Does Bariatric Surgery Improve Assisted Reproductive Technology Outcomes in Obese Infertile Women?

Weight Regain following Bariatric Surgery and in vitro Fertilization Outcomes

INTRODUCTION

The aim of this study was to estimate the time to pregnancy and live birth and evaluate the effect of weight regain in women with a history of bariatric surgery (BS) who underwent in vitro fertilization (IVF) treatments.

METHODS

This is a retrospective cohort study. All patients with previous BS who underwent IVF treatment in a tertiary university-affiliated hospital between 2013 and 2022 were included. Time to pregnancy and live birth were compared between patients who regained less than or greater than three points of body mass index (BMI) from the nadir weight after BS. Kaplan-Meier curves and log-rank tests were used to compare groups.

RESULTS

A total of 78 patients were included in this study. The positive β-hCG, clinical pregnancy, and live birth rates following BS were 89.4%, 78.9%, and 50.8%, respectively. The median time from the beginning of IVF treatments to a positive β-hCG test was 2.97 months (95% CI: 1.04-4.89 months), to a clinical pregnancy was 7.1 months (95% CI: 3.56-10.91), and to a live birth was 20.2 months. Women who maintained their nadir BMI following BS had nearly twice the chance of achieving a clinical pregnancy (HR 1.967, 95% CI: 1.026-3.771, p = 0.042) and were approximately three times more likely to achieve a live birth (2.864, 95% CI: 1.196-6.859, p = 0.018) than those who regained at least three points of BMI.

CONCLUSION

Weight regain after BS is associated with a lower rate of live births and prolonged time to achieve clinical pregnancy and live birth.

Efficacy of LigaSure Versus Harmonic Devices in Laparoscopic Sleeve Gastrectomy: A Systematic Review and Meta-Analysis

Our goal is to conduct a thorough systematic review and meta-analysis of comparative studies to evaluate the efficacy of LigaSure (Valleylab, Boulder, CO) compared with Harmonic (Ethicon Endo-Surgery, Inc., Cincinnati, OH) devices in patients undergoing laparoscopic sleeve gastrectomy (LSG). Our search strategy, from inception until March 1, 2024, involved multiple databases, including the Cochrane Controlled Register of Trials (CENTRAL), Web of Science (WOS), PubMed, Scopus, and Google Scholar. We evaluated randomized clinical trials using the Cochrane Risk of Bias tool for randomized trials (RoB-2) tool and non-randomized studies using the Risk of Bias In Non-randomized Studies for Interventions (ROBINS-I) tool. The primary outcomes assessed were operative time, mean length of hospital stay, and the rates of intraoperative complications such as bleeding, organ injury, leakage, and hematoma formation. Additionally, we collected data on postoperative complications, including bleeding, abscess formation, leakage, fever (>38°C), and reoperation rates. Data were analyzed using random-effects models and reported as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) using Review Manager software (RevMan, version 5.4 for Windows, The Cochrane Collaboration, 2020). Four studies, comprising two randomized clinical trials (RCTs) and two retrospective cohort studies, involving a total of 692 patients, were included in the analysis. Both the operative time and length of hospital stay did not significantly differ between the LigaSure and Harmonic groups (p>0.05). The pooled analysis also revealed no significant difference between the LigaSure and Harmonic groups in terms of intraoperative and postoperative complications (p>0.05). In conclusion, our systematic review and meta-analysis found no significant statistical or clinical differences between LigaSure and Harmonic devices in terms of operative outcomes and complication rates in patients undergoing LSG.

Bariatric Surgery in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine condition in premenopausal women and is a common cause of anovulatory subfertility. Although obesity does not form part of the diagnostic criteria, it affects a significant proportion of women with PCOS and is strongly implicated in the pathophysiology of the disease. Both PCOS and obesity are known to impact fertility in women; obesity also reduces the success of assisted reproductive technology (ART). With or without pharmacotherapy, lifestyle intervention remains the first-line treatment in women with PCOS and obesity. Bariatric surgery is still an experimental treatment in women with PCOS and subfertility. This review will present an overview of the pathophysiology of PCOS and obesity and the role of bariatric surgery. Although data are sparse regarding the impact of bariatric surgery on subfertility in women with PCOS and obesity, existing studies point to a beneficial role in treating metabolic and reproductive dysfunction.

Advancements in Bariatric Surgery: A Comparative Review of Laparoscopic and Robotic Techniques

This article examines the evolution of bariatric surgery, with a focus on emerging technologies such as robotics and laparoscopy. In the case of gastric bypass, no significant differences have emerged between the two techniques in terms of hospitalization duration, weight loss, weight regain, or 30-day mortality. Robotic surgery, while requiring more time in the operating room, has been associated with lower rates of bleeding, mortality, transfusions, and infections. In revisional bariatric surgery, the robotic approach has shown fewer complications, shorter hospital stays, and a reduced need for conversion to open surgery. In the case of sleeve gastrectomy, robotic procedures have required more time and longer postoperative stays but have recorded lower rates of transfusions and bleeding compared to laparoscopy. However, robotic surgeries have proven to be more costly and potentially more complex in terms of postoperative complications. The review has also addressed the topic of the single-anastomosis duodeno-ileal switch (SADIS), finding comparable results between robotic and laparoscopic techniques, although robotic procedures have required more time in the operating room. Robotic technology has proven to be safe and effective, albeit with slightly longer operative times in some cases.

Evaluating the association of female obesity with the risk of live birth following IVF: Implications for clinical practice

Obesity is a well-established risk factor for infertility. Consequentially, women living with obesity may require fertility treatment to support them to conceive. Due to evidence suggesting obesity is also linked with poorer outcomes following in vitro fertilisation (IVF), local commissioning guidelines on assisted conception recommend a BMI of <30kg/m2 before IVF can commence. However, it is currently unclear if these guidelines are evidence based. This commentary aims to critically appraise a recent systematic review by Sermondade et al, 2019 and expand upon the implications of the findings for clinical practice.

