Body mass index is negatively associated with a good perinatal outcome after in vitro fertilization among patients with polycystic ovary syndrome: a national study.

Among the 10,921 identified cycles, 118 (1.1%) were excluded because of a diagnosis of diminished ovarian reserve or hypothalamic amenorrhea ( Supplemental Figure 1 , available online). Forty-six (0.4%) cycles were excluded for missing good perinatal outcomes, 2 (0.02%) for missing parity, and 1,234 (11.3%) for missing BMI. A total of 9,521 cycles among 8,351 unique women were included in the analysis. The mean age across all cycles was 31.5 years, and the median AMH was 7.9 ng/mL ( Table 1 ). Nearly half of the cycles (45.0%) had a secondary cause of infertility in addition to PCOS, most commonly male factor (32.6%). TABLE 1 Demographic and baseline characteristics among women with PCOS who underwent fresh, autologous IVF, 2012-2015. Characteristic Underweight (N=231) Normal (N=4134) Overweight (N=2254) Class I Obesity (N=1556) Class II Obesity (N=937) Class III Obesity (N=381) Super Obesity (N=28) Total (N=9521) Age (y), mean (SD) 30.5 ± 3.6 31.3 ± 3.5 31.5 ± 3.7 31.6 ± 3.8 31.6 ± 3.7 31.7 ± 3.6 31.9 ± 4.1 31.4 ± 3.6 AMH (ng/ml), median (25th percentile, 75th percentile) 7.8 (5.8, 11.3) 8.0 (5.9, 11.5) 8.2 (6.1, 12.0) 8.0 (5.9, 11.1) 7.6 (5.9, 10.7) 7.5 (5.9, 10.0) 7.2 (5.7, 10.4) 8.0 (5.9, 11.3) Race, N (%)  Hispanic or Latina 3 (1.3%) 143 (3.5%) 136 (6.0%) 109 (7.0%) 81 (8.6%) 21 (5.5%) 1 (3.6%) 494 (5.2%)  Non-hispanic Black 5 (2.2%) 100 (2.4%) 150 (6.7%) 118 (7.6%) 58 (6.2%) 27 (7.1%) 5 (17.9%) 463 (4.9%)  Non-hispanic White 121 (52.4%) 2354 (56.9%) 1141 (50.6%) 820 (52.7%) 553 (59.0%) 224 (58.8%) 17 (60.7%) 5230 (54.9%)  Other 32 (13.9%) 521 (12.6%) 275 (12.2%) 157 (10.1%) 44 (4.7%) 5 (1.3%) 0 (0.0%) 1034 (10.9%)  Unknown 70 (30.3%) 1016 (24.6%) 552 (24.5%) 352 (22.6%) 201 (21.5%) 104 (27.3%) 5 (17.9%) 2300 (24.2%) Nulligravid, N (%) 159 (68.8%) 2526 (61.1%) 1263 (56.0%) 850 (54.6%) 524 (55.9%) 216 (56.7%) 17 (60.7%) 5555 (58.3%) Nulliparous, N (%) 192 (83.1%) 3343 (80.9%) 1783 (79.1%) 1227 (78.9%) 756 (80.7%) 293 (76.9%) 25 (89.3%) 7619 (80.0%) Smoker, N (%) 10 (4.3%) 129 (3.1%) 111 (4.9%) 89 (5.7%) 61 (6.5%) 28 (7.3%) 3 (10.7%) 431 (4.5%) Additional infertility diagnoses, n (%)  Male infertility 73 (31.6%) 1339 (32.4%) 739 (32.8%) 518 (33.3%) 309 (33.0%) 119 (31.2%) 6 (21.4%) 3103 (32.6%)  Endometriosis 11 (4.8%) 251 (6.1%) 120 (5.3%) 63 (4.0%) 36 (3.8%) 12 (3.1%) 1 (3.6%) 494 (5.2%)  Uterine factor 7 (3.0%) 170 (4.1%) 108 (4.8%) 83 (5.3%) 39 (4.2%) 13 (3.4%) 1 (3.6%) 421 (4.4%)  Tubal factor 16 (6.9%) 248 (6.0%) 210 (9.3%) 154 (9.9%) 77 (8.2%) 48 (12.6%) 2 (7.1%) 755 (7.9%)  Other 15 (6.5%) 147 (3.6%) 98 (4.3%) 72 (4.6%) 31 (3.3%) 22 (5.8%) 2 (7.1%) 387 (4.1%) SD = standard deviation; AMH = anti-Müllerian hormone. Demographic and baseline characteristics among women with PCOS who underwent fresh, autologous IVF, 2012-2015. SD = standard deviation; AMH = anti-Müllerian hormone. The median number of oocytes retrieved ranged from 19 in the normal BMI group to 15 in the group with class III obesity and super obesity ( Table 2 ). The number of supernumerary embryos cryopreserved decreased from a median of three in the normal weight and overweight categories to two in women with any stage of obesity. There were no significant differences in the use of intracytoplasmic sperm injection or cleavage stage versus blastocyst transfer between BMI categories. TABLE 2 Fresh autologous IVF cycle characteristics among women with PCOS, 2012-2015. Cycle characteristic N Underweight Normal