obesity & female infertility ‘a real and alarming problem for infertility and ivf specialists...
TRANSCRIPT
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