https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article Effect of Body Mass Index, Caffeine Consumption and Physical Activity on in vitro Fertilization Outcome in Erbil City/Iraq” ABSTRACT Background and Objective: Several factors influence the success of in vitro fertilization. In recent years, there has been a lot of focus on how lifestyle factors like body weight, physi- cal activity levels, cigarette smoking, alcohol, and caffeine consumption affect In vitro fer- tilization (IVF) outcome (biochemical pregnancy). The term "biochemical pregnancy" is defined as a pregnancy that can only be determined by the presence of serum levels of the hormone Human Chorionic Gonadotrophin (HCG). This study aimed to assess the effect of women's lifestyle factors, such as body mass index, caffeine consumption, and physical activity, on the outcome of In vitro fertilization (biochemical pregnancy). Methods: A descriptive cross-sectional study design was conducted from September 2021 to September 2022.A convenience sampling technique was used among 110 women in total who consented to take part in this study, but because 10 of them cancelled (IVF) treatment before embryo transfer or oocyte retrieval, were excluded from analysis, only 100 infertile women undergoing (IVF) were included in the analysis in the Maternity Teaching Hospital's (in vitro fertilization center) and some private hospitals in Erbil, Kurdi- stan Region, Iraq. The women in the study ranged in age from 20 to 45, were undergoing IVF. Result: (44%) of infertile women had a successful biochemical pregnancy (positive beta hCG test). The majority (74%) of the study sample consumed caffeinated beverages. Re- sults showed a significant difference between caffeine consumption and IVF outcome (biochemical pregnancy) (P=0.01), but there was no statistically significant difference be- tween body mass index (BMI), and physical activity (vigorous, moderate) with IVF out- come (biochemical pregnancy). Only walking showed a significant difference with IVF out- come (biochemical pregnancy) (P=0.017). Conclusion: Increased caffeine consumption is a significant factor that can affect IVF out- come. Keyword: Physical Activity; BMI; Caffeine Consumption; In vitro Fertilization; Biochemical Pregnancy. Muzhda Masood Fateh; Surgical Specialty Hospital Cardiac Center, Ministry of Health, Kurdistan Region, Erbil, Iraq. (Correspondence: mzhdamasud29@gmail.com) Awaz Azizz Said; Department of Nursing, College of Nursing, Hawler Medical University, Kurdistan Region, Iraq. 137 Received: 26/10/2022 Accepted:22/01/2023 Published: 30/11/2024 Copyright ©2024The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:mzhdamasud29@gmail.com?subject=mzhdamasud29@gmail.com mailto:mzhdamasud29@gmail.com mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article In vitro fertilization success is influenced by several factors. In recent years, there has been a lot of focus on how lifestyle factors like body weight, physical activity levels, cigarette smoking, alcohol, and caffeine consumption affect IVF outcomes [1]. Obe- sity has become much more prevalent in recent decades, particularly in Europe and North America. It has a wide range of health implications, including the function of reproduction. Obesity is linked to an in- creased risk of dysovulation and anovula- tion [2]. Physical activity has been demon- strated to improve reproductive outcomes during pregnancy; the majority of the re- searchers concluded that moderate physi- cal activity improves female fertility [3]. Being overweight and obese are the results of a persistent imbalance between energy intake and energy expenditure. Although energy consumption has increased calori- cally, there has been a concomitant decline in the amount of physical activity, which has contributed to the obesity pandemic [4]. Infertility and a higher likelihood of miscarriage also occur in overweight and obese women who do not exercise. Chang- es in the release of gonadotropin-releasing hormone, luteinizing hormone (LH), and ovarian and adrenal hormones are thought to be the mechanism, leading to anovula- tion, slowed follicular development, stunt- ed fetal growth, and unsuccessful implan- tation [5]. Caffeinated beverages, diet so- das, and sugary sodas are among the most popular drinks drunk by reproductive-age women. Caffeine is a central nervous sys- tem stimulant. Caffeine consumption is linked to reduced estrogen levels during the luteal phase [6]. Wilcox et al. were the first to report that "women who drank more than one cup of coffee per day were less likely to become pregnant than wom- en who drank less” [7]. Assessing