Reproductive considerations and pregnancy after bariatric surgery: current evidence and recommendations

Pregnancy After Bariatric Surgery-Experience from a Tertiary Center

INTRODUCTION

It is estimated that most people undergoing bariatric surgery are women of reproductive age; nonetheless, its effects on pregnancy outcomes are not yet fully understood.

METHODS

Retrospective observational study, conducted in a tertiary center in Portugal, included participants in two groups: (1) pregnant women with a history of bariatric surgery (n = 89) and (2) pregnant women with a BMI ≥ 35 kg/m2, without previous bariatric surgery (n = 176). Data was collected from the medical files. Multivariate analysis was conducted to adjust for confounders.

RESULTS

Pregnancy after bariatric surgery was associated with lower risk of gestational diabetes (15.7% vs. 30.1%, p = 0.002) and cesarean delivery (20.7% vs. 33.5%, p = 0.007), and a higher gestational weight gain (10.58 ± 9.95 vs. 7.33 ± 6.00 kg, p < 0.001). Participants in the bariatric surgery who experienced a gestational weight gain ≤ 10.0 kg had a higher risk of preterm delivery (16.7% vs. 2.5%, p = 0.031). No significant differences were found regarding hypertensive diseases of pregnancy between groups (4.5% vs 11.4%, p = 0.147). Pregnancy after bariatric surgery was associated with lower neonate weight percentile (34.24 ± 21.09 vs. 48.77 ± 27.94, p < 0.001), higher risk of fetal growth restriction (5.6% vs. 0.6%, p = 0.018), and lower risk of fetal macrosomia (0.0% vs. 7.5%, p = 0.005). There were no significant differences in the risk of SGA (12.5% vs. 7.0%, p = 0.127) or LGA neonates (2.3% vs. 6.4%, p = 0.069).

CONCLUSION

Pregnancy after bariatric surgery is associated with both risks and benefits, which should be considered by healthcare providers. Pregnancy after bariatric surgery requires individualized care, to ensure adequate gestational weight and avoid micronutrient deficiencies.

Effect of weight loss before in vitro fertilization in women with obesity or overweight and infertility: a systematic review and meta-analysis

The effect of weight loss before in vitro fertilization (IVF) procedures on pregnancy outcomes in women with overweight or obesity and infertility remains controversial. In this systematic review and meta-analysis, we investigated whether weight loss before IVF in these women affected the IVF results and reproductive outcomes. PubMed, Embase, and the Cochrane Library databases were searched from the inception dates until December 2022, using combinations of relevant keywords. Only six randomized controlled trials, including 1627 women with obesity or overweight, were analyzed. The weight change in the intensive care group, compared to the control group who underwent IVF without weight loss was - 4.62 kg (mean difference; 95% confidence interval [CI] - 8.10, - 1.14). Weight loss before IVF did not significantly increase the live birth rate in women with obesity or overweight and infertility (odds ratio, 1.38; 95% CI 0.88, 2.10). The clinical pregnancy, miscarriage, ongoing pregnancy, and ectopic pregnancy rates did not differ between the weight loss and control groups before IVF. This meta-analysis demonstrated that even significant weight loss before IVF in women with obesity or overweight and infertility did not improve the live birth, clinical pregnancy, ongoing pregnancy, or ectopic pregnancy rates. PROSPERO Registration Number: CRD42023455800.

Reproductive Surgery in Females with Obesity: Reproductive Consequences of Obesity and Applications for Surgical Care

Obesity is the most common medical problem in women of reproductive age. The surgical applications for this population, many of who are interested in current or future fertility, are critical to safe and effective evaluation and management of issues that impact the reproductive system. As rates of obesity continue to rise worldwide, it is projected that one in two individuals will have obesity by 2030 leading to increasing numbers of individuals affected by a disease process that has implications for their gynecologic surgical care, fertility-related assessment, and infertility treatment. Offering patients with obesity access to safe reproductive surgery is a cornerstone of reproductive autonomy. This review will summarize current recommendations regarding surgical concepts for the operating room, office hysteroscopy, oocyte retrieval, and embryo transfer in female patients with obesity.

