Surgery for Obesity and Related Diseases 13 (2017) 750–757 Review article American Society for Metabolic and Bariatric Surgery position statement on the impact of obesity and obesity treatment on fertility and fertility therapy Endorsed by the American College of Obstetricians and Gynecologists and the Obesity Society Michelle A. Kominiarek, M.D.a,1, Emily S. Jungheim, M.D.b,1, Kathleen M. Hoeger, M.D., M.P.H.c,1, Ann M. Rogers, M.D.d,2, Scott Kahan, M.D., M.P.H.e,f,3, Julie J. Kim, M.D.g,*,2 aDepartment of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois bDepartment of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri cDepartment of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York dPenn State Hershey Surgical Weight Loss Program, Hershey, Pennsylvania eGeorge Washington University; Washington D.C. fJohns Hopkins Bloomberg School of Public Health; Baltimore, MD gHarvard Medical School, Mount Auburn Weight Management, Mount Auburn Hospital, Cambridge, Massachusetts Received February 7, 2017; accepted February 8, 2017 Keywords: Obesity; Fertility; Fertility therapy; Bariatric surgery; Polycystic ovary syndrome; Contraception Preamble on fertility and fertility therapy. The statement may be revised in the future should additional evidence become available. The American Society for Metabolic and Bariatric Surgery issues the following position statement for the purpose of enhancing quality of care in metabolic and bariatric surgery. In Prevalence of obesity in reproductive-age women this statement, suggestions for management are presented that are The World Health Organization stratifies body mass index fi derived from available knowledge, peer-reviewed scienti c (BMI) into 6 categories to define underweight, normal literature, and expert opinion. This was accomplished by weight, overweight, and 3 classes of obesity [1]. Based on performing a review of currently available literature regarding the 2011–2012 National Health and Nutrition Examination obesity and obesity treatment and fertility and fertility therapy. Survey, the prevalence of obesity in women of reproductive The intent of issuing such a statement is to provide objective age (20–39 years) in the United States is 31.8%, with the information regarding the impact of obesity and obesity treatment highest prevalence (55.8%) in non-Hispanic black women [2]. Furthermore, the prevalence of obesity increased from 28.4% to 34.0% in women ages 20–39 years from 1999–2008, *Correspondence: Julie J. Kim, M.D, Department of Surgery, Mount highlighting the escalating role that obesity plays in women’s Auburn Hospital, 330 Mount Auburn Street, Cambridge, MA 02138. health, including reproductive health [2,3]. E-mail: [email protected] 1Primary authors from the American College of Obstetricians and Gynecologists. Prepregnancy obesity 2Primary authors from the American Society for Metabolic and Bariatric Surgery. Obesity during pregnancy is typically defined as a 2 3Primary author from the Obesity Society. prepregnancy BMI Z30 kg/m in adult women. If a http://dx.doi.org/10.1016/j.soard.2017.02.006 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved. Downloaded for Anonymous User (n/a) at Gundersen Lutheran - JCon from ClinicalKey.com by Elsevier on June 19, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. Impact of Obesity on Fertility / Surgery for Obesity and Related Diseases 13 (2017) 750–757 751 prepregnancy BMI is not available, then the maternal Table 1 weight at the first prenatal visit is used to determine BMI Lifestyle factors and fertility [9–14] [4]. Not only does obesity impact the health of every organ Factor Impact system, the combination of obesity and pregnancy introdu- Smoking Associated with longer time to pregnancy, reduction in ces additional complications, such as birth defects, pree- per-cycle pregnancy, and earlier age of menopause clampsia, gestational diabetes, stillbirths, and cesarean Caffeine Possible reduction in fecundity with 4500 mg/d deliveries [5]. Obese women are also at greater risk for Alcohol Contradictory evidence, but increased consumption may menstrual irregularities, polycystic ovary syndrome (PCOS), be associated with longer time to pregnancy and anovulation, all of which contribute to an increased risk Diet Possible reduced rate of ovulatory dysfunction with lower animal fat consumption. of infertility. to abnormalities in oocytes or ovulation arising from Natural fertility and impact of lifestyle factors decreased luteinizing hormone amplitude in the The monthly fecundity rate, or the probability of obtain- hypothalamic-pituitary-ovarian axis of eumenorrheic obese ing a clinically recognized pregnancy