the out- comes of in vitro fertilization by biochemical pregnancy can only be identified by the presence of the hormone Human Chorionic Gonadotrophin (HCG) in the serum after a frozen egg transfer, clinics advise waiting two weeks before performing a pregnancy test (HCG), as doing so frequently yields incorrect results [17]. Human Chorionic Gonadotropin, often known as HCG, is frequently referred to as the pregnancy hormone because it is produced by cells in the placenta, which feeds the egg after it has been fertilized and connected to the uterine wall. About 11 days after conception, a blood test can be used to identify levels; about 12–14 days later, a urine test can be used to identify levels [18].Both infertile couples and professionals now view how to enhance assisted reproductive outcomes as a key issue. Many patients want to collaborate with their doctors and want to learn specific practices to have a healthy lifestyle and increase their chances of having a successful IVF. This study aimed to assess the potential effect of women's lifestyle factors, such as body mass index, caffeine consumption, and physical activity, on the outcome of in vitro fertilization (biochemical pregnancy). This cross-sectional descriptive study was conducted on a convenience sample of 110 women in total who consented to take part in this study, but 10 of them cancelled (IVF) treatment before embryo transfer or oocyte retrieval and were excluded from analysis. Only 100 infertile women undergoing IVF were included in the analysis during the period between 1st September 2021 and 1st September 2022 at the IVF unit of a maternity teaching hospital and some private hospitals in Erbil, Kurdistan Region, Iraq. Due to the small number of patients in public hospitals and the lack of support for the 138 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article questionnaire - short form (IPAQ-SF) ask questions about three specific forms of activities (Walking, moderate-intensity ac- tivities, and vigorous-intensity activities) [9]. They were designed to be used by peo- ple aged between (18–65 year) [10]. Each type of activity was measured by the fre- quency of vigorous, walking, and moderate activity per week and recorded time per day [11]. These physical activity data was converted to metabolic equivalent tasks (MET). The (MET) is ratio at which a person expends energy while engaging in a certain activity, according to that person's mass, the quantity of oxygen consumed while sitting at rest, and is equal to 3.5 ml O2 per kg body weight x min [12]. The metabolic equivalent of task (MET) values was used, as well as equations for calculating MET minutes. For each type of activity, a total MET score was calculated. For instance, all types of walking were added, and a walk- ing average MET value was calculated. Moderate-intensity and vigorous-intensity activities were both subject to the same technique. For the analysis of IPAQ data, the following values are being used: Walk- ing equals 3.3 METs, moderate physical activity (PA) equals 4.0 METs, and vigorous PA equals 8.0 METs. researcher summed all of the activities' frequency in minutes per week, and the score was used to cate- gorize the amount of physical activity as low, moderate, or high. and other domains of activity, including the number of hours spent sitting ≤ 3 hours per week of moder- ate-intensity exercise or ≤ 5 hours per week of low-intensity exercise, were con- sidered to be inactive [13].The type of bev- erages consumed and the average amount consumed were recorded. The frequency with which tea, coffee, soda, or energy drink is consumed was recorded in cups per day, each cup=250 ml. The daily caffeine intake (mg) was calculated based on the number of cups of caffeine study in most private hospitals. Women included were aged 20–45 years were hav- ing in vitro fertilization (IVF). The research- er obtained ethical approval from the sci- entific committee and ethical committee of College of Nursing / Hawler Medical Uni- versity (code No.110, date: 7/10/2021). Permission was also obtained from the General Directorate of Health/Erbil as well as the administration of Maternity Teach- ing Hospital in Erbil city. Informed consent was obtained from all the participants who were included in the study. Direct inter- viewing was used to gather the infor- mation, which was then documented in a questionnaire that included socio- demographic characteristics of couples such as age, occupation, religion, level of education, and economic status. Data of study participants obtained from the base- line questionnaire. A detailed history was collected for each woman about past