Pregnancy Conceptualizations in Women Who Have Had Recent Bariatric Surgery

Objectives: To describe bariatric surgery patients' perioperative conceptualizations about pregnancy. Materials and Methods: We performed a secondary analysis of a cross-sectional study performed in 2016, evaluating a nationally recruited convenience sample of U.S. women aged 18-45 years who underwent bariatric surgery within the past 24 months. We assessed four pregnancy constructs: intent, desire, emotional orientation, and importance to avoid. We examined relationships between constructs, with time since surgery, postoperative pregnancy, and contraceptive use using descriptive statistics. Results: We included 363 eligible women (response rate 80%). Participant median age was 36 years, 71% (n = 258) were White, 77% (n = 279) were sexually active at the time of the study, and 39% (n = 140) experienced preoperative infertility. Most reported no desire to become pregnant (59%, n = 175) and that it was important to avoid pregnancy (78%, n = 283) within the first 24 months after surgery. Relationships between constructs were complex. Respondents in their first postoperative year more likely reported they would feel upset about a hypothetical pregnancy (40%, n = 74) than those in their second year (27%, n = 48, p = 0.02). Of those with a postoperative pregnancy, 46% (n = 17) felt it was important to avoid pregnancy compared with 81% (n = 266) of those who did not have a pregnancy (p < 0.001). Most used postoperative contraception (66%, n = 241), and those who felt it was important to avoid pregnancy more likely used contraception (82%, n = 197) than those who did not feel it was important (18%, n = 44, p = 0.01). Conclusions: Women undergoing bariatric surgery have diverse and complex conceptualizations about future pregnancy. These varied based on time from surgery and influenced postoperative contraceptive use.

Body Size, Fertility, and Reproductive Justice: Examining the Complex Interplay between BMI, Reproductive Health, and Access to Care

The relationship between obesity and reproduction is highly complex. While there are clear obstetrical and fertility risks associated with elevated BMI, it is less clear how weight loss impacts these outcomes. Increasingly, patients considered obese according to BMI are being denied access to fertility care, thus leaving them without treatment options for their disease (infertility). Notably, BMI cutoffs disproportionately affect historically marginalized populations in the United States and people of lower socioeconomic status (SES). This paper uses a reproductive justice framework to discuss access to reproductive healthcare based on BMI. In doing so, we connect obesity to larger systems of structural inequalities. We conclude that rather than strict BMI cutoffs, a more holistically patient-centered approach is appropriate taking into account the overall health of the individual, available scientific data, clinical capabilities, and the patient’s value system. This will ultimately make reproductive medicine more accessible to all patients.

Obesity and reproduction: a committee opinion

The purpose of this American Society for Reproductive Medicine Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled "Obesity and reproduction: an educational bulletin" last published in 2015 (Fertil Steril 2015;104:1116-26).

Pharmacokinetics of oral levonorgestrel and ethinylestradiol in women after Roux-en-Y gastric bypass surgery

BACKGROUND

Most patients undergoing Roux-en-Y gastric bypass (RYGB) are women in reproductive age. It is not known if bariatric surgery affects the pharmacokinetics of oral contraceptives.

OBJECTIVES

The primary objective was to evaluate ethinylestradiol (EE) and levonorgestrel (LNG) absorption in women undergoing RYGB, compared with nonoperated controls matched by age and body mass index (BMI). A secondary objective was to assess whether the time since surgery and BMI in the postoperative period influenced the absorption parameters.

SETTING

University hospital, Brazil.

METHODS

This study was designed to compare the maximum plasma concentration (Cmax), the time to the peak plasma level (Tmax), the area under the curve (AUC0-8 and AUC0-∞) after a single dose of a combined oral contraceptive with 0.03 mg EE and 0.15 mg LNG among 20 women after RYGB and 20 controls. Blood samples were obtained for 8 hours.

RESULTS

The mean LNG AUC0-8 and LNG AUC0-∞ were higher in RYGB group (P = .048 and P = .004, respectively). We found a positive correlation for LNG AUC0-8 (P = .045) and AUC0-∞ (P = .004) and the time since surgery, and we found a negative correlation for LNG Cmax (P = .018), AUC0-8 (P = .003), and AUC0-∞ (P = .001) and BMI.

CONCLUSION

No significant differences were found in oral EE pharmacokinetics. The operated group showed higher mean LNG AUC0-8 and AUC0-∞ but it was not considered clinically significant. The present study suggests that RYGB may not affect EE and LNG absorption.

Pharmacokinetics of Oral Levonorgestrel in Women After Roux-en-Y Gastric Bypass Surgery and in BMI-Matched Controls

BACKGROUND

Women are advised to primarily use non-oral contraceptive alternatives after Roux-en-Y gastric bypass since it is not known if the surgery affects the pharmacokinetics of oral contraceptives.

METHODS

This is a multi-center, open label, phase 2 pharmacokinetic study performed at the University Hospital of Linköping and the Clinical Trials Center, Department of Obstetrics and Gynecology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden. Fifteen women aged 18-40 years who had previously undergone Roux-en-Y gastric bypass surgery and reached a BMI < 30 were included. Fifteen BMI-matched women with no previous history of Roux-en-Y gastric bypass surgery served as a control group. After administration of a single dose of a combined oral contraceptive containing 0.03 mg ethinylestradiol/0.15 mg levonorgestrel, serum levonorgestrel concentrations were determined during a 24-h period using ultra performance liquid chromatography/tandem mass spectrometry. The area under the plasma concentration time curve of levonorgestrel (AUC0-24h) was the main outcome measure.

RESULTS

There were no significant differences in the studied pharmacokinetic parameters, AUC0-24h, total AUC, peak serum concentration (Cmax), time to peak serum concentrations (Tmax), apparent oral clearances of levonorgestrel (CLoral), or terminal half-lives (t½) between the groups.

