Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity

Bariatric surgery and reproduction-implications for gynecology and obstetrics

As the rates of obesity continue to rise across the world, there has been an increasing resort to bariatric surgery amongst the options for treatment. Through the reproductive lifespan, between menarche and menopause, women might benefit from this surgical intervention, which may have a bearing on other aspects of their health. The consequences of bariatric surgery have been reported and evaluated from various perspectives in obstetrics and gynecology. Fertility and sexuality are enhanced, but not all gynecological diseases are ameliorated. There are also psychological and behavioral sequelae to be cognizant of. With multi-disciplinary and responsive care, most post-bariatric pregnancies have satisfactory outcomes. The effects of bariatric surgery on the babies conceived thereafter remains a subject of interest, whereas the possible effect on the climacteric is speculative.

Bariatric surgery and its impact on fertility, pregnancy and its outcome: A narrative review

Bariatric procedures are on the rise as a surgical treatment for morbid obesity. In reproductive age of women, bariatric surgeries will improve factors related to anovulation and lead to spontaneous fertility. Spontaneous pregnancy can happen within a year after bariatric surgery due to higher level of sex hormone binding globulin and follicular stimulating hormone and reduction in androgens level. Reduction of length of follicular phase of menstrual cycle was reported and contribute to improved ovulatory status.

The major impact to pregnant women is development of small for gestational age babies due to persistent weight loss but this can be minimized by avoiding pregnancies too soon after bariatric surgery and good nutrition supplement. Risk of developing gestational diabetes mellitus and preeclampsia reduced among post bariatric surgery compared to no surgery. Another benefit observed are reduction in the risk of caesarean section and admission to neonatal intensive care unit. There are no significant changes in composition of breast milk in postpartum women without bariatric surgery and with women whom undergone surgery although more study needed to evaluate this effect.

Good prenatal care, micronutrient supplement during antenatal follow up and close supervision from expert managing this pregnancy are essential component to ensure good outcome to mothers and their newborn.

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Bariatric surgery in obese women will lead to improvement in ovulation.

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Bariatric surgery will improve the BMI and reduce risk associated with Gestational Diabetes Mellitus and Preeclampsia.

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Bariatric surgery will improve BMI and reduce miscarriages.

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Bariatric surgery in obese women will improve perinatal outcome.

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Mode of delivery and role of breastfeeding after bariatric surgery in obese women.

Potential Adverse Effects of Female and Male Obesity on Fertility: A Narrative Review

CONTEXT

Despite several studies documenting that obesity affects female and male fertility and leads to multiple adverse reproductive outcomes, the mechanisms involved are not elucidated. We aimed to summarize the potential adverse effects of female and male obesity, as well as the impact of weight loss on their fertility status.

EVIDENCE ACQUISITION

This review summarizes papers investigating the potential adverse effects of female and male obesity and the impact of weight-loss interventions on fertility among reproductive age populations. PubMed, Scopus, Web of Science, and Google Scholar databases were searched for retrieving studies published up to November 2019 on obesity/overweight among reproductive age populations.

RESULTS

The review of 68 studies revealed that female and male obesity/overweight increases the risk of sub-fecundity and infertility. The destructive effects of female obesity on reproduction are attributed to a variety of ovarian and extra-ovarian factors. In women with overweight or obesity, the time taken to conceive is longer, and they have a decreased fertility rate, increased requirement for gonadotropins, and higher miscarriage rate when compared to those with normal weight. Male obesity may lead to subfertility, mainly because of the disruption of the hypothalamus-pituitary-gonadal (HPG) axis, increased testicular temperature, impairment of the physical and molecular structure of sperm, decreased sperm quality, and erectile dysfunction due to peripheral vascular disease. Most studies recommend lifestyle interventions as first-line therapy in the general population of women and men with obesity and infertility.

CONCLUSIONS

This study shows the negative effects of female and male overweight and obesity on fertility. Therefore, educational interventions on the adverse effects of obesity and the benefits of weight reduction, such as increasing pregnancy rate, should be considered for couples seeking fertility.

