The Impact of Bariatric Surgery on Polycystic Ovary Syndrome: a Systematic Review and Meta-analysis

Unraveling the Connection between PCOS and renal Complications: Current insights and Future Directions

Polycystic ovary syndrome (PCOS) represents the most prevalent endocrine disorder among women of reproductive age, affecting approximately 5-18% of females worldwide. Characterized by irregular ovulation, hyperandrogenism, and polycystic ovaries, hyperandrogenism is the defining feature. Recent evidence highlights that, in addition to its notable reproductive and metabolic consequences, PCOS may also contribute to an elevated risk of renal complications. This increased risk is attributed to chronic low-grade inflammation, hormonal dysregulation, and disturbances in lipid metabolism inherent to the condition. However, the pathological mechanisms, clinical manifestations, and progression of secondary renal damage in this cohort remain insufficiently studied. This review consolidates current understanding of the relationship between PCOS and chronic kidney disease (CKD), aiming to clarify potential mechanisms by which PCOS may induce secondary renal dysfunction, encompassing both direct renal impairment and indirect damage mediated through systemic alterations. Furthermore, it advocates for comprehensive management strategies to mitigate renal risks in patients with PCOS, emphasizing the necessity of multidisciplinary approaches and further research to address these critical gaps.

The Korean Society for Metabolic and Bariatric Surgery (KSMBS) Position Statement on Female Candidates of Reproductive Age for Metabolic Bariatric Surgery

Obesity has emerged as a major global health issue. The ratio of male to female patients undergoing metabolic bariatric surgery (MBS) is 1:3.5. Although not as dramatic compared to the global trend, the rate of obesity in women of reproductive age in Korea has been steadily increasing over the past several decades. The impact of obesity on reproductive health and perinatal outcomes should be carefully considered when consulting female candidates of reproductive age for MBS. Obesity adversely affects reproductive health by causing menstrual irregularities, anovulation, subfertility, and increased miscarriage risk, as well as impairing the success of assisted reproductive technologies. Maternal obesity also heightens the risk of adverse perinatal outcomes, including childhood obesity and metabolic disorders. MBS has been shown to improve fertility outcomes and reduce obesity-related pregnancy complications, although concerns remain regarding potential risks such as small-for-gestational-age infants due to rapid weight loss and nutritional deficiencies. Despite these implications, current MBS guidelines rarely address the unique needs of reproductive-age women. In response, the Korean Society for Metabolic and Bariatric Surgery convened a task force to develop evidence-based recommendations tailored to this population. This position statement aims to guide the management of obesity in women of reproductive age to optimize reproductive and perinatal outcomes.

Glucagon-like peptide-1 receptor agonist use in pregnancy: a review

Glucagon-like peptide-1 receptor agonists are peptide analogues that are used to treat type 2 diabetes mellitus and obesity. The first medication in this class, exenatide, was approved in 2005, and these medications, specifically semaglutide, have become more popular in recent years due to their pronounced effects on glycemic control, weight reduction, and cardiovascular health. Due to successful weight loss from these medications, many women previously diagnosed with oligomenorrhea and unable to conceive have experienced unplanned pregnancies while taking the medications. However, there are currently little data for clinicians to use in counseling patients in cases of accidental periconceptional exposure. In some studies examining small animals exposed to glucagon-like peptide-1 receptor agonists in pregnancy, there has been evidence of adverse outcomes in the offspring, including decreased fetal growth, skeletal and visceral anomalies, and embryonic death. Although there are no prospective studies in humans, case reports, cohort studies, and population-based studies have not shown a pattern of congenital anomalies in infants. A recent large, observational, population-based cohort study examined 938 pregnancies affected by type 2 diabetes mellitus and compared outcomes from periconceptional exposure to glucagon-like peptide-1 receptor agonists and insulin. The authors concluded there was not a significantly increased risk of major congenital malformations in patients taking glucagon-like peptide-1 receptor agonists, although there was no information on maternal glycemic control or diabetic fetopathy. As diabetic embryopathy is directly related to the degree of maternal hyperglycemia and not the diagnosis of diabetes itself, it is not possible to make this conclusion without this information. Furthermore, there is little evidence available regarding fetal growth restriction, embryonic or fetal death, or other potential complications. At this time, patients should be counseled there is not enough evidence to predict any adverse effects, or the lack thereof, of periconceptional exposure of glucagon-like peptide-1 receptor agonists during pregnancy. We recommend that all patients use contraception to prevent unintended pregnancy while taking glucagon-like peptide-1 receptor agonists.

Pharmacological and non-pharmacological interventions for improving endometrial receptivity in infertile patients with polycystic ovary syndrome: a comprehensive review of the available evidence

Direct and indirect evidence suggests that endometrial receptivity may play a crucial role in the reduced fertility rate of women with polycystic ovary syndrome (PCOS). Various pharmacological and non-pharmacological strategies with potential effects on endometrial receptivity in patients with PCOS have been proposed. The aim of this study was to summarize the rationale and the clinical and experimental evidence of interventions tested for improving endometrial receptivity in infertile patients with PCOS. A systematic review was conducted by consulting electronic databases. All interventions with a potential influence on endometrial receptivity in infertile patients with PCOS were evaluated, and their main biological mechanisms were analysed. In total, 24 interventions related to endometrial receptivity were identified. Notwithstanding a strong biological rationale, no intervention aimed at improving endometrial receptivity in women with PCOS is supported by an adequate body of evidence, limiting their use in clinical practice. Further high-quality research is needed in this field to limit potentially ineffective and unsafe add-on treatments in infertile patients with PCOS.

Impact of bariatric surgery on infertility in obese women: a systematic review and meta-analysis

Background

The prevalence of obesity is increasing worldwide, with several consequences, including reduced fertility in both men and women. One of the ways to reduce weight is bariatric surgery. The aim of this systematic review and meta-analysis study was to evaluate the effectiveness of bariatric surgery on weight loss and subsequent improvement of fertility in obese infertile women.

Methods

Several databases were searched using MESH terms to investigate the studies that evaluated the fertility rates after bariatric surgery in infertile obese women. Related data were obtained and analyzed using Stata software with a P-value ≤0.05, which was considered as significant.

Results

Of the 283 articles related to the purpose of this study, 9 articles, including 231 obese infertile women, were included in the study. BMI before surgery was 42.2 [95% CI= 39.2-45.2] and BMI after surgery was 31.9 (95% CI= 28.9-34.8), which shows the significance of weight loss after bariatric surgery. Conception rate after bariatric surgery weight loss was increased and was 67% (95% CI= 47-87%, P-value <0.05).

Conclusions

Bariatric surgery had a significant effect on the reduction of BMI and subsequent significant improvement of fertility in obese infertile women.

Effect of Weight Loss Interventions on the Symptomatic Burden and Biomarkers of Polycystic Ovary Syndrome : A Systematic Review of Randomized Controlled Trials

BACKGROUND

Polycystic ovary syndrome (PCOS) is common in women of reproductive age and is associated with obesity. Clinical guidelines recommend weight loss, but the impact on the clinical manifestations of PCOS is unclear.

PURPOSE

To quantify the effect of weight loss interventions on clinical features of PCOS, compared with usual care.

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, Cochrane, Web of Science, and trial registries were searched from inception through June 2024.

STUDY SELECTION

Randomized controlled trials comparing interventions aiming to reduce weight against usual care, including lower-intensity weight loss interventions in people with PCOS. Conversations with people with PCOS informed the outcomes.

DATA EXTRACTION

Pairs of independent reviewers screened studies, extracted data, and assessed risk of bias (RoB). Outcomes included glycemic control (Homeostasis Model Assessment for Insulin Resistance [HOMA-IR], fasting insulin and glucose), hormonal markers (free androgen index [FAI] and other sex hormones), menstrual frequency, hirsutism, and PCOS-related quality of life (QoL). Pooled mean differences were obtained from random-effects meta-analysis with Knapp-Hartung adjustment.

