There is a big debate among physicians who specialize in treating infertile people all around the world today: Should we treat people who are severely overweight? Or should we require them to lose weight before they conceive? I was just reading a very interesting article on this topic by Vahratian A. and Smith YR, published in the prestigious journal of Human Reproduction (Vol 24, No 7, pp 1532-1537, 2009), titled “Should access to fertility-related services be conditional on body mass index?” The following is a discussion based upon this interesting and provocative article.
The authors point out that there is significant data to demonstrate that obesity has a negative impact upon reproduction. Obesity is defined by the World Health Organization as a BMI of 30 or above. For a woman who is 5 foot 4, that is a weight of 174 pounds or more. Extreme obesity is defined as a BMI of 40 and above – for that 5 foot 4 woman that is a weight of 232 pounds and above. As you may know, more than half the population of the United States is overweight and well over a third are obese or extremely obese. The authors cite numerous international publications discussing the debate over providing infertility services to obese patients. They cite numerous studies demonstrating that obesity and infertility are linked. Obese women are much more likely to suffer from infertility than women who are normal weight. One study quantified the risk of infertility as three times higher in obese women compared to normal weight women! We also know that obese women are less responsive to fertility medications – for the same drug dose, obese women produce less eggs than normal weight women.
Bottom line – fat makes you less fertile.
The problems do not end there. Once pregnant, obese women have much higher rates of miscarriage, their babies have higher rates of birth defects, and there are higher rates of neonatal death as well as maternal death. All other factors being equal, obese patients and their babies are much more likely to die sometime during pregnancy, delivery and post-partum than their normal weight counterparts.
Death is pretty seriousYet most of my overweight patients want me to ignore their weight issues. Most of them just want me to prescribe pills, or shots or anything to help them conceive as quickly as possible. I know how desperately they want a baby. I know how important it is and how painful it is to struggle with infertility. However, I took the Hippocratic Oath to first, do no harm. What would Hippocrates do in this situation?
The answer is not at all clear. Most states, including my home state of New Jersey, have laws against discrimination. Some would consider not treating someone because they are obese a type of discrimination. Some would consider not treating an obese patient the medically and ethically correct thing to do. No one seems to agree.
Outside the United States, some countries have decided that there is enough data to limit access to services based upon success rates. In countries where the government pays for health care, some governments will limit fertility treatments to obese patients. Given much lower success rates in the obese population, New Zealand citizens can only obtain fertility services if their BMI is relatively normal – from 18 to 32 kg/m2 (normal is 18.5 to 24.9, overweight is 25 to 29.9, obese is 30.0 and above). The UK has many guidelines surrounding assisted reproduction and at this time, does not have formal policies, but does recommend that infertility patients be provided with lifestyle advice such as recommendations for quitting smoking and obtaining a normal weight. Many UK clinics will not provide assisted reproduction – IUI or IVF – services to patients outside certain BMI limits.
But what is a person to do? While the ethicists and other experts debate, the biological clock is ticking. You have tried a bazillion diets and you are still overweight and you wanted to have a baby yesterday.
Let’s be practical. Acknowledge the risks. Putting your head in the sand is not helping anyone – not you, not your doctor, not your baby. Sit down with your doctor. Have a serious talk with her or him about your weight. See what ideas your doctor has for helping you. Remember – you do not have to be model-thin to be healthier. There are significant, measurable improvements seen with just 10 pounds of weight loss. Yes! Just 10 pounds! If you weigh 200 pounds that may seem like a drop in the bucket, but it is not. Think about seeing a professional nutritionist. Think about signing up for a program like Weight Watchers, Jenny Craig, Curves, etc – structured programs can often make the overwhelming task of losing weight a little easier, and provide much needed emotional support.
Walk! Move! You don’t have to run a triathlon to be healthy. The more you move, the better off you are. Exercise can help you lose weight and lower stress levels – both of those things will improve your chances of conceiving.
Healthy weight loss while trying to conceive is ok. Just make sure you discuss the plan with your doctor and get the help and support you need. Weight loss can dramatically improve your chances of success regardless of treatment – whether it be medications and IUI or IVF, every pound you lose, gives you a better chance of success.
Some women – ones who are young and have normal ovarian reserve – who have failed diet and exercise and have a bmi over 35 to 40, should consider bariatric surgery. Although this usually requires not conceiving for 1 or 2 years, the improvement in pregnancy rate and overall health for both mother and baby may make that extra 1 or 2 years very worthwhile. For some women, this can mean the difference between life and death.
At this point, given that overweight affects over 50% of people and other common causes for infertility like endometriosis, PCOS, diminished ovarian reserve, sperm problems, blocked tubes each account for much less than 50% of infertile patients – FAT really is the biggest fertility issue!
The good news is that you really can do something about it. Please call today to make an appointment to talk with your doctor!
Copyright Serena H. Chen, MD. 2011.
reprinted with permission