3. Content
Epidemic of obesity
Obesity in India
is obese women at risk infertility ?
What is the spectrum ?
What is the mechanism ?
What we can do about it ?
Pregnancy outcome of treatment
ART in obesity
Role of Beriatric surgery
5. 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
6. PREVALENCE OF OBESITY
is on increase!! ( 1986 – 2000 )
1. BMI > 30 kg / m2
- doubled
2. Morbid Obesity > 40 kg /m2
quadrupled
Super Obesity > 50 kg /m2 –
five fold Increase
Buchwald et al Surg for obesity & realated
diseases(2005) 371-381
7. Obesity in Men & Women in
Reproductive Age in India
Country Male Female
India 9 12 (2000)
12 16 (2001)
Punjab 30 37.5
Gujrat 15 17
UP 16 12
Haryana 14 17
8. • BMI (Body Mass Index)
= Weight in kg / Height in M2
• Waist : Hip Ratio
men > 0.88
women > o.85
Women Waist = 35”
Quantification of Obesity
10. Wonder Why - One Always Gain Weight,
Despite Dieting And Exercise
or just drinking water !!!
Complete
mechanism
11. Possible Mechanism in
Obesity
• The Complex mechanism of obesity
linking fat excess to metabolic syndrome
is not well understood.
• But several experimental studies have
shown that altered production of
adipokines play a main role in
development and progression of this
disorder
12. An important underlying mechanism may be
a genetic predisposition to factors
associated with infertility, including allelic
variants in cytokine genes known to
stimulate inflammation or those known to
down regulate the anti-inflammatory
response
Possible mechanism
of Infertility in obesity
13. Obesity, Metabolic Syndrome & Infertility
Adipokine Possible Physiologic Role Values in Metabolic syndrome
Lepitin Regulation of food intake
regulation of SNS activity
Increased
adiponectin Insulin – sensitizing hormone
protection of liver cells from
negative effects of fat increase
Reduced
resistin Part of the inflammatory
pattern linked to adipose tissue
excess
No changes
visfatin Part of the inflammatory
pattern linked to adipose tissue
excess
Increased
Omentin Protection of endothelial cells reduced
chemerin Regulation of adipogenesis Increased
RBP - 4 May impair insulin sensitivity
may impair liver function
Unclear
cytokines Part of the inflammatory
pattern linked to adipose tissue
excess
increased
14. Obesity is The Root Cause of Some
of the Serious Diseases
Metabolic Disorders
• In Indians , types 2 diabetes and
hypertension has a close link to
obesity
• 60 million people suffered from
diabetes in 2012 and will exceed
100 million by 2030
• People with BMI >35.0 kg/m have a
6-fold higher risk of diabetes
15. Obesity is The Root Cause of Some
of the Serious Disease
CARDIOVASCULAR DISEASES
– Obese women have 30% higher
risk of death , due to
– circulatory system diseases than
weight individuals
CANCER
•Obese women showed more than two times higher
rate of breast cancer as compares with their
normal weight counterpart
16. Morbid Obesity : Takes Heavy
Toll on Women’s Health
- Globally . morbid obesity is responsible for the
following co-morbidities
7-41% of cancer cases like breast colon,
rectum, kidney, pancreas etc
44% of diabetes cases
23%of ischemic heart disease cases
Hyptension , dyslipidemia ,asthma., osteoarthritis
gall bladder disease etc.
17. IMPACT OF OBESITY ON
LONGEVITY
• 2.5 million deaths attributed annually to
obesity
• Direct relationship between increasing BMI
and relative risk of dying prematurely
Nurses health studyNurses health study
• In morbidly obese life expectancy is
reduced by
9 yrs in women
12 yrs in men
Framingham dataFramingham data
18. OBESITY & PSYCHOSOCIAL
HEALTH in WOMAN
1. Poor body image
2. Social stigmatisation (‘a laughing matter’)
3. Lower education levels
4. Lower rates of marriage
5. Lower socio economic levels
19. OBESITY in women creates
OBESOGENIC ENVIRONMENT
1. Women at greater risk from obesity than
men all across the world
2. At disproportionate risk from
complications of obesity
3. Rates of obesity are in women in
India & world over
20. Obesity & Reproductive Health
• Amenorrhea, anovulation , sub fertility and
infertility is increasingly occurring with higher
body weight
• Obese women are more likely to experience
irregular menstrual cycle,
anovulation, and signs of
androgen excess, particurly
when the excess weight
occurred during adolescent
21. Obesity is strongly associated with
PCOS,
central obesity hyperandrogenism, and insulin
resistance with compensatory hyperinsulinenia
Obesity & Reproductive Health
22. Is obese women at risk of infertility
an obese woman is about thrice
as likely to be infertile as a
normal woman
it is seen that adolescent obesity is
associated with a threefold increased risk
of lifetime nulliparity and a fourfold
increased risk of lifetime nulligravidity
Polotsky AJ, hailper SM skurnick JH, LO JC sternfeld B, santoro N associated of adolescent
women’s health across the nation (SWAN) fertility steril 2010;93:2004- 11)
Yes
23.