Obesity and In Vitro Fertilization

Obesity is a highly prevalent chronic disease with a significant effect on reproductive-age women. The clinical implications of obesity on fertility and pregnancy are well studied citing ovulatory dysfunction, hormonal imbalances, higher miscarriage rates, and increased maternal and neonatal risks. For this reason, many patients with obesity seek reproductive specialists to help build their families. Despite this literature base, the effect of weight loss interventions prior to assisted reproductive technology (ART) is lacking. This review aims to outline the impact of obesity on ART, specifically in vitro fertilization (IVF). Response differences to treatment protocols compared with normal weight counterparts, limitations of access to care, and the mixed results of weight-reduction strategies prior to fertility treatment will be addressed. The known data surrounding benefits of lifestyle modification, pharmacologic therapies, and surgical interventions for obesity prior to IVF are outlined and found to emphasize a need for further research to determine the optimal approach for infertility patients with obesity.

Benefits and Risks of Bariatric Surgery on Women's Reproductive Health: a Narrative Review

Bariatric surgery (BS) is escalating as the most efficient and endurable therapy for severe obesity. Women's reproductive health is essential to women's quality of life and is receiving increasing attention. However, despite the high prevalence of BS among women, the effect of BS on reproductive health remains underemphasis. The purpose of this narrative review is to provide an overview of BS on women's reproductive health, including their reproductive health before, during, and after pregnancy. Although limited attention has been given, current evidence highlights the substantial implications of bariatric surgery on reproductive health and reminds us of the importance of adopting decision-making conversations about reproductive health before bariatric surgery.

Worth the wait? Preconception weight reduction in women and men with obesity and infertility: a narrative review

Short and long-term weight reduction interventions are considered in the preconception period for women and men with obesity and infertility as obesity is associated with poorer reproductive outcomes. Short-term weight loss achieved with diet, exercise, and medications does not improve per cycle conception or live birth rates in women undergoing ovulation induction, intrauterine insemination, or in vitro fertilization (IVF), but may increase the rate of natural conception. Long-term weight loss achieved through surgical interventions may increase spontaneous conceptions, particularly among women with polycystic ovary syndrome, and may increase the live birth rate from IVF, though these findings are limited by recent evidence. There is a clear need for additional treatment options and well-designed weight loss intervention trials that address the heterogeneous causes of obesity among women and men with infertility and include fertility outcomes and perinatal morbidity as outcome measures.

Outcomes of in-vitro fertilization after bariatric surgery: a national register-based case-control study

STUDY QUESTION

Does previous bariatric surgery (BS) in women affect cumulative live birth rate in IVF?

SUMMARY ANSWER

Women having had BS seem to have the same cumulative live birth rate as non-operated women of the same BMI at IVF treatment.

WHAT IS KNOWN ALREADY

Because of the perinatal risks of obesity to mother and infant as well as impaired outcomes of IVF, obese women are advised to reduce their weight, but it is not clear whether previous BS could affect IVF results.

STUDY DESIGN, SIZE, DURATION

This national register-based case–control study included all cases of BS (n = 30 436) undergoing IVF (n = 153) from 2007 until 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Swedish women between 18 and 45 years operated with BS, with at least one first started cycle of IVF after surgery, were included. For each woman having IVF after BS (n = 153), up to five non-operated control women (n = 744) starting their first IVF cycle during the study period were matched for age, parity and BMI at treatment. The primary outcome in this study was the cumulative live birth rate (CLBR) after the first IVF cycle, defined as all live births after the first cycle including fresh and frozen embryo transfers.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no significant difference in CLBR between the BS group and the matched controls (29.4% compared to 33.1%), even though the number of retrieved oocytes (7.6 vs 8.9, P = 0.005) and frozen embryos (1.0 vs 1.5, P = 0.041) were significantly fewer in the BS group. There was no association between cumulative live birth and BS, adjusted odds ratio 1.04, 95% CI (0.73, 1.51). However, the birth weight was significantly lower in the children born to mothers with previous BS, mean (SD) 3190 (690) vs 3478 (729) g, P = 0.037.

LIMITATIONS, REASONS FOR CAUTION

Confounders such as age, BMI and previous childbirth were accounted for by the matching design of the study, but there were no data on indication for IVF, anti-Müllerian hormone, smoking or previous comorbidities. The study was exploratory and did not reach sufficient power to detect potential smaller differences in live birth rates.

WIDER IMPLICATIONS OF THE FINDINGS

The findings concur with those in previously published smaller studies and provide somewhat reassuring results considering IVF outcomes after BS with a CLBR comparable to that of controls, despite a lower mean birth weight.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by grants from the Southern Health Care Region of Sweden. The authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

The Impact of Bariatric Surgery on Assisted Reproductive Technology Outcomes: A Systematic Review

OBJECTIVE

There is a paucity of literature on the impact of bariatric surgery on artificial reproductive technology (ART) outcomes. This topic should be examined, given that most bariatric surgery candidates are of reproductive age and those with obesity are significantly more likely to experience poor fertility outcomes. This systematic review aimed to determine if bariatric surgery impacts ART outcomes and if effects vary between females and males.

DATA SOURCES

MEDLINE, EMBASE, SCOPUS, and the Cochrane Central Register of Controlled Trials were searched for English studies published between January 1978 and May 2021.

STUDY SELECTION

Studies with participants who had had bariatric surgery and subsequently underwent ART (i.e., in vitro fertilization or intracytoplasmic sperm injection) were eligible for inclusion. Screening, data abstraction, and risk of bias assessment were conducted independently and in duplicate.

DATA EXTRACTION AND SYNTHESIS

Of the 279 articles screened for eligibility, 25 were sought for full text review, and 7 were included for analysis. Four studies (57%) examined ART interventions in females, while 3 (43%) examined interventions in males. Data on cumulative live birth rate (CLBR) was extracted for all 7 studies (N = 169). There were 50 live births with CLBRs ranging from 0.0% to 80.0%. Changes to female secondary outcomes were varied. Data on male secondary outcomes were contradictory: 1 study indicated improved sperm parameters following bariatric surgery, while 2 showed decreased parameters, with certain participants seeing improvements after several months.

