Bariatric Surgery comes to the rescue of infertile women

Author : Dr. Rajsekhar Nayak
MS, FRCS(Edinburgh), FRCS (Glasgow),UK
Gunasheela Surgical and Maternity Hospital

Bariatric surgery is accepted as the most efficient treatment for weight loss in morbidly obese patients all over the world.  This treatment has been around for over 4 decades.

Morbid obesity is a condition where the patient’s BMI (body mass index) is over 37. The normal BMI is 23-25.

Morbid obesity affects the individual’s health seriously and makes the person more prone to various diseases. These include Diabetes, high Blood pressure, high cholesterol, Fatty liver, sleep disturbances, depression, arthritis and so on. The excess fat has ill effects on all organs of the body. This includes fertility. Therefore Morbid obesity is now considered a disease and has to be treated.

Infertility is on the rise due to various causes. Obesity is one of the recognized causes. With urbanization and a large middle class with access to ‘better’ lifestyle, eating habits, lack of exercise, obesity in the country is increasing in epidemic proportions. India now has a large percentage of young people in the fertile age group.

Awareness of the ill effects of obesity on one’s general health and fertility in particular needs to be created at all levels.

Approximately half the numbers of patients with polycystic ovaries are obese. PCO is a very common cause of infertility and the only treatment these patients need is weight loss. Obese infertile patients in addition have high levels of Insulin, abnormal glucose tolerance (prediabetes) due to Insulin resistance at the cellular level. The female patients have higher levels of testosterone (male hormone) leading to facial hair and acne. The abnormalities in the hormonal levels lead to irregular menstrual cycles and prevent egg release (anovulatory cycles).

Treatment of morbidly obese infertile patients with methods such as IVF also is likely to fail. These patients do not respond to the medication on expected lines. In countries where infertility is funded by the government, patients are denied Infertility treatment if their BMI is over 35.

Bariatric surgery induced weight loss in morbidly obese individuals reverses all these effects. Insulin resistance drops, male to female hormone ratio normalizes leading to regular Menstrual Cycles and normal ovulation. This significantly increases the chances of spontaneous pregnancy. In the event she does not conceive naturally the chances of pregnancy with any assisted reproductive techniques is also increased.

It is important to be aware of the consequences of pregnancy in morbidly obese individuals. There is an n increased risk of pregnancy induced diabetes and high blood pressure. These could make the pregnancy a high risk condition to both the mother and the child. The antenatal period would require multiple visits to the hospital; close monitoring, number of medications, multiple admissions and many anxious moments to the patient and the doctor. Complications such as premature labour, bleeding before or immediately after delivery; blood transfusions  are  all higher in these obese individuals. The growing foetus in the womb is also exposed to risks of congenital malformations.

At Gunasheela Fertility Centre we see a large number of morbidly obese women with infertility. They are all offered a medically supervised weight loss programme initially. If they are unable to lose adequate weight and maintain the weight loss they are then offered Bariatric Surgery. Several counseling sessions are held by the Bariatric team that includes a Surgeon, Physician, Psychologist and Dietician. All the details of the surgery, the pre and post operative care and the need for regular follow up by the team are stressed. Patients are advised not to conceive for at least 12 months following bariatric surgery.

Once they become pregnant they are followed up regularly by the bariatric team and the Obstetrician until delivery.

28 Bariatric surgeries performed for morbidly obese (BMI more than 37) with Infertility. These patients had come to Gunasheela for IVF treatment. 17 patients became pregnant after weight loss. 11 patients with natural pregnancy and others through assisted reproduction.

Considering all the above issues, it is important to know that weight reduction is very important in morbidly obese individuals. This will not only increases the chances of conception but also reduces the risks to the mother and child. It is also important for specialists in the field of infertility to be aware of these issues and effectively communicate this to their patients.

There is no report of any adverse effect on the children born after bariatric surgery on the mother. However pregnant mothers after bariatric surgery should have a combined follow up by the obstetrician along with the bariatric surgery team.

Bariatric surgery is not without risks but should be offered when the benefits outweigh the risks. In morbidly obese individuals this fact has been clearly established through elaborate studies. All the information with respect to the surgery, its risks and complications must be discussed in detail with the patient and relatives. 

Awareness of the ill effects of obesity and its prevention is the key to a healthy future generation in our country where more than half the population is under the age of 35.

What is morbid obesity?

A body mass index (BMI) of more than 37 is morbid obesity. BMI is weight in kgs divided by height in meters squared. The condition is associated with significant health problems besides being a risk to one’s life itself. A morbid obese individual has twice the risk of dying compared to someone of his age with ideal weight.

What are the diseases associated with morbid obesity?

Any system in the body can be affected by obesity. The common ones are Diabetes, blood pressure, arthritis, infertility, sleep apnea, heart attack and skin disorders. These individuals may also have psychological problems such as low self-esteem, low confidence and at times depression.

What causes this condition?

The most important cause is genetic. Certain individuals are predisposed to obesity. Diet, lifestyle and environment contribute to it. It is wrong to think that it is the individual’s fault that he or she is morbidly obese. However it is a preventable condition provided the tendency of an individual to put on weight is identified in the early stages. Expert medical advice at this stage can prevent this condition.

What is Bariatric Surgery?

These are operations done through the keyhole approach (Laparoscopic surgery) for patients with morbid obesity and in situations where obesity is associated with certain diseases, for e.g., Diabetes, Hypertension, Sleep Apnea, etc.

The principle of the operation is to reduce food intake.  These operations involve either removing parts of the stomach or directing the food away from the stomach.  The operation helps the patients to take very small quantities of food without feeling hungry.  The amount of food taken is very small and not sufficient for the daily energy requirements of the individual.  This will result in the body utilizing his / her own fat for energy purposes.  Therefore, in spite of eating small quantities of food, the patient does not feel tired or weak. 

Along with weight loss, most of the patients have a good improvement of their Diabetes, Hypertension, Sleep Apnea, etc. 

These operations DO NOT involve removal of fat which is done in cosmetic procedures such as Liposuction. 

Who needs surgery?

There is a lot of evidence from studies conducted all over the world that morbid obesity does not respond to non-surgical treatments. The person might lose a few kgs only to put it back on a few weeks. Surgery is the only treatment available. One has to compare the risk of surgery and the risk to life by continuing with morbid obesity.

What are the different types of operations?

Operations are either restrictive, malabsorptive or a combination of the two. The common ones are the Sleeve Gastrectomy, Gastric Bypass and Gastric Banding.  The Sleeve Gastrectomy and the Gastric Band are restrictive procedures and the bypass is a combination of restriction and malabsorption. The success of these procedures is comparable. 

What is the advantage of the keyhole approach?

Previously a large cut was made on the abdomen to do these operations. The cut itself used to cause a lot of problems such as lot of pain, long healing time, infection and hernia formation. Therefore patients had to stay in the hospital for weeks. The keyhole approach involves making small (1cm) cuts on the abdomen, passing a camera and performing the SAME operation. It offers significant advantages. Pain is very minimal, recovery is faster and therefore discharge from hospital is within 2-5 days. Patient can return to work early. The scars are small and they would hardly be visible in 3-4 weeks.

What is the expected weight loss?

On an average, patients lose about 60% of excess weight (present weight minus ideal weight) in 12 months. Studies have shown that this weight loss is sustained for over 14 years.

Are there any side effects of surgery?

Many of the side effects are temporary such as nausea, bloating, feeling of not having eaten enough. Other side effects such as iron and calcium deficiency, anaemia, vitamin deficiencies etc., will need treatment.  Complications of surgery are very rare and depend upon the type of operation performed.