A Review of Obstetrical Outcomes and Complications in Pregnant Women after Bariatric Surgery

Bariatric surgery (BS) is a novel treatment for weight reduction with longer lasting health benefits. This review aimed to summarise the available evidence regarding the fetomaternal outcomes and the most common challenges and complications in pregnancies following BS. Google Scholar (Google LLC, Mountain View, California, USA) and PubMed® (National Library of Medicine, Bethesda, Maryland, USA) databases were searched for articles published until December 2018. A total of 64 articles were included in this review and results showed that BS mitigates the risk of gestational diabetes mellitus, hypertensive disorders in pregnancy and fetal macrosomia. However, it can also have detrimental effects on fetomaternal health. There is paucity of data regarding small for gestational age intrauterine growth restriction, premature rupture of membranes and long-term effects on the children born to women who underwent BS.

Immediate return of fertility function following a bariatric surgery: A case report

Obesity in women of childbearing age is linked to lower fertility rates due to chronic oligoovulation and anovulation. Effective weight loss treatment such as bariatric surgery can improve fertility potential. However, pregnancy during the first 12 months after bariatric surgery should be avoided due to an active catabolic state and may increase the potential risk of fetal growth restriction. Here, we report a case with an immediate return of fertility function following a bariatric surgery with favorable outcomes. A 30-year-old woman with obesity, history of polycystic ovarian syndrome and infertility become pregnant within 2-month period following bariatric surgery. She first recognized her pregnancy at the gestational age of 8 weeks. Micronutrient laboratory results at baseline were normal except for low 25-OH vitamin D level of 18.7 ng/dL. She continued to lose her weight during the first trimester but was able to gain some weight during the second and third trimesters. Close fetal ultrasonography monitoring was done during each trimester. The fetal ultrasonography showed an appropriate fetal weight, a normal Doppler study and no abnormality detected in the fetus. Finally, at 36 weeks of gestation, a 2380-g female baby was delivered successfully.

The impact of surgical treatment of obesity on the female fertility

As obesity is considered to be a pandemic of the twenty-first century, the bariatric surgery becomes more common through the global population. The adverse effects of obesity on fertility can be reversed through the bariatric surgery procedures. In this review, we presented the effects of bariatric surgery on hypothalamic-pituitary-ovarian axis and fertility, ovarian reserve, and contraception efficacy.

Gastro-intestinal surgery and fertility

In France, 10 to 15% of couples in the overall population have a fertility problem. Preservation of sexual and reproductive function should be a major concern for all patients capable of procreation who undergo treatment for gastro-intestinal disease. The gastro-intestinal diseases most often responsible for fertility disorders include chronic inflammatory diseases, intestinal cancer and hereditary diseases, such as the Lynch syndrome and familial adenomatous polyposis. Obesity is responsible for a 20% loss of fertility but the effects of bariatric surgery on fertility are controversial. Nonetheless, in the light of progress in surgical techniques and better knowledge of gastro-intestinal disease the negative impact of surgery on fertility warrants attention. Effectively, fertility can be preserved after certain major gastro-intestinal operations such as cytoreductive surgery with intraperitoneal chemotherapy, total coloprotectomy with ileo-anal anastomosis and rectosigmoid resection, as long as the patient's age permits and resection of the reproductive organs is not necessary.

Obstetric and perinatal outcomes in subfertile patients who conceived following low technology interventions for fertility enhancement: a comprehensive review

PURPOSE

Low technology interventions for fertility enhancement (LTIFE) are strategies that avoid retrieval, handling, and manipulation of female gametes. The definition of LTIFE is yet to be widely accepted and clarified, but they are commonly used in milder cases of infertility and subfertility. Based on these considerations, the aim of the present study was comprehensively to review and investigate the obstetric and perinatal outcomes in subfertile patients who underwent LTIFE.

METHODS

A literature search up to May 2017 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science, and Google Scholar. An evidence-based hierarchy was used according to The Oxford Centre for Evidence-Based Medicine to determine which articles to include and analyze, and to provide a level of evidence of each association between intervention and outcome.