CONCLUSION

Bariatric surgery prior to ART may have an impact on CLBRs; however, high-quality research is needed to delineate the direct effects of bariatric surgery on ART outcomes. Various sex-specific outcomes should be considered prior to recommending ART after bariatric surgery. Future research should determine the optimal type of bariatric surgery and timing of ART following bariatric surgery.

The Effect of Gastric Sleeve Resection on Menstrual Pattern and Ovulation in Premenopausal Women with Classes III-IV Obesity

PURPOSE

Bariatric surgery is very efficacious in treating severe obesity. However, its effect on menstruation and ovulation is currently unknown. The purpose of this study was to assess the effect of gastric sleeve resection (GSR) on menstrual pattern in women with stages III-IV obesity and ovulatory dysfunction compared with conventional management.

METHODS

This was a prospective, multicentre, non-randomized trial, in premenopausal women, who fulfilled the criteria for gastric sleeve resection (GSR). Both women with and without polycystic ovary syndrome (PCOS) were evaluated at 3, 6, 9, 12 and 15 months post-surgery.

RESULTS

Menstrual cycle irregularities were identified in 122 severely obese women (60 with PCOS; 62 without PCOS). The % total weight loss was greater with GSR than with conventional management (33.4% vs. 3.6% in PCOS; 24.8% vs. 3.6% in non-PCOS, respectively). Intermenstrual interval was shortened towards normal length (≤ 35 days) both in PCOS and non-PCOS GSR groups, by the 6th and 12th post-surgical month, respectively. Furthermore, ovulation at 6 months was achieved in 63.6% of PCOS and 45% of non-PCOS subjects post-GSR, which was higher than in controls (11.1% and 13.6%, respectively; p < 0.05). This percentage rose to 75.7% and 81.8% at 12 and 15 months in PCOS, respectively, but not in the non-PCOS group (55% and 52.5%, respectively; p < 0.05).

CONCLUSIONS

Weight reduction after GSR improved menstrual irregularity towards normality in women with severe obesity. Ovulation dysfunction was also resumed in more than half of these patients at 6-15 months. These effects were more evident in women with PCOS.

The debated role of bariatric surgery in improving in-vitro fertilization outcomes in morbidly-obese infertile women-a case report and brief overview

OBJECTIVE

Obesity has a negative impact on in-vitro fertilization (IVF) outcomes, and obese women who plan IVF treatments are often encouraged to pursue weight reduction. Bariatric surgery is an effective strategy for the treatment of morbidly obese women. The current case report is to investigate the impact of bariatric surgery on IVF outcome in a morbidly obese woman with subfertility.

CASE REPORT

A 37-year-old, morbidly obese woman with subfertility was indicated for IVF treatment. Due to her high body mass index (47.9 kg/m²), she was advised to lose weight; initial failure at conservative measures of weight loss prompted her to undergo bariatric surgery, combined with post-operative lifestyle change, prior to receiving IVF treatment. The woman successfully conceived at the second cycle and delivered twins by cesarean section smoothly at 36 + 3/7 weeks of gestation. Both twins have normal development up to two years of age.

CONCLUSIONS

Weight reduction mediated by bariatric surgery in subfertile and morbidly obese women can be considered before IVF treatment.

Effects of bariatric surgery on the menstruation- and reproductive-related hormones of women with obesity without polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery is an effective treatment for severe obesity. Several studies have been conducted on the effects of bariatric surgery on the reproductive function of women with obesity who do not have polycystic ovary syndrome (PCOS).

OBJECTIVES

To evaluate the effects of bariatric surgery on the menstruation and reproductive related hormones of women of childbearing age with who do not have PCOS.

SETTING

A systematic review and meta-analysis at a university hospital.

METHODS

Online databases were searched for all studies reporting the efficacy of bariatric surgery for women with obesity until March 2021. The language of publication was limited to English and Chinese. Incidence of abnormal menstruation and reproductive-related hormone levels were the primary outcomes.

RESULTS

Fifteen studies comprising 725 patients were enrolled in this meta-analysis. Results showed a significantly lower incidence of abnormal menstruation (relative risk: .40, 95% confidence interval [CI]: .20-.79, P = .008) after bariatric surgery. Moreover, bariatric surgery led to a decrease in serum insulin levels (mean difference [MD] = -13.12 mIU/L, 95% CI: -15.03 to -11.22, P < .00001), glucose (MD = -.91 mmol/L, 95% CI: -1.26 to -.56, P < .00001), triglyceride (MD = -.61 g/L, 95% CI: -.76 to -.46, P < .00001), total testosterone (MD = -.22 ng/mL, 95% CI: -.24 to -.20, P < .00001), dehydroepiandrosterone (DHEA) (MD = -25.34 μg/dL, 95% CI: -31.19 to -19.49, P < .00001), estradiol (MD = -25.13 pg/mL, 95% CI: -34.13 to -16.13, P < .00001), and anti-Mullerian hormone (AMH) (MD = -.40 ng/mL, 95% CI: -.67 to -.13, P = .003). Serum sex hormone binding globulin (SHBG) levels increased after bariatric surgery (MD = 43.99 nmol/L, 95% CI: 34.99-52.99, P < .00001).

CONCLUSION

Bariatric surgery can lower fasting insulin, glucose, and triglyceride levels, reduce the incidence of abnormal menstruation, decrease total serum testosterone, DHEA, estradiol, and AMH levels, and increase SHBG level for women with obesity of childbearing age who do not have PCOS. This meta-analysis indicated that bariatric surgery could be effective in improving reproductive function for women with severe obesity.

The effects of bariatric surgery on periconception maternal health: a systematic review and meta-analysis

BACKGROUND

Worldwide, the prevalence of obesity in women of reproductive age is increasing. Bariatric surgery is currently viewed as the most effective, long-term solution for this problem. Preconception bariatric surgery can reduce the prevalence of obesity-related subfertility and adverse maternal, pregnancy and birth outcomes. Maternal health during the periconception period is crucial for optimal gametogenesis and for embryonic and fetal development which also affects health in the later lives of both mother and offspring. Although preconception bariatric surgery improves several pregnancy outcomes, it can also increase the prevalence of pregnancy complications due to excessive and rapid weight loss. This can lead to iatrogenic malnutrition with vitamin deficiencies and derangements in metabolic and endocrine homeostasis. Thus, bariatric surgery can greatly influence periconception maternal health with consequences for reproduction, pregnancy and health in later life. However, its influence on periconception maternal health itself has never been reviewed systematically.

