The prevalence of eating disorders in infertile women

The prevalence of eating disorders in infertile women Melissa Freizinger, Ph.D.,a Debra L. Franko, Ph.D.,b Marie Dacey, Ed.D.,c Barbara Okun, Ph.D.,b and Alice D. Domar, Ph.D.d a Laurel Hill Inn, Medford; b Northeastern University, Boston; c Massachusetts College of Pharmacy and Health Sciences, Boston; and d Boston IVF, Beth Israel Deaconess Medical Center, Harvard Medical School, Waltham, Massachusetts Objective: To determine the prevalence of eating disorders in a sample of infertile women. Design: A descriptive comparative two-group design in which collected data were compared with a published community sample. Setting: Private infertility center. Patient(s): Eighty-two participants beginning their first gonadotropin/intrauterine insemination (IUI) treatment cycle completed self-report measures that assessed eating disorder pathology and exercise habits. Each subject was telephone-administered the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) Module H (Eating Disorders) and a demographic questionnaire. Intervention(s): None. Main Outcome Measure(s): Past or current diagnosis of an eating disorder. Result(s): Seventeen participants (20.7%) met criteria for a past or current eating disorder, which is five times higher than the U.S. lifetime prevalence rate. None of the participants who met the criteria for an eating disorder had disclosed their past or current diagnosis to their reproductive endocrinologist. Conclusion(s): Infertility clinics are likely to be treating women with a past or current eating disorder history. Therefore, an eating disorder screening tool should be included in the initial intake, because these patients may be at a higher risk for negative maternal and fetal outcomes than non–eating disorder patients. Additionally, patients with a past or current eating disorder may not disclose this information to reproductive health care providers, which may limit providers’ ability to provide appropriate medical and psychologic referrals. (Fertil SterilÒ 2010;93:72–8. Ó2010 by American Society for Reproductive Medicine.) Key Words: Infertility, eating disorders, prevalence, anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified, binge eating disorder Eating disorders (EDs) are serious psychological and medical illnesses that negatively affect the reproductive health of women. Research has documented that the consequences of an undetected ED in pregnant women can severely and negatively affect the health of the mother and the unborn infant (1–3), including higher risk for low birth weight, miscarriage, and birth defects. There is also evidence that previous or current EDs negatively affect women’s fertility (4–6). Little data exist on the prevalence of EDs in women seeking infertility treatment. The only study published to date (7) screened 66 infertility patients for EDs, finding that 7.6% of these patients could be diagnosed with past or current anorexia nervosa (AN) or bulimia nervosa (BN). When the diagnosis of EDs not otherwise specified (EDNOS) was included, 16.7% of these patients met criteria for an ED. This rate is two to four times higher than seen in general pracReceived May 20, 2008; revised September 12, 2008; accepted September 16, 2008; published online November 11, 2008. M.F. has nothing to disclose. D.F. has nothing to disclose. M.D. has nothing to disclose. B.O. has nothing to disclose. A.D. has nothing to disclose. Presented in part at the International Conference on Eating Disorders, Baltimore, Maryland, May 4, 2007. Reprint Requests: Melissa Freizinger, Ph.D., Laurel Hill Inn, 121 Mystic Street, Medford, MA 02155 (FAX: 781-391-9977; E-mail: mfreizin@aol. com). 72 tice studies of women in this age group (7). Of the women in this study who were diagnosed with menstrual problems, specifically amenorrhea or oligomenorrhea, 58% met criteria for an ED. Although those results were compelling and warranted further research, there have been no additional published reports since that 1990 study. Therefore, the primary objective of the present study was to determine the prevalence of EDs in an infertile sample of women. A second objective was to assess differences in demographics, exercise habits and ED psychopathology between infertile women who have an ED and those who do not. The final objective was to assess the selfdisclosure rate of EDs by infertility patients to their infertility health care providers. MATERIALS AND METHODS Recruitment and Procedures Approval for this study was granted by the Committee on Clinical Investigations at the Beth Israel Deaconess Medical Center and the Institutional Review Board at Northeastern University, Boston, Massachusetts. All English-speaking patients scheduled to start folliclestimulating hormone (FSH) injections for infertility treatment at Boston IVF (BIVF) from February 2005 to April Fertility and Sterilityâ Vol. 93, No. 1, January 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc. 0015-0282/10/$36.00 doi:10.1016/j.fertnstert.2008.09.055 2006 were eligible for the study. As part of BIVF procedures, all patients are required to participate in an initial telephone