RESULTS

This analysis identified preliminary and low-grade evidence on the influence of LTIFE on obstetric and perinatal outcomes in subfertile women.

CONCLUSIONS

LTIFE women should deserve major consideration from Clinicians/Researchers of Reproductive Medicine, because these treatments could be potentially responsible for mothers' and babies' complications. So far, the lack of well-designed and unbiased studies makes further conclusions difficult to be drawn.

Pregnancy after bariatric surgery: improving outcomes for mother and child

The significant increase in the prevalence of obesity has led to an increase in the number of obese women who become pregnant. In this setting, in recent years, there has been an exponential rise in the number of bariatric procedures, with approximately half of them performed in women of childbearing age, and a remarkable surge in the number of women who become pregnant after having undergone bariatric surgery (BS). These procedures entail the risk of nutritional deficiencies, and nutrition is a crucial aspect during pregnancy. Therefore, knowledge and awareness of the consequences of these techniques on maternal and fetal outcomes is essential. Current evidence suggests a better overall obstetric outcome after BS, in comparison to morbid obese women managed conservatively, with a reduction in the prevalence of gestational diabetes mellitus, pregnancy-associated hypertensive disorders, macrosomia, and congenital defects. However, the risk of potential maternal nutritional deficiencies and newborns small for gestational age cannot be overlooked. Results concerning the incidence of preterm delivery and the number of C-sections are less consistent. In this paper, we review the updated evidence regarding the impact of BS on pregnancy.

Pregnancy Following Bariatric Surgery-Medical Complications and Management

Bariatric surgery is most commonly carried out in women of childbearing age. Whilst fertility rates are improved, pregnancy following bariatric surgery poses several challenges. Whilst rates of many adverse maternal and foetal outcomes in obese women are reduced after bariatric surgery, pregnancy is best avoided for 12-24 months to reduce the potential risk of intrauterine growth retardation. Dumping syndromes are common after bariatric surgery and can present diagnostic and therapeutic challenges in pregnancy. Early dumping occurs due to osmotic fluid shifts resulting from rapid gastrointestinal food transit, whilst late dumping is characterized by a hyperinsulinemic response to rapid absorption of simple carbohydrates. Dietary measures are the mainstay of management of dumping syndromes but pharmacotherapy may sometimes become necessary. Acarbose is the least hazardous pharmacological option for the management of postprandial hypoglycemia in pregnancy. Nutrient deficiencies may vary depending on the type of surgery; it is important to optimize the nutritional status of women prior to and during pregnancy. Dietary management should include adequate protein and calorie intake and supplementation of vitamins and micronutrients. A high clinical index of suspicion is required for early diagnosis of surgical complications of prior weight loss procedures during pregnancy, including small bowel obstruction, internal hernias, gastric band erosion or migration and cholelithiasis.

Bariatric Surgery in Women: A Boon Needs Special Care During Pregnancy

Obesity is one of the leading causes of health related disorder and has reached epidemic proportions not only in developed nations but also in developing countries like India. Bariatric surgery has become a popular alternative for obese women planning pregnancy. A multidisciplinary approach involving the obstetrician, the bariatric surgeon and the nutritionist is required to manage pregnancy following bariatric surgery. Early consultation should be done to determine baseline nutritional status and the importance of regular check-ups must be explained. Nutritional supplementation should be tailored to the patient's status and the type of bariatric surgery performed.

Prepregnancy and early adulthood body mass index and adult weight change in relation to fetal loss

OBJECTIVE

To examine prospectively the relationships of prepregnancy body mass index (BMI), BMI at age 18 years, and weight change since age 18 years with risk of fetal loss.

METHODS

Our prospective cohort study included 25,719 pregnancies reported by 17,027 women in the Nurses' Health Study II between 1990 and 2009. In 1989, height, current weight, and weight at age 18 years were self-reported. Current weight was updated every 2 years thereafter. Pregnancies were self-reported, with case pregnancies lost spontaneously and comparison pregnancies ending in ectopic pregnancy, induced abortion, or live birth.