OBJECTIVE AND RATIONALE

The aim of this review was to investigate associations between bariatric surgery and determinants of periconception maternal health such as endocrine changes, fertility, vitamin status, irregular menstrual cycles, miscarriages and congenital malformations.

SEARCH METHODS

Medline, Embase, PubMed, Web of Science, Google Scholar and the Cochrane databases were used for the literature search until 1 November 2020. The search strategy terms included, among others, bariatric surgery, hormones, fertility, malformations, miscarriages and vitamin status. We searched for human studies that were written in English. Abstracts, reviews, meta-analyses and conference papers were excluded. The ErasmusAGE score was used to assess the quality of the included studies.

OUTCOMES

A total of 51 articles were analysed. The mean quality score was 5 (range 2-8). After bariatric surgery, hormonal axes normalized and menstrual cycle regularity was restored, resulting in increased fertility. Overall, there were no short-term risks for reproductive outcomes such as the increased risk of miscarriages or congenital malformations. However, the risk of vitamin deficiencies was generally increased after bariatric surgery. A meta-analysis of 20 studies showed a significant decrease in infertility (risk difference (RD) -0.24, 95% confidence interval (CI) -0.42, -0.05) and menstrual cycle irregularities (RD -0.24, 95% CI -0.34, -0.15) with no difference in rates of miscarriage (RD 0.00, 95% CI -0.09, 0.10) and congenital malformations (RD 0.01, 95% CI -0.02, 0.03).

WIDER IMPLICATIONS

The current systematic review and meta-analysis show associations between bariatric surgery and periconception maternal health and underlines the need for providing and personalizing preconception care for women after bariatric surgery. We recommend preconception care including the recommendation of postponing pregnancy until weight loss has stabilized, irrespective of the surgery-to-pregnancy interval, and until vitamin status is normalized. Therefore, regular monitoring of vitamin status and vitamin supplementation to restore deficiencies is recommended. Furthermore, this systematic review emphasizes the need for a long-term follow-up research of these women from the periconception period onwards as well as their pregnancies and offspring, to further improve care and outcomes of these mothers and children.

The influence of obesity on incidence of complications in patients hospitalized with ovarian hyperstimulation syndrome

OBJECTIVE

To study the impact of body habitus on risk of complications resulting from ovarian hyperstimulation syndrome (OHSS) in hospitalized patients.

METHODS

This is a retrospective observational study examining the National Inpatient Sample between January 2012 and September 2015. Patients were women < 50 years of age diagnosed with OHSS, classified as non-obese, class I-II obesity, or class III obesity. Intervention included multinomial logistic regression to identify factors associated with obesity and binary logistic regression for independent risk factors for complications. Main outcome measures were incidence of (i) any or (ii) multiple complication(s).

RESULTS

Of 2745 women hospitalized with OHSS, 2440 (88.9%) were non-obese, 155 (5.6%) had class I-II obesity, and 150 (5.5%) had class III obesity. Obese women (either class I-II or III) had a higher degree of comorbidity, had lower incomes, and were less likely to have private insurance than non-obese women (all P < 0.001). Obese women had lower rates of OHSS-related complications than non-obese women (any complication: non-obese 65.2%, class I-II 54.8%, and class III 46.7%, P < 0.001; and multiple complications: non-obese 38.5%, class I-II 32.3%, and class III 20.0%, P < 0.001). In the multivariable model, obesity remained independently associated with a decreased risk of complications (class I-II odds ratio 0.57, 95% confidence interval 0.39-0.83, P = 0.003; class III odds ratio 0.30, 95% confidence interval 0.20-0.44, P < 0.001). Obese women were also less likely to require paracentesis (non-obese 32.8%, class I-II 9.7%, and class III 13.3%, P < 0.001).

CONCLUSION

Our study suggests that obesity is associated with decreased OHSS-related complication rates in hospitalized patients.

Effect of bariatric surgery on in vitro fertilization in infertile men with obesity

BACKGROUND

Obesity has previously been related to reduced female fertility, with prolonged waiting time to pregnancy among women with a body mass index (BMI) >35 kg/m² but there are few studies investigating the relationship between high BMI, bariatric surgery, and male fertility.

OBJECTIVES

The primary objective of this article was to investigate the effect of bariatric surgery on in vitro fertilization (IVF) outcomes in a cohort of men with morbid obesity who underwent sleeve gastrectomy (SG).

SETTING

University hospital, bariatric surgery unit.

METHODS

Pre- and postsurgery data on patient age, body mass index (BMI), and variables related to male fertility (semen volume, concentration, progressively motile sperm count, and sperm morphology) were collected; assisted reproductive technology outcomes before and after bariatric surgery were measured by the number of metaphase II oocytes; the number of top-quality oocytes and embryos; the number of fertilized oocytes; the number of transferred embryo; the implantation rate; the pregnancy rate; the live birth rate and the miscarriage rate.

RESULTS

Thirty-five men with obesity and idiopathic infertility were included in this study. We found a significant increase, after bariatric surgery, in semen volume, total sperm concentration, progressively motile sperm count, and sperm morphology. Considering IVF outcomes, mean number of top-quality oocytes, mean number of fertilized oocytes, mean number of embryos obtained, and top-quality embryos were significantly increased after bariatric procedure.

CONCLUSION

Bariatric surgery is confirmed to be safe and effective in increasing the outcomes of assisted reproductive technology treatment also in case of infertile men with obesity, both in terms of pregnancy and live birth rate.

Effect of bariatric surgery on endogenous sex hormones and sex hormone-binding globulin levels: a systematic review and meta-analysis

BACKGROUND

Most studies have shown beneficial effect of bariatric surgery (BS) on serum levels of sex hormones.