DATA SYNTHESIS

Primary analyses included 29 comparisons with 1529 participants: 13, 12, and 4 comparisons were judged as high, some, or low RoB, respectively. Twelve used behavioral interventions, 9 used glucagon-like peptide-1 (GLP1) agonists, and 8 used other weight loss medications. Weight loss interventions were associated with significantly greater improvements in HOMA-IR (mean difference, -0.45 [-0.75 to -0.15]; I 2 = 24%), FAI (mean difference, -2.03 [-3.0 to -1.07]; I 2 = 48%), and menstrual frequency (mean difference, 2.64 [0.65 to 4.63]; I2  = 43%). There was no evidence that weight loss interventions were associated with clinically or statistically significant improvements in hirsutism, QoL, or other sex hormones, which may be due to the limited power of the available data.

LIMITATION

There was high statistical heterogeneity in the interventions, comparators, and outcomes, largely unexplained by sensitivity and subgroup analyses.

CONCLUSION

Weight loss interventions were associated with improvements in some important features of PCOS and should be considered as a routine treatment option for people with PCOS.

PRIMARY FUNDING SOURCE

National Institute for Health and Care Research School for Primary Care Research. (PROSPERO: CRD42022367488).

Maternal and neonatal risks and outcomes after bariatric surgery: a comparative population based study across BMI categories in Qatar

The impact of Bariatric Surgery (BS) on maternal and neonatal outcomes among pregnant women is not fully understood, especially in comparison to different weight categories. The primary aim of this study is to assess the factors associated to women who have undergone BS. The study also investigates the maternal and neonatal outcomes amongst this group in comparison to the three Body Mass Index (BMI) groups (women with obesity, overweight and normal weight). A 12-month population-based retrospective study was conducted using registry data from the PEARL-Peristat Study at the Women's Wellness and Research Center (WWRC) in Qatar from January 1, 2017, through December 31, 2017. Both univariate and multivariable regression analyses were employed to scrutinize risk factors and maternal and neonatal outcomes. The study included 6212 parturient women, of which 315 had a history of BS, while 5897 with no BS history. Qatari women, aged 35 and higher, with parity > 1, diabetes, and hypertension were more likely to be in the post-BS group. Women in the post-BS group were found to be more likely to have a cesarean delivery (37.5% vs. 24%, Adjusted Odds Ratio (aOR) = 1.59, CI 1.18-2.14), preterm babies (10% vs. 7%, aOR = 1.66, CI 1.06-2.59), and stillbirth (1.6% vs. 0.4%, aOR = 4.53, CI 1.33-15.50) compared to the normal weight women group. Moreover, post-BS women had a higher risk of low-birth-weight neonates than women with obesity (15% vs. 8%, aOR = 1.77, CI 1.153-2.73), overweight (15% vs. 7%, aOR = 1.63, CI 1.09-2.43), and normal weight (15% vs. 8%, aOR = 1.838, CI 1.23-2.75). Finally, women in the post-BS group were more likely to have low-birth-weight neonates amongst term babies than women with obesity and overweight. Pregnancies with post-BS should be considered a high-risk group for certain medical outcomes and should be monitored closely. These findings may guide the future clinical decisions of antenatal and postnatal follow-up for post-BS women.

The Cardiometabolic Risk in Women with Polycystic Ovarian Syndrome (PCOS): From Pathophysiology to Diagnosis and Treatment

Polycystic Ovarian Syndrome (PCOS) is a prevalent endocrine disorder affecting women of reproductive age, with significant variations in presentation characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology. Beyond reproductive health, it may also pose crucial long-term cardiometabolic risks, especially for women with specific types of PCOS, contributing to early subclinical cardiovascular atherosclerotic alterations such as endothelial dysfunction, increased arterial stiffness, and coronary artery calcium levels, respectively. Moreover, the precise relationship between clinical cardiovascular disease (CVD) and PCOS remains debated, with studies demonstrating an elevated risk while others report no significant association. This review investigates the pathophysiology of PCOS, focusing on insulin resistance and its link to subclinical and clinical cardiovascular disease. Diagnostic challenges and novel management strategies, including lifestyle interventions, medications like metformin and glucagon-like peptide-1 receptor agonists (GLP-1RAs), hormonal contraceptives, and bariatric surgery, are further discussed. Recognizing the cardiometabolic risks associated with PCOS, a comprehensive approach and early intervention should address both the reproductive and cardiometabolic dimensions of the syndrome.

Precision Medicine in Bariatric Procedures

Obesity is a multi-factorial disease that is influenced by genetic, epigenetic, and environmental factors. Precision medicine is a practice wherein prevention and treatment strategies take individual variability into account. It involves using a variety of factors including deep phenotyping using clinical, physiologic, and behavioral characteristics, 'omics assays (eg, genomics, epigenomics, transcriptomics, and microbiomics among others), and environmental factors to devise practices that are individualized to subsets of patients. Personalizing the therapeutic modality to the individual can lead to enhanced effectiveness and tolerability. The authors review advances in precision medicine made in the field of bariatrics and discuss future avenues and challenges.

Bariatric surgery for spontaneous ovulation in women living with polycystic ovary syndrome: the BAMBINI multicentre, open-label, randomised controlled trial

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. Obesity exacerbates the reproductive complications of PCOS; however, the management of obesity in women with PCOS remains a large unmet clinical need. Observational studies have indicated that bariatric surgery could improve the rates of ovulatory cycles and prospects of fertility; however, the efficacy of surgery on ovulation rates has not yet been compared with behavioural modifications and medical therapy in a randomised trial. The aim of this study was to compare the safety and efficacy of bariatric surgery versus medical care on ovulation rates in women with PCOS, obesity, and oligomenorrhoea or amenorrhoea.

METHODS

In this multicentre, open-label, randomised controlled trial, 80 women older than 18 years, with a diagnosis of PCOS based on the 2018 international evidence-based guidelines for assessing and managing PCOS, and a BMI of 35 kg/m2 or higher, were recruited from two specialist obesity management centres and via social media. Participants were randomly assigned at a 1:1 ratio to either vertical sleeve gastrectomy or behavioural interventions and medical therapy using a computer-generated random sequence (PLAN procedure in SAS) by an independent researcher not involved with any other aspect of the clinical trial. The median age of the entire cohort was 31 years and 79% of participants were White. The primary outcome was the number of biochemically confirmed ovulatory events over 52 weeks, and was assessed using weekly serum progesterone measurements. The primary endpoint included the intention-to-treat population and safety analyses were per-protocol population. This study is registered with the ISRCTN registry (ISRCTN16668711).

FINDINGS

Participants were recruited from Feb 20, 2020 to Feb 1, 2021. 40 participants were assigned to each group and there were seven dropouts in the medical group and ten dropouts in the surgical group. The median number of ovulations was 6 (IQR 3·5-10·0) in the surgical group and 2 (0·0-4·0) in the medical group. Women in the surgical group had 2.5 times more spontaneous ovulations compared with the medical group (incidence rate ratio 2·5 [95% CI 1·5-4·2], p<0·0007). There were more complications in the surgical group than the medical group, although without long-term sequelae. There were 24 (66·7%) adverse events in the surgical group and 12 (30·0%) in the medical group. There were no treatment-related deaths.

INTERPRETATION

Bariatric surgery was more effective than medical care for the induction of spontaneous ovulation in women with PCOS, obesity, and oligomenorrhoea or amenorrhoea. Bariatric surgery could, therefore, enhance the prospects of spontaneous fertility in this group of women.

FUNDING

The Jon Moulton Charity Trust.

The effect of bariatric surgery on polycystic ovary syndrome patients' obstetric and neonatal outcomes: a population-based study

PURPOSE

To examine the effect of bariatric surgery (BS) on obstetric and neonatal outcomes in patients with polycystic ovary syndrome (PCOS).