RESULTS

Incident fetal loss was reported in 4,494 (17.5%) pregnancies. Compared with those of normal BMI, the multivariate relative risks of fetal loss were 1.07 (95% CI [confidence interval] 1.00-1.15) for overweight women, 1.10 (95% CI 0.98-1.23) for class I obese women, and 1.27 (95% CI 1.11-1.45) for class II and class III obese women (P trend ≤ .001). Body mass index at age 18 years was not associated with fetal loss (P trend=.59). Compared with women who maintained a stable weight (± 4 kg) between age 18 years and before pregnancy, women who lost weight had a 20% (95% CI 9-29%) lower risk of fetal loss. This association was stronger among women who were overweight at age 18 years.

CONCLUSION

Being overweight or obese before pregnancy was associated with higher risk of fetal loss. In women overweight or obese at age 18 years, losing 4 kg or more was associated with a lower risk of fetal loss.

LEVEL OF EVIDENCE

: II.

Mid-term results of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in adolescent patients

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m2. The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m2. Fifteen of the patients were available for follow-up. Thirteen out of 16 (81%) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.

Medical and surgical interventions to improve outcomes in obese women planning for pregnancy

Obesity is a known risk factor for infertility in women. The exact mechanism through which obesity is linked to infertility is still not fully understood. Hyperleptinaemia, hyperinsulinaemia and resultant hyperandrogenism are all thought to play a role. Various medical and surgical interventions have been attempted to improve fertility rates in obese women. Encouraging evidence for pharmacotherapy, bariatric surgery and assisted reproduction are yet to be seen. In this chapter, we review the hormonal changes in obesity and the evidence behind medical and surgical interventions to improve fertility in obese women.

Polycystic ovary syndrome: current status and future perspective

Polycystic ovary syndrome (PCOS) is a widespread reproductive disorder that encompasses many associated health conditions and has an impact on various metabolic processes. PCOS is depicted by hyperandrogenism, polycystic ovaries, and anovulation. It increases the risk of insulin resistance (IR), type 2 diabetes, obesity, and cardiovascular disease. The etiology of the disease remains unclear, and the subjective phenotype makes a united diagnosis difficult among physicians. It seems to be a familial genetic syndrome caused by a combination of environmental and genetic factors. It can be linked with metabolic disorders in first-degree family members. PCOS is the cause of up to 30% of infertility in couples seeking treatment. Currently, there is no cure for PCOS. Despite the growing incidence of this syndrome, limited research has been done that encompasses the entirety of PCOS spectrum. In this review, the current status and possible future perspective will be discussed.

Bariatric surgery: impact on pregnancy outcomes

The dramatic increase in the prevalence of obesity in women of reproductive age has resulted in approximately 1 in 5 women being obese when they conceive. Bariatric surgery has been shown to be the most effective long-term weight loss strategy in obese women in this age group. Clinicians should be aware of the effects of bariatric surgery on fertility and future pregnancies. Regarding certain complications, pregnancy after bariatric surgery appears to be safer than pregnancy in the obese. In patients where nutrition is properly maintained and monitored, the risks for obesity-related obstetric complications, such as gestational diabetes mellitus and hypertension, are significantly reduced, but possibly at the expense of an increase in neonates born small-for-gestational-age. At the present, definitive conclusions cannot be drawn concerning the risk for Caesarian delivery, differences in type of bariatric procedure, or the optimal surgery-to-conception interval.