OBJECTIVE

A systematic review and meta-analysis was conducted to examine the magnitude of possible changes in levels of sex hormones following BS.

SETTINGS

Electronic databases were searched, including PubMed, Scopus, Web of Science, and Embase, for relevant studies.

METHODS

The heterogeneity of the studies was examined by χ² tests and the degree of heterogeneity was estimated using I² statistic.

RESULTS

The results of pooled analyses revealed that BS caused a significant increase in luteinizing hormone (LH), follicular stimulating hormone (FSH), total testosterone (TT), and sex hormone binding globulin (SHBG) levels and conversely, decreased dehydroepiandrosterone (DHEA) and estradiol (E2) levels in males. For females, BS significantly increased LH, FSH, and SHBG levels and conversely, decreased androstenedione (AE), E2 and TT levels. Additionally, the level of progesterone (P), prolactin (PRL), free testosterone (FT) and dehydroepiandrosterone sulfate (DHEA-S) showed no significant changes in patients who had undergone BS.

CONCLUSION

BS changed most sex hormones levels including LH, FSH, TT, SHBG, AE, DHEA, and E2. It seems that BS is able to exert substantial impacts on sex hormones levels and as well as sexual function, however, larger, and more precise trials are required to specifically focus on these claims.

IVF outcomes in patients with a history of bariatric surgery: a multicenter retrospective cohort study

STUDY QUESTION

How does a history of dramatic weight loss linked to bariatric surgery impact IVF outcomes?

SUMMARY ANSWER

Women with a history of bariatric surgery who had undergone IVF had a comparable cumulative live birth rate (CLBR) to non-operated patients of the same BMI after the first IVF cycle.

WHAT IS KNOWN ALREADY

In the current context of increasing prevalence of obesity in women of reproductive age, weight loss induced by bariatric surgery has been shown to improve spontaneous fertility in obese women. However, little is known on the clinical benefit of bariatric surgery in obese infertile women undergoing IVF.

STUDY DESIGN, SIZE, DURATION

This exploratory retrospective multicenter cohort study was conducted in 10 287 IVF/ICSI cycles performed between 2012 and 2016. We compared the outcome of the first IVF cycle in women with a history of bariatric surgery to two age-matched groups composed of non-operated women matched on the post-operative BMI of cases, and non-operated severely obese women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The three exposure groups of age-matched women undergoing their first IVF cycle were compared: Group 1: 83 women with a history of bariatric surgery (exposure, mean BMI 28.9 kg/m2); Group 2: 166 non-operated women (non-exposed to bariatric surgery, mean BMI = 28.8 kg/m2) with a similar BMI to Group 1 at the time of IVF treatment; and Group 3: 83 non-operated severely obese women (non-exposed to bariatric surgery, mean BMI = 37.7 kg/m2). The main outcome measure was the CLBR. Secondary outcomes were the number of mature oocytes retrieved and embryos obtained, implantation and miscarriage rates, live birth rate per transfer as well as birthweight.

MAIN RESULTS AND THE ROLE OF CHANCE

No significant difference in CLBR between the operated Group 1 patients and the two non-operated Groups 2 and 3 was observed (22.9%, 25.9%, and 12.0%, in Groups 1, 2 and 3, respectively). No significant difference in average number of mature oocytes and embryos obtained was observed among the three groups. The implantation rates were not different between Groups 1 and 2 (13.8% versus 13.7%), and although lower (6.9%) in obese women of Group 3, this difference was not statistically significant. Miscarriage rates in Groups 1, 2 and 3 were 38.7%, 35.8% and 56.5%, respectively (P = 0.256). Live birth rate per transfer in obese patients was significantly lower compared to the other two groups (20%, 18%, 9.3%, respectively, in Groups 1, 2 and 3, P = 0.0167). Multivariate analysis revealed that a 1-unit lower BMI increased the chances of live birth by 9%. In operated women, a significantly smaller weight for gestational age was observed in newborns of Group 1 compared to Group 3 (P = 0.04).

LIMITATIONS, REASONS FOR CAUTION

This study was conducted in France and nearly all patients were Caucasian, questioning the generalizability of the results in other countries and ethnicities. Moreover, 950 women per group would be needed to achieve a properly powered study in order to detect a significant improvement in live birth rate after bariatric surgery as compared to infertile obese women.

WIDER IMPLICATIONS OF THE FINDINGS

These data fuel the debate on the importance of pluridisciplinary care of infertile obese women, and advocate for further discussion on whether bariatric surgery should be proposed in severely obese infertile women before IVF. However, in light of the present results, infertile women with a history of bariatric surgery can be reassured that surgery-induced dramatic weight loss has no significant impact on IVF prognosis.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by unrestricted grants from FINOX-Gédéon Richter and FERRING Pharmaceuticals awarded to the ART center of the Clinique Mathilde to fund the data collection and the statistical analysis. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

NCT02884258.

A non-linear dose-response relation of female body mass index and in vitro fertilization outcomes

PURPOSE

Obesity, measured by body mass index (BMI), is implicated in adverse pregnancy outcomes for women seeking in vitro fertilization (IVF) care. However, the shape of the dose-response relationship between BMI and IVF outcomes remains unclear.

METHODS

We therefore conducted a dose-response meta-analysis using a random effects model to estimate summary relative risk (RR) for clinical pregnancy (CPR), live birth (LBR), and miscarriage risk (MR) after IVF.

RESULTS

A total of 18 cohort-based studies involving 975,889 cycles were included. For each 5-unit increase in BMI, the summary RR was 0.95 (95% CI: 0.94-0.97) for CPR, 0.93 (95% CI: 0.92-0.95) for LBR, and 1.09 (95% CI: 1.05-1.12) for MR. There was evidence of a non-linear association between BMI and CPR (Pnon-linearity < 10-5) with CPR decreasing sharply among obese women (BMI > 30). Non-linear dose-response meta-analysis showed a relatively flat curve over a broad range of BMI from 16 to 30 for LBR (Pnon-linearity = 0.0009). In addition, we observed a J-shaped association between BMI and MR (Pnon-linearity = 0.006) with the lowest miscarriage risk observed with a BMI of 22-25.

