on endometrial receptivity rather than on oocyte quality. However, other studies have found that obesity does not affect IVF outcomes in women receiving donor oocytes, suggesting that oocyte quality rather than endometrial receptivity may be the driving factor behind adverse outcomes related to obesity (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur results showed that high BMI was associated with reduced numbers of oocytes, 2PN zygotes, and good-quality embryos among women with PCOS, which is consistent with previous reports (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). We found that fertilization rates decreased as BMI increased, suggesting that obesity not only affects the number of oocytes but also adversely impacts oocyte development among women with PCOS. Previous studies have not clearly identified the association between the fertilization rate and BMI among women with PCOS (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and one study even reported higher fertilization rates among women with higher BMI (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In an obese mouse model, oocyte examination revealed disorganized meiotic spindles and disrupted mitochondrial architecture. The potential mechanism for compromised oocyte quality may be through lipotoxicity, high levels of leptin, and a chronic inflammatory state (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Further studies are needed to determine the impact of obesity on oocyte quality in PCOS.\u003c/p\u003e \u003cp\u003eOur study is unique in that we defined normal weight, overweight, and obesity using the WHO BMI cut-off points for Asia\u0026ndash;Pacific populations. We also recruited a large cohort of women with PCOS who underwent their first IVF cycle, and we obtained detailed information on their ovarian stimulation results, embryological data, and pregnancy outcomes, which were used for analysis.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, our study participants were recruited from only one assisted reproductive technology clinic at a tertiary care hospital in Hangzhou, a city located in southeast China. The prevalence of obesity among women with PCOS varies across different Asian countries and even across different regions of China. Whether our findings can be applied to other Asian populations needs to be validated. Second, this was a retrospective observational study. Although we adjusted for several confounding factors, large multicenter prospective studies are required to verify our results.\u003c/p\u003e \u003cp\u003eIn conclusion, we found that a BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e was associated with adverse IVF outcomes among women with PCOS. Women with PCOS and a BMI of 23\u0026ndash;24.9 kg/m\u003csup\u003e2\u003c/sup\u003e are considered to have normal BMI when using the standard WHO BMI cut-off values. In our study, nearly 40% of women had a BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e. These PCOS patients with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;23 kg/m\u003csup\u003e2\u003c/sup\u003e may have obtained better IVF outcomes if they had received appropriate advice for BMI reduction from clinicians before IVF treatment. The actual effect of individual weight loss on IVF outcomes among Chinese women with polycystic ovary syndrome needs to be verified by a large prospective study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNational Key R\u0026amp;D Program of China (2021YFC2700100)， National Natural Science Foundation of China (81974228), and Key R\u0026amp;D Program of Zhejiang (2021C03G2013079)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the Department of Assisted Reproduction of Women\u0026apos;s Hospital staff for their support and cooperation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYinghui Ye was responsible for conceptualization, funding acquisition, project administration, and editing. Ruimin Zhao was responsible for data curation, investigation, and writing-Original draft preparation. Xinyun Yang contributed to extracting and analyzing data and validation of results. Long Cui was responsible for the election of methodology and software. Lefeng Wang contributed to interpreting results and providing feedback on the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study will be made available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMa YM, Li R, Qiao J, Zhang XW, Wang SY, Zhang QF, et al. Characteristics of abnormal menstrual cycle and polycystic ovary syndrome in community and hospital populations. 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CMAJ. 2006;175(9):1071-7.\u003c/li\u003e\n\u003cli\u003eThe World Health Organization Western Pacific Region, the International Association for the Study of Obesity, and the International Obesity Task Force. The Asia\u0026ndash;Pacific Perspective: Redefining Obesity and its Treatment. Melbourne: Health Communications Australia, 2000.\u003c/li\u003e\n\u003cli\u003eChen X, Ni R, Mo Y, Li L, Yang D. Appropriate BMI levels for PCOS patients in Southern China. Hum Reprod. 2010;25(5):1295-302.\u003c/li\u003e\n\u003cli\u003eRotterdam EA-SPCWG. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19-25.\u003c/li\u003e\n\u003cli\u003ePan X, Gu Y, Zhang X, Shi B, Cui L, Wang F, et al. Chinese herbal medicine (Bu-Shen-Tian-Jing Formula) for outcomes of IVF in Chinese patients with polycystic ovary syndrome: a retrospective cohort study. Integr Med Res. 2022;11(1):100775.\u003c/li\u003e\n\u003cli\u003eWang L, Yin M, Liu Y, Chen Q, Wang Y, Ai A, et al. Effect of Frozen Embryo Transfer and Progestin-primed Ovary Stimulation on IVF outcomes in women with high body mass index. Sci Rep. 2017;7(1):7447.\u003c/li\u003e\n\u003cli\u003eYe Y, Qian Y, Xu C, Jin F. Meiotic segregation analysis of embryos from reciprocal translocation carriers in PGD cycles. Reprod Biomed Online. 2012;24(1):83-90.\u003c/li\u003e\n\u003cli\u003eFang L, Hu X, Cui L, Lv P, Ma X, Ye Y. Serum and follicular fluid fetuin-B levels are correlated with fertilization rates in conventional IVF cycles. J Assist Reprod Genet. 2019;36(6):1101-7.\u003c/li\u003e\n\u003cli\u003eBroughton DE, Moley KH. Obesity and female infertility: potential mediators of obesity\u0026apos;s impact. Fertil Steril. 2017;107(4):840-7.\u003c/li\u003e\n\u003cli\u003eTang K, Wu L, Luo Y, Gong B. In vitro fertilization outcomes in women with polycystic ovary syndrome: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021;259:146-52.\u003c/li\u003e\n\u003cli\u003eProvost MP, Acharya KS, Acharya CR, Yeh JS, Steward RG, Eaton JL, 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(3):663-9.