Preventing and Treating Obesity in Girls and Young Women to Curb the Epidemic

Obesity and its serious comorbidities, type 2 diabetes, coronary heart disease, hypertension, and dyslipidemia, have reached epidemic proportions in adults and children. Female obesity is more prevalent and, thus, has greater epidemiological importance: mothers transmit the disease epigenetically and genetically. Maternal obesity affects maternal health, pregnancy outcome, and fetal, neonatal, childhood, and ultimately adult morbidity and mortality. Obesity is easy to diagnose, as are most of its risk factors, yet very little progress has been made in preventing the disease. During a brief period of rapid early growth, there is imprinting of antecedents of adult obesity and obesity-related disease. Because of the rapidity of this early growth and the relative brevity of the critical period, early recognition and prompt intervention are necessary and possibly sufficient to prevent the development of obesity. Identification of inappropriate rapid weight gain through frequent weighing should trigger immediate adjustment of energy intake, a simple intervention in bottle-fed infants, the ones at greatest risk for becoming obese. This review presents a step-care strategy with fail-safe action levels starting with maternal education and diet, exercise, and behavior modification for mother and child and progressing to drug treatment and, in selected cases, laparoscopic surgery for young women of childbearing age in whom other measures have failed. This approach is predicated on the assumption that careful monitoring and responsive supplementation of potential deficiencies is easier to achieve, more cost-effective, and safer than effectively treating manifest obesity and its comorbidities in adults.

Defining the role of bariatric surgery in polycystic ovarian syndrome patients

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women. To meet PCOS criteria, women must have a combination of hyperandrogenism, anovulation and ultrasound findings. Almost 10% of all reproductive age women worldwide show signs of PCOS. Although women often seek care for gynecological or body image concerns, many PCOS women are at risk for metabolic syndrome (MS). Many of the metabolic consequences are overlooked and undertreated by physicians because these patients tend to be young, reproductive age women. MS and obesity coexist commonly with PCOS. These young women are predisposed to glucose abnormalities and ultimately diabetes mellitus, dyslipidemia and eventually cardiovascular disease. Bariatric surgery can be an effective means of weight loss in PCOS women. Surgical techniques have become safer and less invasive over time and have been found to be effective in achieving significant weight loss. Surgical options have also increased, giving patients more choices. Bariatric surgery may prevent or reverse metabolic syndrome. Bariatric surgery may also have reproductive benefits in PCOS patients. Although bariatric surgery has historically been performed in older, reproductive aged women, it has recently gained favor in adolescents as well. This is of particular importance due to the prevalence of both PCOS and MS in adolescents. Treatment of PCOS and MS certainly requires a combination of medical therapy, psychological support and lifestyle modifications. These treatments are difficult and often frustrating for patients and physicians. Bariatric surgery can be effective in achieving significant weight loss, restoration of the hypothalamic pituitary axis, reduction of cardiovascular risk and even in improving pregnancy outcomes. Ultimately, bariatric surgery should be considered part of the treatment in PCOS women, especially in those with MS.

Preparing for and managing a pregnancy after bariatric surgery

The number of bariatric surgeries performed in the United States has increased exponentially. Given that most patients are female and of reproductive age, it is important for clinicians who manage women's health issues to be aware of the surgery, its long-term goals, and the potential effect on future pregnancies. Most pregnancies after bariatric surgery have successful outcomes with decreased occurrences of gestational diabetes and hypertension and lower birth weight compared with control patients. Following nutritional guidelines and supplementation in the event of deficiencies are critical in the provision of prenatal care to this unique population. Other important issues include a multidisciplinary team management, a different approach to screening for gestational diabetes, careful evaluation of any gastrointestinal complaints, and appropriate counseling for gravidas who still remain obese during pregnancy. Further research should investigate the long-term maternal outcomes in pregnancies after bariatric surgery as well as the effect on the offspring.

Effect of bariatric surgery on obesity-related infertility

BACKGROUND

There is a strong association between obesity and infertility, and weight loss can increase fecundity in obese women. In an attempt to determine the effect of bariatric surgery on obesity-related infertility, we reviewed the fertility outcomes after intragastric balloon placement, adjustable gastric banding, sleeve gastrectomy, and gastric bypass in childbearing women with a diagnosis of infertility at a university hospital in Italy.

METHODS

This was a retrospective study of 110 obese infertile women. We evaluated the effectiveness of bariatric surgery in improving fertility, assessing the influence of age, surgical technique, co-morbidities (hypertension and diabetes), weight loss, and body mass index before and after surgery.