CONCLUSIONS

In conclusion, obesity contributed to increased risk of adverse IVF outcomes in a non-linear dose-response manner. More prospective trials in evaluating the effect of body weight control are necessary.

Obesity and IVF: weighing in on the evidence

Obesity is associated with serious health risks, and its rising prevalence represents a growing public health emergency. Ongoing research into the association of obesity and assisted reproductive technology (ART) outcomes aims to disentangle selective detrimental effects of obesity on the oocyte and the endometrium. More translational studies involving women with severe obesity and in the third-party reproduction setting will help improve the standard of care in the provision of ART services for obese patients.

Endometrial function in women with polycystic ovary syndrome: a comprehensive review

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. An endometrial component has been suggested to contribute to subfertility and poor reproductive outcomes in affected women.

OBJECTIVE AND RATIONALE

The aim of this review was to determine whether there is sufficient evidence to support that endometrial function is altered in women with PCOS, whether clinical features of PCOS affect the endometrium, and whether there are evidence-based interventions to improve endometrial dysfunction in PCOS women.

SEARCH METHODS

An extensive literature search was performed from 1970 up to July 2020 using PubMed and Web of Science without language restriction. The search included all titles and abstracts assessing a relationship between PCOS and endometrial function, the role played by clinical and biochemical/hormonal factors related to PCOS and endometrial function, and the potential interventions aimed to improve endometrial function in women with PCOS. All published papers were included if considered relevant. Studies having a specific topic/hypothesis regarding endometrial cancer/hyperplasia in women with PCOS were excluded from the analysis.

OUTCOMES

Experimental and clinical data suggest that the endometrium differs in women with PCOS when compared to healthy controls. Clinical characteristics related to the syndrome, alone and/or in combination, may contribute to dysregulation of endometrial expression of sex hormone receptors and co-receptors, increase endometrial insulin-resistance with impaired glucose transport and utilization, and result in chronic low-grade inflammation, immune dysfunction, altered uterine vascularity, abnormal endometrial gene expression and cellular abnormalities in women with PCOS. Among several interventions to improve endometrial function in women with PCOS, to date, only lifestyle modification, metformin and bariatric surgery have the highest scientific evidence for clinical benefit.

WIDER IMPLICATIONS

Endometrial dysfunction and abnormal trophoblast invasion and placentation in PCOS women can predispose to miscarriage and pregnancy complications. Thus, patients and their health care providers should advise about these risks. Although currently no intervention can be universally recommended to reverse endometrial dysfunction in PCOS women, lifestyle modifications and metformin may improve underlying endometrial dysfunction and pregnancy outcomes in obese and/or insulin resistant patients. Bariatric surgery has shown its efficacy in severely obese PCOS patients, but a careful evaluation of the benefit/risk ratio is warranted. Large scale randomized controlled clinical trials should address these possibilities.

Curbing Obesity from One Generation to Another: the Effects of Bariatric Surgery on the In Utero Environment and Beyond

Approximately 250,000 individuals seek bariatric surgery each year in the USA for the long-term resolution of obesity-related comorbidities. Greater than 80% of these individuals are women and approximately half are of child-bearing age. Although there are many positive metabolic benefits that are realized through surgical weight loss for both men and women, the various long-term hormonal, molecular, nutrient, and epigenetic changes following bariatric surgery have not been evaluated for the surgical recipient or in the context of pregnancy and the offspring. Pregnancy may be a vulnerable period of time for the bariatric surgery recipient, and thoughtful consideration of pregnancy management should be taken by health care providers and recipients alike. The purpose of this review is to explore potential etiologies of some of the gestation-specific outcomes for the mother and offspring.

Extremely early pregnancy (<6 mo) after sleeve gastrectomy: maternal and perinatal outcomes

BACKGROUND

Data are scarce regarding outcomes of pregnancies occurring very early after bariatric surgery.

OBJECTIVES

We compared outcomes of pregnancies occurring extremely early (surgery-to-conception interval <6 mos) after laparoscopic sleeve gastrectomy (LSG) with those occurring later (≥6 mos postsurgery).

SETTING

A university hospital.

METHODS

We reviewed the records of all women who underwent LSG and delivered during 2006-2019.

RESULTS

Of 196 women, 23 (11.7%) became pregnant within 6 months of surgery. For these women, the median surgery-to-conception interval was 116 [interquartile range 76-161] days, compared with 903 [465-1377] days for the remaining cohort. Three (13.0%) women turned out postoperatively to be pregnant at the time of LSG. Compared with women who conceived later, the extremely early pregnancy group had lower gestational weight gain (median 4 versus 10 kg, P < .001), including negative gestational weight gain in 9 (39.1%) women. The proportion of small for gestational age (SGA) infants was higher among women who conceived within 6 months after surgery rather than later (26.1% versus 10.4%, P = .04). Other maternal and perinatal outcomes were similar between the groups. In multivariate analysis, conceiving within 6 months after LSG was the only independent factor associated with delivering a SGA infant (odds ratio [95% confidence interval]: 3.35 (1.12, 10.01), P = .03).

CONCLUSIONS

Pregnancy occurring in the first 6 months after LSG was independently associated with a higher rate of SGA infants. Delaying conception during the very early postoperative period is recommended. Providing adequate contraception and excluding the presence of early pregnancy at the time of surgery are of utmost importance.

The effect of excess body fat on female and male reproduction

The dramatic increase in the prevalence of obesity coincides with a decline in reproductive health indices in both sexes. Energy excess mediates changes to the regulatory mechanisms of the reproductive system. Obese individuals exhibit increased estrogen concentrations, due to the overexpression of aromatase in the adipose tissue; via a negative feedback loop, men present with symptoms of hypogonadotropic hypogonadism. These hormonal changes, along with increased oxidative stress, lipotoxicity and disturbances in the concentrations of adipokines, directly affect the gonads, peripheral reproductive organs and the embryo. Clinical evidence is somewhat contradicting, with only some studies advocating worse semen parameters, increased incidence of erectile dysfunction, increased doses of ovulation induction medications, and worse live birth rates in assisted reproductive technology (ART) cycles in obese individuals compared with those of normal weight. Similar conclusions are drawn about patients with insulin resistance syndromes, namely polycystic ovary syndrome (PCOS). As far as treatment options are concerned, lifestyle changes, medical therapy and bariatric surgery may improve the reproductive outcome, although the evidence remains inconclusive. In this review, we summarize the evidence on the association of obesity and reproductive health on both the molecular and the clinical level, and the effect of weight-loss interventions on reproductive potential.