Overweight Class I obesity Class II obesity Class III obesity or super obesity P ∗ Total FSH dose, IU a 9320 1802.2 ± 832.4 1900.6 ± 899.6 2058.0 ± 926.0 2302.5 ± 1010.2 2634.3 ±1198.9 2900.6 ± 1267.6 Beta (95% CI) -93.7 (-209.8–22.3) Reference 155.7 (105.5–205.8) 391.5 (333.2–449.9) 686.2 (602.6–769.9) 1022.6 (896.2–1149.1) <.001 Oocytes retrieved b 9521 18.0 (13.0, 25.0) 19.0 (13.0, 26.0) 18.0 (12.0, 25.0) 18.0 (12.0, 25.0) 16.0 (10.0, 23.0) 15.0 (9.0, 22.0) Beta (95% CI) -0.78 (-2.26–0.69) Reference -0.78 (-1.35 to -0.21) -1.23 (-1.88 to -0.58) -2.86 (-3.64 to -2.09) -4.03 (-5.10 to -2.95) <.001 Embryos cryopreserved b 9521 4.0 (1.0, 7.0) 3.0 (0.0, 7.0) 3.0 (0.0, 7.0) 2.0 (0.0, 6.0) 2.0 (0.0, 5.0) 2.0 (0.0, 5.0) Beta (95% CI) -0.02 (-0.62–0.57) Reference -0.35 (-0.60 to -0.10) -0.85 (-1.11 to -0.58) -1.06 (-1.40 to -0.73) -1.33 (-1.73 to -0.93) <.001 ICSI N (%) 9521 158 (68.4) 2854 (69.0) 1593 (70.7) 1053 (67.7) 640 (68.3) 285 (69.7) Odds ratio (95% CI) 0.96 (0.72–1.29) Reference 1.09 (0.97–1.22) 0.94 (0.83 – 1.07) 1.00 (0.85 ˗ 1.17) 1.04 (0.83 ˗ 1.31) .488 Assisted hatching, N (%) 9521 39 (16.9) 675 (16.3) 418 (18.5) 303 (19.5) 168 (17.9) 83 (20.3) Odds ratio (95% CI) 1.03 (0.71–1.49) Reference 1.18 (1.03–1.35) 1.23 (1.06 – 1.44) 1.13 (0.93 – 1.37) 1.35 (1.04 – 1.74) .036 Blastocyst transfer c N(%) 6834 122 (75.3) 2146 (74.0) 1209 (74.0) 848 (73.9) 486 (71.3) 206 (66.9) Odds ratio (95% CI) 1.10 (0.75–1.60) Reference 0.99 (0.86–1.14) 0.97 (0.83–1.14) 0.87 (0.72–1.05) 0.72 (0.55–0.93) .178 Embryos transferred b , c 6834 2.0 (1.0, 2.0) 2.0 (1.0, 2.0) 2.0 (1.0, 2.0) 2.0 (1.0, 2.0) 2.0 (1.0, 2.0) 2.0 (1.0, 2.0) Beta (95% CI) -0.03 (-0.12–0.06) Reference 0.07 (0.04–0.11) 0.08 (0.04–0.12) 0.12 (0.08–0.17) 0.16 (0.09–0.23) <.001 FSH = follicle stimulating hormone; ICSI = intracytoplasmic sperm injection. ∗ P value for overall association between BMI and cycle characteristic. a Reported as mean (standard deviation). b Reported as median (25th percentile, 75th percentile). c Reported among cycles with transfer attempted. Fresh autologous IVF cycle characteristics among women with PCOS, 2012-2015. FSH = follicle stimulating hormone; ICSI = intracytoplasmic sperm injection. P value for overall association between BMI and cycle characteristic. Reported as mean (standard deviation). Reported as median (25th percentile, 75th percentile). Reported among cycles with transfer attempted. With increasing BMI, women had lower rates of implantation, clinical pregnancy, and live birth ( Table 3 ). Elevated BMI was also significantly associated with miscarriage, macrosomia, and prematurity, but not multiple birth or low birth weight. Among women with BMI in the overweight range or higher, rates of ovarian hyperstimulation syndrome declined with increasing BMI. TABLE 3 Associations between BMI and cycle outcomes among women with PCOS undergoing fresh, autologous IVF, 2012-2015. Cycle outcome N Underweight Normal Overweight Class I obesity Class II obesity Class III obesity or super obesity P ∗ Implantation a --- 0.49 0.48 0.43 0.40 0.37 0.32 --- Clinical pregnancy b n (%) 9521 105 (45.5) 1828 (44.2) 958 (42.5) 657 (42.2) 362 (38.6) 138 (33.7) Odds ratio (95% CI) 1.04 (0.80–1.35) Reference 0.93 (0.84–1.03) 0.93 (0.82–1.04) 0.79 (0.68–0.92) 0.65 (0.52–0.81) <.001 Live birth b n (%) 9521 93 (40.3) 1591 (38.5) 796 (35.3) 527 (33.9) 293 (31.3) 107 (26.2) Odds ratio (95% CI) 1.07 (0.82–1.39) Reference 0.87 (0.78–0.97) 0.82 (0.72–0.93) 0.73 (0.62–0.84) 0.57 (0.45–0.72) <.001 Miscarriage c n (%) 4048 11 (10.5) 208 (11.4) 148 (15.4) 112 (17.0) 67 (18.5) 30 (21.7) Odds ratio (95% CI) 0.80 (0.41–1.57) Reference 1.41 (1.12–1.77) 1.67 (1.30–2.15) 1.74 (1.27–2.37) 2.31 (1.50–3.57) <.001 Multiple birth d n (%) 3407 23 (24.7) 407 (25.6) 239 (30.0) 127 (24.1) 81 (27.6) 38 (35.5) Odds ratio (95% CI) 0.95 (0.59–1.55) Reference 1.24 (1.03–1.50) 0.92 (0.73–1.16) 1.11 (0.84–1.47) 1.61 (1.06–2.43) .055 Low birth weight d n (%) 3380 21 (22.8) 386 (24.4) 190 (24.1) 125 (23.9) 79 (27.3) 30 (28.3) Odds ratio (95% CI) 0.91 (0.55–1.51) Reference 0.98 (0.81–1.20) 0.97 (0.77–1.23) 1.16 (0.88–1.54) 1.23 (0.79 –1.90) .815 Macrosomia d n (%) 3380 2 (2.2) 68 (4.3) 48 (6.1) 45 (8.6) 23 (8.0) 4 (3.8) Odds ratio (95% CI) 0.49 (0.12–2.05) Reference 1.42 (0.97–2.08) 2.00 (1.32–3.03) 2.07 (1.23–3.48) 0.88 (0.31–2.46) .002 Prematurity d n (%) 3394 22 (23.7) 402 (25.3) 241 (30.4) 151 (28.8) 94 (32.4) 36 (33.6) Odds ratio (95% CI) 0.91 (0.56–1.49) Reference 1.28 (1.06–1.55) 1.19 (0.96 ˗ 1.49) 1.41 (1.07–1.84) 1.50 (0.99–2.28) .024 OHSS b n (%) 9521 37 (16.0) 683 (16.5) 320 (14.2) 197 (12.7) 104 (11.1) 41 (10.0) Odds ratio (95% CI) 0.96 (0.67–1.38) Reference 0.84 (0.72– 0.97) 0.73 (0.62 ˗ 0.87) 0.63 (0.51 ˗ 0.79) 0.56 (0.40 –0.79) <.001 CI = confidence interval; OHSS = ovarian hyperstimulation syndrome. ∗ P value for overall association between BMI and outcome. a Implantation rate presented as ratio of implantations per number of embryos transferred. b Reported among all cycles. c Reported among cycles with clinical pregnancy. d Reported among cycles with live birth. Associations between BMI and cycle outcomes among women with PCOS undergoing fresh, autologous IVF, 2012-2015. CI = confidence interval; OHSS = ovarian hyperstimulation syndrome. P value for overall association between BMI and outcome. Implantation rate presented as ratio of implantations per number of embryos transferred. Reported among all cycles. Reported among cycles with clinical pregnancy. Reported among cycles with live birth. The proportion of cycles with a good perinatal outcome was highest in the women with underweight BMI (25.1%) and decreased with increasing BMI to a low of 12.2% in the group with class III obesity or super obesity ( Table 4 , unadjusted odds ratio [OR] 0.47, 95% confidence interval [CI], 0.35–0.65; P <.001, compared with normal weight group). TABLE 4 Association between BMI and good perinatal outcome among women with PCOS, 2012-2015. BMI category Good perinatal outcome a Unadjusted Adjusted ∗ N (%) OR (95% CI) P OR (95% CI) P  Underweight 58 (25.1) 1.14 (0.84–1.54) .401 1.14 (0.84–1.55) .396  Normal 940 (22.7) Reference — Reference —  Overweight 425 (18.9) 0.79 (0.70–0.90) <.001 0.83 (0.73–0.94) .005  Class I obesity 286 (18.4) 0.76 (0.66–0.89) <.001 0.81 (0.70–0.94) .006  Class II obesity 140 (14.9) 0.60 (0.49–0.72) <.001 0.62 (0.51–0.75) <.001  Class III obesity/Super obesity 50 (12.2) 0.47 (0.35–0.65) <.001 0.49 (0.36–0.67) <.001 BMI = body mass index; OR = odds ratio; CI = confidence intervals. ∗ Adjusted for age, race, parity, secondary infertility diagnoses, and smoking status. a Good perinatal outcome defined as a singleton live birth at ≥ 37 weeks with birth weight ≥ 2,500 g and ≤ 4,000 g. Association between BMI and good perinatal outcome among women with PCOS, 2012-2015. BMI = body mass index; OR = odds ratio; CI = confidence intervals. Adjusted for age, race, parity, secondary infertility diagnoses, and smoking status. Good perinatal outcome defined as a singleton live birth at ≥ 37 weeks with birth weight ≥ 2,500 g and ≤ 4,000 g. The multivariable GEE model demonstrated that BMI was significantly and inversely associated with the odds of a