Comparison of Assisted Reproductive Technology (ART) Outcomes between Fasting during Ramadan, Pre and Post Ramadan Patients: A Retrospective Study

Background: Infertility is a problem that affected all aspect of life in couples. Infertility treatment create stressful condition for patients and control of this stress is effective for success rate of pregnancy. Ramadan is a holy month for Muslims and they believe that Ramadan can effect on their spiritual lives and they become closer to God. So we think that maybe Assisted Reproductive Technology (ART) outcomes improve in the fasting patients during Ramadan. The aim of this study was to evaluate the outcome of ART in fasting patients during Ramadan and compare with non-fasting pre and post Ramadan.

Methods: In this retrospective study, we reviewed the demographic, clinical and laboratory records of 367 patients who were in treatment plan in Ramadan, 424 patients in pre and 386 in post Ramadan. All data including Age, number of retrieved oocytes, matured oocytes, types of ART procedures, number of fertilized oocytes, number of transferred embryo, pregnancy rates were collected from the hospital records. The data analyzed by SPSS v 16. The level of significance was p < 0.05.

Results: We analyzed 1177 case in 3 groups. There was an increase in the ART outcomes including Number of COC, oocyte, ET and pregnancy rate, however, this difference was not statistically significant.

Conclusion: Although, positive results were slightly higher in Ramadan, but it was not statistically significant. We conclude that fasting during Ramadan has no significant negative effect on the outcomes of ART. More studies needed to evaluate hormonal and psychological parameters in ART patients during Ramadan.

Infertility is the inability to conceive a child after a year of regular sexual intercourse without contraception the woman has not become pregnant (and there is no other reason, such as breastfeeding or postpartum amenorrhea). Primary infertility is infertility in a couple who have never had a child. Secondary infertility is failure to conceive following a previous pregnancy [1].

Prevalence of infertility varies depending on the definition, i.e. on the time span involved in the failure to conceive [2]. Some estimates suggest that worldwide 15-30% of couples have an problem of infertility [3,4].

The Assisted Reproductive Technology (ART) was used for infertility treatment and infertility treatment process can induce the stress and psychological disturbances in infertile couples [5]. Boivin J, et al. [6] reported that stress resulting from infertility has direct and indirect effects on treatment and pregnancy outcome.

Psychological stress and coping styles may also play a role in the success rate of ART [7]. In psychological science, coping, refers to strategies that a person does in response to stress in his life and occurs when encounter to a situation, and its success can be related to his behaviors and emotions [8]. There was several coping strategies that one of them is religious coping [9].

Religious coping can be helpful in several ways include of spiritual support through relationship with God, charitable religious reframing that a person uses positive religious terms in dealing with life problems [10].

Ramadan, is a holly month for one billion Muslims in the world and it is the time for devotion to God and self-control. Muslims believe that Ramadan can effect on their spiritual lives and they become closer to God in this month [11]. Several studies assessed the effect of fasting during Ramadan on some aspects of physiological, biological and psychological in human body [12-16]. To date our research findings about fasting during Ramadan and ART outcome showed only one study published in this issue and the result of this study showed In Vitro Fertilization (IVF) and Intra Cytoplasmic Sperm Injection (ICSI) outcome doesn’t have a significant changes between fasting and non-fasting patients during Ramadan but depression and anxiety was decreased in fasting patients [17].

Whereas fasting was effective in reducing stress in infertile couples and this may be improves the outcomes of ART, then the aim of this study was to know the effect of fasting during Ramadan on ART outcome in comparison with pre and post Ramadan.

This study was approved by the Ethics Committee of Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran (IR.SSU.RSI.REC.1390.31). In this retrospective cohort study, we reviewed the demographic, clinical and laboratory records of 367 patients who were in treatment plan in Ramadan and at least into 3-10 days fasting, at oocyte puncture, in vitro fertilization and fresh Embryo Transfer (ET) cycle in Ramadan were enrolled the study. All data collected from over a 10-years period from 2010 to 2020. Women in frozen thawed embryo transfer cycle were excluded from study. 424 patients in pre Ramadan and 386 in post Ramadan who were matched to case group randomly selected as a non-fasting control group.

Data were collected from the hospital records. All data including Age, number of retrieved oocytes and matured oocytes, types of ART procedures, number of fertilized oocytes, zygote and embryo scores, number of transferred embryo, clinical pregnancy rates were recorded in computer system.

Statistical analysis

Data was analyzed using Statistical Package for the Social Sciences 20.0 (SPSS, SPSS Inc, Chicago, Illinois). Quantitative variables were presented as mean ± Standard Deviation (SD) and compared with Analysis of Variance (ANOVA) test and Kruskal-Wallis test based on their distribution pattern assessed by Kolmogorov-Smirnoff test. Qualitative variables were expressed as percentages and analyzed by Chi-square test. p-value less than 0.05 considered statistically significant.

We analyzed 1177 case in 3 groups. The mean age of female was, 30.75 ± 5.49 and in male 35.51 ± 6.32 years old (Table 1). As we showed in table 1 the patients was homogeny and there was not statistically significance between demographic parameters between groups.