CONCLUSION

This is to our knowledge the first study to evaluate the pharmacokinetics of oral levonorgestrel in women with a BMI < 30 at least 1 year after RYGB compared with a BMI-matched group of women. We could not find any significant pharmacokinetic differences between the groups, suggesting that oral levonorgestrel may be used in non-obese women after Roux-en-Y gastric bypass once a stable body weight has been reached.

CLINICAL TRIAL NUMBER

EudraCT 2014-004677-17.

Weight Status of Brazilian's Mother-Son Dyad after Maternal Bariatric Surgery

PURPOSE

Pregnant women who have undergone bariatric surgery must be followed to ensure healthy mother-child nutritional status. This study aimed to compare weight status of mother-child dyad after maternal bariatric surgery in public and private Brazilian healthcare system units.

MATERIALS AND METHODS

This retrospective matched case-control included 19 women who underwent Roux-en-Y gastric bypass surgery performed by the same private clinical surgical team and 19 age- and preoperative body mass index (BMI) matched patients from a public hospital. All 38 female patients reported a postoperative spontaneous pregnancy. The T test of independent samples and Pearson chi-square test were used to investigate inter-group differences.

RESULTS

Patients in the private system were more frequently married (94.7% versus 68.4%, p = 0.036) and had a higher educational level (94.7% versus 36.8%, p = 0.01 for tertiary education) but lower BMI, compared with those in the public system (pre-gestational = 25.7 ± 3.2 versus 28.5 ± 5.0 kg/m², p = 0.049; post-gestational = 24.6 ± 1.6 versus 29.0 ± 6.0 kg/m², p = 0.040). The interval from bariatric surgery to conception was shorter among public system patients (21.1 ± 13.9 versus 43.4 ± 31.2 months, p = 0.009). In both groups, almost 90% of children were born at full term and with adequate weights.

CONCLUSION

Despite differences in the characteristics of public and private systems, the mother-child dyads in both groups achieved satisfactory post-bariatric surgery gestation outcomes. The type of medical system does not appear to influence pregnancy outcomes or neonatal weight status conditions.

Early pregnancy after bariatric surgery: a single-institute preliminary experience

Background/aim

Pregnancy after bariatric surgery is an issue of growing importance with increasing number of women undergoing bariatric surgery. Therefore, in this study we present patients who conceived after sleeve gastrectomy and evaluate the obstetric outcomes.

Materials and methods

This retrospective case-control study includes 23 women who conceived after laparoscopic sleeve gastrectomy. Patients were evaluated in two groups according to the number of months between surgery and conception (group 1: ≤12 months; group 2: >12 months).

Results

The mean body mass index of patients before surgery and at the time of conception was 46.6 kg/m2 and 29.7 kg/m2, respectively. Nine patients (39.1%) had a history of infertility. There was no statistical difference between groups 1 and 2 for haemoglobin, ferritin, and 25-OH Vit-D levels or maternofoetal complication rates and pregnancy outcomes. Enteral nutrition requirements and intravenous iron replacement needs were higher in group 1, although this difference was not statistically significant.

Conclusion

Pregnancy in the first years after sleeve gastrectomy seems to have similar obstetric outcomes compared to pregnancies occurring later, but it remains a controversial issue. Although the results did not have statistical significance in our study, well-designed prospective series may determine the role of enteral nutrition and intravenous iron replacement in patient management.

Obesity and Reproduction

OBJECTIVE

To provide a comprehensive review and evidence-based recommendations for the delivery of fertility care to women with obesity.

OUTCOMES

The impact of obesity on fertility, fertility treatments, and both short and long-term maternal fetal outcomes was carefully considered.

EVIDENCE

Published literature was reviewed through searches of MEDLINE and CINAHL using appropriate vocabulary and key words. Results included systematic reviews, clinical trials, observational studies, clinical practice guidelines, and expert opinions.

VALUES

The Canadian Fertility & Andrology Society (CFAS) is a multidisciplinary, national non-profit society that serves as the voice of reproductive specialists, scientists, and allied health professionals working in the field of assisted reproduction in Canada. The evidence obtained for this guideline was reviewed and evaluated by the Clinical Practice Guideline (CPG) Committee of the CFAS under the leadership of the principal authors.

BENEFITS, HARMS, AND COSTS

The implementation of these recommendations should assist clinicians and other health care providers in counselling and providing reproductive care to women with obesity.

VALIDATION

This guideline and its recommendations have been reviewed and approved by the membership, the CPG Committee and the Board of Directors of the CFAS.

SPONSORS

Canadian Fertility & Andrology Society.

RECOMMENDATIONS

Twenty-one evidence based recommendations are provided. These recommendations specifically evaluate the impact of obesity on natural fertility, fertility treatments, and maternal-fetal outcomes. Strategies to lose weight and BMI cut-offs are also addressed.

Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care

The objective of the study is to provide evidence-based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow-up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print-friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high-quality evidence and warrant further research. These areas are highlighted in the paper.

A Review of Obstetrical Outcomes and Complications in Pregnant Women after Bariatric Surgery

Bariatric surgery (BS) is a novel treatment for weight reduction with longer lasting health benefits. This review aimed to summarise the available evidence regarding the fetomaternal outcomes and the most common challenges and complications in pregnancies following BS. Google Scholar (Google LLC, Mountain View, California, USA) and PubMed® (National Library of Medicine, Bethesda, Maryland, USA) databases were searched for articles published until December 2018. A total of 64 articles were included in this review and results showed that BS mitigates the risk of gestational diabetes mellitus, hypertensive disorders in pregnancy and fetal macrosomia. However, it can also have detrimental effects on fetomaternal health. There is paucity of data regarding small for gestational age intrauterine growth restriction, premature rupture of membranes and long-term effects on the children born to women who underwent BS.

Pregnancy after bariatric surgery: a narrative literature review and discussion of impact on pregnancy management and outcome

Bariatric surgery (BS) is regarded to be the most effective treatment of obesity with long lasting beneficial effects including weight loss and improvement of metabolic disorders. A considerable number of women undergoing BS are at childbearing age.Although the surgery mediated weight loss has a positive effect on pregnancy outcome, the procedures might be associated with adverse outcomes as well, for example micronutrient deficiencies, iron or B12 deficiency anemia, dumping syndrome, surgical complications such as internal hernias, and small for gestational age (SGA) offspring, possibly due to maternal undernutrition. Also, there is no international consensus concerning the ideal time to conception after BS. Hence, the present narrative review intents to summarize the available literature concerning the most common challenges which arise before and during pregnancy after BS, such as fertility related considerations, vitamin and nutritional deficiencies and their adequate compensation through supplementation, altered glucose metabolism and its implications for gestational diabetes screening, the symptoms and treatment of dumping syndrome, surgical complications and the impact of BS on pregnancy outcome. The impact of different bariatric procedures on pregnancy and fetal outcome will also be discussed, as well as general considerations concerning the monitoring and management of pregnancies after BS.Whereas BS leads to the mitigation of many obesity-related pregnancy complications, such as gestational diabetes mellitus (GDM), pregnancy induced hypertension and fetal macrosomia; those procedures pose new risks which might lead to adverse outcomes for mothers and offspring, for example nutritional deficiencies, anemia, altered maternal glucose metabolism and small for gestational age children.

Fertility, Pregnancy and Lactation After Bariatric Surgery - a Consensus Statement from the OEGGG

Bariatric surgery is recommended when other weight loss interventions, such as lifestyle modification or medications, have failed. A considerable number of women undergoing bariatric surgery are of childbearing age; hence, it is necessary to be aware of the effects of bariatric surgery on pregnancy for managing these patients. Although bariatric surgery is associated with positive effects on cardiovascular and metabolic parameters, side effects such as anaemia, the risk of developing internal hernia, altered glucose metabolism and the risk of small for gestational age offspring have to be considered. Pregnant women with a history of gastric bypass should not undergo the oral glucose tolerance test (OGTT) due to the high risk of hypoglycaemia. There are no contraindications for vaginal delivery and breastfeeding. This paper has been published as a consensus statement by the Austrian Society of Gynaecology and Obstetrics (OEGGG).

Plasma concentrations of etonogestrel in women using oral desogestrel before and after Roux-en-Y gastric bypass surgery: a pharmacokinetic study

OBJECTIVE

To investigate whether Roux-en-Y gastric bypass (RYGB) affects oral desogestrel (etonogestrel) pharmacokinetics.

DESIGN

Single centre, open label, phase-2 pharmacokinetic study.

SETTING

University hospital of Linköping, Sweden.

POPULATION

Fourteen women with planned RYGB surgery were included; nine women aged 18-45 years using 75 micrograms desogestrel completed the study.

METHODS

Steady-state etonogestrel pharmacokinetic (PK) parameters were measured on three occasions for each individual (at 8 ± 6 weeks before surgery, and at 12 ± 2 and 52 ± 2 weeks after surgery). Each patient served as her own control. On each occasion, serum samples were collected during a 24-hour period and etonogestrel concentrations were determined with ultra-performance liquid chromatography/tandem mass spectrometry.

MAIN OUTCOME MEASURES

Area under the plasma concentration time curve of etonogestrel (AUC_{0-24 hours} ).

RESULTS

All women had significant postoperative weight loss. There were no significant differences in AUC_{0-24 hours} , terminal half-lives (t_½ ), time to peak serum concentrations (T_max ), or apparent oral clearances of etonogestrel (CL_oral ) before and after gastric bypass surgery on any occasion. Peak serum concentrations (C_max ) increased after 52 ± 2 weeks compared with preoperative values (0.817 ng/ml versus 0.590 ng/ml, P = 0.024).