\u003c/li\u003e\n\u003cli\u003eRush E, Plank L, Chandu V, Laulu M, Simmons D, Swinburn B, et al. Body size, body composition, and fat distribution: a comparison of young New Zealand men of European, Pacific Island, and Asian Indian ethnicities. N Z Med. 2004;117(1207):U1203.\u003c/li\u003e\n\u003cli\u003eHuang Z, Yong EL. Ethnic differences: Is there an Asian phenotype for polycystic ovarian syndrome? Best Pract Res Clin Obstet Gynaecol. 2016;37:46-55.\u003c/li\u003e\n\u003cli\u003eBellver J, Mart\u0026iacute;nez-Conejero JA, Labarta E, Alam\u0026aacute; P, Melo MA, Remoh\u0026iacute; J, 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(7):2335-41, 41.e1-8.\u003c/li\u003e\n\u003cli\u003eBellver J, Pellicer A, Garc\u0026iacute;a-Velasco JA, Ballesteros A, Remoh\u0026iacute; J, Meseguer M. Obesity reduces uterine receptivity: clinical experience from 9,587 first cycles of ovum donation with normal weight donors. Fertil Steril. 2013;100(4):1050-8.\u003c/li\u003e\n\u003cli\u003eProvost MP, Acharya KS, Acharya CR, Yeh JS, Steward RG, Eaton JL, et al. Pregnancy outcomes decline with increasing recipient body mass index: an analysis of 22,317 fresh donor/recipient cycles from the 2008-2010 Society for Assisted Reproductive Technology Clinic Outcome Reporting System registry. Fertil Steril. 2016;105(2):364-8.\u003c/li\u003e\n\u003cli\u003eJungheim ES, Schon SB, Schulte MB, DeUgarte DA, Fowler SA, Tuuli MG. IVF outcomes in obese donor oocyte recipients: a systematic review and meta-analysis. Human Reprod. 2013;28(10):2720-7.\u003c/li\u003e\n\u003cli\u003eStyne-Gross A, Elkind-Hirsch K, Scott RT, Jr. Obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation. Fertil Steril. 2005;83(6):1629-34.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"718\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Baseline characteristics\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eaccording to BMI in PCOS patients.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 23 (n=630)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u003cstrong\u003e23-24.9 (n=241)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e25 (n=195)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eAge (y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e29 (27-31) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e30 (27-32)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e29 (27-31)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e20.8 (19.5-22.0)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e24.0 (3.4-24.5)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e26.4 (25.6-27.6)\u003csup\u003e\u0026nbsp;c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eDuration of infertility (y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e3(2-4)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e3 (2-5)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e3 (2-5)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eEducation background\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eHigh school and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e382 (60.6)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e182 (75.5)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e155 (79.5)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eBachelor degree and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e248 (39.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e59 (24.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e40 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eIndication combined with PCOS\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003e \u0026nbsp;PCOS only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e340 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e112 (46.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e99 (50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003ePCOS + Tubal factor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e137 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e58 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e51 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003ePCOS + Male factor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e44 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e22 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e13 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003ePCOS + other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e109 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e49 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e32 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eInfertility type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.651\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003ePrimary infertility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e423 (67.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e157 (65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e127 (65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eSecondary infertility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e207 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e84 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e68 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eBasal FSH level (IU/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e6.0 \u0026plusmn; 1.5\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e6.0 \u0026plusmn; 1.4\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e5.6 \u0026plusmn; 1.5\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eBasal LH level (IU/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e9.1 (6.0-15)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e9.0 (5.2-13.3)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e7.3 (4.4-11.6)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eLH/FSH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e1.5 (1.0-2.4)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e1.4 (1.0-2.1)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e1.3 (0.8-2.1)\u003csup\u003e\u0026nbsp;c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eBasal prolactin (IU/L) level\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e15.9 (18-22.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e15.2 (11.2-22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e15.0 (10.3-22.