Obesity & Female Infertility‘A real and alarming problem for

Infertility and IVF specialists ’

Dr. Jyoti Agarwal

Dr . Sharda jain

Have you ever thought of the following ??

Fertility is often taken for granted …… until one is unable to have a child

Many a times it may be late

I’m healthy strong person I would not have any problem producing a baby

Reproductive profileOne year

85 % will conceive

15 % need medical help

80 % duringinvestigation

20 % needs ARTi,e IVF

20 %needs ART i,e

IVF

Obesity is the new worldwide Epidemic

1. BMI > 30 kg / m2 - doubled

2. Morbid Obesity > 40 kg /m2 quadrupled

Super Obesity > 50 kg /m2 –

five fold Increase

• These trends have been noticed across all races, age groups, and nations

• Largest increase has

been seen in young adolescents and young women

OBESITY“AN EMERGING MENACE”

1. > 1 Billion overweight

2. > 300 Million – Obese

3. 26% of non pregnant women ages 20 – 39 are overweight / obese

W

H

O

In India …..

Country Male Female

India 9 12 (2000)

12 16 (2001)

Punjab 30 37.5Gujrat 15 17

UP 16 12

Haryana 14 17

Are obese women at risk of infertility ?

An Obese Woman is about Thrice as likely to be Infertile as

a normal woman

Yes

Obesity and Infertility

Chances of pregnancy is reduced by 5% for every BMI unit that exceeds 29 kg/m2

SUBTRACT 2.5in each category for INDIANS

MOST COMMONLY USED INDEX TOQUANTIFY OBESITY IS BMI

High prevalence of Infertility in Obese women

Obesity can be

• Main

• Secondary or

• Accompanying

infertility factor

The impact of obesity on A.R.T. outcomes is debatable

Obesity is strongly associated with

PCOS

CENTRAL PLAYER ………

• Insulin resistance

• Hyperandrogenism

• Elevated leptin

• Leptin resistance

UNDERLYING MECHANISM bothregular or irregular cycle

• anovulation

• release of oocytes with reduced fertilization potential

• endometrial abnormalities

“Both seed and soil defective”

British Fertility Society guidelines …

• Infertility treatment should be deferred until BMI<35 kg/m2

• preferably BMI<30 kg/m2 in young women with good ovarian reserve

Treatment ModalitiesFor Infertility in Obesity

Life – Style &NutritionChanges

• Diet• Exercise• Psychological

Counseling

Surgical

Intervention

• Bariatric surgery

ART

• IUI

• IVF

• ICSI

Pharmacological interventionAppetite suppressant, Weight Loss Drugs (Orlistat)

Drugs Increase sucidal tendency

Even 5% Weight lossimproves fertility outcome

Obese women : not only have a lower chance of pregnancy following In Vitro Fertilization

They require higher doses of gonadotropinsand

Have an increased miscarriage rate

OBESITY & ASSISTEDREPRODUCTION

Facts……..

There are about 20 Million couples in India who need advanced

Infertility treatment

only about 40,000 treatment cycles are performed in India in approx 500 odd registered IVF centres

Which is mere 0.2%

Under served infertility treatment

• Not enough awareness about various available options

• Costly treatment• Costly set-up • No insurance /

governmental support

Bellver et al, 2009:

the largest single

center study

(6500 IVF cycles)

Obesity and ovarian stimulation

Total dose of gonadotropins: Higher in obese

WMD: weighted mean difference

Maheshwari et al, 2007 : 37

Gonadotropin Resistance

Greater amount of body surface

Differences in absorption and metabolic

clearance

Altered peripheral steroid metabolism

Impaired absorption due to increased

subcutaneous fat

obesity and ovarian stimulation

Number of retrieved oocytes: Fewer in obese

Maheshwari et al, 2007

WMD: weighted mean difference

obesity and ovarian stimulation

Cycle cancellation rates: Higher in obese

Maheshwari et al, 2007

OR: odds ratio

obesity and pregnancy rates

Maheshwari et al, 2007 : 37 papers for effects of obesity on ART- 12 papers actually included

BMI > 25 vs < 25 : Lower pregnancy rates

obesity and miscarriages

BMI >25 vs <25: Higher miscarriage rates

Maheshwari et al, 2007

obesity and pregnancy rates

Bellver et al, 2009

Raising BMI by 1 unit: odds for pregnancy decrease by 0.98

Reducing BMI by 1 unit: odds for pregnancy increase by 1.19

obesity and endometriumBellver et al, 2007 2656 first oocyte donation cycles

Lower implantation and pregnancy rates as BMI increases•Higher miscarriage rate as BMI increases

•Lower ongoing pregnancy rate in OW and OB

ongoing PRin BMI<25: 45.5%in BMI>25: 38.3%

Complications of Obesity during Pregnancy:

• Gestational HTN, Pre-Eclampsia, Eclampsia• Gestational Diabetes• Fetal Macrosomia• Risk of medical and surgical complications• Higher rate of C-Sections • infection and PPH• wound related complications• Miscarriages• Premature deliveries• PROM• IUGR, Intra-uterine fetal death• Placenta Previa and abruption- placenta

Bariatric SurgeryA serious approach to serious problem

Safety of operation in India

In Good Hands

is as Safe as

Lap Chole

Our Experience of Infertility and Bariatric Surgery

Total cases – 17

All started having regular periods

2 had spontaneous pregnancy

4 had pregnancy with IUI &

6 had IVF ICSI pregnancy

12 Pregnancies

Hypertension, DM, Cholesterol has magical relief

ENHANCED FERTILITY attempt with Bariatric Surgery Before

ENHANCED FERTILITY after Bariatric Surgery

Pregnancy after Bariatric Surgery

Pre-Pregnancy Counselling

When ever possible, pregnancy should be

delayed till weight loss stabilizes for 12-24 months.

Special Nutritional Consideration

• With malabsorptionthere can be nutritional deficiencies

• Decreased folate level may cause neural tube defects

• Poor caloric intake can lead to ketosis and weight loss

• Provide supplements & consult with nutritionist

Post Bariatric surgery pregnancies are generally safe

Work in collaboration with the Bariatric surgery team to manage

Labor & Delivery

• H/o of Bariatric surgery should not change course of labor & delivery

• C-section rates are slightly higher in these patients

Practical Recommendations

• Improve ovulation

• Reduce the risk of miscarriage and other complications during pregnancy

• Look and feel better

Loose weight to

Weight loss is one of the corner stone to achieve a healthy pregnancy and child birth

Success at lifecare IVF

• Overall conception rate 47 %

• Take home baby rate 35 %

• Blastocyst rate 50%

• Surrogacy 75 – 80 %

We should be able to slow down this trend.

We could do better.

Thank

you