RESULTS

Of these 110 women who had tried unsuccessfully to become pregnant before weight loss, 69 became pregnant afterward. The pregnancies proceeded without complications and ended with a live birth. Only the weight loss (odds ratio 20.2, P = .001) and the achieved body mass index (P = .001) after surgery were the predictors of pregnancy.

CONCLUSION

Bariatric surgery might be effective in young infertile obese women who wish to become pregnant. Weight loss appears to be independent from the surgical technique in determining the increase in the pregnancy rate as well as the body mass index achieved at pregnancy.

The potential role of intragastric balloon in the treatment of obese-related infertility: personal experience

The prevalence of people who are overweight or obese has increased dramatically in high-income countries over the past 20 years. There is a strong association between obesity and infertility, and weight loss can result in increased fecundity in obese women. The aim of this study is to demonstrate the potential role of intragastric balloon in the treatment of obese-related infertility. This is a retrospective study. A chart review of 27 obese women seen between September 2003 and July 2008 was performed. They all presented with the diagnosis of infertility and had undergone endoscopic intragastric balloon positioning. Among these women who tried unsuccessfully to become pregnant before weight loss, 15 became pregnant afterward. The pregnancies proceeded without complications and ended with live births. An improvement in the fertility status after weight loss has been described, although data on fertility after weight loss following bariatric surgery are still limited. The results obtained in our experience are not different from data reported in literature for bariatric surgery. Therefore, balloon treatment might be effective in young infertile obese women who wish to become pregnant.

[Prognosis criteria for the management of the infertile couple]

Advanced maternal age, obesity and cigarette smoking are associated with decreased fertility, adverse Assisted Reproductive Technologies (ART) outcomes and fetal and neonatal complications. IVF failures increase dramatically in women aged between 42-43 years. Advanced paternal age is associated with fetal and neonatal adverse outcomes. However, it remains uncertain that advanced paternal age could impair IVF results. Obesity (Body mass index more than 30 kg/m(2)) is associated with lower fecundity, pregnancy complications and adverse ART results. The rate of complications is increasing with higher BMI. Cigarette smoking is associated with longer time to conceive and decreased IVF results. In case of infertility associated with obesity or cigarette smoking, physicians have to inform their patient about the benefits of smoking cessation and weight loss. However, maternal age had to be considered as the main prognosis factor before delaying ART because of dietary or smoking cessation program.

Pregnancy after bariatric surgery: a review

Maternal obesity is a major cause of obstetric morbidity and mortality. With surgical procedures to facilitate weight loss becoming more widely available and demanded and increasing number of women becoming pregnant after undergoing bariatric surgery, it is important and timely to consider the outcome of pregnancy following bariatric surgery. This paper aims to synthesize the current evidence regarding pregnancy outcomes after bariatric surgery. It concludes that bariatric surgery appears to have positive effects on fertility and reduces the risk of gestational diabetes and preeclampsia. Moreover, there appears to be a reduced incidence of fetal macrosomia post-bariatric procedure, although there remains uncertainty about the increased rates of small-for-gestational age and intrauterine growth restricted infants, as well as premature rupture of membranes in this group. A number of case reports highlight that pregnancy following bariatric surgery is not without complications and it must be managed as high risk by the multidisciplinary team.

Pregnancy after bariatric surgery

The incidence of obesity is increasing rapidly, and it affects a greater proportion of women than men. Unfortunately, obesity has a negative impact on women's reproductive health, including increased adverse perinatal outcomes. Weight loss surgery, also known as bariatric surgery, is performed in many hospitals, and can allow for significant weight loss and improvement in medical comorbidities such as diabetes and hypertension. A woman who becomes pregnant after bariatric surgery usually has an uncomplicated pregnancy but requires special attention to some complications that can occur after these procedures. This article reviews the perinatal outcomes and provides recommendations for care regarding the unique issues that arise during a pregnancy after bariatric surgery.