good perinatal outcome after adjusting for age, race, parity, infertility diagnoses other than PCOS, and smoking status ( Table 4 ). Compared with women with normal BMI, the odds of a good perinatal outcome were reduced by 17% (OR, 0.83; 95%, CI 0.73–0.94), 19% (OR, 0.81; 95% CI, 0.70–0.94), 38% (OR, 0.62; 95% CI, 0.51–0.75), and 51% (OR, 0.49; 95% CI, 0.36–0.67) with overweight, class I obesity, class II obesity, and class III obesity or super obesity, respectively. To confirm that the findings were not skewed by excluding cycles with missing BMI, a sensitivity analysis including these 1,234 cycles was performed with a “missing BMI” category. When the unadjusted and adjusted primary outcome models were refit with this additional BMI category as a covariate, the results were consistent with those of the primary analysis ( Supplemental Table 1 , available online).

This was a retrospective cohort study and was declared exempt by the Duke Health institutional review board (Pro00100912) as the data were de-identified. All 2012-2015 fresh, autologous IVF cycles with patient age <41 and no use of preimplantation genetic testing were queried from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS). The SART CORS database contains comprehensive data from >90% of all clinics performing ART cycles in the United States. The data were collected through voluntary submission, verified by SART, and then reported to the Centers for Disease Control and Prevention in compliance with the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102-493). The SART maintains HIPAA-compliant business associates' agreements with reporting clinics. In 2004, after a contract change with Centers for Disease Control and Prevention, SART gained access to the SART CORS data system for the purposes of conducting research. The data in the SART CORS are validated annually, with select clinics having on-site visits for chart review based on an algorithm for clinic selection ( 19 ). During each visit, data reported by the clinic were verified with information recorded in patients’ charts. In 2012, records for 2,045 cycles at 35 clinics were randomly selected for full validation, along with 238 egg or embryo banking cycles ( 19 ). The full validation included a review of 1,318 cycles for which pregnancy was reported. Among the nondonor cycles, 331 were multiple-fetus pregnancies. Ten out of 11 data fields selected for validation were found to have discrepancy rates of ≤5%. The exception was the diagnosis field, which, depending on the diagnosis, had a discrepancy rate between 2.1% and 9.2% ( 19 ). The analysis included women with a diagnosis of “ovulation disorder polycystic ovaries.” Women with a secondary infertility diagnosis of diminished ovarian reserve were excluded. Women were also excluded if their indication for ART was designated as “other” with “hypothalamic,” “hypogonadotropic hypogonadism,” or “hypo-hypo” in the comments. The SART CORS data field “ovulation disorder polycystic ovaries” is broadly defined as “one or more disorders causing reduced fecundity associated with structural, anatomic, or functional impairment of one or both ovaries.” Therefore, this category includes women with ovulatory disorders other than PCOS. Recognizing this limitation, we used antimüllerian hormone (AMH) as a surrogate marker to help differentiate PCOS from diminished ovarian reserve or primary ovarian insufficiency. Although not part of the formal diagnostic criteria, AMH is known to be higher in patients with PCOS ( 20 , 21 , 22 , 23 ). We selected an AMH cutoff of 4.45 ng/mL, which