Infertility and The Overweight Woman

David Kreiner, MD Obesity, PCOS 18 Comments

voluptuous+womanThe most shocking thing I’ve experienced in my 30 year career in Reproductive Endocrinology has been the consistent “resistance” among specialists to treat women with obesity. This “resistance” has felt at times to both me and many patients to be more like a prejudice. I have heard other REI specialists say that it is harder for women to conceive until they shed their excess weight. “Come back to my office when you have lost 20, 30 or more pounds,” is a typical remark heard by many at their REI’s office. “It’s not healthy to be pregnant at your weight and you risk your health and the health of the baby.” Closing the door to fertility treatment is what most women in this condition experience.

A new article appearing in Medical News Today, “Obese Women Undergoing Infertility Treatment Advised Not To Attempt Rapid Weight Loss”, suggests that weight loss just prior to conception may have adverse effects on the pregnancy, either by disrupting normal physiology or by releasing environmental pollutants stored in the fat. The article points out what is obvious to many who share the lifelong struggle to maintain a reasonable Body Mass Index (BMI): Weight loss is difficult to achieve. Few people adhere to lifestyle intervention and diets which may have no benefit in improving pregnancy in subfertile obese women.

The bias in the field is so strong that when I submitted a research paper demonstrating equivalent IVF pregnancy rates for women with excessive BMIs greater than 35 to the ASRM for presentation, it was rejected based on the notion that there was clear evidence to the contrary. Here’s the point I was trying to prove: IVF care must be customized to optimize the potential for this group.

Women with high BMI need a higher dose of medication. Those with PCOS benefit from treatment with Metformin. Their ultrasounds and retrievals need be performed by the most experienced personnel. Often their follicles will be larger than in women of lower weight. Strategies to retrieve follicles in high BMI women include using a suture in the cervix to manipulate the uterus and an abdominal hand to push the ovaries into view. Most importantly, a two-stage embryo transfer with the cervical suture can insure in utero placement of the transfer catheter and embryos without contamination caused by inadvertent touching of the catheter to the vaginal wall before insertion through the cervical canal. Visualization of the cervix is facilitated by pulling on the cervical suture, straightening the canal and allowing for easier passage of the catheter. The technique calls for placement of one catheter into the cervix through which a separate catheter, loaded with the patient’s embryo, is inserted.

Using this strategy, IVF with high BMI patients is extremely successful. With regard to the health of the high BMI woman and her fetus, it’s critical to counsel patients just as it is when dealing with women who live with diabetes or any other chronic situation that adds risk.

We refuse to share in the prejudice that is nearly universal in this field. It’s horrible and hypocritical to refuse these patients treatment. Clearly, with close attention to the needs of this population, their success is like any others.

Women who have time and motivation to lose significant weight prior to fertility therapy are encouraged to do so and I try to support their efforts. Unfortunately, many have tried and are unable to significantly reduce prior to conception.

What right do we have to deny these women the right to build their families?

It can be hard to deal with obesity and even more so when combined with infertility. If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition. I advise you to ask your doctor about support groups and for treatment that can help you including fertility treatment.

Remember, though this condition can be annoying, aggravating and even depressing, seek an REI who is interested in supporting you and helping you build your family and reject those who simply tell you to return after you have lost sufficient weight.

Comments 18

  1. Jo

    Thank you so much for this kind article. I’ve never been slim, but I was thinner when I got married. Due to infertility problems, 4miscarriages and family issues, the weight’s come back. I’m not giant, but I am definitely overweight. It has been hell dealing with the baby issue, but when the doctor suggested it being my fault for being overweight, it nearly destroyed me. I had my fourth miscarriage in December, but have been too emotionally damaged to even go back to the doctor. A dear friend has suggested an access to try IVF, which we’d never be able to afford on our own, but I’ve been so afraid of how they’d treat me regarding my weight.
    Anyway, thank you for helping me realize that not all doctors refuse to work with you and take you seriously because you’re overweight.

  2. Colleen

    Thank you for writing this.

    I too have had a weight related issue with a Dr in relation with IF. The first Dr I approached about our inability to get pregnant after 5 years of trying was super supportive but she didn’t have much experience with IF. She ended up sending me to a “specialist”.

    He basically walked in the room, took one look at me and told me to lose weight and that it was because I was overweight that I was unable to conceive. He also handed me a prescription for clomid without listening to our struggles and my cycle history or anything else and he never did an exam or anything.

    2 cycles of clomid and an ectopic pregnancy later it turns out the reason I was unable to get pregnant was because of the huge tumors on my ovary that were messing up my cycles and causing me not to ovulate. Not me being 25 pounds overweight.

    We now have 2 children conceived without any medical assistance. Just goes to show that weight isn’t the cause or reason for all IF problems.