The adverse effects of obesity on conception and implantation

Whilst many multiparous women are obese (body mass index >30 kg/m(2)), obesity has been associated with impaired fecundity; however, the mechanism which links obesity to reduced fertility remains to be fully elucidated. Obese women, particularly those with central obesity, are less likely to conceive per cycle. Obese women suffer perturbations to the hypothalamic-pituitary-ovarian axis, menstrual cycle disturbance and are up to three times more likely to suffer oligo-/anovulation. A fine hormonal balance regulates follicular development and oocyte maturation, and it has been observed that obesity can alter the hormonal milieu. Leptin, a hormone produced by adipocytes, is elevated in obese women, and raised leptin has been associated with impaired fecundity. Obesity impairs ovulation but has also been observed to detrimentally affect endometrial development and implantation. The expression of polycystic ovary syndrome (PCOS) is regulated, in part, by weight, and so obese women with PCOS often have a more severe phenotype and experience more subfertility. Obesity also impairs the response of women to assisted conception treatments. Weight loss through lifestyle modification or bariatric surgery has been demonstrated to restore menstrual cyclicity and ovulation and improve the likelihood of conception. In this article, we will discuss the effect of obesity upon key reproductive mechanisms and its relation to fertility treatments.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Reproductive outcome after bariatric surgery: a critical review

BACKGROUND

After many cycles of weight loss and weight gain, more and more morbidly obese patients undergo bariatric surgery, like gastric banding or gastric bypass, as the ultimate treatment for their obesity-problem. Since women of reproductive age are candidates for bariatric surgery, concerns arise regarding the potential impact on future pregnancy.

METHODS

English-language articles were identified in a PUBMED search from 1982 to January 2008 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.

RESULTS

The few reported case-control and cohort studies clearly show improved fertility and a reduced risk in obstetrical complications, including gestational diabetes, macrosomia and hypertensive disorders of pregnancy, in women after operatively induced weight loss when compared with morbidly obesity women. The incidence of intrauterine growth restriction (IUGR) appears to be increased, however. No conclusions can be drawn concerning the risk for preterm labour and miscarriage, although these risks are probably increased compared with controls matched for body mass index. Operative complications are not uncommon with bariatric surgery and several cases have pointed to the increased risk for intestinal hernias and nutritional deficiencies in subsequent pregnancy. Deficiencies in iron, vitamin A, vitamin B(12), vitamin K, folate and calcium can result in both maternal complications, such as severe anaemia, and fetal complications, such as congenital abnormalities, IUGR and failure to thrive.

CONCLUSIONS

Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can help to prevent nutrition-related complications and improve maternal and fetal health, in this high-risk obstetric population.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Pregnancy following gastric bypass for morbid obesity: effect of surgery-to-conception interval on maternal and neonatal outcomes

BACKGROUND

Conception is discouraged during the period of maximal weight loss following Roux-en-Y gastric bypass (RYGB) because of speculative maternal and fetal concerns. We therefore performed a retrospective cohort study of obstetrical and neonatal outcomes by surgery-to-conception interval.

METHODS

Women with RYGB were stratified into two groups by surgery-to-conception interval of <or=18 or >18 months. Pregnancy and newborn outcomes excluding miscarriages were compared using the chi-square or unpaired t-test for dichotomous and continuous variables, respectively.

RESULTS

Twenty subjects conceived <or=18 months (11.4+/-5.0) and 32 conceived >18 months (47.5+/-41) after RYGB, p< .05. Maternal age, parity, body mass index, and weight gain were similar by group. There were no statistically significant differences in adverse obstetrical outcomes (preterm premature membrane rupture, gestational diabetes, oligohydramnios, intrauterine growth restriction, preterm or post-term delivery) or adverse newborn outcomes (5-min Apgar score <7, intensive care admission, or birth defect).

CONCLUSION

Obstetrical and neonatal outcomes are similar in women conceiving during or after the period of maximal weight loss following RYGB.

Pregnancy after bariatric surgery: a comprehensive review

BACKGROUND

Obesity continues to be a global epidemic, and strong evidence exists linking it with gestational complications such as macrosomia, hypertensive disorders of pregnancy, gestational diabetes, and cesarean section. Bariatric surgery, a highly effective treatment for obesity, may prevent such complications in subsequent pregnancies.