has been shown to have 76% sensitivity and 75% specificity for PCOS ( 20 ). Women with an AMH below this cutoff point were excluded from the analyses. Patients were assigned to BMI categories according to the World Health Organization BMI guidelines: underweight (< 18.5 kg/m 2 ), normal (18.5–24.9 kg/m 2 ), overweight (25.0–29.9 kg/m 2 ), class I obesity (30.0–34.9 kg/m 2 ), class II obesity (35.0–39.9 kg/m 2 ), class III obesity (40.0–49.9 kg/m 2 ), and super obesity (≥ 50.0 kg/m 2 ) ( 24 ). Women were excluded if BMI data was missing. Super obesity was left as a standalone category for descriptive tables, but because of the low frequency and lack of events, this category was grouped with class III obesity for statistical analyses. Race and ethnicity were categorized as “Hispanic or Latina,” “Non-hispanic White,” “Non-hispanic Black,” “Other,” and “Unknown,” as reported by each clinic to the SART CORS. The term “Unknown” was used to identify those patients without race or ethnicity documented in the medical record. The primary outcome was a “good perinatal outcome,” defined as a singleton live birth at ≥ 37 weeks with birth weight ≥ 2,500 g and ≤ 4,000 g. Women were further excluded if data were missing for any component of the composite primary outcome. Secondary outcomes included live birth rate, defined as the proportion of cycles with a live birth entered in SART CORS; multiple birth rate, calculated as the proportion of live births with two or more infants; and prematurity rate, defined as the proportion of live births occurring < 37 weeks gestational age. Low birth weight was defined as birth weight 4,000g. Implantation rate, as defined by SART CORS, was the greater of the number of fetal hearts on ultrasound or the number of live births plus still births, divided by the total number of embryos transferred. The clinical pregnancy rate was defined as the proportion of cycles with a gestational sac on first-trimester ultrasound. Miscarriage was defined as clinical pregnancy ending before 24 completed weeks of gestation. Ovarian hyperstimulation syndrome was defined as abdominal distension and discomfort with nausea, vomiting, diarrhea, ovarian enlargement, and ultrasonic evidence of ascites. Analyses were performed in SAS 9.4 (SAS Institute Inc., Cary, NC) at a two-tailed significance level of 0.05. All available cycles within the study period for a woman were included in the analysis. Marginal models using generalized estimating equations (GEE) were implemented to account for the correlation between repeated IVF cycles. A GEE-type model with a binomial distribution and logit link was implemented to test the association between BMI and a good perinatal outcome with and without the following covariates: age, race, parity, infertility diagnoses, and smoking status. Secondary outcomes were analyzed using GEE-type models without adjustment for covariates. An autoregressive( 1 ) working correlation structure was used along with the robust variance estimator for all models. Cycles with missing values for the primary outcome were excluded from the analysis. Two cycles with missing parity were also excluded. Given that BMI was missing for > 10% of cycles, we confirmed that outcomes were clinically similar between cycles with missing and nonmissing BMI. Cycles with missing values in BMI were then excluded from the analysis. As a sensitivity analysis, an additional BMI category was created for the cycles with missing BMI. The unadjusted and adjusted primary outcome models were then refitted with this additional BMI category included as a covariate.