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.402\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eBasal testosterone (ng/mL) level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e1.2 (0.8-1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e1.3(0.9-1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e1.2 (0.9-1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.659\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eBasal AMH (pmol/mL) level,\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e9.4 \u0026plusmn; 4.3\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e8.4 \u0026plusmn; 4.0\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e7.5 \u0026plusmn; 3.9\u003csup\u003e\u0026nbsp;c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eBasal E2 (pg/mL) level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e142.3 \u0026plusmn; 157.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e120.2 \u0026plusmn; 51.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e139 \u0026plusmn; 152.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eThe number of patients with\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e566\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eembryo transferred, N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eThe number of transferred\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e2 (1-2)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e2 (1-2)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e2 (2-2)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eembryos (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eSingle embryo transfer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e211 (37.3)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e66 (29.9)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e39 (22.5)\u003csup\u003e\u0026nbsp;c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eFresh embryo transfer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e191 (33.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e90 (40.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e72 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.01529902642559%\"\u003e\n \u003cp\u003eDay 3 embryo transfer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e441 (77.9)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e196 (88.7)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e156 (90.2)\u003csup\u003e\u0026nbsp;c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.2461752433936%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: \u0026nbsp; Data are presented as mean \u0026plusmn; standard deviation (SD) for continuous variables with normal distribution or as median (IQR) for continuous variables that did not show a normal distribution, and categorical variables are reported as no. (%). Superscript letters indicate between-group differences (for example, groups with the same superscript did not significantly differ from one another, while different superscripts indicate a statistical difference) BMI = body mass index; PCOS = polycystic ovary syndrome; FSH = follicle-stimulating hormone; LH = luteinizing hormone; E2 = estradiol; AMH = antimullerian hormone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Ovarian stimulation outcomes and embryological data.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"718\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99.8607%;\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 23 (n=630)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e\u003cstrong\u003e23-24.9 (n=241)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e25 (n=195)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eStimulation protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e0.082\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eAgonist-based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e170 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e59 (24.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e46 (23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eAntagonist-based\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e392 (62.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e154 (63.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e124 (63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003ePPOS and others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e68 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e28 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e25 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eTotal gonadotropin dose (IU)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e1162.5 (1125-1875) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e1800 (1350-2250)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e2150 (1650-2625)\u003csup\u003e\u0026nbsp;c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eStimulation days (d)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e10 (9-11)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e10 (9-12)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e11 (10-13)\u003csup\u003e\u0026nbsp;c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eE2 on the day of trigerring (pg/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e19954 (11476.4)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e16260.9 (11246.3)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e14911.7 (11710.1)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eFertilization method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e0.914\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eIVF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e357 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e129 (53.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e112 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eICSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e168 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e\u0026nbsp;70 (29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e\u0026nbsp;50 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eIVF + ICSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e105 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e42 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e\u0026nbsp;33 (16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eTotal oocytes retrieved, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e18.1 \u0026plusmn; 8.9 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e15.9 \u0026plusmn; 7.9\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e15.3 \u0026plusmn; 9.1\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eMII oocytes, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e10.7 \u0026plusmn; 7.4 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e8.9 \u0026plusmn; 7.4\u003csup\u003e\u0026nbsp;ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e7.7 \u0026plusmn; 6.9\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eMII oocytes rate, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e55.5 \u0026plusmn; 26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e50.3 \u0026plusmn; 28.