CONCLUSION

To our knowledge, this is the first study to investigate the effects on desogestrel pharmacokinetics after RYGB. This study did not reveal any clinically significant changes in etonogestrel pharmacokinetics, suggesting that oral desogestrel may be used by women after RYGB surgery. The sample size was limited, however, and therefore the results should be interpreted cautiously.

TWEETABLE ABSTRACT

The pharmacokinetics of oral desogestrel does not appear to change after gastric bypass surgery.

Perioperative pregnancy interval, contraceptive counseling experiences, and contraceptive use in women undergoing bariatric surgery

BACKGROUND

Reproductive-aged women represent about half of those undergoing bariatric surgery in the United States. Obstetric and bariatric professional societies recommend that women avoid pregnancy for 12-18 months postoperatively due to concern for increased pregnancy risks, and that providers should counsel women about these recommendations and their contraceptive options. However, knowledge about women's experience with perioperative counseling and postoperative contraceptive use is limited.

OBJECTIVE

We sought to: (1) determine prevalence of perioperative contraceptive and pregnancy interval discussions among women who have recently undergone bariatric surgery; and (2) describe postoperative contraceptive use within the first year of surgery in this population.

STUDY DESIGN

We performed a cross-sectional study of US women, aged 18-45 years and recruited through Facebook, who underwent bariatric surgery within the last 24 months.

RESULTS

We enrolled 363 geographically diverse women. Three-quarters recalled perioperative pregnancy or contraceptive discussions, the majority with a bariatric provider. Half felt it was "very important" to discuss these issues perioperatively, and 41% of those who reported discussions wished they had had more. Of the 66% of women who reported using contraception in the first 12 months postoperatively, 27% used oral contraceptives and 26% used an intrauterine device. One third of contraceptive users who had undergone Roux-en-Y gastric bypass, a combined restrictive-malabsorptive procedure, were using oral contraceptives. Perioperative contraceptive or pregnancy discussions were independently associated with increased postoperative contraceptive use (odds ratios, 2.5; 95% confidence interval, 1.5-4.3, P < .001).

CONCLUSION

A substantial proportion of women who had undergone bariatric surgery reported having had no perioperative pregnancy or contraception counseling, and many women who had felt the discussions were insufficient. Those who had had perioperative discussions were more likely to use contraception postoperatively. Reproductive-aged women should be routinely counseled perioperatively about pregnancy and contraception in the context of their reproductive desires, so they can make informed decisions about perioperative pregnancy prevention and contraceptive method use.

The Controversy of the Most Proper Time for Pregnancy After Bariatric Surgery: a Review of Ten Cases

BACKGROUND

Many infertile obese women conceive after bariatric surgery after many years, while guidelines prohibit them from pregnancy for at least 12-18 months after surgery, due to complications.

METHODS

We hereby present 11 cases in our research center, pregnant in less than 12 months after surgery from 2011 to 2015, to evaluate their pregnancy outcome and complications.

RESULTS

The mean conception time was 3.6 months after surgery and mean birth weight was 2695 g. Regarding neonatal/fetal complications, there was one case of intrauterine growth retardation and one NICU hospitalization. Among pregnancy complications, eight patients had hyperemesis gravidarum and one had pre-eclampsia.

CONCLUSIONS

The results of the present study suggest revising setting a contraindication for conception for patients undergoing bariatric surgery.

A Time Interval of More Than 18 Months Between a Pregnancy and a Roux-en-Y Gastric Bypass Increases the Risk of Iron Deficiency and Anaemia in Pregnancy

OBJECTIVE

The aim of the study is to explore the impact of time between Roux-en-Y gastric bypass (RYGB) and pregnancy on obstetrical outcome and nutritional derangements.

METHODS

In a retrospective cross-sectional study of pregnant women admitted for antenatal care at two tertiary hospitals, we examined 153 women with RYGB and a singleton pregnancy of at least 24 weeks. The women were stratified according to a pregnancy <18 months (40 women) or ≥18 months (113 women) after RYGB. Main outcome measures were nutritional parameters and glycated haemoglobin 1Ac (HbA1c) in second and third trimester of pregnancy, gestational hypertension, length of pregnancy, mode of delivery and foetal birth weight.

RESULTS

The two groups were comparable regarding age, parity and prepregnancy body mass index. The frequency of iron deficiency anaemia (ferritin <12 μg/L and haemoglobin <6.5 mmol/L/10.5 g/dL) was significantly higher in the late group, 29 vs. 8 % in the early group, p = 0.010. No differences were found for vitamin B12, vitamin D and zinc. Median HbA1c was significantly higher in the late group than in the early group (33 vs. 31 mmol/mol, p = 0.027). There were no significant differences in the risk of adverse pregnancy outcome or birth weight between the two groups.

CONCLUSION

A long surgery-to-pregnancy time interval after a RYGB increases the risk of iron deficiency anaemia but not of other nutritional deficits. Time interval does not seem to have an adverse effect on the obstetrical outcome, including intrauterine growth restriction. Specific attention is needed on iron deficit with increasing surgery-to-pregnancy time interval.