METHODS

A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database, including women who delivered in the third trimester or had a maternal death in the USA (2004-2014). We compared obstetric and neonatal outcomes between groups in three analyses: (1) Primary analysis-women with an ICD-9 PCOS diagnosis who underwent BS compared to pregnant PCOS patients without BS. (2) Sub-group analysis-PCOS women with BS compared to obese PCOS women (body mass index (BMI) ≥ 30 kg/m2) without BS. (3) Women with and without PCOS who underwent BS.

RESULT

In the primary analysis, pregnant PCOS women who underwent BS (N = 141), compared to pregnant PCOS women without BS (N = 14,741), were less likely to develop pregnancy-induced hypertension (PIH) (9.2% vs. 16.2%, respectively, aOR 0.39, 95% CI 0.21-0.72) and gestational diabetes mellitus (GDM) (9.9% vs. 18.8, aOR 0.40, 95% CI 0.23-0.70). In the sub-group analysis, PCOS women with BS, compared to obese PCOS women without BS (N = 3231), were less likely to develop gestational hypertension, preeclampsia, and preeclampsia or eclampsia superimposed on hypertension (P < 0.05). Lastly, PCOS patients with BS had a higher cesarean section rate when compared to non-PCOS patients with BS (N = 9197) (61.7% vs. 49.2%, aOR 1.48, 95% CI 1.05-2.09), with otherwise comparable obstetric and neonatal outcomes.

CONCLUSIONS

BS in PCOS patients was associated with reduced risks for GDM and PIH when compared to PCOS controls without BS and reduced risk for gestational hypertension, preeclampsia, and preeclampsia or eclampsia superimposed on hypertension when compared to obese PCOS controls without BS. Moreover, BS was associated with reduced inherent pregnancy risks of PCOS, almost equating them to those of non-PCOS counterparts.

The impact of metabolic surgery on natural conception rates in women with infertility, obesity and polycystic ovary syndrome: a retrospective study

BACKGROUND

Women with obesity and polycystic ovary syndrome (OPOS) are at high risk for infertility. However, the reproductive effects of metabolic surgery on women with infertility and OPOS have not been fully elucidated.

OBJECTIVES

We investigated the natural conception rates after metabolic surgery, and the variables associated with infertility in women with OPOS.

SETTING

Shanghai Sixth People's Hospital, Shanghai, China.

METHODS

This study included 72 women with infertility and OPOS who underwent metabolic surgery and were followed up for 4 years after surgery. Finally, 54 patients completed the study. Reproductive outcomes were assessed, along with changes in anthropometric parameters and metabolic indices before and 1 year after surgery (prepregnancy). Logistic regression analysis was used to identify variables influencing natural conception and delivery outcomes.

RESULTS

After metabolic surgery, 35 patients (64.8%) became pregnant naturally, while 16 were still unable to conceive naturally. Preoperative body mass index (BMI) tended to be lower in the natural conception group than in the no natural conception group (38.9 ± 6.9 versus 43.6 ± 11.0 kg/m2, P = .070) and there were no significant differences in weight loss between the 2 groups after surgery. Logistic regression analysis showed that the BMI 1 year after surgery (prepregnancy) was an independent predictor of natural conception, and receiver operating characteristic analysis showed that a BMI of 27.0 kg/m2 was the optimal cutoff for predicting successful natural conception after surgery.

CONCLUSIONS

Metabolic surgery can improve fertility in women with OPOS. Patients with a BMI < 27.0 kg/m2 1 year after surgery (prepregnancy) are more likely to become pregnant naturally and give birth.

Effects of Sleeve Gastrectomy on Patients with Obesity and Polycystic Ovary Syndrome: a Meta-analysis

PURPOSE

This study aimed to evaluate the efficacy of sleeve gastrectomy (SG) on patients with obesity and polycystic ovary syndrome (PCOS).

MATERIALS AND METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science to identify relevant studies published prior to December 2, 2022. Meta-analysis was performed on menstrual irregularity, total testosterone, sex hormone-binding globulin (SHBG), anti-Mullerian hormone (AMH), glucolipid metabolism indicators, and body mass index (BMI) following SG.

RESULTS

Six studies and 218 patients were included in the meta-analysis. Following SG, menstrual irregularity significantly decreased (odds ratio [OR] 0.03; 95% confidence intervals [CIs], 0.00-0.24; P=0.001). Additionally, SG can lower total testosterone levels (MD -0.73; 95% CIs -0.86-0.60; P< 0.0001), as well as BMI (MD -11.59; 95% CIs -13.10-10.08; P<0.0001). A significant increase was observed in the levels of SHBG and high-density lipoprotein (HDL) after SG. In addition to reducing fasting blood glucose, insulin, triglycerides (TG), and low-density lipoprotein levels, SG significantly reduced low-density lipoprotein levels as well.

CONCLUSIONS

Following SG, we firstly demonstrated significant improvements in menstrual irregularity, testosterone and SHGB levels, glycolipid metabolism indicators, and BMI. Therefore, SG may be considered as a new option for the clinical treatment of patients with obesity and PCOS.

The Potential Utility of Tirzepatide for the Management of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most prevalent endocrinopathy in women of reproductive age. The metabolic dysfunction associated with PCOS increases the probability of developing type 2 diabetes (T2D), endometrial cancer, and cardiovascular disease. Research has shown that the metabolic features of PCOS may be improved by weight loss following treatment with glucagon-like peptide-1 receptor (GLP-1R) agonists. Tirzepatide is a dual GLP-GIP (gastric inhibitory polypeptide) receptor agonist that shares a very similar mechanism of action with GLP-1R agonists, and it is hypothesized that it may be a potential contender in the treatment of PCOS. The success of GLP-1R agonists is usually hindered by their adverse gastrointestinal effects, leading to reduced compliance. The mechanism of action of Tirzepatide partly addresses this issue, as its dual receptor affinity may reduce the intensity of gastrointestinal symptoms. Tirzepatide has been licensed for the treatment of type 2 diabetes and given the metabolic issues and obesity that accompanies PCOS, it may be of value in its management for those PCOS patients who are obese with metabolic syndrome, although it may not benefit those who are of normal weight. This study reviews the current therapies for the treatment of PCOS and evaluates the potential use of Tirzepatide to address the symptoms of PCOS, including reproductive dysfunction, obesity, and insulin resistance.

Women's lived experiences of sex hormones and life-related to bariatric surgery: an interpretative qualitative study

OBJECTIVES

The study aimed to explore the lived experiences of women with severe obesity before and after undergoing bariatric surgery with a special focus on possible effects of changed sex hormone levels.

DESIGN

A qualitative interview study with transcribed text analysis based on Gadamer's hermeneutics.

SETTING

Regional hospital and outpatient bariatric clinic in central Sweden.

PARTICIPANTS

Ten women (age 23-38 years) having undergone Roux-en-Y gastric bypass surgery between 2016 and 2019 were interviewed.

RESULTS

The transcribed interviews were analysed according to Gadamer's hermeneutics. Text horizons, interpreter horizons and fact horizons were derived and formed the fusions 'Recognition of unhealthy body weight', 'Dealing with other people's opinions and society's norms', 'Life has changed in a positive way' and 'Accepting inner self and bodily changes'.

CONCLUSION

Women highlighted weight and body size in their responses. The study provided a deeper understanding of the situation of women living with obesity and pros and cons of having undergone bariatric surgery. Experiences of changes in sex hormones and fertility were discussed but not central to the informants. Participants emphasised the need to be prepared and properly supported in dealing with changes in life after bariatric surgery and subsequent weight loss.

Quality of life improvements after bariatric surgery in reproductive age women with and without PCOS: a cohort study

BACKGROUND

Obesity can negatively influence quality of life (QoL). Polycystic ovarian syndrome (PCOS), associated with obesity, presents with sub-fertility, hyperandrogenism, and/or insulin resistance. These features can also negatively influence QoL. This study aimed to determine whether bariatric surgery improves QoL in women of reproductive age, with and without PCOS. We hypothesized greater QoL improvements would be seen post-operatively in women with PCOS.

