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 * Add mechanism of action of joint injection
 * Add reason for it's utility in these disease states (explain disease states)
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Women
Higher weights have shown to inhibit female reproductive hormones. Obesity disrupts normal endocrine function, leading to irregularities in ovulation, endometrial development, and embryo development.

In women with non-disrupted reproduction function, they hypothalamic-pituitary-ovarian (HPO) axis facilitates proper ovulation and egg implantation. Through producing gonadotropic and steroid hormones, the HPO is responsible for follicular and oocyte development. However, the regulatory functions of the HPO can be disrupted due to the up or down regulation of certain hormones in the setting of obesity.

Insulin
One such disruptor of proper HPO function is insulin. Obesity, particularly the presence of visceral fat (fat around the abdomen), is associated with increased risks of insulin resistance. Insulin resistance, leading to high levels of insulin in the blood due to cells reduced sensitivity to insulin and reduced ability to uptake glucose, can disrupt gonadotropin release. Insulin has been shown to increase androgen production, leading to hyperandrogenism. These androgens are converted to estrogen which exert negative feedback on the HPO, leading to its down regulation and limiting gonadotropin production. This hyperinsulinemia and resulting hyperandrogenism have been associated with disruptions in ovulation.

Adipocytes (fat cells) secrete proteins and signaling molecules known as adipokines. Adiponectin, the protein secreted in greatest amounts from adipocytes, functions to increase the sensitivity of cells to insulin. Circulating adiponectin levels have been shown to be reduced in obese women. These reduced levels of adiponectin have also been associated with insulin resistance.

Leptin
Leptin is a satiety adipokine released from adipocytes. Normally, leptin interacts with leptin receptors (LEPRs) in the brain in order to decrease hunger and facilitate energy expenditure. In obesity, the greater number of adipocytes release higher amounts of leptin. Higher amounts of leptin have been implicated in disrupted endometrial maturation and embryo implantation in to the endometrium. Leptin may also inhibit the production of certain steroids, such as progesterone, which is also necessary for proper endometrial development.

Inflammation and Oxidative Stress
Obesity has been associated with higher levels of circulating triglycerides and inflammatory markers. Pro-inflammatory adipokines secreted by adipocytes have been demonstrated to stimulate fatty acid accumulation. Fatty acids are normally stored in adipocytes as triglycerides. However, as triglycerides accumulate in adipocytes, fatty acids can deposit in other tissues. These fatty acids can create oxidative stress, disrupting the functions of mitochondria and endoplasmic reticula, leading to apoptosis. This process is known as lipotoxicity. Lipotoxicity can impair follicular development, lead to errors in meiotic divisions, and disrupt the implantation of the trophoblast in the endometrium. Lipotoxicity can further contribute to insulin resistance in the setting of an inflammatory state.

Stigma
Apart from biological factors, social factors, such a stigma in health care environments, can limit care and desirable health outcomes. In health care settings, overweight and obese women experience weight-related stigma. Surveys have demonstrated that health care workers view overweight and obese individuals as more lazy, less intelligent, and more self-indulgent than individuals with smaller body sizes. These attitudes may limit overweight and obese women's ability to receive high-quality care or limit their desire to become connected to care due to disrespectful treatment by providers.

This stigma and reluctance to provide high quality care has been suggested to exacerbate problems of infertility in those who are overweight or obese. Due to the perceived biological associations between excess body fat and infertility, overweight and obese women's inability to conceive can be pre-judged by health care providers. Many women who are overweight and obese report that their infertility is attributed solely to their excess body weight and that providers may be unwilling to treat infertility in women who are overweight and obese until they lose weight. Of note, no formal guidelines exist from the American Society for Reproductive Medicine or the Society for Assisted Reproductive Technology that dictate when women should receive fertility treatment based on weight.

It has also been shown that obese women have higher rates of mood disorders compared to non-obese women. Rates of mood disorders are even higher among women who are treated via IVF and increase further upon IVF failure. Mood disorders, as well as medications used to treat mood disorders, can exacerbate hormonal and menstrual dysfunction, worsening outcomes of infertility management.