call with a BIVF nurse who reviews information regarding patients’ upcoming injections. Each patient was asked whether she would be interested in participating in a research study that assessed the health and eating habits of women undergoing infertility treatment. Patients were also told that the research involved a one-time telephone interview and completion of a questionnaire packet. If the patient agreed to participate, the nurse informed her that she would receive a phone call from the study’s principal investigator (PI; M.F.) at the patient’s preferred time and day. Patients were informed that refusal to participate would not affect their medical treatment in any way. The nurse documented whether the patient agreed or declined to be in the study. Patients were not asked for further elaboration if they refused to participate in the research. When an individual agreed to participate, she was scheduled for the telephone interview and was mailed a packet of self-report questionnaires. Of the 123 eligible patients invited to participate, 82 patients accepted, a 67% acceptance rate. The PI contacted each participant via phone, gained verbal consent, and administered two structured interviews, the Structured Clinical Interview for DSM-IV (SCID) Module H–Eating Disorders (8), and an investigator-developed Brief Demographic Form. The self-report questionnaires (Eating Disorder Examination Questionnaire [EDE-Q], International Physical Activity Questionnaire [IPAQ], and Lifestyle Questionnaire) were mailed back to the PI; however, to avoid investigator bias, none of the measures were reviewed until all of the structured telephone interviews were completed. Measures The SCID Module H is a semistructured diagnostic interview designed to assist clinicians and researchers in making reliable DSM-IV psychiatric diagnoses (8). The SCID Module H was used to diagnose participants for a past or current ED. The SCID Module H differentiates among three defined EDs: AN, BN, and binge eating disorder (BED). A diagnosis of EDNOS may also be ascertained by matching the participant’s answers to the DSM-IV criteria for EDNOS. There is not a separate category in the SCID for EDNOS; therefore, the authors of the tool recommended using the DSM-IV criteria combined with the SCID H module to diagnosis EDNOS (9). The Brief Demographic Form is an investigator-generated 11-item measure designed to attain basic demographic information (i.e., age, marital status, education, menstrual cycle status, length of infertility, and medical diagnosis). This measure also inquires as to whether or not participants have a prior ED history and whether or not they informed their current infertility doctors of any past or current ED diagnoses. The EDE-Q is a 28-item self-report measure adapted from the Eating Disorder Examination (10, 11). The EDE-Q has four subscales (dietary restraint, eating concerns, shape conFertility and Sterilityâ cerns, and weight concerns), which measure the frequency of ED behaviors and attitudes and reflect the severity of the psychopathology of the ED, and a global score which is an overall measure of ED psychopathology. The EDE-Q assesses both severity and diagnostic items over the previous 28 days. The test-retest reliability and internal consistency of the EDE-Q showed 2-week test-retest coefficients ranging from 0.81 to 0.94 for the four EDE-Q subscales, with Cronbach alpha coefficients ranging from 0.78 to 0.93 (12). The test-retest reliability for binge eating episodes was lower (r ¼ .68). The EDE-Q has high internal consistency and is appropriate for use in two-phase screening studies (13). Normative data from a community sample is available for comparative purposes. Normative data for the EDE-Q was established using a community sample of 243 women with a mean age of 26.6 years. (11). This community sample consisted of female volunteers who were selected at random from the case registers of two general medical practices in England representing both rural and suburban settings. The IPAQ short form is a self-report seven-item measure of physical activity behavior over the past 7 days (14). Vigorous and moderate intensity activities (at least 10 min in duration) are measured separately in hours, minutes, and days. One measure of the volume of activity can be computed by weighting each type of activity by its energy requirements, defined in metabolic equivalents (METs), to yield a score in MET-minutes. Computation of the total score requires summation of the duration (in minutes) and frequency (days) of walking and moderate-intensity and vigorous-intensity activities. The IPAQ instrument is recommended as a viable method of monitoring levels of physical activity for populations ranging from 18 to 69 years of age (14). Studies that have investigated the short-term test-retest reliability and validity of both the short and long IPAQ instruments indicate 0.80 reliability and good concurrent and criterion validity (15). Data collected using the IPAQ are reported as a continuous variable. The Lifestyle Questionnaire is an investigator-generated dichotomous 19-item self-report survey that gathers information about past and