METHODS

Women undergoing bariatric surgery (N.=77) completed questionnaires exploring health-related quality of life (HR-QoL) prior to and at 3, 6 and 12 months post-surgery. Weight loss, symptoms, and association with change in QoL were assessed.

RESULTS

Bariatric surgery resulted in significant QoL improvements, independent of PCOS status. Oligo/amenorrhea was reported in 68% of women at baseline, decreasing to 35% by 12 months. Sixty-five percent of women whose menstrual irregularity resolved over follow-up had PCOS. Hirsutism was reported in 64% of women at baseline (all of whom had PCOS), decreasing to 19% by 12 months. Weight loss at 12-months was 45.8±20.7 kg for women without PCOS compared to 44.3±16.8 kg in women with PCOS (P=0.07). Weight loss was moderately associated with 12-month QoL improvements for both groups.

CONCLUSIONS

Bariatric surgery provides significant physical and psychological health benefits for women with obesity both with and without PCOS. Surgery can also ameliorate the clinical syndrome of PCOS, including oligomenorrhoea, hirsutism, and subfertility, with subsequent QoL benefits. Psychological support perioperatively may aid QoL outcomes by acknowledging factors influencing QoL beside absolute weight loss.

The Effect of Sleeve Gastrectomy on Pregnancy Complications: A Cross-Sectional Study in Saudi Arabia

BACKGROUND

Obesity is defined as abnormal or excessive fat accumulation that may impair health. Until recently, the only effective method for treating morbid obesity over the long term was bariatric surgery (BS). During pregnancy, obesity is correlated with higher risks for numerous complications, including gestational diabetes mellitus, pre-eclampsia, mortality, and large-for-gestational-age neonates. The most commonly reported complications among women who underwent sleeve gastrectomy and experienced pregnancy were placental bleeding, oligohydramnios, urinary tract infection, appendicitis, and recurrent abortions.

OBJECTIVES

We aim to estimate the consequence of sleeve gastrectomy and its relation with pregnancy outcomes among women in Saudi Arabia.

METHODOLOGY

This study adopted a quantitative, descriptive, cross-sectional design. It was conducted in Saudi Arabia between February and May 2023 among women who became pregnant after undergoing sleeve gastrectomy.  Result: Anemia was experienced by 78.8% of the patients during pregnancy. In our study, 18% of the individuals experienced complications during or right after delivery, with postpartum hemorrhage being the most frequent (43.1%). We discovered that pre-eclampsia and delivering a baby small for gestational age were considerably more common in pregnant women who smoked (p ≤ 0.05). On the other hand, no significant association was discovered between any comorbidity and mode of delivery, birth weight, child complications, or difficulties that occurred during or right after labor.

CONCLUSION

We concluded that weight gain after sleeve gastrectomy negatively impacted pregnancy and increased the probability of several complications for the mother and fetus. Healthcare providers must inform every woman undergoing BS about the possible complication of an unhealthy lifestyle after the procedure.

Dysregulated Liver Metabolism and Polycystic Ovarian Syndrome

A significant fraction of couples around the world suffer from polycystic ovarian syndrome (PCOS), a disease defined by the characteristics of enhanced androgen synthesis in ovarian theca cells, hyperandrogenemia, and ovarian dysfunction in women. Most of the clinically observable symptoms and altered blood biomarker levels in the patients indicate metabolic dysregulation and adaptive changes as the key underlying mechanisms. Since the liver is the metabolic hub of the body and is involved in steroid-hormonal detoxification, pathological changes in the liver may contribute to female endocrine disruption, potentially through the liver-to-ovary axis. Of particular interest are hyperglycemic challenges and the consequent changes in liver-secretory protein(s) and insulin sensitivity affecting the maturation of ovarian follicles, potentially leading to female infertility. The purpose of this review is to provide insight into emerging metabolic mechanisms underlying PCOS as the primary culprit, which promote its incidence and aggravation. Additionally, this review aims to summarize medications and new potential therapeutic approaches for the disease.

Successful pregnancy following gastric sleeve surgery for long-duration primary infertility: A case report

INTRODUCTION AND IMPORTANCE

Morbid obesity negatively affects patients' life quality in several ways. One of the major obesity-related problems is getting pregnant, even when using assisted reproductive technology. Obesity contributes to anovulation and menstrual irregularities, with a lower conception rate, a lower response to fertility treatment, poor implantation, low-quality oocytes, and miscarriages. Managing morbid obesity and then assessing the pregnancy outcome is crucial.

CASE PRESENTATION

We reported a case of a 42-year-old woman who had primary infertility for 26 years, polycystic ovary syndrome (PCOS), and a body mass index (BMI) of 51. She was able to get pregnant after having bariatric sleeve surgery, which brought her BMI down to 27. She had a successful pregnancy and live birth by Intrauterine insemination (IUI) from the first trial.

CLINICAL DISCUSSION

Patients with morbid obesity (BMI 35) and obesity-related health problems have often turned to bariatric surgery as their first line of treatment. Extremely overweight females with PCOS and infertility may benefit more from bariatric surgery.

CONCLUSION

Extremely overweight females with PCOS and infertility may benefit more from bariatric surgery, such as laparoscopic sleeve gastrectomy, than rather than only a healthier lifestyle change. Larger studies that assess the effect of bariatric surgeries in highly morbid females with PCOS are needed.

Considerations in the Treatment of Depression and Anxiety in Women with PCOS

Women with polycystic ovary syndrome (PCOS) are known to be at a greater risk of depression and anxiety. What is less clear is whether existing treatments for PCOS are effective in managing this increased risk and what the optimal approach to treatment is. In this review, currently available interventions are explored including lifestyle modifications, oral contraceptives, insulin sensitizing agents, psychosocial interventions and psychiatric medications. While data are often conflicting, lifestyle interventions, and cognitive behavioral therapy (CBT) appear most promising in reducing depression and anxiety symptoms in this population. There is an urgent need for large prospective studies to fill gaps in the literature.

Bariatric surgery and health outcomes: An umbrella analysis

BACKGROUND

There is a relative lack of data that systematically investigates the breadth and validity of the association between bariatric surgery and health-related outcomes. We aimed to evaluate the quantity, validity, and credibility of evidence regarding the association between bariatric surgery and health-related outcomes using an umbrella review of meta-analyses.

METHODS

We systematically searched PubMed, Embase, and the Web of Science databases from inception until December 2, 2021, to identify meta-analyses of observational or interventional studies that investigated the association between bariatric surgery and multiple health outcomes. We extracted the summary effect size and 95% confidence interval (CI) data. The Assessment of Multiple Systematic Reviews (AMSTAR-2) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines were used for methodological and evidence quality assessments, respectively.

RESULTS

Twenty-eight studies with 82 different health-related outcomes were included in this umbrella review. Beneficial effects of bariatric surgery have been observed in cancer incidence, mortality, cardiovascular risk, polycystic ovary syndrome (PCOS), anxiety symptoms, depressive symptoms, gestational diabetes mellitus, gestational hypertension, large for gestational age (LGA), macrosomia, post-term birth, risk of kidney stones, albuminuria, urinary incontinence, fecal incontinence, Barrett's esophagus, and diabetic retinopathy. However, adverse effects of bariatric surgery were observed for maternal anemia, perinatal mortality, congenital anomalies, preterm birth, neonatal intensive care unit (NICU) admission, intrauterine growth restriction, small for gestational age (SGA), fracture risk, upper limb fracture, suicide, self-harm, and alcohol use disorder (AUD).

CONCLUSIONS

Current evidence suggests that bariatric surgery improves the majority of health-related outcomes; however, caution is advised given it may increase the risk of adverse mental effects, perinatal problems, and fractures.