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e48.7 \u0026plusmn; 28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e0.197\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003e2PN zygotes, n\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e9 (5-13)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e7 (4-11)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e7 (3-10)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003e2PN rate, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e59.2 \u0026plusmn; 25.6\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e54.5 \u0026plusmn; 25 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e55.0 \u0026plusmn; 27.1\u003csup\u003e\u0026nbsp;ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2649930264993%\"\u003e\n \u003cp\u003eGood-quality embryos, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e4 (2-6)\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e3 (1-5)\u003csup\u003e\u0026nbsp;ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.549511854951184%\"\u003e\n \u003cp\u003e2 (1-5)\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.08647140864714%\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.224209078404403%\"\u003e\n \u003cp\u003eGood-quality embryos rate per 2PN, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29436038514443%\"\u003e\n \u003cp\u003e45.6 (25-66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29436038514443%\"\u003e\n \u003cp\u003e50 (25-79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.29436038514443%\"\u003e\n \u003cp\u003e50 (20-72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.89270976616231%\"\u003e\n \u003cp\u003e0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Data are presented as mean \u0026plusmn; standard deviation (SD) for continuous variables with normal distribution or median (IQR) for continuous variables that did not show a normal distribution, and categorical variables are reported as no. (%).\u003c/p\u003e\n\u003cp\u003eSuperscript letters indicate between-group differences (for example, groups with the same superscript are not significantly different from one another, while different superscripts indicate a statistical difference). BMI = body mass index; PPOS = Progestin Primed Ovary Stimulation; E2 = estradiol; IVF = in vitro fertilization; ICSI = intracytoplasmic sperm injection; MII = metaphase II; 2PN = two pronuclear.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"677\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Logistic regression on clinical outcomes according to female BMI.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99.5569%;\" colspan=\"5\"\u003e\u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 23 (n=566)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge; 23 (n=394)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e\u003cstrong\u003e23-24.9 (n=221)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e25 (n=173)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eImplantation rate, %\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e43.9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e33.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eCrude OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.79 (0.65-0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.82(0.60-1.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.84 (0.60-1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.76 (0.61-0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.80 (0.63-1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.71 (0.54-0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003ehCG positive rate, %\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e64.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e57.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e57.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e56.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eCrude OR\u0026nbsp;(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.74 (0.60-0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.77 (0.56-1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.71 (0.50-1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.75 (0.57-0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.79 (0.57-1.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.70 (0.49-0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.037\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eClinical pregnancy rate, %\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e58.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e52.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e52.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e51.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u0026nbsp; Crude OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.77 (0.64-0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.82 (0.60-1.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.77 (0.54-1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.81 (0.62-1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.85 (0.62-1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.76 (0.54-1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.325\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eLive birth rate, %\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e41.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e42.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u0026nbsp; Crude OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.73 (0.60-0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.74 (0.54-1.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.77 (0.55-1.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.75 (0.57-0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.71 (0.52-0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.78 (0.55-1.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.030\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.037\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eEarly miscarriage rate, %\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u0026nbsp; Crude OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e1.10 (0.72-1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e1.29 (0.70-2.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.81 (0.37-1.