current health habits, including caffeine intake and nicotine and alcohol use. The questionnaire also queries participant’s lifetime usage of alternative medicine, antidepressants, and antianxiety medicines, average hours of sleep per night, and whether or not they have a chronic and major medical condition. After each question, participants are asked whether or not they shared this information with their reproductive endocrinologist. Data Analysis All responses to the administered measures were coded for data entry and participants were assigned identification numbers. Random range checking was performed to ensure that the coding was entered correctly. Data were analyzed using SPSS for Windows, version 13 (SPSS, Chicago, IL), and SAS (SAS Institute, Cary, NC) software. 73 TABLE 1 Demographic comparisons of eating disorder and non–eating disorder groups. Eating disorders (n [ 17) No eating disorders (n [ 65) P valuea Characteristic Age, yrs, mean (SD) Education, yrs, mean (SD) Spouse’s education, yrs, mean (SD) Ethnicity, n (%) Caucasian Asian African American Hispanic Other Marital Status, n (%) Married Single Height, in, mean (SD) Weight, lbs, mean (SD) a 35.5 (3.8) 16.1 (2.4) 15.7 (2.9) 35.2 (4.1) 16.5 (2.8) 16.3 (2.7) .764 .537 .442 .444 16 (94%) 1 (6%) 0 (0) 0 (0) 0 (0) 53 (83%) 6 (9%) 1 (2%) 3 (5%) 1 (2%) 16 (94%) 1 (6%) 65.5 (3.3) 157.8 (51.8) 64 (99%) 1 (2%) 64.7 (2.9) 149.9 (35.1) .374 .291 .459 Independent-sample t test assuming equal variance was used except where noted. Freizinger. Eating disorders in infertile women. Fertil Steril 2010. Eating disorder prevalence rates were determined using the participants’ diagnoses from the SCID Module H. Participants were categorized as having either a lifetime ED or no ED. Eating disorder participants were categorized by ED diagnosis, and then assessed to determine if the ED was a past or current diagnosis. The lifetime prevalence rate was used for all women with either a past or current ED. The entire sample was divided into those who reported a past or present ED (ED group), and those who reported no ED (non-ED group). To determine participants’ physical activity levels using the IPAQ, four different criterion variables were calculated: the amount of minutes per week of vigorous activity, moderate activity, walking activity, and total activity. Average frequency of total weekly exercise minutes was computed for ED and non-ED groups. Descriptive statistics were applied to describe and summarize the ED and non-ED groups. Significant differences between groups on the brief demographic form, lifestyle questionnaire, and IPAQ were examined using t tests. Data were adjusted for heterogeneity of variance if necessary. A multivariate analysis of variance was performed to determine if there were overall significant differences in eating disordered behaviors between the ED and non-ED groups when compared simultaneously on the five subscales of the EDE-Q. Follow-up t tests for independent samples were also conducted, with equal variances assumed except for the global and eating concerns subscale; t tests for independent samples assuming nonequal variance were used on the global and eating concerns subscale. Further analysis examined whether eating disordered behaviors for ED and non-ED groups were significantly differ74 Freizinger et al. Eating disorders in infertile women ent from community norms (11). Single sample t tests were used to compare each of the five subscales of the EDE-Q for each group to published community norms. RESULTS Prevalence Rates of Eating Disorders in Infertile Women Seventeen participants (20.7%) met the criteria for a past or current ED based on the SCID Module H criteria. Five participants (6.09%) met criteria for a current ED, which in all cases was a diagnosis of EDNOS. Seven participants (8.5%) had a past diagnosis of AN. No participants had a current diagnosis of AN. Two participants (2.4%) had a past diagnosis of BN–purging type. None of the participants had a current diagnosis of BN. Three participants (3.6%) met criteria for a past diagnosis of EDNOS, specifically BED. Of the five participants (6.9%) with a current diagnosis of EDNOS, four (4.8%) met criteria for BED. Therefore, a total of eight participants (9.7%) met lifetime prevalence for EDNOS. Of the total participants diagnosed with a past or current ED (n ¼ 17), 47.5% met criteria for a current or past diagnosis for EDNOS. Nondisclosure of Eating Disorders to Health Care Providers The majority (76.4%) reported during the interview that they did not disclose their ED history or current ED to their infertility health provider, and the remainder (23.6%) did not respond to the question. Thus, there is no evidence that any of the participants reported their ED history or current symptoms to their reproductive endocrinologist. Comparisons Between ED and Non-ED Participants: Demographic and infertility characteristics Table 1 demonstrates that there were no statistically significant differences Vol. 93, No. 1, January 2010 TABLE 2 Infertility characteristic comparisons between eating disorder and non-eating disorder groups. Characteristic Eating disorder (n [ 17) Infertility