New Year’s resolution: Shed pounds, optimize fertility

One of the woes of our modern lifestyle and eating habits has been the development of the obesity epidemic. There are many medical conditions caused by or worsened by obesity, such as diabetes, heart disease, stroke and infertility.  Recently there have been several studies demonstrating the negative impact of obesity on reproduction. Pregnancy rates in obese women may be as much as 30% lower than those of non-obese women with otherwise similar characteristics.  We also know that obese women can be less responsive to fertility medications. For the same medication dose, obese women often produce less eggs than normal weight women.

What is obesity?

A standard medical definition of "normal" body weight is a body mass index (BMI) of 18.5 - 24.9

• A BMI under 18.5 indicates that the person is "underweight"
• A BMI of 25.0 - 29.9 indicates that the individual is "overweight", but not obese
• A BMI over 30 indicates obesity
• A BMI over 40 indicates extreme obesity.

The BMI is calculated based on a person’s height and body weight. That being said, BMI calculation does not take into account percent body fat, so theoretically someone with lot of muscle mass could have a higher BMI but not have the same negative health consequences as someone with the same BMI but much higher percent body fat.

Why does obesity cause infertility?

The main culprit in the metabolic manifestations of obesity is the increased number of fat cells. The extra fat can cause insulin resistance, leading to type-2 diabetes and an increased production of male-like hormones which, in women, can lead to ovulation disorders. In obese women, there are increased inflammatory processes in the body that can contribute to infertility, increased risk of miscarriage, as well as other unrecognized metabolic abnormalities.

Not only do women that are obese have a more difficult time getting pregnant, but once pregnant, they also have a higher risk of miscarriage and giving birth to babies with birth defects. While maintaining a healthy weight is important, one does not have to aim towards becoming a size 2 supermodel. Even just a 5%-10% weight loss can significantly improve the chances for successful conception.

More causes of infertility here.

How can I lose weight?

I always recommend a healthy, balanced diet and moderate exercise. Stay away from “Fad” diets as they are not sustainable. The goal is to lose the weight and keep it off, which may involve a complete change in the way one approaches food. Consider the advice  of a professional dietician.  Think about signing up for a program like “Weight Watchers”, “Jenny Craig” etc., since structured programs can often make the difficult task of losing weight a little easier, providing discipline and emotional support. A healthy rate of weight loss while trying to conceive is acceptable, but be sure to discuss the plan with your doctor and get the help and support you need.  Weight loss can dramatically improve your chances of success, regardless of which infertility-treatment option is chosen.

When is bariatric surgery appropriate?

If a woman has been unsuccessful with diet and lifestyle modifications and still has a BMI greater than 35-40, bariatric surgery can be considered. Often, in people with a BMI over 45, bariatric surgery in conjunction with lifestyle modifications is needed to effectively lose an adequate amount of weight.

Can one undergo fertility treatments if obese?

The answer is yes, as long as the patient has realistic expectations and is aware of the lower success rates of any fertility treatment in obese patients. Since the age of the woman as well as the egg reserve have a more profound impact on fertility than anything else, it would not be prudent to expect a 40-year-old woman or a woman with a very low egg reserve to lose weight and then come back at a later time, because sometimes the window of opportunity may be lost. It is always my advice to patients to do the best they can to optimize their lifestyle and weight before they start attempting pregnancy or while undergoing treatment. Unless a pregnancy is unsafe for the patient, withholding treatment only based on weight may be an unfair thing to do, especially in older women.

Contributed by: Dr. Rinku Mehta, published extensive research in Polycystic Ovarian Syndrome and specializes in all forms of male and female infertility.

Current Practice:
Frisco Infertility Clinic Frisco, TX
8380 Warren Pkwy., Suite 201
(972) 377-2625

Schedule an appointment here

PCOS

What is PCOS?

Polycystic ovary syndrome (PCOS) is a very common reproductive endocrine disorder affecting about 5-10% of reproductive age women. Research is still ongoing to delineate the causes of PCOS, however most experts believe that it may have a multifactorial etiology that invloves genetics, environmental factors as well as fetal and childhood exposures. Some of the symptoms commonly experienced by women with PCOS are menstrual irregularity, increased male hormone actions in the woman (such as increased coarse facial hair), resistance to the actions of insulin in the body and a characteristic appearance of the ovaries on pelvic ultrasound.  Although many women with PCOS are overweight or obese, thin women can have PCOS as well.

How does PCOS affect fertility?

