Despite the fact that bariatric surgery does not reduce absolute BMI to within normal range in most patients, studies suggest it improves some important markers of fertility including hyper-insulinemia and ovulation in polycystic ovary syndrome. Moreover, maternal outcomes and morbidity in pregnancy are better than for women who are similarly obese and are comparable with that of the general population. Obese women who have weight loss surgery before becoming pregnant have a lower risk of pregnancy-related health problems and their children are less likely to be born with complications. Life-long vitamin supplementation is advised. It is advised against falling pregnant during the initial weight loss phase (1 year)

1. Wafaa B. Basta
Specialist Gynaecology & Obstetrics at Mataria Teaching Hospital
MBBch., MSc ., Egyptian Fellowship, MRCOG
ERC MEMBER
EFSS 16th Annual international Conference
MARIOTT ZAMALEK CAIRO 8th 2011

2.  What are the degrees of obesity ?
 How far is the impact of obesity on fertility
& reproduction ?
 How strong is the evidence supporting weight
loss?
 What are the bariatric surgeries?
 To whom bariatric surgery should be offered
?
 What are the effect of bariatric surgery on
fertility & obesity co-morbidities ?
 Pregnancy &labour clinical considrations
after bariatric surgery.

3.  One of the most serious public health
problems of the 21st century.
 Obesity is a leading preventable cause of
death worldwide.

4. Genetics Behavior
Environment

5. a person’s weight in kilograms
square of height in metres
(kg/m2).

6. * <18.5 : Underweight
* 18.5-24.9 : Normal/Healthy
* 25.0-29.9 : Overweight (pre-obese)
* 30.0-34.9 : Obese (Class I)
* 35.0-39.9 : Obese (Class II)
* ≥40 Obese ( Class III = morbid obesity)
o Waist –hip ratio correlates more with the
metabolic disorder.

7. **In1997 the WHO
formally recognized
obesity as a global
epidemic.
**At 2008, The WHO
claimed that 1.5 billion
individuals over the age
of 20 are considered
obese.
**Obesity rates are rising
worldwide.

8.  Data from the Demographic and Health
Surveys show that:
 In 1992, mothers with young children had
a mean (BMI) of 26.9.
 By 2005, rise to a mean BMI of 30.1, with
nearly half of Egyptian women of
reproductive age classified as obese.
WHO study (Musaiger 2004)

9.  Obesity is associated with reduced fertility
primarily as a result of oligo-ovulation and
an-ovulation .
 In one study of 500 women, there was a 30%
reduction in rate of conception with each
0.1 point increase in waist–hip ratio.
Fat and female fecundity: prospective study of effect of body fat distribution
on conception rates. BMJ 1993;306:484–7.

10.  Compared with normal weight women with
PCOS, those obese women with PCO are
characterised by:
* Worsened hyper-androgenic state.
* Worsened metabolic state.
* Poorer menses.
* Poorer ovulatory performance.
* Poorer pregnancy rates.
• Obese women with PCOS often report
extreme difficulty in loosing weight .

11.  Compared with women with a BMI of 25
kg/m2 or less, women with a BMI ≥ 25 kg/m2
have:
* A lower chance of pregnancy following
IVF.
* Require higher dose of gonado-trophins .
* More days of ovarian stimulation.
* Have an increased miscarriage rate.

12.  There is insufficient evidence on the effect
of BMI on:
* Live birth,
* Cycle cancellation,
* Oocyte recovery ,
* Ovarian hyper-stimulation syndrome.
 Further studies are needed to investigate
the true impact of weight on the outcome of
ART.

13. Pregnancy complications:
• Miscarriage
• PE
• TE
• Gestational diabetes
Labour risks:
• Dys-functional labour
• Labour induction
• Higher CS rates
• Shoulder dystocia
• Anaesthetic complications
Post-partum risks:
• PPH
• TE
• Wound infection
• Failure to lactate
Fetal & neonatal complications:
• SB (2.1 -4.3 fold)
• NND
• NICU admission
• Congenital anomalies(NTD, cardiac)
• Later in life(childhood obesity, diabetes, growth abnormalities)
O
B
E
S
I
T
Y

14. Maternal Death
Confidential Enquiry into Maternal and Child Health’s report UK 2003–2005
Taken all together

15.  women seeking fertility advice with a BMI
above 29 kg/m2 should be informed that:
 They will take longer time to conceive.
 ART is less likely to be effective at this BMI.
 Losing weight in a structured group
programme of exercise and dietary advice is
likely to increase their chances of
conceiving.
National Institute for Clinical Excellence. Fertility: Assessment and Treatment for People
with Fertility Problems. Clinical Guideline 11. London: NICE; 2004

16.  Fertility treatment should be deferred in
women who are morbidly obese, until they
have lost weight to below a BMI of 35
kg/m2, although in those with more time
(under 37 years with normal ovarian
reserve) a weight reduction to less than 30
kg/m2 is preferable.
Balen AH, Anderson RA. Impact of obesity on female reproductive health: British Fertility
Society, Policy and Practice Guidelines. Hum Fertil (Camb) 2007;10:195–206.