Effects of Bariatric Surgery on People with Obesity and Polycystic Ovary Syndrome: a Large Single Center Study from India

PURPOSE

Bariatric surgery has been proven to be a successful management strategy for morbid obesity, but limited studies exist on its effect on polycystic ovary syndrome (PCOS) in terms of clinical, hormonal, and comorbidities.

MATERIALS AND METHODS

This is a prospective observational study of 1013 PCOS patients who underwent bariatric surgery from a single high-volume center. Assessment of demographic data and menstrual irregularity as well as hirsutism and comorbidities was done preoperatively 6-month and yearly follow-up, whereas data regarding %TWL and %EWL was taken at follow-up visits conducted at regular intervals of 6 months, and 1, 2, 3, 4, and 5 years following surgery.

RESULTS

Out of 1013 PCOS patients, 993 patients had hirsutism before surgery, and 741 (74.6%; p < 0.001) had complete resolution of hirsutism at end of 6 months' follow-up. A total of 202 (20.3%) had moderate resolution at follow-up of 1 year, 5 patients had minimal resolution at end of 2 years, and 45 (4.5%) patients reported no change in their hirsutism at 4 and 5 years of follow-up. Among 1007 women with PCOS who had menstrual dysfunction, 936 (93% p < 0.0001) women restored their normal menstrual cycle at 6 months post-surgery with 55.4% EWL while remaining other 71 (7%) women reported regular menses at 2 years post-surgery at 74.2% EWL and continued to have normal menstrual pattern during the entire follow-up period. Similarly, all the associated comorbidities T2DM (79.7%), HTN (78.7%), DLP (93.2%), and OSA (98.5%) and symptoms of PCOS were statistically (p < 0.0001) and completely resolved at end years of follow-up.

CONCLUSION

Bariatric surgery is a good option for women with obesity and PCOS. It is effectively reducing weight along with PCOS and its disorder including hirsutism and menstrual irregularity in women with obesity and PCOS.

Obesity: A Doorway to a Molecular Path Leading to Infertility

The dramatic rise in obesity has recently made it a global health issue. About 1.9 billion were overweight, and 650 million global populations were obese in 2016. Obese women suffer longer conception time, lowered fertility rates, and greater rates of miscarriage. Obesity alters hormones such as adiponectin and leptin, affecting all levels within the hypothalamic-pituitary-gonadal axis. Advanced glycation end products (AGEs) and monocyte chemotactic protein-1 (MCP-1) are inflammatory cytokines that may play an important role in the pathophysiology of ovarian dysfunction in obesity. In obese males, there are altered sperm parameters, reduced testosterone, increased estradiol, hypogonadism, and epigenetic modifications transmitted to offspring. The focus of this article is on the possible adverse effects on reproductive health resulting from obesity and sheds light on different molecular pathways linking obesity with infertility in both female and male subjects. Electronic databases such as Google Scholar, Embase, Science Direct, PubMed, and Google Search Engine were utilized to find obesity and infertility-related papers. The search strategy is detailed in the method section. Even though multiple research work has shown that obesity impacts fertility in both male and female negatively, it is significant to perform extensive research on the molecular mechanisms that link obesity to infertility. This is to find therapeutics that may be developed aiming at these mechanisms to manage and prevent the negative effects of obesity on the reproductive system.

What is clinically relevant weight loss for your patients and how can it be achieved? A narrative review

Obesity is a chronic disease with increasing prevalence. It affects quality of life and renders those affected at increased risk of mortality. For people living with obesity, weight loss is one of the most important strategies to improve health outcomes and prevent or reverse obesity-related complications. In line with newly released clinical practice guidelines, weight loss targets for people living with obesity should be defined individually based on their clinical profile, and progress measured in the context of improvements in health outcomes, rather than weight loss alone. We outline current treatment options for clinically meaningful weight loss and briefly discuss pharmacological agents and devices under development. Numerous studies have shown that weight loss of ≥5% results in significant improvements in cardiometabolic risk factors associated with obesity; this degree of weight loss is also required for the approval of novel anti-obesity medications by the US Food and Drug Administration. However, some obesity-related comorbidities and complications, such as non-alcoholic steatohepatitis, obstructive sleep apnea, gastroesophageal reflux disease and remission of type 2 diabetes, require a greater magnitude of weight loss to achieve clinically meaningful improvements. In this review, we assessed the available literature describing the effect of categorical weight losses of ≥5%, ≥10%, and ≥15% on obesity-related comorbidities and complications, and challenge the concept of clinically meaningful weight loss to go beyond percentage change in total body weight. We discuss weight-loss interventions including lifestyle interventions and therapeutic options including devices, and pharmacological and surgical approaches as assessed from the available literature.

Anti-Mullerian Hormone Levels Increase After Bariatric Surgery in Obese Female Patients With and Without Polycystic Ovary Syndrome

This study was aimed to investigate the effect of weight loss by bariatric surgery on the level of anti-Mullerian hormone (AMH) in morbidly obese female patients with or without polycystic ovary syndrome (PCOS). This prospective study includes 70 females, obese, and fertile patients of reproductive age. All patients were evaluated to determine the changes in weight, body mass index (BMI), serum AMH, and other biochemical parameters at the end of six months. The mean levels of the preop and postop AMH were 1.66±0.87 ng/ml and 5.99±1.39 ng/ml in the PCOS group; 1.35±0.76 ng/ml and 6.23±1.47 ng/ml in the non-PCOS group, respectively. The postop AMH levels were significantly higher than the preop levels for both groups (p<0.001). There were significant differences in the level of glucose, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride, total cholesterol, hemoglobin A1c, HOMA-IR, insulin between preop and postop 6th month. A negative correlation was found between postop AMH and body weight in all patients (r=-0.337, p=0.031). Postop AMH levels were negatively correlated with postop BMI levels in the non-PCOS patient group (r=-0.408, p=0.043). No significant difference was observed between the PCOS and non-PCOS groups in terms of all the parameters examined. In conclusion, our study suggests that the significantly increased AMH levels by losing weight with bariatric surgery in patients with morbid obesity with and without PCOS may indicate the improvement of fertilization potential. It could be considered when evaluating fertility in patients with morbid obesity.

Maternal Nutritional Status and Pregnancy Outcomes Post-bariatric Surgery

Obesity in childbearing women leads to pregnancy-related complications such as gestational diabetes mellitus, pregnancy-associated hypertensive disorders, and macrosomia. Weight loss helps reduce these complications. Studies show bariatric surgery reduces obesity-related complications during and after pregnancy. However, bariatric surgery might be associated with adverse outcomes, such as low birth weight and small-for-gestational-age infants. In addition, several studies suggest pregnancy occurring less than a year post-bariatric surgery adversely affects pregnancy outcomes and causes micronutrients deficiency since the dramatic weight loss occurs in the first year. These adverse outcomes may lead to nutritional malabsorption, such as anemia and low vitamin B12 and folic acid levels. The review aims to overview obesity-related complications during pregnancy and the benefits and risks of bariatric surgery on pregnancy outcomes and maternal nutrition status.