OBJECTIVE

This review seeks to describe the risks and benefits of post-bariatric procedure pregnancies, in comparison to both community and obese cohorts.

RESULTS

A thorough review of the literature suggests that post-surgery women are not at increased risk for poor perinatal outcomes, and moreover their risks for many obesity-related gestational complications are reduced after bariatric surgery. Data regarding fertility after bariatric surgery are quite ambiguous, however, and studies exist demonstrating both positive and negative associations between weight loss procedures and fertility.

CONCLUSIONS

Clinicians should be aware that data collected on this subject were often gathered from post-op pregnant women provided with good prenatal care and screening for nutritional deficiencies. Although pregnancy after bariatric surgery appears to be safe, providers should take extra care to properly monitor their post-op pregnant patients for appropriate weight gain and nourishment.

Female reproductive issues following bariatric surgery

One in 3 adult American women is obese. Almost half of the approximately 100,000 bariatric surgeries performed in 2004 were on reproductive-aged women. Anatomic and physiologic changes resulting from such surgery may have significant clinical implications for preconception, pregnancy, and postpartum care. This review summarizes these issues and the available related literature, and offers guidelines for care of these patients.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that bariatric surgery has many anatomic and physiologic changes that potentially will affect future pregnancies, and state that attention to these physiologic changes and attention to potential nutritional deficiencies significantly improves the chances of a good pregnancy outcome.

Anneau gastrique et grossesse

Laparoscopic adjustable gastric banding and pregnancy.

OBJECTIVES

We intend to understand the interactions between pregnancy and laparoscopic adjustable gastric banding in order to ensure better care for patients.

MATERIALS AND METHOD

We undertake an observation retrospective study, from January 2004 to December 2005, at Edouard Herriot hospital, of births from women with laparoscopic adjustable gastric banding with a study of gastric banding interaction with pregnancy, neonatal outcomes and postpartum; we read through literature.

RESULTS

We studied 35 pregnancies from women with a gastric banding out of 5773 pregnancies (0.6%); we noted lower obstetrical complications with loss of weight that we attributed to the gastric banding comparing with the pregnancies before the gastric banding: three hypertensive diseases and one gestational diabetes had been avoided; we observed a complication due to the gastric banding: occlusive syndrome, which implied gastric banding calibration during immediate postpartum.

CONCLUSION

Our record folders are in accordance with literature and confirm improvement in obstetrical prognostic. Waiting for stabilization of weight is recommended before starting a pregnancy after gastric banding surgery; the adjustment of the gastric banding during pregnancy must be undertaken individually according to symptoms (vomiting, gain of weight...).

Improvement in infertility and pregnancy outcomes after weight loss surgery

The majority of bariatric surgical procedures are performed in young women. There is a concern about safety and outcomes of pregnancies after weight loss surgery. Pregnancy after weight loss surgery is not only safe, but is associated with more favorable outcomes in comparison to obese populations who do not undergo weight loss surgery. An interval of 2 years is recommended from surgery to pregnancy. This delay helps avoid most of the potential nutritional complications. Optimal patient care is achieved in an experienced, multidisciplinary center. Early involvement of the bariatric surgeon in evaluating abdominal pain is critical because the underlying pathology may relate to the previous weight loss surgery. Although infertility is improved after weight loss surgery, reliable modes of contraception may be limited in this population.

Challenging oral contraception after weight loss by bariatric surgery

As surgical weight loss becomes more commonly performed in fertile women, adequate contraception is more frequently becoming an issue. The purpose of this article is to appraise the literature to ascertain whether the use of oral contraception is effective and adequate after bariatric surgery. The literature search revealed that the combination of lower oral contraception dosages and surgical gastrointestinal disturbances might place patients at higher risks of unintended pregnancy. Until clinical trials show its efficacy, physicians should use oral contraception with prudence after bariatric surgery.

Weight loss by bariatric surgery and subsequent fertility

The purpose of this article is to appraise the literature to ascertain whether the use of bariatric surgery should have a role in the contemporary management of the morbidly obese infertile patient before proceeding with infertility treatment.