med- ical, surgical, family, and gynecological his- tory, obstetrical data, and data about the menstrual cycle. It also included questions on lifestyle and health habits, which con- tain data about caffeine consumption, body mass index, and performing physical activity. To assess body mass index, the researcher was extracting body weight and height from clinical records; when missing, data was calculated from the self-reported height and weight. In this study, the re- searcher measured obesity using an index called BMI, which is calculated and defined as women's weight in kilograms divided by the square of their height in meters (kg/ m2). The women were grouped according to the World Health Organization classifi- cation of BMI (<18.50 underweight, 18.50 –24.99 normal , 25.00–29.99 overweight, and obese ≥30.00 kg/m2 )[8]. To assess and collect information on physical activi- ty, the investigator used simple language for communication, and questions about the international physical activity 139 Copyright ©2024The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article beverage consumed [14]. The researcher calculated each person's total caffeine in- take by assuming that one cup of instant ( coffee had 65 mg of caffeine, 40 mg of caffeine in soft drinks, and 50 mg of caffeine in tea) [15].Total caffeine con- sumption was grouped into four catego- ries: 0–800 mg/week, 801–1400 mg/week, and > 1400 mg/week [16].To assess IVF outcome, researchers obtained (biochemical pregnancy). According to hos- pital policy, a positive β-hCG pregnancy test 12-14 days after embryo transfer was used to detect pregnancy, and successful biochemical pregnancy was defined as a serum β-hCG level over 10 mIU/mL The pilot study was conducted from 1st January to 15th January 2022on 10% of the women surveyed (10 women) to assess the clarity of the questions and to identify any addi- tional issues or challenges that would aid in making the necessary changes that would necessitate reconstructing the question- naire. The data was analyzed using Statisti- cal Package for Social Science (SPSS) Ver- sion 26, to calculate descriptive statistical analysis (frequency and percentage). Infer- ential statistical analysis (independent sam- ple t-test) was used to determine the difference between variables. A Chi-Square test used to find out the association be- tween two variables; and the P-value ≤ 0.05 is considered statistically significant [31]. Table1shows the descriptive statistics for all demographic questions such as the age of the husband and wife, type of hospital, level of education, nationality, religion, res- idence, duration of the marriage, economic status, and occupation. The percentage of patients from the public hospital (61%) is higher than the percentage of patients from private clinics or hospitals (39%). The mean age (+ SD) of husbands was (37 ± 7.07) years, ranging from 20 to 45 years. Table 1 shows that the highest 31% of the study sample (husband) were aged 41 years and over, and only 6% were 26 years. The mean age (+ SD) of wives was (33 ± 5.91) years, most of the study sample (wives) 30% were aged between 36 and 40 years, and only 7% were 41 years and over. The highest duration of marriage in this study is higher than 9 years (34%) followed by 7-9 years (22%), 4-6 years (29%), and 1- 3 years (15%) since the average of their duration of marriage is 9 years. The majori- ty of the study sample (75%) is unem- ployed individuals, followed by employed (25%). The most prevalent type of infertili- ty in the study sample was primary infertil- ity (58%). 140 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT Table1: Distribution of the socio- demographic characteristics of the study sample (n=100) Variable Category F. (%) Hospital Public 61 (61) Private 39 (39) Age group hus- band(years) ≤25 6 (6.0) 26-30 12 (12) 31-35 25 (25) 36-40 26 (26) ≥41 31 (31) Age group wife (years) ≤25 14 (14) 26-30 24 (24) 31-35 25 (25) 36-40 30 (30) ≥41 7 (7) Marriage Dura- tion (years) 1-3 15 (15) 4-6 29 (29) 7-9 22 (22) more than 9 34 (34) (Mean ± SD) (9 ± 5.68) Occupation Employed 25 (25) Non em- ployed 75 (75) Type of infertility Primary 58 (58) Secondary 42 (42) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article 141 (31%), soda (21%), and energy drinks (8%), respectively. Most of the caffeine group is between 0 and 800 mg/week (44%), followed by greater than 1400 mg/week (19%), and 801–1400mg/week (11%) respectively, since 26% of them do not drink at all. followed by overweight (30%), and nor- mal (27%). Table 2 shows the descriptive statistics for lifestyle and health habit characteristics such as drinking caffeine