in a menstrual cycle, women, a gonadotropin defect that is distinct from that is approximately 20–25% in couples not using contra- noted in women with PCOS [18]. ception. Approximately 10–15% of couples experience PCOS is a well-recognized and common endocrinopathy that delays in fertility or subfertility [6]. Fertility declines with affects 5–10% of women of reproductive age. It is defined by age across all populations. Infertility is defined by the the presence of at least 2 of 3 conditions: irregular menses, failure to achieve a clinical pregnancy after 12 months or hyperandrogenism, and the finding of polycystic ovary morphol- more of appropriate, timed, unprotected intercourse. Earlier ogy on ultrasound [19]. PCOS has been associated with obesity evaluation and treatment may be justified based on specific since the original description of the condition; however, the medical history and physical findings and is warranted after disorder itself is independent of obesity, and many women with 6 months for women over the age of 35 years [7]. PCOS are not overweight or obese [20]. The prevalence of Fertility rates are decreased in women who are either obesity in PCOS is highly variable, with rates ranging from 30– underweight or overweight, with underweight women demon- 70%, and this variation is likely related to both genetic and strating a 4-fold longer time to pregnancy than normal-weight environmental factors [21]. There is some evidence that the women. Obesity is also associated with a 2-fold longer time to diagnosis of PCOS is associated with an increased risk of pregnancy compared with normal-weight women for couples obesity [22], although not all studies support this [23].The attempting pregnancy without intervention [8]. relative risk of obesity in women with PCOS in one meta- Several lifestyle factors may be associated with infertility. analysis was 2.77 (95% confidence interval [CI] 1.80–4.10), Although there is no evidence that specific diets are with obesity prevalence highest in Caucasian women and lowest associated with improved fertility, diets that replace animal in Asian women [20]. PCOS is associated with infertility due to sources of protein and fat with vegetable sources may be oligo-anovulation even in normal-weight patients; however, associated with a lower risk of ovulatory infertility [9]. increased weight is known to exacerbate the symptoms of Smoking has a proven detrimental effect on the time to PCOS and is associated with significantly more reproductive pregnancy, chance for conception, and success of fertility dysfunction and abnormal bleeding and increased androgenic treatments. Smoking is also associated with an earlier age of symptoms [15]. The symptoms of PCOS are remarkably menopause, suggesting an impact on follicular development sensitive to weight changes, and weight loss of as little as 5% [10]. There is no clear link between conception and alcohol can improve ovulatory dysfunction and restore fertility [16]. consumption [11], although the amount of consumption Obesity and excess adiposity are also associated with may matter. In several series, heavy alcohol consumption insulin resistance (IR) and significant metabolic perturba- was associated with decreased fertility [12,13]. Moderate tion. Specifically, increased abdominal fat mass may worsen caffeine consumption has not been shown to impair fertility, the metabolic consequences of obesity and is associated but increased intake (4500 mg/day) may delay time to with an increased risk of metabolic syndrome (hyper- pregnancy (Table 1) [14]. tension, elevated fasting glucose, increased waist circum- ference, elevated triglycerides, and low HDL cholesterol) [17,18,24]. The metabolic disturbance associated with Impact of obesity, polycystic ovary syndrome, and excess adiposity is likely due to lipotoxicity and increased insulin resistance on natural fertility production of excess free fatty acids, resulting in tissue Obesity is independently associated with a longer time to inflammation and increased IR [25]. Women with PCOS pregnancy even in eumenorrheic women, despite similar have a high predisposition to IR, seen in both normal- coital frequency noted among normal-weight and over- weight and obese individuals [26]. Abnormalities in the weight/obese women participating in studies of couples production of adipokines might play a main role in the trying to conceive [15–17]. This delay may be due, in part, development and progression of PCOS. In particular, Downloaded for Anonymous User (n/a) at Gundersen Lutheran - JCon from ClinicalKey.com by Elsevier on June 19, 2017. For personal use only. No other uses without permission.