The results of this large national study demonstrate that BMI is negatively associated with the odds of a singleton, term delivery of a normal weight infant after fresh, autologous IVF among women with PCOS. Our data indicate that obesity is strongly associated with worse ART outcomes, even among a study population with a high baseline prevalence of obesity. Our findings are consistent with those of a retrospective cohort study that used 2008-2010 SART CORS data to demonstrate a negative association between BMI and live birth rates among women with a diagnosis of ovulation disorder ( 9 ). Because the ovulation disorder diagnosis was not exclusive to PCOS, however, many women with other causes of ovulation dysfunction were inadvertently included in their analysis. Given the limitations of that study, we chose to use an AMH cutoff of > 4.45ng/mL to improve the likelihood of excluding women without PCOS ( 20 ). We also excluded women with a secondary infertility diagnosis of diminished ovarian reserve or an ART indication consistent with hypothalamic amenorrhea. Therefore, the results of the present study have greater internal validity and are more applicable to the PCOS population. Other existing studies have been too small to categorize women into more than two or three BMI categories, and some were underpowered to detect a meaningful difference in live birth rates ( 16 , 17 , 18 ). Those that did compare live birth rates did not examine rates of multiple birth or associated neonatal morbidities such as prematurity and low birth weight. The present study is strengthened by its large sample size and the use of clinically relevant WHO BMI categories. It is also strengthened by the use of a composite variable, a good perinatal outcome, advocated as the most clinically relevant measure of IVF success ( 25 , 26 , 27 ). The use of live birth rate as the primary outcome underestimates the morbidity associated with multiple births, specifically prematurity and low birth weight ( 28 ). Notably, the median number of embryos transferred in the present study population was two across all BMI categories despite national guidelines advocating single embryo transfer to maximize the likelihood of a healthy live birth ( 26 , 27 , 29 , 30 ). Consequently, the multiple birth rate was as high as 36%, with up to one-third of women delivering prematurely. Even in the lowest BMI categories, only one-quarter of women experienced a good perinatal outcome. Our results accentuate the importance of performing single embryo transfer in good-prognosis patients, regardless of BMI. The present study also has limitations, most notably the challenge of identifying a population of women with PCOS from SART CORS. We recognize that AMH level is not a traditional diagnostic criterion for PCOS. However, no distinct category existed for PCOS in SART CORS at the time of data collection. Given that previous studies did not address this limitation at all, we feel that the use of an AMH cutoff significantly reduces the risk of misclassification bias compared with those of prior SART CORS studies in which a PCOS diagnosis was incorrectly assigned to all women with ovulatory dysfunction. Despite the use of an AMH cutoff and the exclusion of women with a clear diagnosis of hypothalamic amenorrhea, we acknowledge that there was no way to definitively exclude all women without PCOS from our cohort. We also acknowledge that some women with PCOS and an AMH level on the lower end of the spectrum may inadvertently have been excluded. Additionally, despite the large cohort, there were a limited number of women with super obesity (BMI > 50). However, this reflects reality as many IVF centers have BMI limits in place to prevent dangerous anesthesia complications or the numerous obstetric risks associated with such morbid obesity ( 3 , 31 ). By combining the class III obesity and super obesity groups, we maintained the ability to show clinically meaningful differences in ART outcomes in women with morbid obesity. Notably, whereas approximately 10% of women were missing BMI data, the sensitivity analysis is reassuring that this missing data does not affect the results. However, this remains a potential source of bias if an unequal proportion of these women with unknown BMI came from a single BMI category. During our study period (2012-2015), the rate of missing AMH data was approximately 50%, likely based on the newness of this variable at that time. However, the proportion of missing AMH data was similar between women, with (49%) and without (50%) a diagnosis of “ovulatory disorder polycystic ovaries.” Moreover, when applying our inclusion/exclusion criteria to the cohort, aside from AMH > 4.45, the rate of a good perinatal outcome was similar between the group with AMH data (19.5%) compared with the group with missing AMH data (20.1%). Taken together, these findings support a lack of bias introduced by this missing AMH data. Although SART CORS includes abundant IVF cycle data, it does not include obstetric complications that may affect the likelihood of our composite outcome via pathways unrelated to ART; for example, iatrogenic preterm delivery for preeclampsia or macrosomia in the setting of gestational diabetes. Regardless of the causal pathway, these complications are known risks for women with obesity and PCOS and should be accounted for when counseling patients about their chances of a healthy infant after IVF. Finally, our dataset includes only fresh cycles and may not be generalizable to subsequent frozen embryo transfers ( 32 ). However, our results show that the women with obesity have fewer cryopreserved embryos for future use, and thus, their cumulative success per oocyte retrieval is likely similarly decreased.

This large, national, retrospective study demonstrated that the odds of a good perinatal outcome decline with increasing BMI among women with PCOS. Women with PCOS and elevated BMI should be counseled that a decreased BMI may optimize their odds of achieving term delivery of a normal weight singleton—the ultimate goal of IVF.