Review: Sex-Specific Aspects in the Bariatric Treatment of Severely Obese Women

This systematic literature review aims to point out sex-specific special features that are important in the bariatric treatment of women suffering from severe obesity. A systematic literature search was carried out according to Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. After the literature selection, the following categories were determined: sexuality and sexual function; contraception; fertility; sex hormones and polycystic ovary syndrome; menopause and osteoporosis; pregnancy and breastfeeding; pelvic floor disorders and urinary incontinence; female-specific cancer; and metabolism, outcome, and quality of life. For each category, the current status of research is illuminated and implications for bariatric treatment are determined. A summary that includes key messages is given for each subsection. An overall result of this paper is an understanding that sex-specific risks that follow or result from bariatric surgery should be considered more in aftercare. In order to increase the evidence, further research focusing on sex-specific differences in the outcome of bariatric surgery and promising treatment approaches to female-specific diseases is needed. Nevertheless, bariatric surgery shows good potential in the treatment of sex-specific aspects for severely obese women that goes far beyond mere weight loss and reduction of metabolic risks.

Ethnic Disparities in Use of Bariatric Surgery in the USA: the Experience of Native Americans

Purpose

To examine disparities in use of bariatric surgery in the USA with particular focus on the experience of Native Americans.

Materials and Methods

Multivariable logistic regression models were applied to the hospital discharge HCUP-NIS dataset (2008–2016) in order to examine the influence of ethnicity in use of bariatric surgery while controlling for aspects of need, predisposing and enabling factors. Separate models investigated disparities in length of stay, cost and discharge to healthcare facility among patient episodes for bariatric surgery.

Results

Full data for 1,729,245 bariatric surgery eligible participants were extracted from HCUP-NIS. The odds of Native Americans receiving bariatric surgery compared to White Americans were 0.67 (95% CI, 0.62–0.73) in a model unadjusted for covariates; 0.65 (95% CI, 0.59–0.71) in a model adjusted for demography and insurance; 0.59 (95% CI, 0.54–0.64) in a model adjusted for clinical variables; and 0.72 (95% CI, 0.66–0.79) in a model adjusted for demographic, insurance types and clinical variables. Native Americans who underwent surgery had significantly shorter lengths of stay, lower healthcare expenditures and lower likelihood of discharge to other healthcare facilities relative to White Americans (controlling for covariates).

Conclusion

Our study, the first study to examine this subject, showed apparent variations in receipt of bariatric surgery between Native Americans and White Americans even after a range of covariates were controlled. In addition, Native Americans have shorter lengths of stay and significantly lower expenditures.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-04529-w) contains supplementary material, which is available to authorized users.

Maternal and fetal outcomes of Asian pregnancies after bariatric surgery

INTRODUCTION

Obesity is a risk factor for pregnancy-induced hypertension, preeclampsia, gestational diabetes, and large gestational age pregnancy. Bariatric surgery is widely accepted to treat obesity but associated with small for gestational age fetuses.

OBJECTIVE

To report maternal and fetal outcomes after bariatric surgery in morbidly obese Asian females.

SETTING

University Hospital, Singapore.

METHODS

We maintain a prospective cohort of patients who underwent bariatric surgery in our institution. Maternal and fetal outcomes are compared with a control group of 31 pregnancies matched for age, parity, presurgery weight, and year of delivery.

RESULTS

Twenty-four pregnancies occurred in 16 patients in our postoperative cohort. Morbidly obese women in the control group were more likely to develop gestational diabetes (19.3% versus 5.0%, P = .150) and pregnancy-induced hypertension/preeclampsia (32.2% versus 0%, P = .003) compared with the postoperative group. Of fetuses, 37.5% in the bariatric group had low birth weight compared with only 9.4% fetuses in the control group (P = .016). Preoperative body mass index, short interval between conception and surgery, and poor weight gain during pregnancy did not predict for small for gestational age fetuses. Subsequent weights were available for 37.5% of the children in the surgical cohort and none of these children exhibited growth retardation.

CONCLUSION

Bariatric surgery lowers the risk of maternal co-morbidities and large gestational age fetus during pregnancy. Asians are at high risk of small for gestational age pregnancies after bariatric surgery and should undergo close monitoring for fetal growth throughout their pregnancy.

The combined impact of maternal age and body mass index on cumulative live birth following in vitro fertilization

BACKGROUND

It is critical to evaluate the combined impact of age and body mass index on the cumulative likelihood of live birth following in vitro fertilization, as achieving a lower body mass index before infertility treatment often is recommended for women with overweight and obesity. It is important to consider whether achieving a particular body mass index, thus resulting in an older age at in vitro fertilization cycle start, is beneficial or harmful to the likelihood of live birth.

OBJECTIVES

To evaluate the combined impact of age and body mass index on the cumulative live birth rate following in vitro fertilization to inform when delaying in vitro fertilization treatment to achieve a lower body mass index may be beneficial or detrimental to the likelihood of live birth.

STUDY DESIGN

This is a retrospective study using linked fresh and cryopreserved/frozen cycles from January 2014 to December 2015 from the Society for Reproductive Technology Clinic Outcome Reporting System, representing >90% of in vitro fertilization cycles performed in the United States. The primary outcome was live birth as measured by cumulative live birth rate. Secondary outcomes included implantation rate, clinical pregnancy rate, and miscarriage rate. Poisson and logistic regression were used to calculate risk and odds ratios with 95% confidence intervals to determine differences in implantation, clinical pregnancy, and miscarriage, as appropriate, among first fresh in vitro fertilization cycles compared across age (years) and body mass index (kg/m²) categories. Cox regression was used to calculate hazard ratios with 95% confidence intervals to determine differences in the cumulative live birth rate using fresh plus linked frozen embryo transfer cycles.