17.  Women who are obese, increased their
chances of getting pregnant and reduced
their risk of pregnancy complications by
having bariatric surgery and the outcomes
after delivery for both mother and child
were acceptable, provided that adequate
nutrition and vitamin supplementation was
maintained.
The US Agency for Healthcare Research and Quality: a technology assessment
on weight-loss surgery and pregnancy, commissioned by the American College
of Obstetricians and Gynecologists

18. Weight loss
Non-surgical
Behavioral changesDiet
Exercise Pharmacotherapy
Bariatric surgery

19. Traditional methods
of weight loss are
less successful than
bariatric surgery to
induce successful
long-term weight
loss.!!!!!!!!

20.  First performed in the 1960s.
 Women : men ratio = 3:1
 70% of these women fall within childbearing
age.
 15–30% weight loss, sustained in the long-
term.
 Effectiveness acknowledged by NICE (in the
UK) and FDA (in the USA).
 Low rate of complications.

21.  Within current guidelines, bariatric surgery is
considered 1st, line treatment in adults with
a BMI above 50kg/m2.
 It is considered for patients with:
 BMI above 40kg/m2
 BMI above 35kg/m2 + obesity co-morbidity

22.  Restrictive Procedures
 Vertical banded gastro-plasty
( VBGP )
 Laparoscopic adjustable
gastric banding (LAGB)
 Mal-absorptive Procedures
 Bilio-pancreatic diversion (
BPD )
 Bilio-pancreatic diversion
with duodenal switch (BPD-
DS)
 Combined Procedures
 Laparoscopic Roux-en-Y
gastric bypass (RYGB )

23. -adjustable silicone band is
placed around the upper
part of the stomach to
create a small upper-
stomach pouch .
- limits hunger
- promote early feeling of
satiety
-Can be performed by
laparotomy
Common complications :
band slipping,
erosion
the port site becoming
infected.

24. • Restrictive procedure
• staples are used to
create a smaller
stomach pouch.
• Complication:
• Stomal narrowing with
persistent vomiting
• Staple line leak
• Band erosion
• Wound infection or
hernia

25. A small stomach pouch is
isolated from the rest of
the stomach with staples
and empties directly into
the lower portion of the
jejunum.
Delaying mixing of food
with bile and pancreatic
juices. The result is an
early sense of satiety .
Can be performed by
laparotomy.
 Complications
Anastomotic leak with
peritonitis
DVT
Internal hernias
creates a roux limb ( or straight limb)
connected to the gastric pouch and the
“Y” portion is down- stream as the
entero-enterostomy

26.  Mal-absorptive procedure
which reduce nutrient
absorption by bypassing a
large portion of the small
intestine.
 Three segments
 Alimentary tract
 Biliary tract
 Common channel
-
-Complications:
- steatorrhoea
- protein malnutrition
-Anastomotic leak
-Deep-vein thrombosis
-Internal hernia.

27.  The aims of Bariatric surgery in morbidly
obese are to:
 Normalise metabolic & psych-social
development
 Enhance fertility
 Improve the outcome of pregnancy
 Improve the weight & metabolic
development of offspring.

28. Sjöström L, Lindroos AK, Peltonen M et al. N Engl J Med. 2004;351:26

29. Diabetes Completely resolved 76.8 %
Hyper-lipidaemia improved 70 %
Hypertension resolved 61 %
Sleep apnoea Resolved 86 %
Psychiatric morbidity improved 88 %
Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric
surgery:a systematic review and meta-analysis. J Am Med Assoc 2004;292:1724–37.

30.  Improved pregnancy rates
 Improved PCO markers affecting fertility.
 Possible decreased miscarriage rates
 Reduced pregnancy related co-
morbidity(gestational diabetes,
hypertension, average weight gain )
 Improved fetal complication(congenital
anomalies,macrosomia )

31.  The effect of weight loss through bariatric
surgery on fertility and childbirth outcomes
has not yet been fully elucidated.