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003eAdjusted OR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e1.18 (0.67-2.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e1.04 (0.95-1.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.84 (0.37-1.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.104972375690608%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.441988950276244%\"\u003e\n \u003cp\u003e0.564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.230\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.81767955801105%\"\u003e\n \u003cp\u003e0.674\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: After controlling for confounding factors, adjusted values are presented as aOR with 95% CI. 95%CI =95% confidential intervals; aOR=adjusted odds ratio. Bold numbers indicate differences with statistical significance compared with the reference group.\u003c/p\u003e\n\u003cp\u003ea, Models were adjusted for age, basal FSH level, the number of transferred embryos, and the type of embryo transfer.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-obesity","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijo","sideBox":"Learn more about [International Journal of Obesity](http://www.nature.com/ijo/)","snPcode":"41366","submissionUrl":"https://mts-ijo.nature.com/cgi-bin/main.plex","title":"International Journal of Obesity","twitterHandle":"@intjobesity","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"polycystic ovary syndrome, body mass index, in vitro fertilization, live birth, race","lastPublishedDoi":"10.21203/rs.3.rs-2834297/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2834297/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eObesity is a common feature in women with polycystic ovary syndrome (PCOS) and associated with multiple adverse reproductive outcomes. However, the impact of overweight and obesity on reproductive outcome of PCOS women underwent the \u003cem\u003ein vitro \u003c/em\u003efertilization-embryo transfer (IVF-ET) is currently controversial. Since appropriate body mass index (BMI) levels differ across ethnic groups, this study was performed to investigate the effects of BMI on IVF outcomes among women with PCOS using BMI cut-off values proposed by the World Health Organization for Asian populations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod(s): \u003c/strong\u003eThis was a retrospective study including\u003cstrong\u003e \u003c/strong\u003e1066 women with PCOS receiving IVF treatment at our institution between January 2018 and June 2021, among whom 960 underwent their first fresh or frozen embryo transfer. Participants were categorized according to their BMI as follows: patients with normal weight (BMI \u0026lt; 23 kg/m\u003csup\u003e2\u003c/sup\u003e), patients with overweight (BMI: 23–24.9 kg/m\u003csup\u003e2\u003c/sup\u003e), and patients with obesity (BMI ≥ 25 kg/m\u003csup\u003e2\u003c/sup\u003e). The effect of BMI on IVF outcomes (the numbers of oocytes, two pronuclear zygotes, and good-quality embryos; the rates of implantation, miscarriage, clinical pregnancy and live birth) was evaluated by descriptive statistics and logistic regression models with confounders adjusted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventions:\u003c/strong\u003e no\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult(s): \u003c/strong\u003eHigh BMI was associated with significantly lower numbers of total oocytes retrieved, mature oocytes, two pronuclear zygotes, and good-quality embryos among women with PCOS. PCOS patients with a BMI ≥ 23 kg/m\u003csup\u003e2 \u003c/sup\u003ehad significantly lower live birth rates (41.9% vs. 49.1%; adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.57–0.97) and implantation rates (35.8% vs. 43.9%; aOR, 0.76; 95% CI, 0.61–0.93) than those with normal BMI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion(s):\u003c/strong\u003e PCOS patients with a BMI ≥ 23 kg/m\u003csup\u003e2\u003c/sup\u003e have lower live birth rates than those with a BMI \u0026lt; 23 kg/m\u003csup\u003e2\u003c/sup\u003e. Defining obesity and overweight with ethnicity-specific BMI cut-offs may help to improve IVF outcomes among PCOS patients.\u003c/p\u003e","manuscriptTitle":"Overweight and obesity determined by body mass index criteria for Asian populations adversely affect assisted reproductive outcomes among Chinese women with polycystic ovary syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-26 20:13:51","doi":"10.21203/rs.3.rs-2834297/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2023-05-31T16:03:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2023-05-29T03:27:16+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2023-05-15T00:53:37+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2023-05-08T10:25:56+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2023-04-25T08:44:06+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2023-04-24T17:44:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-04-19T10:24:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-04-19T02:28:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Obesity","date":"2023-04-19T02:28:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-obesity","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijo","sideBox":"Learn more about [International Journal of Obesity](http://www.nature.com/ijo/)","snPcode":"41366","submissionUrl":"https://mts-ijo.nature.com/cgi-bin/main.plex","title":"International Journal of Obesity","twitterHandle":"@intjobesity","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bef2bfd8-5dd1-4c84-b9d6-3b9089e69469","owner":[],"postedDate":"April 26th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":20968301,"name":"Health sciences/Endocrinology/Endocrine system and metabolic diseases/Obesity"},{"id":20968302,"name":"Health sciences/Diseases/Endocrine system and metabolic diseases/Obesity"}],"tags":[],"updatedAt":"2023-12-09T08:32:07+00:00","versionOfRecord":{"articleIdentity":"rs-2834297","link":"https://doi.org/10.1038/s41366-023-01430-1","journal":{"identity":"international-journal-of-obesity","isVorOnly":false,"title":"International Journal of Obesity"},"publishedOn":"2023-12-08 05:00:00","publishedOnDateReadable":"December 8th, 2023"},"versionCreatedAt":"2023-04-26 20:13:51","video":"","vorDoi":"10.1038/s41366-023-01430-1","vorDoiUrl":"https://doi.org/10.1038/s41366-023-01430-1","workflowStages":[]},"version":"v1","identity":"rs-2834297","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2834297","identity":"rs-2834297","version":["v1"]},"buildId":"re_ckhLnmML6MCF96OHNJ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}