  3. PCOS Mom

    I have PCOS and have just been denied further treatment. I exercise at a gym, no diabetes, and my bloodwork shows great health. I just saw the doctor 2 months ago and he refuses to treat me further. He recommended lapband or a surrogate (or lose weight). I can’t afford lapband or a surrogate after spending out of pocket for the last 5 years. Plus my insurance won’t cover it because I’m not consider morbidly obese, so I am going to try the hcg diet which I haven’t tried yet. That said, the doctor won’t transfer my remaining blastocysts until I lose 40 lbs. 40lbs… not 20 lbs. I was ~20 lbs lighter when I was pregnant with my daughter (conceived naturally). Now he wants me to lose 40lbs. I’ve also recently read about Inositol and am hoping that this is the miracle that I need versus Metformin. I’m 5 years older after all this having undergone IUI, then IVF and now IVF with donor. It is a very hopeless feeling to be denied treatment. Now I have to live with the fact that I might not be able to lose the weight and have another child. Funny thing is that she wrote “recommended to patient weight loss” in my medical records but in reality it is mandatory.

  4. Jo Horwell

    Hi, found your post while googling. It’s fab! I’m in the uk and have suffered with pcos for 15 yrs. every doc I have seen has refused treatment due to my weight, now 10yrs after meeting my hubby we are married and childless due to the nhs and their sick attitudes that fat women can’t have babies. I wish you were in the uk… I’d be booking to see you right now! Keep up your amazing work for us huggable mums to be.xx

  5. Miyan

    God sent me to this post. Just today, I was told by Shady Grove Fertility Center that they could not treat me with IVF because my BMI was over 40. I was destroyed. I am 37, no children, lost both fallopian tubes due to ectopic pregnancies. I was slimmer, but due to the depression of loosing both pregnancies and both tubes, I put on some weight. When that doctor told me that I would not be able to have a child, I just cried when I got to my car. She was so “matter of fact” when she told me this. She didn’t realize that she just ripped my heart out! I am in the process of trying to locate a doctor that will help me become a mother, inspite of my weight. If anyone knows of a doctor that would be willing to take a chance on me with IVF in the Washington DC Metropolitan area, please let me know. I am willing to travel.

  6. Lily

    Thank you for your post. For those of us not on the East Coast, could you offer any advice on how to find clinics that will treat high BMI women?

    I am 33 with stage 2 endometriosis. I underwent laparoscapy yesterday for both pain and infertility. The surgery went very smoothly, and I’m feeling surprisingly good. My Ob/Gyn says we should try for 3-4 more months and then look into IVF. He has warned me not to lose too much weight. He says my age is more of a fertility concern than my weight and said he has delivered three healthy babies to women weight more than double what I weigh within the past year.

    I called our local IVF center today to try to find out how much IVF would cost and what all it would involve, and they said they will not treat me until my BMI is below 25. My BMI is currently 38. I have been overweight my entire life and have worked quite hard to lose weight many many times. I have never had a BMI below 25 in my entire life!

    I do not have diabetes (recent A1C was 5.3), and my blood pressure is generally within the normal range. My periods are very regular, and I’ve had a positive OPK on days 14 and 15 every month for the past six months. Prolactin, FSH, metabolic panel, T3 and free T4 and liver panel are all normal. There is no male infertility factor. Laparoscopy showed no signs of PCOS. Although I did have endo on the exterior surface of my right ovary, I did not have any ovarian cysts. HSG showed no signs of blockages. I do have an arcuate uterus, but the radiologist who did the HSG said mild uterine anomolies are common and usually not clinically relevant.

    The two most common justifications I’ve heard for not offering overweight women IVF are 1) fear that they can not tolerate anesthesia, and 2) concerns about having to use large amounts of drugs to spur ovulation. I do not believe the anesthesia is a big concern for me. I don’t have sleep apnea and only have mild asthma. I had no problem with yesterday’s operation under general anesthesia. In addition, I’m pretty sure I am ovulating on my own. If I don’t need ovulation drugs, how can there be a high risk of me over-using them??

    I know I need to lose weight, and I am willing to try to lose some of the pounds. I think I could realistically lose 10-15 pounds in the next 3-4 months and get my BMI down to about 36 or 37 before attempting IVF, but it would take a lot of work, and I am afraid the fertility clinics will tell me my BMI is not good enough no matter what I do. I may never hit 25, and, if I try to lose that much weight, I will almost certainly be too old to have children by the time I do get there.

    I’m so glad there are doctors like you out there who are willing to take patients’ individual situations into consideration when determining who is eligible for IVF. Unfortunately, you seem to be in the minority, and non-discriminatory, pro-health fertility specialists seem to be hard to find. I would love any suggestions you may have for finding a facility near me who will treat me as a person, not as a number on a scale.

    Thanks so much!

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