Metabolic Surgery on Patients With Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis

Polycystic ovary syndrome (PCOS) is a complicated reproductive endocrine disease that is closely related to obesity. Metabolic surgery ameliorates a series of clinical manifestations and related comorbidities of PCOS. However, the overall efficacy of metabolic surgery on PCOS remains uncertain. This systematic review and meta-analysis aimed to evaluate the therapeutic effects of metabolic surgery on obese patients with PCOS. A systematic literature search for relevant studies was conducted on PubMed, Embase, Web of Science, and the Cochrane Library from inception to June 2021. Data extraction and quality evaluation were performed by three researchers, and RevMan 5.4 software was used to conduct the meta-analysis. A total of 14 studies involving 501 obese patients with PCOS were included. Incidence of PCOS in obese women ranged from 5.5% to 63.5% among the included studies. The results showed the incidence of abnormal menstruation decreased from 81% to 15% (OR=0.03, 95% confidence interval (CI): 0.01-0.08), while the incidence of hirsutism dropped from 71% to 38% (OR=0.21, 95% CI: 0.06-0.74). Serum total testosterone and free testosterone levels decreased by 25.92 ng/dL (MD = -25.92, 95% CI: -28.90- -22.93) and 2.28 ng/dL (SMD = -2.28, 95% CI: -3.67- -0.89), respectively. Sex hormone-binding globulin (SHBG) levels increased by 26.46 nmol/L (MD = 26.46, 95% CI: 12.97-39.95). Serum anti-Mullerian hormone (AMH) levels decreased by 1.29 ng/mL (MD = -1.29, 95% CI: -1.92- -0.66). Small sample size studies revealed that pregnancy rates ranged from 95.2% to 100% postoperatively. Metabolic surgery contributed to marked improvement of abnormal menstruation, hirsutism, and levels of free testosterone, total testosterone, SHBG, and AMH in patients with PCOS. Our findings indicate that patients with PCOS are expected to benefit from metabolic surgery, and could help potentially improve their reproductive outcomes. Metabolic surgery could thus be a new viable option for the clinical treatment of PCOS.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021251524.

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Obesity and reproduction: a committee opinion

The purpose of this American Society for Reproductive Medicine Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled "Obesity and reproduction: an educational bulletin" last published in 2015 (Fertil Steril 2015;104:1116-26).

Impact of bariatric surgery on androgen profile and ovarian volume in obese polycystic ovary syndrome patients with infertility

Obesity has major adverse effects on reproductive performance and fertility potential especially in women with polycystic ovary syndrome. In this study, we aimed to evaluate the consequences of excess weight reduction by bariatric surgery on androgen levels, and ovarian volume by ultrasonography in obese polycystic ovary patients. This one year Cohort study was carried out in Zagazig university hospitals. The study included 36 infertile women with PCOS and obesity, who underwent bariatric surgery(sleeve gastrectomy or gastric bypass). Patients were evaluated for free and total serum testosterone levels, Sex hormone binding globulin (SHBG), free androgen index (FAI) and also ovarian volume by ultrasound pre-operatively, 6 months and 1 year after surgery. The results showed significant reduction in Body Mass Index, free and total serum testosterone levels and rise in SHBG and regulation of menstrual cycle at 6 and 12 months after operation. Free androgen index and ovarian volume by ultrasound also significantly decreased (p < 0.001) .As a conclusion, Bariatric surgery results in durable loss of weight and restores the normal physiological balance of androgenic milieu and ovarian morphology by ultrasound, in infertile women who have Polycystic ovary syndrome.

Metabolomics in Bariatric Surgery: Towards Identification of Mechanisms and Biomarkers of Metabolic Outcomes

Bariatric surgery has been widely performed for the treatment of obesity and type 2 diabetes. Efforts have been made to investigate the mechanisms underlying the metabolic effects achieved by bariatric surgery and to identify candidates who will benefit from this surgery. Metabolomics, which includes comprehensive profiling of metabolites in biological samples, has been utilized for various disease entities to discover pathophysiological metabolic pathways and biomarkers predicting disease progression or prognosis. Over the last decade, metabolomic studies on patients undergoing bariatric surgery have identified significant biomarkers related to metabolic effects. This review describes the significance, progress, and challenges for the future of metabolomics in the area of bariatric surgery.

Successful pregnancy in morbidly obese lady with polycystic ovary syndrome after bariatric surgery: A case report

INTRODUCTION

Obesity has been proven to have adverse effects on fertility and is one of the predisposing factors for delay in pregnancy even with the use of assisted reproductive technique. There are many pathways in which obesity can affect fertility such as anovulation, poor implantation and low-quality oocyte.

CASE PRESENTATION

We report a case of a 40-year-old lady with primary infertility for six years with underlying polycystic ovary syndrome (PCOS) and BMI 45.7 whom was successfully conceived twice following bariatric surgery procedure in which reduction of 70% of her BMI prior to bariatric surgery lead to her spontaneous conception without fertility intervention and successful live birth.

CLINICAL DISCUSSION

Obese PCOS needs multidisciplinary approaches which include weight loss program such as dietary advice, exercise intervention as part of preliminary treatment prior to ovulation induction and counselling.

CONCLUSION

Bariatric surgery has been a mainstay treatment in patients with morbid obesity and those with BMI more than 35 associated with obesity related problems such as joint pain, hypertension or diabetes mellitus. Bariatric surgery such as laparoscopic sleeve gastrectomy should be considered more often in contrast to lifestyle modification for morbidly obese lady with PCOS and infertility prior to the use of standard ovulation induction regime for treating infertility.

The comparative effectiveness of 55 interventions in obese patients with polycystic ovary syndrome: A network meta-analysis of 101 randomized trials

BACKGROUND

Polycystic ovary syndrome (PCOS) affects up to 18% of reproductive-age females. The prevalence of obesity in PCOS patients reaches up to 80%, which is 2-fold higher than the general population.

OBJECTIVE

The present study aimed to compare the effectiveness of 55 pharmacological interventions across 17 different outcomes in overweight/obese PCOS patients with hyperandrogenism manifestations for both short- and long-term follow-ups. A comprehensive literature search was performed on PubMed, Scopus, Embase, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled trials comparing any conventional pharmacological intervention as a monotherapy or a combination in overweight/obese patients with polycystic ovary syndrome and hyperandrogenism manifestations. Extracted data included three main parameters; I. Anthropometric parameters (BMI, Waist and Hip circumferences, and Waist/HIP ratio), II. Hormonal parameters (FSH, LH, FSG, SHBG, Estradiol, Total Testosterone, Free testosterone, DHEAS, Androstenedione), and III. Metabolic parameters (Total Cholesterol, LDL-C, HDL-C, Triglycerides, Fasting glucose, Fasting glucose, HOMA-IR). Critical appraisal and risk of bias assessments were performed using the modified Jadad scale, and the overall quality of this network meta-analysis was evaluated according to the CINeMA framework. We performed both a pairwise meta-analysis and a network meta-analysis to evaluate the effect sizes with 95% CI, and we calculated the surface under the cumulative ranking curve (SUCRA) for each intervention.

RESULTS

Our final search on May 15th 2021 retrieved 23,305 unique citations from searching six electronic databases. Eventually, 101 RCTs of 108 reports with a total of 8,765 patients were included in our systematic review and multi-treatments meta-analysis. 55 different interventions were included: 22 monotherapies, and 33 combinations. The two-dimensional cluster ranking of the average SUCRA values for metabolic and hormonal parameters with significant estimates revealed flutamide (77.5%, 70%; respectively) as the highest and rosiglitazone (38.2%, 26.3%; respectively) as the lowest, in terms of the overall efficacy in reducing weight and hyperandrogenism. However, cyproterone-acetate+ethinylestradiol exhibited a higher ranking in improving hormonal parameters (71.1%), but even a lower-ranking regarding metabolic parameters (34.5%).

CONCLUSIONS AND RELEVANCE

Current evidence demonstrated the superiority of flutamide in improving both metabolic and hormonal parameters, and the higher efficacy of cyproterone-acetate+ethinylestradiol only in improving hormonal parameters. Nearly all interventions were comparable in female hormones, FGS, HDL, glucose, and insulin levels improvements.

Effects of bariatric surgery on patients with obesity and polycystic ovary syndrome: a meta-analysis

BACKGROUND

Bariatric surgery is effective for polycystic ovary syndrome (PCOS), while the exact mechanism remains unclear.

OBJECTIVES

To assess the impact of bariatric surgery on PCOS patients and further explore the possible mechanism.

SETTING

A meta-analysis.

METHODS

We searched PubMed, Web of Science, The Cochrane Library, and Embase to identify relevant studies published before November 2020.