diagnosis, n (%) Unexplained Male factor Other PCOS Menstrual, n (%) Amenorrhea Oligomenorrhea Other Normal Infertility duration, mos, mean (SD) Infertility treatment duration, mos, mean (SD) No eating disorder (n [ 65) P valuea .772 10 (59%) 2 (12%) 3 (18%) 2 (18%) 44 (68%) 4 (6%) 9 (14%) 8 (12%) 2 (12%) 2 (12%) 0 (0%) 13 (77%) 21.7 (10.1) 1 (2%) 20 (31%) 1 (2%) 42 (66%) 27.8 (26.4) .351 6.6 (27.7) 8.1 (14.3) .373b .097 Note: PCOS ¼ polycystic ovary syndrome. a Owing to insufficient expected cell sizes, the Freeman-Halton test for independence between the demographic variables and the cohort variable was used. b Independent-sample t test assuming nonequal variance was used. Freizinger. Eating disorders in infertile women. Fertil Steril 2010. in demographic characteristics between the ED and non-ED groups. Table 2 demonstrates that there were no statistically significant differences in infertility characteristics between the two groups. Body mass index Each participant self-reported weight and height on the EDE-Q. Body mass index (BMI) was then calculated using the online BMI calculator from the Department of Health and Human Services (16). Participants’ BMI were categorized as underweight (<18.5), normal (18.5–24.9), overweight (25–29.9), or obese (R30). Over one-half (58.5%) of the total sample had a normal BMI (n ¼ 48), 25.6% of participants were overweight (n ¼ 21), and 15.9% of the participants were obese (n ¼ 13). No participants fell into the underweight range. No significant differences in BMI or specific categories were found between the ED and non-ED groups. Eating disorder psychopathology Three of the four EDE-Q subscales and the global score were significantly different between the two groups, as shown in Figure 1. The ED and non-ED groups differed significantly on the global scores [t(20) ¼ 2.23; P¼.037], the eating concerns subscale [t(18) ¼ 2.51; P¼.022], the shape concerns subscale [t(80 ¼ 2.36; P¼.020), and the weight concerns subscale [t(80) ¼ 2.45; P¼.038]. The two groups did not differ on the dietary restraint subscale [t(80) ¼ .923; P¼.359]. Comparison with the normative community sample. Table 3 displays the results of the single-sample t tests for the global score and the four subscales of the EDE-Q. The entire sample (ED group and non-ED group combined) scored significantly higher than the community norm on the global subscale of the Fertility and Sterilityâ EDE-Q. On the dietary restraint subscale, neither group differed significantly from community norms. On the eating concerns subscale, the non-ED group did not differ from the norm, whereas the ED group was significantly higher than the norm. On the shape concerns subscale, both the ED group and the non-ED group scored significantly higher than the community norm. On the weight concerns subscale, only scores from the ED group were significantly higher than the community norm. Lifestyle behaviors No significant differences between the ED and non-ED groups were observed on any of the four exercise variables. The differences between groups regarding alcohol consumption were not significant. Most participants in this study did not consume more than the weekly recommended amount by the American Heart Association guidelines (17). Similarly, none of the study participants smoked cigarettes and therefore there were no significant differences between the ED group and the non-ED group. DISCUSSION The lifetime prevalence rate of EDs for women has been estimated to be 1% to 4% (18–21). In the present study, 20.7% of the participants met criteria for a past or current ED, which is over five times the U.S. prevalence rate (18). Interestingly, 8.53% of the participants met past criteria for AN. Women’s lifetime prevalence estimates for AN range from 0.3% to 3.7% (14). Therefore, the participants in the present study had more than twice the lifetime prevalence rate for AN. However, this was not the case for participants who met past criteria for BN. These participants had a prevalence 75 TABLE 3 FIGURE 1 Study group means (SD) compared with community sample (CS). EDE-Q study group comparisons. 3 Scale Average Score 2.5 2 Eating Disorder Group 1.5 1 No Eating Disorder Group 0.5 0 Dietary Restraint Eating Concerns* Shape Concerns* Weight Global Score* Concerns* Dietary restraint Eating concerns Shape concerns Weight concerns Global score ED Non-ED CS 1.50 (1.40) 1.21 (1.10) 0.94 (1.09) 1.12* (1.21) 0.36 (0.60) 0.26 (0.59) 2.67* (1.57) 1.82* (1.25) 1.33 (1.09) 2.29* (1.43) 1.46 (1.19) 1.18 (0.92) 1.90* (1.23) 1.19* (0.82) 0.93 (0.80) EDE-Q Scales Freizinger. Eating disorders in infertile women. Fertil Steril 2010. Note: ED ¼ eating disorder; Non-ED ¼ no eating disorder. * P< .05. Freizinger. Eating disorders in infertile women. Fertil Steril 2010. rate of 2.4%, which is within the U.S. lifetime prevalence rate of 1% to 4% (20,21). Although there are no prevalence studies for EDNOS (22), EDNOS is a diagnosis that is given to over 50% of all patients with EDs who present to outpatient treatment centers (20). This diagnosis encompasses a wide variety of symptoms. A diagnosis of EDNOS may be given to patients who may meet all but one criterion for