in tea, coffee, so- da, energy, and the total caffeine group. Caffeine is consumed by the majority of patients (74%), as opposed to those who did not consume it (26%), because the ma- jority of them drink tea (68%), coffee Figure 1 Depending on BMI results, most of the patients in this survey are obese (43%) Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Variable Category F (%) Did you drink any caffeine beverages? Yes 74 (74) No 26 (26) Tea Yes 68 (68) No 32 (32) Coffee Yes 31 (31) No 69 (69) Soft drinks Energy drinks Yes 21 (21) No 79 (79) Total caffein consumption mg/weak Yes 8 (8) No 92 (92) 0–800 44 (44) 801–1400 11 (11) > 1400 19 (19) Table 2 :Descriptive Statistics for caffeine consumption Figure 1 percentage about Body mass index classification https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article survey have low activity (66%) followed by moderate (25%). results(56%) is higher than the percentage of successful results of IVF (44%). 142 Figure 2 shows the classification of physi- cal activities, depending on the physical activity results, most of the patients in this Figure 3 shows the percentage about the biochemical pregnancy rate, depending on the result , the percentage of failed Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Figure 2 level of physical activity Figure3 Percentage of biochemical pregnancy Rate (successful and failed) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article energy mg (6.364) is lower than the mean of those patients who have failed IVF (35). Next, the mean of successful IVF patients who drink caffeine in general (382.965) is lower than the mean of those patients who have failed IVF (1022.795). There is no statistically significant difference in the mean of the biochemical pregnancy with each of the drinks separately, including coffee (mg) and soda (mg) because their p- values (0.234, 0.201) respectively, are higher than the significant level of α=0.05. the Chi-square test because the p-value (0.489) is greater than the significance lev- el of α = 0.05. Table 3 shows there is a statistically signifi- cant difference between the mean of bio- chemical pregnancy with each of the drinking tea/ mg, energy drink/mg, and total caffeine separately because their (P= 0.004, 0.044, and 0.001) respectively are less than the significant level of α=0.05.For example, the mean of successful IVF pa- tients who drink tea/mg (274.709) is lower than the mean of those patients who have failed IVF (827.273).For example, the mean of successful IVF patients who drink Table 4 shows that there is no statistically significant difference between a biochemi- cal pregnancy and BMI classification using 143 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3 :Difference between biochemical pregnancy (success and failure) with caffeine consumption Biochemical pregnancy N Mean SD t-value P-value How much tea mg/weak Success 44 274.709 314.085 -2.99 0.004 Failure 56 827.273 1178.374 How much coffee mg /weak Success 44 82.727 163.398 -1.198 0.234 Failure 56 132.031 231.373 How much soda mg/weak Success 44 27.045 69.536 -1.286 0.201 Failure 56 48.750 93.363 How much energy drink mg/weak Success 44 6.364 42.212 -2.043 0.044 Failure 56 35.000 93.439 TOTAL caffeine mg /weak Success 44 382.965 423.134 -3.435 0.001 Failure 56 1022.795 1295.720 Table 4: Association between the classification of BMI and biochemical pregnancy (success and failure) biochemical pregnancy Total Chi-square p-value Success failure classification of BMI normal F 13 14 27 1.432 0.489 % 48.1 51.9 100.0 over F 15 15 30 % 50.0 50.0 100.0 obese F 16 27 43 % 37.2 62.8 100.0 Total F 44 56 100 % 44.0 56.0 100.0 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article There is no statistically significant differ- ence between the means of biochemical pregnancy (success and failure) with each of the vigorous, moderate, walking, and total physical activities because their (P- values=0.557, 0.334, and 0.508) are higher than the significant level of α=0.05. higher than what it has been reported in our study [19]. While the mean age for in- fertile husbands in Erbil (2016) was 35.28 years [20]. The highest percentage of the age group for women looking for infertility treatment in the current study was ranged between (36 and 40) with a mean of 33 years. This is comparable to the reported mean ages of women in Erbil (2018) and (2016) which were 33.36 ± 4.5, 31.25 ± 7.0 years [17,20]. While in the UK, which mean age was 31± 6 years [21]. In Italy (2018), the women's mean age was 36.6 [19]. In our study, the mean ± SD for marriage du- ration was 9 ±5.68, while in Iraq (2015) was 7.4 ± 4.5 years [23].The