32.  Case series suggest improvement in the
ability to conceive after bariatric surgery .
-Dixon JB, Dixon ME, O’Brien PE. Pregnancy after Lap-Band surgery:management of the band to achieve healthy weight
outcomes. Obes Surg 2001;11:59–65.
-Marceau P, Kaufman D, Biron S, Hould FS, Lebel S, Marceau S, et al. Outcome of pregnancies after biliopancreatic
diversion. Obes Surg 2004;14:318–24.
-Martin LF, Finigan KM, Nolan TE. Pregnancy after adjustable gastric banding. Obstet Gynecol 2000;95:927–30.

33.  but studies which document improvements in
fertility after bariatric surgery are hampered
by a lack of power to determine statistical
significance.
-Bilenka B, Ben-Shlomo I, Cozacov C, Gold CH, Zohar S. Fertility, miscarriage and pregnancy after vertical banded
gastroplasty operation for morbid obesity. Acta Obstet Gynecol Scand 1995;74;42–4.
-Deitel M, Stone E, Kassam HA, Wilk EJ, Sutherland DJ. Gynecologic–obstetric changes after loss of massive excess weight
following bariatric surgery. J Am Coll Nutr 1988;7:147–53.
-

34.  Bariatric surgery improves the markers of
PCO which influence fertility, such as
 Anovulation,
 Hirsutism,
 Hormonal changes,
 Insulin resistance,
 Sexual activity .
 However, bariatric surgery should not be
considered a treatment for infertility .
Teitelman M, Grotegut CA, Williams NN, Lewis JD. The impact of bariatric surgery on menstrual
patterns. Obes Surg 2006;16:1457–63.

35.  The effect of bariatric surgery on miscarriage
rates is difficult to evaluate because of small
numbers in studies .
 Two retrospective studies record changes
,One found no difference in miscarriage rates
pre- and postoperatively (21.6% compared
with 26% )1 and another recorded a reduction
(17% compared with 11%),2 .
1-Marceau P, Kaufman D, Biron S, Hould FS, Lebel S, Marceau S, et al. Outcome of pregnancies after biliopancreatic diversion.
Obes Surg 2004;14:318–24.
2- Friedman D, Cuneo S, Valenzano M, Marinari GM, Adami GF, Gianetta E, et al. Pregnancies in an 18-year follow–up after
biliopancreatic diversion. Obes Surg 1995;5:308–313.

36. postoperative
pregnancies
(LAGB)
Community
levels
women who
were similarly
obese
Pregnancy
induced
hypertension
10% 10% 38%
Gestational
diabetes
6.3% 5.5% 19%
Dixon JB, Dixon ME, O’Brien PE. Birth outcomes in obese women after lagb
A prospective cohort study Obstet Gynecol 2005;106:965–72.

37.  Compared with the general population:
 The No. of congenital anomalies, not
increased .
 The No. of perinatal death, not increased.
 A trend towards lower mean birth weight:
 More SGA infants.
 Decreased macrosomia .

38.  Contraception
 Timing of pregnancy
 Nutritional dificiency
 Drug absorption

39.  Recommendation is to wait 12-24 months
after bariatric surgery before conceiving so
that:
1) The fetus is not exposed to a rapid
maternal weight loss environment .
2) The patient can achieve full weight loss
goals .
3) Any operative complications should have
appeared.

40.  Increased risk of oral contraception failure
with mal-absorption .
 Non-oral rout should be considered .

41.  The most common nutritional deficiencies
are of protein, iron, vitamin B12,folate,
vitamin D. and calcium.
 Evaluate for micronutrient deficiencies at
the beginning of pregnancy .
 If there is a proven deficit, then treat &
monitor.
 In the absence of a deficiency, monitor the
blood count, iron, ferritin, calcium, and
vitamin D levels every trimester .

42.  It is not known if women require higher dose
of folic acid ( greater than 0.4mg/d)
 The daily recommendation for protein intake
of 60g is the same regardless of bariatric
surgery status .
 Caloric and protein restriction during
pregnancy may impair fetal growth so, there
is no recommendation for caloric restriction
during pregnancy.

43.  Fluid from the gastric band is removed or
lessened during a pregnancy allowing for less
gastric constriction and an increase in oral
intake & relieve nausea and vomiting during
the first trimester .


44.  Delay in the diagnosis of bariatric-related
operative complications including intestinal
obstruction and GI hemorrhage -----There
should be a high index of suspicion for
gastrointestinal surgical complication.
 Exploratory surgery during pregnancy may be
required to treat these complications .
 Maternal deaths have been reported .