AN or BN or meet criteria for BED. The percentage of participants in the present study who met past or current criteria for EDNOS was 9.8%. Of the participants who met past or present criteria for an ED, 47.1% had a diagnosis of EDNOS, a rate that is similar to the national average of patients who present to mental health clinics for outpatient therapy (20, 23). Of the eight participants who met past or current criteria for EDNOS, 87.5% met criteria for BED. Overall, approximately 8.5% of participants in the present study met past or current criteria for BED, which is over three times the national prevalence rate. Binge eating disorder is a diagnosis that has not yet been studied in infertility clinics, and these data suggest that it should be included in an initial screening for infertility patients. The reproductive system is highly sensitive to physiologic stress. Forty percent of female infertility problems result from ovulatory disorders, which include amenorrhea, oligomenorrhea, and anovulation (24). Two of the recovered AN participants still suffered from amenorrhea, although they reported normal weight. These findings are consistent with research indicating that although a patient has recovered from an ED and is at normal weight, amenorrhea persists in 5% to 44% of cases (25). It is also possible that some study participants may have subclinical EDs. Individuals are considered to have a subclinical ED if they endorse certain eating disordered attitudes and 76 Freizinger et al. Eating disorders in infertile women behaviors but do not meet criteria for either AN, BN, EDNOS, or BED (26). Many more women engage in this type of disordered behavior and do not meet criteria for the full disorder than women who actually do meet full criteria for an ED. Earlier research reports that patients with subclinical EDs frequently present to clinicians at gynecologic outpatient clinics (27). These researchers found that patients with subclinical EDs had longer and more irregular menstrual cycles than non-ED infertile women (27). It is noted that 58.8% of the participants in this study with a current or past ED had a diagnosis of unexplained infertility. Past research has demonstrated that when women with unexplained infertility ceased restricting their caloric intake and increased their weight to their ideal body weight, normal menstruation resumed and was then followed by subsequent spontaneous conception (28). Although the mean BMI in the present study did not differ between the ED and non-ED groups, and 59% of the ED group reported a BMI in the normal range (18.5 to 24.9), participants’ BMIs may have been lower when they started the process of trying to become pregnant. The average time trying to conceive for the ED cohort was 21 months, and it is possible that the infertility medications increased their body weight without the participants increasing their caloric intake. Another explanation for the high prevalence rate of EDs in this study could be the participants’ body weight. In the nonED group, 28% met criteria for being overweight (BMI >25 to 29.9) and 14% met criteria for obesity (BMI >30). Of the ED women, 18% met criteria for being overweight and 24% met criteria for obesity. Overweight women have a high incidence of menstrual irregularity, an altered GnRH secretion, reduced SHBG, Vol. 93, No. 1, January 2010 increased ovarian and adrenal androgen, increased LH, and insulin resistance (29). Wang et al. (29) demonstrated that overweight women have a higher fecundity than normal weight women. Nondisclosure of Eating Disorders to Heath Care Providers Results from the present study are comparable to those of Stewart et al. (7) on the issue of nondisclosure to infertility heath care providers, where none of the participants had told their gynecologist about their ED history. Similarly, most (76.4%) of the participants in the present study did not disclose their ED history or current ED to their infertility health care provider. The remainder of the sample did not respond to this question. When queried as to why they did not disclose this information to their provider, several patients reported that they did not think their past ED history was relevant to their current infertility treatment. The participants’ nondisclosure is not surprising; the literature supports that ED patients are more likely to disclose their eating concerns to a friend rather than to a health professional (30). A small case study found that pregnant women were reluctant to disclose their ED history to their obstetrician (31). Both past research and the results of the present study underscore the importance of educating health professionals to ask the appropriate questions. Becker et al.’s research (30) indicated that when asked by a doctor, women are likely to disclose information about their ED; however, of the 68% who had not volunteered this information, fewer than one-fourth had been asked by a health professional about their ED. The published research documents severe health risks of an ED to the mother and child (1–3); therefore, knowledge of a patient’s ED history is essential information for health professionals who are