majority of the Table 5 shows there is a statistically signifi- cant difference between the mean of bio- chemical pregnancy (success and failure) and walking as a physical activity because its p-value (0.017) is less than the signifi- cant level of α=0.05. For example, the mean of successful IVF patients who walk in physical activities (434.615) is higher than the mean of those patients who have failed IVF (262.232). Socio-demographic characteristic of the sample The present study aimed to assess the effect of women's lifestyle factors, such as body mass index, caffeine con- sumption, and physical activity, on the outcome of in vitro fertilization. The sub- jects in this study included (n =100) infer- tile women; the majority of the sample was in a public hospital. According to our finding, the highest percentage of the age group for the study sample (husbands) was (≥41) with a mean of 37 years. The mean age of husband in Milan, Italy in (2018) who studied 339 couples. The mean age husband who seeking infertility treatment was 39.4 years. This result 144 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 5: Difference between biochemical pregnancy (success and failure) with Physical activities Physical activity biochemical N Mean SD t-value P-value vigorous Success 4 3560.000 2678.507 0.605 0.557 Failure 9 2808.889 1783.231 moderate Success 26 434.615 709.897 0.976 0.334 Failure 28 295.000 254.944 Walking Success 44 487.875 549.038 2.426 0.017 Failure 56 262.232 317.348 Total Physical Activity Success 44 1068.330 1558.646 0.664 0.508 Failure 56 861.161 1540.145 *There is a sample missing because not all sample engaged (vigorous and moderate) activities like (swimming, or running ..) you can skip that question if you do not engage. Discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article only (20%) of participants reported drink- ing caffeinated beverages [26]. A study car- ried out on 339 infertile couples in an Ital- ian fertility clinic showed that caffeine con- sumption was not associated with a nega- tive effect on IVF outcome [19]. The finding in the present study shows that most of the study sample (44%) indicated they con- sumed 0 - 800 mg/week. Which is nearly consistent with a study conducted by Choi et al., which shows that most of the study sample consumed 0 -800 mg/week [16]. Body Mass Index: Regarding BMI, our find- ings show that the highest percentage (43%) of the sample were obese and the lower percentage was normal weight. However, this disagrees with the result of a study by Cesta et al., for 485 women re- ceiving fertility treatment, in which the highest percentage (69.9%) of the sample was of normal weight and the lowest per- centage was obese [27]. There were no statistically significant differences between the BMI and IVF outcome. However, our study is not the first that has failed to demonstrate any association between fe- male obesity and IVF outcome [28]. Similar findings have been validated in other re- cent studies, which found no link between rising female body weight and poor IVF outcome and live birth rate, showing that BMI should not be used as a cause to re- fuse IVF therapy [29]. These results are not consistent with a result of previous studies conducted by Kudesia et al., indicate that female obesity negatively affects the suc- cess of IVF [30].Physical activity: Based on the analysis, the majority (66%) of the sample has low physical activity, and the lowest percentage (9%) of the study sam- ple has high physical activity. It is worth mentioning that the results of the present study do not agree with the findings of a study by Youness in Egypt (2018) showing that the highest percentage (52%) of infer- tile women was highly active while only sample was unemployed (housewives) (75%). This finding is nearly consistent with other studies done in Erbil (2018) for 1158 infertile couples, showing that the highest percentage (73.9 %) of wives were unem- ployed [20].In this study, the highest per- centage of the sample (58%) was primary infertility. This finding is nearly consistent with other studies done in Iraq (2020), and in Erbil (2016), primary infertility (64%,63%) higher than secondary infertility [20,22]. In Duhok (2002), a primary infer- tility rate was (77.2%) and a secondary in- fertility rate was (22.8%) [23]. Regarding IVF outcome, (44%) of infertile women had a successful biochemical pregnancy (positive HCG test). These results are simi- lar to a study carried out on 107 infertile women done by Sõritsa et al., which men- tioned that (43.6%) of the women who un- derwent an HCG test had a positive result [24].Caffeine consumption: The majority (74%) of the study sample reported drink- ing caffeinated beverages such as tea, coffee, soft drinks, and energy drinks and tea was the most common source of caffeine consumption. No association was found between coffee or soda drinking and biochemical pregnancy; while there is a statistically significant difference between tea or energy drinks and biochemical preg- nancy, only caffeine consumption by wom- en was significantly associated with the biochemical pregnancy of IVF (p = 0.001). While a study conducted by Al-Saleh et al., for 619 women showed that the majority of the study sample (97%) was drinking caffeinated beverages, and coffee was the most common source of caffeine consump- tion, and there is a significant association between coffee drinking and IVF outcome [25]. These results are not coordinated with a previous study conducted in Egypt for 200 women, which reported that the majority (72%) of the study sample was not drinking any caffeinated beverage and that 145 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article Reproduction Outcomes . Womens Health. 2010 Jul 1;6(4):517–24. [5] Mangum MM. The Effects of Exercise on Success Rates of In Vitro Fertilization. Med Heal Sci Commons. 2013Aug;10:437. [6] Hey E. Coffee and pregnancy. British Medical Journal. 2007 Feb 24;334(7590):377. [7] Machtinger R, Gaskins AJ, Mansur A, Adir M, Racowsky C, Baccarelli AA, et al. Association between preconception maternal beverage intake and in vitro fertilization outcomes. Fertility and Sterility. 2017 Dec;108(6):1026– 33. [8] Banker M, Sorathiya D, Shah S. Effect of Body Mass Index on the Outcome of In-Vitro Fertilization/Intracytoplasmic Sperm Injec- tion in Women. Journal of human reproduc- tive sciences. 2017;10(1):37–43. [9] Sepidarkish M, Omani-Samani R, Mansour- nia MA, Yekaninejad MS, Mardi-Mamaghani A, Vesali S, et al. The casual effect of lifestyle factors on outcomes of assisted reproduc- tive techniques: a protocol study on Iranian infertile couples. Reproductive Health. 2018 Dec 17;15(1):210. [10] Craig CL, Marshall AL, SJ ̈ OSTRO ̈ M M, Bau- man AE, Booth ML, Ainsworth BE, et al. In- ternational Physical Activity Questionnaire: 12-Country Reliability and Validity: Medicine and science in sports and exercise. 2003 Aug;35(8):1381–95. [11] scoring_protocol.pdf [Internet]. 2005 [cited 2022 Mar 9]. Available from: https:// docs.google.com/viewer? a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFp bnx0aGVpcGFxfGd4OjE0NDgxMDk3NDU1Y WRlZTM [12] Jetté M, Sidney K, Blümchen G. Metabolic equivalents (METS) in exercise testing, exer- cise prescription, and evaluation of function- al capacity. Clinical Cardiology. 1990 Aug;13 (8):555–65. [13] Ramezanzadeh F, Kazemi A, Yavari P, Nasr- Esfahani MH, Nejat S, Rahimi-Foroshani A, et al. Impact of body mass index versus physi- cal activity and calorie intake on assisted reproduction outcomes. European Journal of Obstetrics &Gynecology and Reproductive Biology. 2012 Jul 1;163(1):52–6. [14] Salih Joelsson L, Elenis E, Wanggren K, Ber- glund A, Iliadou AN, Cesta CE, et al. Investi- gating the effect of lifestyle risk factors upon number of aspirated and mature oocytes in in vitro fertilization cycles: Interaction with antral follicle count. PloS one. 2019 Aug (29%) of infertile women was low activity [26]. The main finding of our study is that there is no statistically significant differ- ence between women's physical activity (vigorous, moderate activity) and IVF out- comes. Only there is a statistically signifi- cant difference between walking and bio- chemical pregnancy because (P=0.017). Few women in our sample engaged in vig- orous activity before IVF. This is in line with previous findings, where no associa- tions of physical activities in women be- fore and during IVF treatment with IVF outcomes such as positive HCG, clinical pregnancy and live birth were detected [24]. It has been concluded that caffeine con- sumption and physical activity (walking) are significant factors that can affect IVF outcome. [1] Petanovska Kostova E. The Interaction of Female Age and Active Male Smoking has Negative Influence on Success Rates of the in Vitro Fertilization Treatments. Balkan journal of medical genetics. 2020 Jun;23 (1):57–62. [2] Qu P, Mi Y, Zhao D, Wang M, Dang S, Shi W, et al. Effect of the Interaction Between Pre- pregnancy Body Mass Index and Fresh/ Frozen Embryo Transfer on Perinatal Out- comes of Assisted Reproductive Technology- Conceived Singletons: A Retrospective Co- hort Study. Frontiers in Endocrinology [Internet]. 