Should weight or BMI affect how and when assisted reproduction is begun?
If you flip open any textbook of Gynecology or Reproductive Endocrinology and read the chapter about Polycystic Ovarian Syndrome (PCOS), it will be noted that obesity and overweight status is double in this population of women as compared to the rest of their non-PCOS counterparts. Moreover, you will determine that the recommended first-line therapy for these particular patients is weight loss. Not clomid. Not gonadotropin injections. Not ovarian laser drilling. Not even metformin. Weight loss as a treatment is recommended not only for restoration of ovulation and enhanced fertility but also to diminish the unpleasant symptoms that also accompany PCOS such as acne, hirsutism, alopecia, and insulin resistance.
It is important to also point out that there are many women who do not specifically suffer from PCOS, who in fact ovulate regularly, but who are overweight and infertile. Their infertility may stem from a number of factors besides their weight, and in fact, for many years merely being overweight was not deemed to be a risk factor for fertility issues, but it now is recognized as such. Nowhere is the evidence of this clearer than from the study of IVF outcomes in which we see that women with weight issues do not do nearly as well as those women with more normal weight status. There is something about being on the heavier side that can negatively affect pregnancy outcomes with advanced fertility treatments. We do not know for certain why, but it seems that both egg quality and uterine receptivity may be affected. But the benefits of weight loss in these women are not different from those women with PCOS. In fact, there was an excellent study published this past month demonstrating that pregnancy rates are higher in women who lose weight before undergoing and fertility treatments:
Am J Clin Nutr. 2015 Nov 11. pii: ajcn117200. Short-term effects of a hypocaloric diet with low glycemic index and low glycemic load on body adiposity, metabolic variables, ghrelin, leptin, and pregnancy rate in overweight and obese infertile women: a randomized controlled trial. Becker GF1, Passos EP2, Moulin CC3.
Given the salutary effect of weight loss on reproductive outcomes, why is that nearly all PCOS patients initially get placed by their physicians on medications of some sort to battle the acute problems rather than being helped to address the underlying reason for potentially all their problems….their overweight status. Well, it is a conversation that can be difficult to have sometimes. No one wants to be told they need to lose weight. In fact, virtually all overweight patients know they need to lose weight, but are unable to. Such conversations can make patients believe their doctors do not care about them as a person or are not genuinely interested in helping them. Sometimes patients themselves do not want to talk about a more natural approach to their infertility….it’s tough to wait when one wants a baby so badly. As a physician, I know that sometimes the hardest conversations are the most important conversations, and if one addresses tough issues from a place of concern and compassion, and then backs up the recommendations with evidence, then real progress can be made. And there is no shortage of evidence to demonstrate that weight loss is a good thing for fertility in overweight or obese women struggling to conceive.
I think the time is coming for an integrated approach in which doctors and patients unite to focus on these issues. We need to surround patients with a team designed to help them achieve their weight loss goals while simultaneously assessing their health and fertility markers. If there was ever a time in a woman’s life to make it happen, it would be when she wishes to conceive. It will help her reach her fertility goals safer and with a minimum of medications needed. It will also make the subsequent pregnancies smoother and less prone to nearly all possible complications. I very much look forward to hearing your comments about this. What are your experiences and what do you want from your doctors? Look to Sher Fertility Institute New York for expanding both the conversation and the treatments available in the months to come.
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