treating eating disordered women who are considering becoming pregnant. Of note, there is evidence that infertile women are more likely to have a psychiatric diagnosis than fertile controls. In a recent study examining psychiatric morbidity in infertile patients, the authors found significant differences between infertile subjects and fertile control subjects regarding psychiatric disorders at the time of their initial meeting at an infertility clinic (32). Binge eating disorder was the second most diagnosed disorder in those patients. This study also found that women with functional infertility and women with polycystic ovaries exhibited more past and current ED behavior than women with anatomic infertility. The authors hypothesized that these eating disordered behaviors could be contributing to hormonal disturbances, menstrual irregularities, and emotional difficulties (32). Reproductive health professionals may also want to query patients who present with hypothalamic amenorrhea. It is possible that many of these patients have a previous or current history of an ED. Although patients may be within a normal weight, an adequate body composition and well represented fat mass are not necessarily enough for the return of the menstrual cycle (33). It is important for reproductive Fertility and Sterilityâ health professionals to know if these patients are restricting food intake or engaging in disordered eating and/or compensatory behaviors that may be affecting their fertility. In contrast to the existing literature (34, 35), the ED group in the present study did not report more exercise than the nonED group. It may be that the participants were aware that excessive exercise might hamper their fertility and chose not to exercise. A recent study investigating the effects of lifetime exercise on IVF outcomes concluded that regular exercise before IVF may negatively affect outcomes, particularly in women who participated in cardiovascular exercise (36). The current research is not without limitations. The small number of participants in the study limited the statistical power. It is also more difficult to ascertain meaningful relationships between variables with a small number of participants. Future research should include a control group of women, perhaps using a sample from a medical clinic. Future Research and Clinical Implications Further studies should assess infertility clinic populations to understand how patients with specific diagnoses within the ED spectrum present for treatment. In the present study, several participants diagnosed with BED did not realize that their compulsive overeating was an ED. Several participants stated that ‘‘they have always been this way’’ and that they were ashamed of their compulsive bingeing. This is an important area of concern, because research has shown that obese women, who are more likely to have BED than nonobese women, had 25% higher IVF cancellation rates than normal-weight control subjects and are at a higher risk for obstetric complications (37). Additionally, research has shown that women with higher BMIs required significantly more days of gonadotropin stimulation, but had lower peak E2 levels (37). The authors of that study recommended that women with high BMIs be counseled about the risks involved before starting infertility treatment. Because a high BMI does not automatically indicate that a patient has BED, it would be important for reproductive health professionals to understand the differences between obesity and EDs. Reproductive endocrinologists generally follow their patients after they conceive for approximately 6 weeks before they are referred to an obstetrician. This window of time can serve as an opportunity to make appropriate referrals for any patient experiencing current ED behaviors or with a past history of an ED. This is important because there is evidence that being hospitalized for an ED up to 7 years before pregnancy raises the risk of impaired pregnancy outcome (3). The risk of low birth weight was twice as high in children of women with an ED that had been diagnosed before pregnancy than in children of women without an ED. Therefore, even if the infertility patient is currently recovered from her ED, the reproductive and obstetric treatment team should be aware of the increased risk for negative outcomes (38,39) and should proceed appropriately. These patients 77 may be better served with a referral to an OB/GYN who can treat higher risk patients. Our findings lead us to strongly recommend that physicians be informed of their patient’s ED history through screening and assessment at the patient’s initial intake so that they may provide adequate and appropriate care. It is also possible that patients may unknowingly be contributing to physiologic and hormonal disturbances, and a reduction in their ED behaviors may help reproductive endocrinologists better treat their infertility. Infertility clinics would benefit from including an ED screening tool as part of the initial intake. Training in the assessment of EDs for infertility health providers would likely increase detection rates. 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