2020 [cited 2021 Jul 15];0. Availa- ble from: https://www.frontiersin.org/ articles/10.3389/fendo.2020.560103/full [3] Rao M, Zeng Z, Tang L. Maternal physical activity before IVF/ICSI cycles improves clini- cal pregnancy rate and live birth rate: a sys- tematic review and meta-analysis. Repro- ductive Biology and Endocrinology. 2018 Feb 7;16:11. [4] Ferreira RC, Halpern G, de Cássia Savio Figueira R, de Almeida Ferreira Braga DP, Iaconelli A, Borges E. Physical Activity, Obe- sity and Eating Habits Can Influence Assisted 146 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. CONCLUSION REFERENCES https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article a longitudinal study exploring the associa- tions with controlled ovarian stimulation and pregnancy outcomes. Journal of assisted reproduction and genetics. 2020 Aug 1;37 (8):1869–81. [25] Al-Saleh I, El-Doush I, Grisellhi B, Coskun S. The effect of caffeine consumption on the success rate of pregnancy as well various performance parameters of in-vitro fertiliza- tion treatment. International Medical Sci- ence Monitor. 2010 Nov;16(12):CR598-605. [26] Youness EM. Lifestyle factors between fertile and infertile women at Assiut Women’s Health Hospital. Egyptian Nursing Journal. 2018;15(1):9. [27] Cesta CE, Johansson ALV, Hreinsson J, Rodri- guez-Wallberg KA, Olofsson JI, Holte J, et al. A prospective investigation of perceived stress, infertility-related stress, and cortisol levels in women undergoing in vitro fertiliza- tion: influence on embryo quality and clinical pregnancy rate. Acta Obstetricia et Gyneco- logica Scandinavica. 2018 Mar;97(3):258–68. [28] Styne-Gross A, Elkind-Hirsch K, Scott Jr RT. Obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation. Fertili- ty and sterility. 2005 Jun 1;83(6):1629–34. [29] Friedler S, Cohen O, Liberty G, Saar-Ryss B, Meltzer S, Lazer T. Should high BMI be a reason for IVF treatment denial? Gynecolog- ical Endocrinology. 2017 Nov 2;33(11):853– 6. [30] Kudesia R, Wu H, Hunter Cohn K, Tan L, Lee JA, Copperman AB, et al. The effect of female body mass index on in vitro fertiliza- tion cycle outcomes: a multi-center analysis. Journal of Assisted Reproduction and Ge- netics.2018 Nov 1;35(11):2013–2 [31] Blbas HT, Aziz KF, Nejad, SH, & Barzinjy AA. Phenomenon of depression and anxiety re- lated to precautions for prevention among population during the outbreak of COVID-19 in Kurdistan Region of Iraq: Based on ques- tionnaire survey. Journal of Public Health. 2020 Jun 10:1-5. doi:10.1007/s10389-020- 01325-9 16;14(8):e0221015. [15] Wilcox A, Weinberg C, Baird D. Caffeinated beverages and decreased fertility. The Lan- cet. 1988 Dec;332(8626–8627):1453–6. [16] Choi JH, Ryan LM, Cramer DW, Hornstein MD, Missmer SA. Effects of caffeine con- sumption by women and men on the out- come of in vitro fertilization. Journal of Caffeine Research. 2011 Mar;1(1):29–34. [17] Hussein MJ, Alalaf SK, Al-Tawil NG. Effect of maternal age on the ovarian reserve mark- ers, and pregnancy outcome in a sample of Kurdish women in Erbil city. Zanco Journal of Medical Sciences. 2018 Apr 1;22(1):8 _ 16 -8 _ 16. [18] What is HCG? [Internet]. American Pregnan- cy Association. 2021 [cited 2022 Dec 9]. Available from: https:// americanpregnancy.org/getting-pregnant/ hcg-levels/ [19] Ricci E, Noli S, Cipriani S, La Vecchia I, Chi- affarino F, Ferrari S, et al. Maternal and pa- ternal caffeine intake and ART outcomes in couples referring to an Italian fertility clinic: a prospective cohort. Nutrients. 2018 Aug 17;10(8):1116. [20] Ahmed AS, Othman SM. Patterns of infertili- ty among couples attending IVF center in maternity teaching hospital in Erbil. Zanco Journal of Medical Science (Zanco J Med Sci). 2016;20(3):1467_1475-1467_1475. [21] Wilkes S, Chinn DJ, Murdoch A, Rubin G. Epidemiology and management of infertili- ty: a population-based study in UK primary care. Family Practice. 2009 Aug 1;26(4):269– 74. [22] MATIN HH, SEHHATI SF, Zoodfekr L. compar- ing menarche age, Menstrual regularity, Dysmenorrhea and analgesic consumption among athletic and non-athletic female stu- dents at universities of Tabriz-Iran. Interna- tional Journal of Women’s Health and Re- production Sciences.2014 Jan 1;2(5):307– 10. [23] Hasan NA, Abdulhameed WA, Rahim AI. Correlation Among Obesity, Oocyte Charac- teristics, Embryo Characteristics and Mater- nal Plasma Folate Level in a Sample of Iraqi Women Undergoing Intracytoplasmic Sperm Injection (ICSI). Iraqi Journal of Embryos Infertility Researches. 2020 Dec 13;10:1–19. [24] Sõritsa D, Mäestu E, Nuut M, Mäestu J, Mi- gueles JH, Läänelaid S, et al. Maternal physi- cal activity and sedentary behaviour before and during in vitro fertilization treatment: 147 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/