Obstructive Sleep Apnea: Another Condition to Screen for in Women with Infertility

Round 1

Reviewer 1 Report

Patients with sleep apnoae are more likely to be older and have a higher BMI than those that are not. Patients with infertility and PCOS are more likely to have a high BMI. It is therefore not a surprise to me that a cohort of infertility patients have apnoae. 

Interestingly in The NHS I am not allowed to even consider IVF if the woman's BMI is >30 and this situation would therefore not be left with the infertility doctors in UK to deal with. 

I do end up seeing patients requesting support for fertility who have a BMI that is too high for commisioned treatment. The private clinics would probably not agree to treat  them either because of the league table of results so we do have to encourage and support them losing weight. 

This paper has helped me consider a consequence of obesity that I had not really considered . It would therefore be good to see this in print even though it would not directly impact on my practice.

The conclusions about fertility patients needing screening for apnoa only really are justified for those women with a high BMI. The discussion should really also discuss the likely benefits of losing weight to both fertility as well as the reduction in apnoea (I assume) with improvement to health in consequence. 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Thanks for the opportunity to review this interesting article. My suggestions are shown as below: 

1. Line 42, "Obstructive sleep apnea" is redundant as it has been abbreviated previously. By contrast, it should be clarified that what the acronyms used in the article, such as BMI, CPAP, GAD-7, PHQ-2, PCOS..., stand for when they appear first in the text.  
2.  Line 76, the two words "who (4.7%)" should be opposite. 
3. In Table 1, There are many variables that have significant difference between OSA group and no OSA group but do not mentioned in the "Results", such as race, marital status,.... Why?
4. Line 81, "with" is redundant. 
5. Line 83-85, the information of this paragraph should be incorporated into Table 1, making it clearer to the readers.  
6. Line 97-110, in this paragraph, the provided evidence together with the present study's results seem be not able to explain the difference of OSA diagnosis and treatment between female and male. 
7. The main outcomes of this study are the prevalence of OSA in female with infertility and the association between OSA and depression/ anxiety. However, there are few information regarding the main outcomes in the "Discussion". Please have more capacity to discuss the main outcomes of this work in the "Discussion". 
8. The major concern of this study is that the diagnosis of OSA for the study population is based on STOP-BANG questionnaire, making the study group categorization (OSA group vs. no OSA group) invalid and the conclusions not supported by the methods and results. Taken together, this makes this study unable to provide exact information to the readers.  

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Thank you for the opportunity to review your work. OSA is an underestimated maternal comorbidity with significant implications on pregnancy and foetal status.

I suggest considering the following recommendations:

Abstract: Please add the unit of measurement for each result that you present.

Introduction: Should be focused on presenting more in detail the latest knowledge regarding the OSA subject and its obstetrical implications.

Please use the recommended settings for the paper format. Please present inclusion and exclusion criteria for patients included in your study and the associated variables that you sought to investigate. Was there any written informed consent for patients? Why did you consider these specific questionnaires for anxiety and depression screening and why did you screen for these pathologies? How did you document patient history of OSA, anxiety or depression? Also, there should be some information regarding the methodology on how the patients completed the questionnaires.

Conclusion section: please be more specific, avoid using generally known information.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

The authors have addressed all the suggestions raised by me.

I have no additional comments and suggest to accept this article for publication.