45.  Dumping syndrome: hyper-insulinemia and
hypoglycemia due to rapid empty of the
stomach into the small intestine.
 Patients with dumping syndrome may not
tolerate the 75g GTT.
 Alternative measures to screen for
gestational diabetes is home glucose
monitoring ( fasting and 2-hours PP blood
sugar) for approximately 1 week during the
24-28 weeks of gestational .

46.  Absorptive surface of the intestine
Extended-release preparations not
recommended .
 Smaller gastric pouch caution against
using non steroidal anti-inflammatory drugs
postpartum to avoid gastric ulceration .
 In using medications in which a therapeutic
drug level is critical testing drug levels
may be necessary to ensure a therapeutic
effect.

47.  Does not alter the course of labor and
delivery.
 Cesarean delivery rates are higher after
bariatric surgery, as high as 62% .
 Bariatric surgery itself should not be
considered an indication for a cesarean
delivery.

48.  Obesity has many deleterious effects for
women of reproductive age.
 Obese women are more likely to encounter
fertility problems & miscarriage.
 Maternal& foetal mortality and morbidity is
significantly elevated for obese women due
to complications in pregnancy labour and
postpartum period .

49.  The management of obesity requires a
multidisciplinary approach.
 Stepwise programmes with realistic time-
related goals are required, starting with
modification of lifestyle, progressing to
pharmacotherapy and ultimately obesity
surgery.
 Weight loss interventions do not appear to
be common practice among fertility centres&
pre-pregnancy clinics in spite of clear
evidence as to the benefits.

50.  Obese women who have weight loss surgery
before becoming pregnant have a lower risk
of pregnancy-related health problems and
their children are less likely to be born with
complications.
 Life-long vitamin supplementation is advised.
 It is advised against falling pregnant during
the initial weight loss phase (1 year)

51.  Despite the fact that bariatric surgery does not
reduce absolute BMI to within normal range in
most patients, studies suggest it improves some
important markers of fertility including hyper-
insulinemia and ovulation in polycystic ovary
syndrome.
 Moreover, maternal outcomes and morbidity in
pregnancy are better than for women who are
similarly obese and are comparable with that of
the general population.
 Long-term cardiac and metabolic outcomes for
infants born following bariatric procedures are
also improved.

52.  Pregnancy is better to be delayed for 1-2
years after bariatric surgery.
 During pregnancy adequate nutrition and
vitamin supplementation should be
maintained,
 Caution should be exercised when
determining eligibility for in vitro
fertilisation in women who have undergone
bariatric surgery.

53.  Prevention of childhood obesity is a priority.
In particular, barriers to physical activity in
girls and young women should be addressed.

54.  CMACE/RCOG Joint Guideline. Management of Women with Obesity in Pregnancy March 2010
 CMACE release: National enquiry into maternal obesity – Implications for women, babies and
the NHS
 Obesity and Reproductive Health - study group statement .Consensus views arising from the
53rd Study Group: Obesity and Reproductive Health
 Effect of overweight and obesity on assisted reproductive technology—a systematic review
2007. Published by Oxford University Press on behalf of the European Society of Human
Reproduction and Embryology.
 Fertility: assessment and treatment for people with fertility problems Clinical Guideline 11
February 2004 Developed by the National Collaborating Centre for Women’s and Children’s Health
(NICE)
 The Impact of Obesity on PCOS and Reproductive Health. Review article: Obesity in pregnancy
,Review article: The short- and long-term implications of maternal obesity on the mother and
her offspring ,Review article: The impact of obesity on reproduction in women with
polycystic ovary syndrome .The BJOG October edition (Volume 113, number 10)
 THE ROLE OF BARIATRIC SURGERY IN THE MANAGEMENT OF FEMALE FERTILITY Scientific
Advisory Committee Opinion Paper 17 March 2010
 National Institute for Health and Clinical Excellence. Obesity. Guidance on the prevention,
identification, assessment and management of overweight and obesity in adults and children.
London: National Institute for Health and Clinical Excellence (NICE), 2006.
 World Health Organization. Obesity: Preventing and managing the global epidemic. Geneva: World
Health Organization, 2000.
 Green-Top Guideline No. 37. Reducing the risk of thrombosis and embolism during pregnancy and
puerperium. London: Royal College of Obstetricians and Gynaecologists, 2009.
 The Pre-eclampsia Community Guideline Development Group. Pre-eclampsia Community Guideline
(PRECOG). Middlesex: Action on Pre-Eclampsia (APEC), 2004