New Debate: Is It Time for Infertility Weight-loss Programmes to be Couple-based?

Damian Best; Alison Avenell; Siladitya Bhattacharya; Gertraud Stadler


Hum Reprod. 2017;32(12):2359-2365. 

In This Article

What Is Needed for a Couple-based Intervention?

Need for a Systematic Approach to Intervention Development

The existing studies have a number of weaknesses. First, most suffered from small sample sizes. Second, few studies have been conducted outside the United States. Strong cultural differences in eating, physical activity and close relationships call for adequately powered studies in other countries to establish the generalizability of these findings. Third, most studies were not based on systematic intervention development such as an intervention mapping approach (Eldredge et al., 2016). Studies based on systematic intervention development draw on theory and behaviour change methods; thus, they have the potential to focus interventions on the active ingredients of behaviour change, and systematically improve intervention effect sizes and weight-loss maintenance. In summary, the current evidence underlines the need for systematic intervention development in this field.

Need for a Tailored Intervention

A weight-loss intervention for couples seeking fertility treatment would need to be tailored to the individual needs of both partners. If both partners are obese or overweight, the intervention would need to focus on weight loss in both partners. For non-obese partners, the intervention would focus on supporting weight loss in the obese partner and changing relevant health behaviours for the non-obese partner, for example, eating a healthier diet or becoming more active.

Need for Measures to Maximize Retention

As stated above, a prior review of intervention studies for overweight and obese infertile women had a median discontinuation rate of 24% (Mutsaerts et al., 2013), with lesser weight loss and fewer spontaneous pregnancies in dropouts compared to retained participants. Measures to maximize retention will therefore be critical in the design of future lifestyle interventions for infertile women and their partners. These could encompass tailored information and behavioural recommendations based on participants' prior knowledge and preferences (e.g. offering individualized sessions to develop behavioural recommendations).

Need to Address a Comprehensive set of Behavioural Outcomes for Fertility

An intervention for overweight partners should include standard recommendations for a calorie-reduced diet, and could include meal replacements, dependent on participant preference. Prior trials have found that exercise alone has minimal effects on weight loss (Franz et al., 2007). However, exercise may help to maintain weight loss, and may be important to include, particularly for its ability to appeal to the male partner (Robertson et al., 2014). Thus, the intervention should include a behavioural goal to increase physical activity, such as gradually increasing walking towards a daily 10 000-step goal, or by taking at least 30 min of moderate-to-vigorous activity per day. Non-overweight partners could receive a standard recommendation to eat a healthy diet and increase physical activity, if necessary. Because general recommendations for infertile couples' treatment include advice regarding alcohol and smoking, the intervention should include elements to support either partner in quitting these habits as required. Last, but not least, a couples' intervention could also include a module to improve social processes to facilitate behaviour change.

Need for a Better Understanding of Underlying Social Processes in Weight Loss

Few trials so far have assessed the underlying social processes in weight loss, even with inclusion of social network members in some studies. Therefore, there is ample room for improvement in delineating active ingredients and optimizing these interventions. Behaviour change methods aimed at changing social support and social influence should boost effects when a behaviour is at least partly influenced by the social environment (Eldredge et al., 2016). Baseline data from a weight-loss trial in women (Kiernan et al., 2012) found low support from family and friends. Many women reported 'never' or 'rarely' receiving support for healthy eating (from family: 77.9%, from friends: 90.3%) or for physical activity (from family: 77.2%, from friends: 87.6%). Women also reported some sabotaging behaviour from close others, e.g. they 'ate high-fat or unhealthy foods in front of me' or they 'refused to eat healthy or low-fat foods with me'.

The few available trials including partners have used a variety of intervention approaches. These have included partner training for social support to increase positive reinforcement (e.g. praise), role modelling healthier eating, setting goals and focusing on problem solving; also reduction of negative social control including criticism, punishment and nagging (McLean et al., 2003). To identify the social processes most relevant to couples seeking fertility treatment, it will be necessary to study support, but also processes that have received less attentions such as social control, companionship, person-to-person contact, and access to resources and material goods (Berkman et al., 2000). Skilled support and positive influence should facilitate behaviour change (Cutrona and Russell, 1990; Rafaeli and Gleason, 2009; Scholz et al., 2013). Diminishing negative control and sabotaging behaviours (e.g. tempting the dieting partner with high-caloric food) should benefit weight loss additionally (Gorin et al., 2014). Last but not least, the intervention should also promote relationship-strengthening behaviours such as companionship and emotional and physical intimacy (e.g. date nights, joint fun activities) to counter the distress and irritability that accompanies attempts at behaviour change.

A Weight-loss Intervention Will Need State-of-the-art Methodology

It is feasible and acceptable to use real-time assessments via smartphone apps, passive sensors, and text messages in individuals and couples. Examples have been given for diet (Inauen et al., 2016), physical activity (Berli et al., 2016), alcohol intake (Muench et al., 2017) and for smoking. These assessments could boost intervention effects and facilitate the maintenance of behaviour change. These methods should be tested in couples experiencing fertility problems, underscoring the need for careful pilot work during intervention development.