RESULTS

There were 51,959 first fresh cycles using autologous eggs and 16,067 subsequent frozen embryo transfer cycles. There were 21,395 live births, for an overall cumulative live birth rate of 41.2% per cycle start. The implantation rate, clinical pregnancy rate, and cumulative live birth rate decreased with increasing body mass index and age, and the miscarriage rate increased with increasing body mass index and age (linear trend P<.001 for all). Body mass index had a greater influence on live birth at younger ages as compared with older ages.

CONCLUSIONS

Age-related decline in fertility has a greater impact than body mass index on the cumulative live birth rate at older ages, suggesting that taking time to achieve lower body mass index before in vitro fertilization may be detrimental for older women with overweight or obesity. Delaying conception to lose weight before in vitro fertilization should be informed by the combination of age and body mass index.

Vitamin D and Obesity: Two Interacting Players in the Field of Infertility

Obesity plays an important role in human fertility in both genders. The same is true for vitamin D, for which accumulating evidence from observational human studies suggests a key role for both male and female fertility. In the latter case, however, robust data from relevant interventional studies are currently lacking. It is also not clear whether obesity and vitamin D deficiency, besides their independent effect on human infertility, act in synergy. Several pathogenetic mechanisms may be proposed as a linkage between vitamin D deficiency and obesity, with respect to infertility. In any case, the independent contribution of vitamin D deficiency in obese infertile states needs to be proven in interventional studies focusing on either vitamin D supplementation in obese or weight loss strategies in vitamin D-deficient infertile patients.

Comparison between LigaSure™ and Harmonic® in Laparoscopic Sleeve Gastrectomy: A Single-Center Experience on 422 Patients

BACKGROUND

New laparoscopic devices, such as electrothermal bipolar-activated devices (LigaSure™ (LS)) or ultrasonic systems (Harmonic® scalpel (HS)), have been applied recently to bariatric surgery allowing to reduce blood loss and surgical risks. The aim of this study was to retrospectively compare intraoperative performance of HS and LS, postoperative results, and clinical outcomes in a large cohort of patients undergoing LSG.

METHODS

Data from 422 morbidly obese patients undergoing LSG in our Bariatric Unit at the Advanced Biomedical Sciences Department of the "Federico II" University of Naples (Italy) between January 2009 and December 2017 were retrospectively analyzed. Subjects were divided into two groups (HS and LS), and operative time, intraoperative complications, and postoperative (within 30 days from surgery) complications were compared. Bleeding from the omentum or from the staple line, use of hemostatic clips, and absorbable hemostat were recorded as intraoperative complications; hemorrhages, abscess formation, gastric leaks, fever, and mortality were considered as postoperative complications.

RESULTS

Statistical analysis showed no difference in terms of baseline demographics between the two cohorts. Operative time (48 ± 9 vs 49 ± 6 min, p=0.646) and the rates of intraoperative and postoperative complications did not significantly differ between groups.

CONCLUSION

Harmonic® and LigaSure™ are both useful tools in bariatric surgery, and these two advanced power devices are user-friendly and can facilitate surgeon work; from this point of view, the choice of the energy device should be based on the preference of the surgeon and on the hospital costs policy and availability.

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).

One-year impact of bariatric surgery on serum anti-Mullerian-hormone levels in severely obese women

INTRODUCTION

Although bariatric surgery seems to increase spontaneous fertility by improving ovulatory function in young women, its impact on ovarian reserve remains largely unknown.

OBJECTIVE

To evaluate changes in serum anti-Mullerian hormone (AMH) levels in reproductive-age severely obese women after bariatric surgery (BS).

METHODS

AMH levels were measured retrospectively in 39 women (mean age 34.6 ± 1.1 years, range 18-45) that underwent a sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) at baseline, and 6 and 12 months after BS. Metabolic and micronutrient status, including fasting plasma insulin and glucose, HOMA-IR, leptin, adiponectin, calcium, albumin, transthyretin, ferritin, vitamins (B9, B12, B1, A, E, D), zinc, and selenium, were assessed in all patients before and 1 year after BS.

RESULTS

Of the patients, 79% had class-3 obesity. At 6 and 12 months, mean total weight losses (TWL) were 26 and 30%; mean excess weight losses (EWL) were 61.7 and 70.2%. Compared to baseline, AMH levels significantly decreased by 18% at 6 months, and 32% at 12 months post-operatively (p = 0.010 and p = 0.001, respectively). There was no correlation between AMH variation and changes in metabolic parameters or micronutrient levels. Remarkably, changes in AMH levels did not differ between sleeve and RYGB patients and were not correlated with EWL.

CONCLUSION

This pilot study shows a drastic reduction in AMH levels at 1 year after BS in reproductive-age severely obese women, which was not related to weight loss: this suggests a negative impact of BS on ovarian reserve, at least in the short term.

The role of female obesity on in vitro fertilization outcomes

The aim of this review is to analyze the role of obesity on fertility outcome in women undergoing in vitro fertilization (IVF) with respect to clinical or live birth rates and pregnancy loss rates. Despite findings from several earlier and newer studies that obesity does not adversely affect pregnancy outcome in women attempting conception, numerous reports from mostly recent studies suggest that obesity undoubtedly impairs IVF outcomes. Obesity impairs ovarian responsiveness to gonadotrophin stimulation, requiring higher doses of medication, increased risk of cycle cancelation, pre-term delivery, low birth weight or miscarriage, and decreases implantation, clinical pregnancy or live birth rates compared to women of normal weight. The mechanisms underlying the adverse effects of female obesity on IVF outcome may be primarily explained by functional alterations to the hypothalamic-pituitary-ovarian axis. Additionally, obesity appears to affect deleteriously the number and quality of oocytes or embryos, and impairs endometrial decidualization which is necessary for uterine receptivity. Nevertheless, attaining normal body weight by the use of lifestyle modifications, including a healthy diet and exercise over time of several months before and during an IVF treatment, may be successful in achievement of gradual and sustainable weight loss with improvement of IVF outcome.