Nutritional Recommendations for Adult Bariatric Surgery Patients: Clinical Practice

Bariatric surgery is currently the most effective treatment for morbid obesity and its associated metabolic complications. To ensure long-term postoperative success, patients must be prepared to adopt comprehensive lifestyle changes. This review summarizes the current evidence and expert opinions with regard to nutritional care in the perioperative and long-term postoperative periods. A literature search was performed with the use of different lines of searches for narrative reviews. Nutritional recommendations are divided into 3 main sections: 1) presurgery nutritional evaluation and presurgery diet and supplementation; 2) postsurgery diet progression, eating-related behaviors, and nutritional therapy for common gastrointestinal symptoms; and 3) recommendations for lifelong supplementation and advice for nutritional follow-up. We recognize the need for uniform, evidence-based nutritional guidelines for bariatric patients and summarize recommendations with the aim of optimizing long-term success and preventing complications.

Perspectives in obesity and pregnancy

Obesity is currently recognized as a health epidemic worldwide. Its prevalence has doubled in the last three decades. Obesity is a complex clinical picture associated with physical, physiologic, hormonal, genetic, cultural, socioeconomic and environmental factors. The rate of obesity is also increasing in the pregnant women population. Maternal obesity is associated with less than optimal obstetrical, fetal and neonatal outcomes. It is also associated with significant adverse long-term effects on both obese parturients and the infants born from obese women. A number of guidelines have been published to educate health care workers and the general population in an attempt to develop effective interventions on a large scale to prevent obesity. These guidelines are multiple, confusing and inconsistent. There are no standard recommendations regarding gestational weight gaining goals, nutrients and additional elements necessary for certain obese women who have been treated with bariatric surgical procedures, screening for metabolic diseases such as diabetes, additional preventive health care services indicated for obese women in the pregnancy planning stages, during prenatal care, in the immediate post-partum period and as a long-term approach for health preservation. In 2013, the American Medical Association supported by several US national medical specialty organizations published Resolution 420 (A-13) recognizing obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to improve its prevention and treatment. The goal of this decision was to encourage a broader spectrum of health care benefits insurance coverage for the prevention and treatment of obesity. There are a number of myths and misconceptions associated with obesity. These perspectives present our views and clinical experience with a partial review of recent bibliography addressing the associations between obese reproductive age women and their risks during pregnancy.

Pregnancy Following Bariatric Surgery-Medical Complications and Management

Bariatric surgery is most commonly carried out in women of childbearing age. Whilst fertility rates are improved, pregnancy following bariatric surgery poses several challenges. Whilst rates of many adverse maternal and foetal outcomes in obese women are reduced after bariatric surgery, pregnancy is best avoided for 12-24 months to reduce the potential risk of intrauterine growth retardation. Dumping syndromes are common after bariatric surgery and can present diagnostic and therapeutic challenges in pregnancy. Early dumping occurs due to osmotic fluid shifts resulting from rapid gastrointestinal food transit, whilst late dumping is characterized by a hyperinsulinemic response to rapid absorption of simple carbohydrates. Dietary measures are the mainstay of management of dumping syndromes but pharmacotherapy may sometimes become necessary. Acarbose is the least hazardous pharmacological option for the management of postprandial hypoglycemia in pregnancy. Nutrient deficiencies may vary depending on the type of surgery; it is important to optimize the nutritional status of women prior to and during pregnancy. Dietary management should include adequate protein and calorie intake and supplementation of vitamins and micronutrients. A high clinical index of suspicion is required for early diagnosis of surgical complications of prior weight loss procedures during pregnancy, including small bowel obstruction, internal hernias, gastric band erosion or migration and cholelithiasis.

Contraceptive Use Before and After Gastric Bypass: a Questionnaire Study

Background

At present, women are recommended to avoid pregnancy 12–18 months after bariatric surgery. Our aim in this study was to describe patterns of contraceptive use before and after gastric bypass in Sweden, and to describe the contraceptive counseling given preoperatively to women undergoing gastric bypass.

Methods

In October 2012, a questionnaire was sent to 1000 Swedish women who all had undergone gastric bypass during 2010. The women had been included in the Scandinavian Obesity Surgery Register at time of surgery. The main outcome measures were patterns of use of contraception before and after bariatric surgery.

Results

The response rate was 57 %. The most commonly used contraceptive methods were intrauterine devices, 29 % preoperatively and 26 % postoperatively even though there was a postoperative switch from the copper intrauterine device to the levonorgestrel intrauterine system. Thirty percent did not use any contraceptive during the first 12 months after surgery. Sixty percent of the responders were aware of the recommendations to avoid pregnancy after surgery.

Conclusions

Many women who undergo bariatric surgery are not using any contraceptive method despite the recommendation that they should avoid pregnancy for at least 12 months. There is a great need to improve contraceptive counseling for this growing group of women.