RESULTS

Twenty-one studies met our inclusion criteria, and we identified 552 patients with PCOS study. Results showed that the prevalence of preoperative PCOS, menstrual irregularity, hirsutism, type 2 diabetes (T2D), hypertension, infertility, and depression significantly decreased after bariatric surgery. Levels of total testosterone, fasting insulin, and luteinizing hormone (LH) decreased and estradiol increased, while levels of follicle-stimulating hormone (FSH) and LH/FSH did not show significant changes during the 3-month follow-up. There were decreases in testosterone and fasting insulin levels when the postoperative follow-up time was 6 months or ≥12 months. Levels of fasting blood glucose and triglycerides were significantly reduced after 6 months or ≥12 months of bariatric surgery. High-density lipoprotein (HDL) and sex hormone-binding globulin (SHBG) significantly improved ≥12 months after bariatric surgery.

CONCLUSION

Symptoms of PCOS and related complications are significantly alleviated after bariatric surgery. In addition, we found a significant improvement on anomalous secretion of gonadotropins, glucose metabolism, and lipid metabolism in patients with PCOS after bariatric surgery.

Weight management strategies for patients with PCOS: current perspectives

INTRODUCTION

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder of reproductive-aged women. Overweight and obesity commonly accompany the syndrome at the clinic and are significant concerns for women with PCOS.

AREAS COVERED

Herein, we provide an overview of the relevant literature on weight management strategies in women with PCOS. We performed an electronic-based search using PubMed until February 2021. We aimed to summarize available evidence of different weight-reducing interventions in PCOS and outline the gaps in our current knowledge and recommend areas for further research.

EXPERT OPINION

PCOS is closely linked to obesity and increased adiposity enhances severity and expression of PCOS phenotype. Current data suggest that weight loss is associated with improved metabolic, endocrine, reproductive, cardiovascular and psychological features in overweight and obese women with PCOS. Lifestyle interventions including diet and exercise, anti-obesity medications and bariatric surgery have been used as therapeutic approaches for short-term management of obesity in PCOS with varying success rates. Large and sufficiently powered studies are required in order to determine long-term effects of weight management strategies and potential benefits beyond weight loss in the syndrome. This would allow informing the guidelines to make PCOS specific evidence-based recommendations.

Metabolic surgery: A clinical update

Metabolic and bariatric surgery has grown beyond 'experimental' weight-loss surgery. As techniques have advanced over the last few decades, so has the growing body of research and evidence, proving that both weight-loss and metabolic health improvement are induced. Metabolic surgery has become the more appropriate term for weight-loss surgery because of the altered gastrointestinal anatomy and subsequent beneficial metabolic effects. Although the tool of metabolic surgery has been well refined, a large portion of the global population does not have adequate access to it. This clinical update aims to (a) inform healthcare providers from all disciplines about the myriad of benefits of metabolic surgery and (b) equip them with the necessary knowledge to bridge the gap between patients in need of metabolic treatment and the therapies in metabolic surgery available to them.

Obesity as a multisystem disease: Trends in obesity rates and obesity-related complications

Obesity is a chronic multisystem disease associated with increased morbidity and mortality. The increasing prevalence of obesity makes it a major healthcare challenge across both developed and developing countries. Traditional measures such as body mass index do not always identify individuals at increased risk of comorbidities, yet continue to be used in deciding who qualifies for weight loss treatment. A better understanding of how obesity is associated with comorbidities, in particular non-metabolic conditions, is needed to identify individuals at risk in order to prioritize treatment. For metabolic disorders such as type 2 diabetes (T2D), weight loss can prevent T2D in individuals with prediabetes. It can improve and reverse T2D if weight loss is achieved early in the course of the disease. However, access to effective weight loss treatments is a significant barrier to improved health for people with obesity. In the present paper, we review the rising prevalence of obesity and why it should be classed as a multisystem disease. We will discuss potential mechanisms underlying its association with various comorbidities and how these respond to treatment, with a particular focus on cardiometabolic disease, malignancy and mental health.

The Impact of Bariatric Surgery Compared to Metformin Therapy on Pregnancy Outcomes in Patients with Polycystic Ovarian Syndrome: a Systematic Review and Meta-analysis

BACKGROUND

Polycystic ovarian syndrome (PCOS) is a leading cause of infertility among women of reproductive age. The interplay between hyperinsulinemia and obesity results in many of the reproductive and hormonal changes seen in PCOS including abnormal menses, infertility, and pregnancy loss. While bariatric surgery has been found to be an effective treatment strategy for morbid obesity, its role in the management of PCOS-related infertility compared to standard therapy (metformin) is less clear.

AIMS

To assess the impact of bariatric surgery on pregnancy outcomes in women with PCOS compared to metformin therapy in a systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, PubMed, and Google Scholar were searched from inception to August 2019. Studies that reported quantitative data on pregnancy outcomes on women of reproductive age with PCOS with at least a 3-month follow-up and a minimum of 5 or more sample size were included. The primary outcome was pregnancy rate, expressed as an event rate and 95% confidence interval (95% CI).

RESULTS

Ten studies with a total of 587 patients were included in the final analyses (Metformin: 5 studies, n = 192; Bariatric surgery (BS): 5 studies (2 Roux-en-Y gastric bypass, 2 sleeve gastrectomy, 1 Roux-en-Y gastric bypass + sleeve gastrectomy), n = 186). The average time to follow-up was 18.25 months (range 3-36) with a shorter time to follow-up in the metformin group compared to the bariatric surgery group (Metformin: 11.2 vs BS: 24.5 months). While metformin increased the likelihood of pregnancy compared to placebo or non-surgical interventions (OR = 3.08, 95% CI 1.29-7.37, p = 0.01), the pregnancy rate after bariatric surgery was greater than metformin (34.9%, 95% CI 0.20-0.53 vs 17.1%, 95% CI 0.12-0.23, p = 0.026 for the difference). Additionally, there was a trend to a greater improvement in menstrual irregularity in the bariatric group compared to the metformin group with a reduction of 92% in the bariatric cohort compared to a reduction of 54% in the metformin cohort, but the data was limited.

CONCLUSION

Bariatric surgery appears to be a more effective treatment strategy for patients with PCOS and class 3 obesity compared to metformin alone. Women with PCOS and infertility should consider bariatric surgery for weight loss and improvement in pregnancy outcomes.

Infertility management in women with polycystic ovary syndrome: a review

Polycystic ovary syndrome is the most common endocrine disorder in women and a major cause of anovulatory infertility. Various medical options are used, alone or in combination, to treat subfertility associated with polycystic ovary syndrome. This narrative review was conducted to provide an update and summarize the available evidence on the management of polycystic ovary syndrome related infertility. A wide literature search was performed and preferably randomized controlled trials and systematic reviews were included. Management is often centered on lifestyle changes. Pharmacological ovulation induction is the next step, with recommended use of letrozole, clomiphene citrate or gonadotropins. When it fails, assisted reproductive technologies or laparoscopic ovarian drilling are frequently advised. Combination treatment with metformin is often recommended. More recent alternative and adjunctive treatments have been suggested, like inositol, vitamin D, bariatric surgery and acupuncture, but further research is needed for recommendation.

Barocrinology: The Endocrinology of Obesity from Bench to Bedside

Obesity has reached pandemic proportions. Hormonal and metabolic imbalances are the key factors that lead to obesity. South Asian populations have a unique phenotype, peculiar dietary practices, and a high prevalence of consanguinity. Moreover, many lower middle-income countries lack appropriate resources, super-specialists, and affordability to manage this complex disorder. Of late, there has been a substantial increase in both obesity and diabesity in India. Thus, many more patients are being managed by different types of bariatric procedures today than ever before. These patients have many types of endocrine and metabolic disturbances before and after bariatric surgery. Therefore, these patients should be managed by experts who have knowledge of both bariatric surgery and endocrinology. The authors propose “Barocrinology”, a novel terminology in medical literature, to comprehensively describe the field of obesity medicine highlighting the role of knowing endocrine physiology for understating its evolution, insights into its complications and appreciating the changes in the hormonal milieu following weight loss therapies including bariatric surgery. Barocrinology, coined as a portmanteau of “baro” (weight) and endocrinology, focuses upon the endocrine and metabolic domains of weight physiology and pathology. This review summarizes the key pointers of bariatric management from an endocrine perspective.