Table 1: Demographic parameters in study groups.
Factors	Pre-Ramadan 424	Ramadan 367	Post-Ramadan 386	p-value
Female age (Years)	30.79  ±  5.48	30.81 ± 5.43	30.66 ± 5.56	NS
Male age (Years)	35.06 ± 6.01	35.84 ± 6.56	35.68 ± 6.39	NS
Infertility duration (Years)	8.33 ± 4.74	9.02 ± 7.11	8.64 ± 5.05	NS
Data presented as Mean ± SD. p-value ≤ 0.05 was considered significant. Note: NS: Not Significant.

In table 2 all of data about Art parameters were showed. In Ramadan month the number of follicles and oocytes was higher than other months but there was not significantly different between Ramadan and other months (p = 0.1).

The outcome of pregnancy were similar in three groups and was not statistically significant between groups (Table 2).

Table 2: ART parameters and outcome of pregnancy in study groups.
ART Parameters	Pre-Ramadan 424	Ramadan 367	Post-Ramadan 386	p-value
Follicle (COC) (n)	13.76 ± 21.08	15.13 ± 23.59	12.01 ± 17.00	NS
Oocyte  MII (n)	11.41 ± 21.40	13.28 ± 24.51	10.44 ± 17.88	NS
Embryo transfer (n)	2.44 ± 0.87	2.79 ± 5.77	2.52 ± 1.41	NS
ART procedure IVF n (%) ICSI n (%) ZIFT n (%)	90 (21%) 329 (77.8%) 5 (1.2%)	78 (21.3%) 286 (77.9%) 3 (0.8%)	64 (16.5%) 316 (81.9%) 6 (1.6%)	NS
Outcome Positive n (%) Negative n (%)	106 (25%) 318 (75%)	102 (17.8%) 165 (72.2%)	95 (24.6) 29 (75.4)	NS

Quantitate variables presented by mean ± SD. Qualitative variables presented by numbers and percentage. p-value below 0.05 were considered significant. Note: ART: Assisted Reproductive Technique; COC: Cumulus Oophorous Cell; IVF: In Vitro Fertilization; ICSI: Intra- cytoplasmic Sperm Injection; ZIFT: Zygote intra-fallopian transfer; NS: Not Significant.

In the present study we compared ART outcomes between Ramadan with pre and post Ramadan. Ramadan is the holly month and Muslims restricted to eating and drinking in day to sunset. People with disease, pregnant women, breastfeeding mothers, travelers are exempted from fasting. During this month some aspects of life altered specially in food quantity, eating times and sleep quality [18]. In other side Ramadan can effect on emotional and psychological aspects of life because this is based on Muslims religious believes [19].

Several studies have published and assessed the effect of fasting on some biological activity, hormonal and physiological system in human body [12,20]. In the reproductive and pregnancy issues, researchers focused on the effect of fasting on menstrual cycle [19] and neonatal outcome in pregnant women [21]. In a study Awwad J, et al. [22] reported fasting in Ramadan cannot increase the preterm delivery risk. Infertility and its treatment in general is a stressful condition for both of couples. Psychologists believe reduction of stress and anxiety in infertile patients can help them to have a successful pregnancy [23]. Psychological stress can change the secretion of gonadotropins, local effects on the uterus and functions of ovarian ducts and fertilization, by changing the immune logical process. Also stress can alter patterns of cortisol secretion during the menstrual cycle and finally had negative effect on the hormonal profile in the fertilization process. Norepinephrine and cortisol concentration as a biological stress markers may negatively influence the outcome of IVF and ICSI [24].

Studies have shown the use of self-management and religious believes was effective for patients with depression and anxiety [25], cancer [26], Multiple Sclerosis (MS) [27] and recovery after surgical operation [28].

The result of present study showed there was an increase in the ART outcomes including Number of COC, oocyte, ET and pregnancy rate, however, this difference was not statistically significant.

Wahba KA [17] published a study and assessed the outcome of IVF and ICSI in Ramadan. He compared the outcome of the procedures in fasting and non-fasting patients. The result of his study showed outcome of IVF and ICSI doesn’t increase in fasting patients in comparison with non-fasting patients. The finding of our study is similar to his study. Also the result of psychological aspects including depression and anxiety in his study showed a significant decrease in depression and anxiety in fasting patients.

Hence based on our search to date only one paper was published to assessment fasting on fertility treatment outcome and our study was second in this issue, it seems that more studies are necessary for assessing the effects of fasting during Ramadan on ART outcome. Our result showed ART outcome in fasting patients during Ramadan was better than pre or post Ramadan, but this increasing was not statistically significant.

The limitation of this study was retrospective and so we don’t have any data in psychological aspect of infertility and treatment procedures condition, but we propose a prospective study and it can be measured the rate of their stress along with religion believes and also hormonal levels, for example cortisol, in patients, before and after Ramadan.

The authors grateful to the Monavar Naderi and Zahra Ahmadi for helpful comments in journal search.

Conflict of Interest

The authors have no financial or nonfinancial conflicts of interest.

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