Tools for Successful Weight Management in Primary Care

Obesity is one of the most pervasive and costly public health problems. Clinicians need effective tools to address weight management in primary care, including evaluation and communication methods, guideline-based weight management interventions and safe and effective weight loss medications and surgery. The objective of this Grand Rounds presentation is to provide practicing clinicians with the latest information regarding effective ways to care for and communicate with patients about weight loss; evidence-based guidelines for selecting weight management therapies and safety, efficacy and adverse effects of weight loss medications and surgery.

Obesity and reproduction: a committee opinion

The purpose of this ASRM Practice Committee report is to provide clinicians with principles and strategies for the evaluation and treatment of couples with infertility associated with obesity. This revised document replaces the Practice Committee document titled, "Obesity and reproduction: an educational bulletin," last published in 2008 (Fertil Steril 2008;90:S21-9).

Preconception care and reproductive planning in primary care

Preconception care is designed to identify and reduce biomedical, behavioral, and social risks to the health of a woman or her baby before pregnancy occurs. Few women present requesting preconception care; however, 1 in 10 US women of childbearing age will become pregnant each year. As primary care physicians (PCPs) care for reproductive-aged women before, between, and after their pregnancies, they are ideally positioned to help women address health risks before conception, including optimizing chronic conditions, to prevent adverse pregnancy and longer-term health outcomes. PCPs can help women make informed decisions both about preparing for pregnancy and about using effective contraception when pregnancy is not desired.

Optimizing Weight for Maternal and Infant Health - Tenable, or Too Late?

Obesity in pregnancy is the leading cause of maternal and fetal morbidity, and gestational weight gain (GWG) is one modifiable risk factor that improves pregnancy outcomes. Most pregnant women gain more than the 2009 Institute of Medicine recommendations, particularly overweight and obese women. GWG even less than the 2009 IOM guidelines in obese women may improve pregnancy outcomes and reduce large-for-gestational-age (LGA) infants, an independent risk factor for childhood obesity, without increasing small-for-gestational-age (SGA) infants. Unfortunately, despite the fact that over 50 interventional trials designed to decrease excess GWG have been conducted, these interventions have been only modestly effective, and interventions designed to facilitate weight postpartum weight loss have also been disappointing. Successful interventions are of paramount importance not only to improve pregnancy outcomes but also for the future metabolic health of the mother and her infant, and may be key in attenuating the trans-generational risk on childhood obesity.

Does bariatric surgery improve ovarian stimulation characteristics, oocyte yield, or embryo quality?

Background

Obesity is a major global health concern associated with multiple co-morbidities. Bariatric surgery has been considered a good treatment option in cases of morbid obesity. This preliminary study aims to investigate the effect of bariatric surgery on ovarian stimulation characteristics and IVF treatment cycle outcome.

Methods

A retrospective study that was performed in a tertiary, university-affiliated medical center and included all patients who underwent IVF treatment both before and after bariatric surgery. Data on ovarian stimulation variables of IVF treatment cycle prior and following the bariatric surgery were reviewed and compared.

Results

From January 2005 to June 2014, seven women fulfilled the inclusion criteria. After the operation, BMI was significantly reduced (mean ± SD) (43.1 ± 3.3 vs. 29.6 ± 7.33, p = 0.018), as was the number of gonadotropin ampoules required during stimulation (69.3 ± 10.5 vs. 44.5 ± 17, p = 0.043). No between-cycle differences were observed in peak estradiol level, the number of oocytes retrieved, and percentage of mature oocytes.

Conclusions

To the best of our knowledge, this preliminary case series is the first comparison of IVF cycle characteristics prior to and following bariatric surgery. The operation seems to reduce treatment costs without affecting oocyte or embryo quality. Further large studies are required to establish the surgery’s effect on IVF outcome among infertile women.

Female obesity and infertility

Infertility affects one in seven couples, and its rate is on the increase. Ovulatory defects and unexplained causes account for >50% of infertile aetiologies. It is postulated that a significant proportion of these cases are either directly or indirectly related to obesity. The prevalence of overweight and obese men and women has topped 50% in some developed countries. Obesity is on the increase worldwide; in turn, the consequences in terms of the associated morbidity and mortality have also been increasing. Obesity is associated with various reproductive sequelae including anovulation, subfertility and infertility, increased risk of miscarriage and poor neonatal and maternal pregnancy outcomes. Thus, the combination of infertility and obesity poses some very real challenges in terms of both the short- and long-term management of these patients. The mechanism with which obesity impacts female reproductive function is summarised in this review.

Reproductive health counseling and practices: a cross-sectional survey of bariatric surgeons

BACKGROUND

Nearly 50% of bariatric surgery patients are women of reproductive age. Both obstetric and gynecology and surgery professional guidelines recommend a delay of fertility 1-2 years postbariatric surgery.