24. OBESITY & ASSISTED
REPRODUCTION
1. Obesity leads to poorer prognosis
with Assisted Reproduction
2. Pregnancy Rates in ART halved
for women with BMI > 35 kg/m2
25. Obese women : not only have a lower
chance of pregnancy following
In Vitro Fertilization,
they require higher doses of
gonadotropins and
have an increased miscarriage rate
OBESITY & ASSISTED
REPRODUCTION
26. Causes of Poor Pregnancy Rate
Endometrial Factor
It is postulated that lower pregnancy rate associated
with obesity is caused by altered receptivity of
endomertium due to disturb endometrium function
Oocyte factor
Obese women using donor Oocytes eliminates
bad effect of quality of egg & however
reduced Live birth rate with increasing BMI
regardless of Oocytes source is seen.
LUKE B, et al. fujimoto VY the effect of maternal body mass index (BMI) and
oocyte source on assisted reproductive technology(ART)pregnancy rates
andobstetric outcomes. Fertile sterile 2009;92 suppl 1:s52
27. • In women with assisted conception,
obesity may further potentiate this
infammatory response, increasing the
known risks for adverse reproductive
outcome, including fetal loss and stillbirths
associated with higher body weight
Causes of Poor Pregnancy Rate
28. OBESITY & PREGNANCY
1. Obesity leads to twinning and
rate of miscarriage
2. rates of medical complications
( pregnancy induced hypertension, pre
eclampsia, gestational diabetes,
thromboembolism….)
29. OBESITY & PREGNANCY
1. Adverse impact on labor
I.e. increase rate of fetal deathe , still birth &
neonatal death & cong. Malformation.
2. Higher rates of post partum events &
complications
30. Management of Obesity
in general
1st
line of management : Lifestyle changes like modification
of diet , physical activity and daily habits
2nd
line of Management : introduction of pharmacotherapy
for patients with BMI above 25 with co – morbidities and
BMI above 27 with no co- morbidity
Bariatric Surgery : Bariatric Surgery may be an option for
treatment of extreme obesity (BMI > 32) when diet and
exercise
1
2
3
31. Treatment Modalities
For Infertility in Obesity
Life – Style &
Nutrition
Changes
• Diet
• Exercise
• Psychological
Counseling
Surgical
Intervention
• Bariatric
surgery
ART
• IUI
• IVF
• ICSI
Pharmacological intervention
Appetite suppressant, Weight Loss Drugs (Orlistat)
Drugs Increase sucidal tendency
32. Even 5% Weight loss improves
fertility outcome
Impacts Fertility Outcomes
33. Word of caution
Prior to ART therapy
Weight loss should be the fist – line
treatment even 5% weight loss improves
fertility outcome.
• Dietary weight loss, Regular physical
exercise , elimination of tabacco of alcohol
consumption behavior modification and
stress management may be of benefit
ESHRE human reproduction 2010;25:578-83
34. Points to Remember
• The new “Fad” diets promoting low- carbs
and only liquid intake show only short –
terms results
• Genes may influence your fats stored ,
distributed and consumed during exercises
family influence.
• Medical conditions like hypothyroidism,
Cushing syndrome , polycystic ovary
syndrome and depression needs due medical
care
35. Bariatric Surgery
A serious approach to serious problem
LAP Adjustable Gastric Banding
Given - up in India
SLEEVE Gastractomy &
Gastric Bypass surgery
are the only alternative
Safety of operation in India –
in good hands - is as safe as Lap. Cholecystectomy
36. Our Experience with
Beriatric surgery
Total cases - 17
Unmarried - 5
All started having regular periods of 30 – 45
days Got married. Two had spontaneous
pregnancy & delivered
12 cases – Married
Two had pregnancy with IUI & three had IVF
ICSI pregnancy
7 Pregnancy
Hypertension, DM, Cholesterol has magical relief
39. Take Home Messages
• Prevalence of obesity has doubled since 1970 s & so is the
infertility in obese women -.
• In obese women - it can result in hyperandrogenism , PCOS, and
other metabolic co-morbidities like DM, Hypertension
• Obese women undergoing IVF needs higher doses of
gonadoprophines & have a lower pregnancy rate
• Pregnancy performance in obese women is highly subnormal
• With Bariatric Surgery in morbidly obese women - there is big
help in ART cycles
40. ADDRESS
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Morh Flyover, Delhi - 51
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