Polycystic Ovary Disease and Obesity: Leptin, Weight-loss Medication, and Bariatric Surgery

For many patients, weight loss is a first-line measure recommended to reduce comorbidities associated with polycystic ovary disease. When lifestyle modifications such as diet and exercise are insufficient at achieving this goal, the addition of weight loss medications has proven effective for many patients. In patients with severe obesity, bariatric surgery is often used when other methods have been unsuccessful and has shown promising results for improving health and fertility in patients with polycystic ovary disease.

Endometrial function in women with polycystic ovary syndrome: a comprehensive review

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. An endometrial component has been suggested to contribute to subfertility and poor reproductive outcomes in affected women.

OBJECTIVE AND RATIONALE

The aim of this review was to determine whether there is sufficient evidence to support that endometrial function is altered in women with PCOS, whether clinical features of PCOS affect the endometrium, and whether there are evidence-based interventions to improve endometrial dysfunction in PCOS women.

SEARCH METHODS

An extensive literature search was performed from 1970 up to July 2020 using PubMed and Web of Science without language restriction. The search included all titles and abstracts assessing a relationship between PCOS and endometrial function, the role played by clinical and biochemical/hormonal factors related to PCOS and endometrial function, and the potential interventions aimed to improve endometrial function in women with PCOS. All published papers were included if considered relevant. Studies having a specific topic/hypothesis regarding endometrial cancer/hyperplasia in women with PCOS were excluded from the analysis.

OUTCOMES

Experimental and clinical data suggest that the endometrium differs in women with PCOS when compared to healthy controls. Clinical characteristics related to the syndrome, alone and/or in combination, may contribute to dysregulation of endometrial expression of sex hormone receptors and co-receptors, increase endometrial insulin-resistance with impaired glucose transport and utilization, and result in chronic low-grade inflammation, immune dysfunction, altered uterine vascularity, abnormal endometrial gene expression and cellular abnormalities in women with PCOS. Among several interventions to improve endometrial function in women with PCOS, to date, only lifestyle modification, metformin and bariatric surgery have the highest scientific evidence for clinical benefit.

WIDER IMPLICATIONS

Endometrial dysfunction and abnormal trophoblast invasion and placentation in PCOS women can predispose to miscarriage and pregnancy complications. Thus, patients and their health care providers should advise about these risks. Although currently no intervention can be universally recommended to reverse endometrial dysfunction in PCOS women, lifestyle modifications and metformin may improve underlying endometrial dysfunction and pregnancy outcomes in obese and/or insulin resistant patients. Bariatric surgery has shown its efficacy in severely obese PCOS patients, but a careful evaluation of the benefit/risk ratio is warranted. Large scale randomized controlled clinical trials should address these possibilities.

Curbing Obesity from One Generation to Another: the Effects of Bariatric Surgery on the In Utero Environment and Beyond

Approximately 250,000 individuals seek bariatric surgery each year in the USA for the long-term resolution of obesity-related comorbidities. Greater than 80% of these individuals are women and approximately half are of child-bearing age. Although there are many positive metabolic benefits that are realized through surgical weight loss for both men and women, the various long-term hormonal, molecular, nutrient, and epigenetic changes following bariatric surgery have not been evaluated for the surgical recipient or in the context of pregnancy and the offspring. Pregnancy may be a vulnerable period of time for the bariatric surgery recipient, and thoughtful consideration of pregnancy management should be taken by health care providers and recipients alike. The purpose of this review is to explore potential etiologies of some of the gestation-specific outcomes for the mother and offspring.

The Impact of Sleeve Gastrectomy on Females With Polycystic Ovarian Syndrome From 2018 to 2020 in Riyadh, Saudi Arabia: A Prospective Study

Background: Obesity is one of the most common risk factors for polycystic ovarian syndrome (PCOS). Reducing body weight has shown to improve the symptoms of PCOS; however, it is still unclear if the surgical treatment of obesity can have better outcomes to control obesity and improve PCOS.

Objective: This study aims to identify the impact of sleeve gastrectomy on PCOS symptoms in Riyadh, Saudi Arabia with a comparison of other weight reduction surgeries.

Design and Setting: This is a prospective study that included patients with PCOS who had weight reduction surgeries between 2018 and 2020, in Riyadh, Saudi Arabia. Using an online questionnaire, demographic data will be collected and information about menstruation, abortion, polycystic ovarian syndrome, and bariatric surgeries (if any). Data analysis was done through Statistical Package for the Social Sciences (SPSS) v26 (IBM Corp., Armonk, NY, USA).

Results: Ninety-nine female patients responded to this survey, all of whom had PCOS; 57.6% of these patients had a positive family history of PCOS. The most-reported PCOS symptoms were irregular menses (63.6%) and weight gain (53.5%), while 9.1% were asymptomatic. 52.5% were obese, and 91.1% underwent gastric sleeve surgery to treat their obesity. 41.4% of the females had a regular cycle before the operation, which increased to 60.6% after the operation; 48.5% had a normal flow before the operation, which increased to 61.6% after the operation. 15.2% conceived once before the operation, which increased to 16.2% after the operation. 11.1% had one abortion before surgery, which decreased to 7.1% after surgery. 55.6% observed an improvement in their PCOS symptoms after surgery, and 47.5% found that their fertility improved according to their own perception. Females with a positive family history of PCOS had a higher prevalence of PCOS (p-value <0.001). Also, females 30-39 years old are significantly more likely to have PCOS (p-value <0.001). The incidence of abnormal menstrual flow and irregular menstrual cycle was seen significantly more in PCOS patients than non-PCOS (p-value=0.019 and 0.004, respectively). PCOS symptoms and fertility significantly improved after surgery (p-value=0.031 and 0.043, respectively).

Conclusion: Sleeve gastrectomy can lead to significant improvement in fertility and symptoms of PCOS. It can also reduce the incidence of abortion. Other surgical techniques should be investigated.

Fertility and Pregnancy Outcomes in Women with Polycystic Ovary Syndrome Following Bariatric Surgery

CONTEXT

Restoration of ovulation is quite common in women with polycystic ovary syndrome (PCOS) after surgically induced weight loss. Whether or not this results in an improvement of PCOS-associated infertility is uncertain.

OBJECTIVE

To study fertility and gestational outcomes in women with PCOS after bariatric surgery.

DESIGN

Unicenter cohort study.

SETTING

Academic hospital.

PATIENTS

Two hundred and sixteen premenopausal women were screened for PCOS before bariatric surgery. Women were followed-up after the intervention until mid-2019 regardless of having or not PCOS.

INTERVENTIONS

All participants underwent bariatric surgery from 2005 to 2015.

MAIN OUTCOME MEASURES

Pregnancy and live birth rates in the PCOS and control groups.

RESULTS

In women seeking fertility, pregnancy rates were 95.2% in PCOS and 76.9% in controls (P = 0.096) and live birth rates were 81.0% and 69.2%, respectively (P = 0.403). The time to achieve the first pregnancy after surgery was 34 ± 28 months in women with PCOS and 32 ± 25 months in controls. Albeit the mean birth weight was lower (P = 0.040) in newborns from women with PCOS (2763 ± 618 g) compared with those from controls (3155 ± 586 g), the number of newborns with low birth weight was similar in both groups (3 in the PCOS group and 1 in the controls, P = 0.137). Maternal (17.6% in PCOS and 22.2% in controls, P = 0.843) and neonatal (23.5% in PCOS and 14.8% in controls, P = 0.466) complications were rare, showing no differences between groups.

CONCLUSIONS

Pregnancy and fertility rates in very obese women with PCOS after bariatric surgery were high, with few maternal and neonatal complications.