METHODS

We sought to assess bariatric surgeons' perioperative reproductive counseling and contraceptive provision for women of reproductive age. We conducted a cross-sectional, national 32-question mail survey of bariatric surgeons. Survey topics included demographic factors, contraceptive counseling and provision, and method preference. Descriptive statistics were reported and Χ2 tests compared results among respondent demographic characteristics.

RESULTS

A total of 574 of 1,935 physicians returned surveys (30%). After excluding 41 surveys due to missing data, we analyzed 533 (27%) surveys. Mean respondent age was 48.1 years. Most respondents were male (89%), white (78%), and completed residency training ≥10 years ago (72%). The majority of respondents' bariatric surgery patients were female (77%), 63% of which were of reproductive age. Most respondents recommended that their female patients delay pregnancy 12-24 months (87%). Whereas 70% of respondents did not require preoperative contraception, 52% always required postoperative contraceptive use. Although the majority of respondents (64%) referred patients to an obstetrician-gynecologist or primary care physician to obtain contraception, 35% did not know how their female patients obtained contraception. Female respondents were more likely than male respondents to always require a medicine consultation and preoperative contraception, P<.05.

CONCLUSION

Despite consistently recommending a delay in pregnancy, bariatric surgeons inconsistently address perioperative contraceptive needs of women of reproductive age. These findings highlight the need for greater collaboration between bariatric surgeons and women's healthcare providers to address the reproductive health needs of women having bariatric surgery.

Nutrition for a Healthy Pregnancy

Nutrition is a known, powerful determinant of perinatal health and one that is increasingly recognized to have further reaching effects than previously understood. It is well known that healthy nutrition during the peripartum period can prevent birth defects in the neonate. New research suggests that peripartum nutrition may also modulate the risk of chronic disease in later life. Proper nutrition and weight gain during pregnancy also have maternal benefits including lowered risks of pregnancy related disorders. Good peripartum nutrition is a potential tool to impact the rising prevalence of obesity and related health disorders. This article will review nutrition guidance in pregnancy including macro and micronutrient recommendations, newer recommendations for appropriate weight gain based upon body mass index categories, and avoidance of potentially harmful substances. Current topics will also be discussed including fetal origins of adult disease, pregnancy after weight loss surgery, environmental bisphosphonates, and glycemic index diets.

Obesity and reproductive function

Obesity is associated with multiple adverse reproductive outcomes, but the mechanisms involved are largely unknown. Obesity has been referred to as a "complex system," defined as a system of heterogeneous parts interacting in nonlinear ways to influence the behavior of the parts as a whole. Human reproduction is also a complex system; hence the difficulty in identifying the mechanisms linking obesity and adverse reproductive function. This review discusses the adverse reproductive outcomes associated with obesity and the mechanisms involved and concludes with a discussion of public health policy with respect to the treatment of infertility in obese women.

Endocrine changes (beyond diabetes) after bariatric surgery in adult life

Bariatric surgery is nowadays an effective therapeutic option for morbid obesity. Endocrinologists may thus have a growing opportunity to diagnose and treat obese patients eligible for surgery in pre- and post-operative phase. This requires a better understanding of endocrine changes caused by either obesity or weight loss surgery. Despite the large number of studies available in literature, only limited well-designed clinical trials have been performed so far to investigate changes of endocrine axes following bariatric procedures. There are still areas of unclear results such as female and male fertility, however, weight loss after bariatric surgery is considered to be associated with favorable effects on most endocrine axes. The aim of this clinical review is to overview the available literature on the effects of weight loss after bariatric surgery on the endocrine systems to suggest the most appropriate pre- and post-operative management of obese patients undergoing bariatric surgery in terms of "endocrine" health.

Bariatric surgery: impact on pregnancy outcomes

The dramatic increase in the prevalence of obesity in women of reproductive age has resulted in approximately 1 in 5 women being obese when they conceive. Bariatric surgery has been shown to be the most effective long-term weight loss strategy in obese women in this age group. Clinicians should be aware of the effects of bariatric surgery on fertility and future pregnancies. Regarding certain complications, pregnancy after bariatric surgery appears to be safer than pregnancy in the obese. In patients where nutrition is properly maintained and monitored, the risks for obesity-related obstetric complications, such as gestational diabetes mellitus and hypertension, are significantly reduced, but possibly at the expense of an increase in neonates born small-for-gestational-age. At the present, definitive conclusions cannot be drawn concerning the risk for Caesarian delivery, differences in type of bariatric procedure, or the optimal surgery-to-conception interval.

Nutrition and pregnancy after bariatric surgery

Obesity is an escalating problem in all age groups and it is observed to be more common in females than males. About 25% of women meet the criteria of obesity and one-third of them are in the reproductive age. Because morbid obesity requiring surgical treatment is observed with increasing frequency, surgeons and gynecologists are undergoing new challenges. It is not only a matter of women's health and their quality of life but also proper development of the fetus, which should be a concern during bariatric treatment. Therefore complex perinatal care has to be provided for morbid obesity patients. The paper reviews pregnancy and fertility issues in bariatric surgery patients.