Women with PCOS often have irregular periods because of lack of regular ovulation caused by abnormal hormonal secretory patterns. This leads to infertility caused by ovulatory dysfunction. However, it is extremely important to exclude other causes of ovulatory dysfunction such as thyroid or pituitary abnormalities before pinpointing PCOS as the cause of the irregular periods.  Due to chronic anovulation in women with PCOS, intercourse can be difficult to time and pregnancy hard to achieve. Treatment for infertility due to ovulatory dysfunction involves the use of medications such as clomiphene citrate (“Clomid”) which help induce ovulation. Most pregnancies achieved with Clomid occur within 3-4 ovulatory cycles. If you are not successful by that time then it would be prudent to seek care from a reproductive endocrinologist.  If you are already seeing one, then it makes sense to move on to more aggressive treatment modalities. Not all women will respond to clomid, even at the higher doses, such as 200-250 mg. For these women, treatment options involve injections of the hormone FSH which helps induce ovulation. The biggest “side effect” of treatment is multiple gestations. The risk of twins is estimated to be about 5-8% with clomid and 15-20% with injectable medication. Another medication to consider before moving on to the injectable medications is an aromatase inhibitor such as letrozole which is an oral medication like clomid, but with a different mechanism of action. Some clomid resistant women may respond to letrozole.

What are the long term impacts of PCOS?

Since PCOS is an endocrine disorder associated with resistance to the action of insulin in the body, there can be long term metabolic impacts on the development of disorders such as diabetes and coronary artery disease. It is important for women with PCOS to have testing for glucose and lipid levels at least once every two years. This is done by checking a 2 hour glucose tolerance test and a fasting lipid panel. Often women with glucose intolerance can benefit from medications such as metformin which help improve the action of insulin in the body. The development of the “metabolic syndrome”, which involves high triglyceride levels, abnormal glucose levels, hypertension, and an increased waist to hip ratio, can have a profound impact on the development of cardiovascular disease. Maintaining a healthy diet and weight is of great importance to slow or prevent the onset of type 2 diabetes, lipid disorders, metabolic syndrome and ultimately coronary artery disease.

Another important aspect of chronic anovulation is its effect on the endometrium, which is the lining of the uterus. If a woman goes for long periods of time without having menses, then she can be prone to developing hyperplasia (precancerous abnormal growth) of the endometrium.  Atypical hyperplasia can ultimately lead to endometrial cancer if untreated. It is important to protect the endometrium either by using a progesterone containing contraceptive or by inducing a period every couple of months by taking a course of Provera or other such progesterone.

PCOS is a complex disorder with no easy fix, but many of its manifestations can be controlled with the right lifestyle modifications, medications and of course fertility treatments in those desiring pregnancy.

Contributed by: Dr. Rinku Mehta, published extensive research in Polycystic Ovarian Syndrome and specializes in all forms of male and female infertility.

Current Practice:
Frisco Infertility Clinic Frisco, TX
8380 Warren Pkwy., Suite 201
(972) 377-2625

Schedule an appointment here

How Common is Infertility?

Infertility is a more common medical problem than most people realize. Recent statistics estimate that approximately 1 in 6 couples have issues relating to infertility. This number may actually be underestimating the true incidence since many couples never end up seeking care. According to statistics maintained by the Center for Disease Control (CDC), Assisted Reproductive Technologies (ART) account for slightly more than 1% of total U.S. births. There were 148,055 ART cycles reported in 2008 and 61,426 infants born as a result of ART cycles in 2008. Only births of babies that were conceived via in-vitro fertilization procedures are reflected in these statistics. Many couples are able to successfully conceive with simpler and much less expensive treatment than in-vitro fertilization. Seeking care early is of utmost importance so that appropriate interventions and treatment can be done in a timely fashion. Age of the female partner is one of the most important factors governing the chances of successful conception. Additionally, the emotional toll of prolonged infertility can keep couples from getting the care they need.

When Should I Seek Help?

Current recommendations are that if the female partner is under age 35 and the couple has been attempting conception at least for a year without success, then they should consider undergoing an evaluation to diagnose factors that can contribute to infertility. It would be best to seek an evaluation after 6 months of trying if the age of the female partner is greater than 35 yrs. If there are known causes of infertility present such as blocked tubes or lack of ovulation or poor sperm etc, then evaluation should be sought as soon as possible. Evaluation can be initiated either with one’s own ObGyn doctor or primary care physician, or go directly to see a reproductive endocrinologist. There have been studies showing that time to pregnancy is shortest under the care of a specialist. Once pregnant, the patient is usually followed by the reproductive endocrinologist until about 8-10 weeks gestation and then referred back to their ObGyn for continued obstetric care.

Exceptional Pregnancy Rates

In summary, infertility is a very common problem and many causes of infertility are amenable to simple treatment options. Chances of successful conception are high for many couples. If in-vitro fertilization is needed, current laboratory advances have led to exceptional pregnancy rates compared to before. Seeking care in a timely fashion is crucial. It is extremely important for patients obtain all the information they may need about their diagnosis and treatment options, so as to make well informed decisions on how they want to proceed to build their family.

-Dr. Mehta, Frisco Infertility of Plano