Portal de Periódicos da CAPES

Weight loss by bariatric surgery and subsequent fertility

2006; Elsevier BV; Volume: 87; Issue: 2 Linguagem: Inglês

10.1016/j.fertnstert.2006.07.1499

1556-5653

Zaher Merhi,

Ovarian function and disorders

The purpose of this article is to appraise the literature to ascertain whether the use of bariatric surgery should have a role in the contemporary management of the morbidly obese infertile patient before proceeding with infertility treatment. The purpose of this article is to appraise the literature to ascertain whether the use of bariatric surgery should have a role in the contemporary management of the morbidly obese infertile patient before proceeding with infertility treatment. Obesity, defined as a body mass index (BMI) of 30 kg/m2 or greater, is one of the fastest-growing health problems in the United States. Its prevalence has been increasing strikingly during the past two decades (1Hedley A.A. Ogden C.L. Johnson C.L. Carroll M.D. Curtin L.R. Flegal K.M. Prevalence of overweight and obesity among U.S. children, adolescents, and adults, 1999–2002.J Am Med Assoc. 2004; 291: 2847-2850Crossref PubMed Scopus (3539) Google Scholar). The increasing prevalence and associated sociodemographic disparities of morbid obesity are serious public health concerns. It is estimated that about one third of all U.S. women are obese (1Hedley A.A. Ogden C.L. Johnson C.L. Carroll M.D. Curtin L.R. Flegal K.M. Prevalence of overweight and obesity among U.S. children, adolescents, and adults, 1999–2002.J Am Med Assoc. 2004; 291: 2847-2850Crossref PubMed Scopus (3539) Google Scholar). The majority of those are women of reproductive age, and many of the risk factors that are linked to obesity may also predispose them to infertility (e.g., anovulation) (2The ESHRE Capri Workshop GroupNutrition and reproduction in women.Hum Reprod Update. 2006; 12: 193-207Crossref PubMed Scopus (162) Google Scholar, 3Pasquali R. Pelusi C. Genghini S. Cacciari M. Gambineri A. Obesity and reproductive disorders in women.Hum Reprod Update. 2003; 9: 359-372Crossref PubMed Scopus (364) Google Scholar).Because weight loss can correct ovulatory dysfunction, it is not uncommon for an infertility doctor to recommend a morbidly obese patient to lose a massive amount of weight before proceeding with the fertility treatment. Very commonly, that morbidly obese patient, especially if she is late in her reproductive age, is educated about all the methods of rapid weight loss. Of those options, bariatric surgery is becoming popular. Several studies of nonsurgical weight loss in obese women have shown improved fertility (4Crosignani P.G. Colombo M. Vegetti W. Somigliana E. Gessati A. Ragni G. Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements in anthropometric indices, ovarian physiology and fertility rate induced by diet.Hum Reprod. 2003; 18: 1928-1932Crossref PubMed Scopus (247) Google Scholar, 5Clark A.M. Thornley B. Tomlinson L. Galletley C. Norman R.J. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment.Hum Reprod. 1998; 13: 1502-1505Crossref PubMed Scopus (557) Google Scholar). The purpose of this article is to appraise the literature to ascertain whether the use of bariatric surgery should have a role in the contemporary management of the morbidly obese infertile patient before proceeding with infertility treatment.Data about the effect of obesity on fertility outcome has been controversial. In some studies, it has been reported to be associated with unfavorable outcome. For instance, one study revealed that increased BMI was associated with higher cancellation rate, lower mature oocyte yield, and lower number of cryo cycles (6Esinler I. Bozdag G. Yarali H. Does obesity have an adverse effect on conception rates with ICSI?.Fertil Steril. 2005; 84: S256Abstract Full Text Full Text PDF PubMed Google Scholar). In a study on mice, dietary-induced obesity was associated with reduced fertility. The mechanism, though not definite, was likely to be due to chronic hyperleptinemia caused by the accumulation of excess adipose tissue, leading to central leptin resistance as manifested by the reduction in leptin receptor expression in the hypothalamus. Additionally, subfertility in those female mice appeared reversible through dietary modification (7Wang J.G. Tortoriello D.V. Subfertility associated with dietary-induced obesity in female Dba/2j mice can be reversed by diet modification.Fertil Steril. 2005; 84: S382-S383Abstract Full Text Full Text PDF Google Scholar). Additionally, other data demonstrated that women with a BMI more than 27 kg/m2 had a significantly lower delivery rate (8Lintsen A.M. Pasker-de Jong P.C. de Boer E.J. Burger C.W. Jansen C.A. Braat D.D. et al.Effects of subfertility cause, smoking and body weight on the success rate of IVF.Hum Reprod. 2005; 20: 1867-1875Crossref PubMed Scopus (206) Google Scholar) and that obesity was associated with lower chances for live birth after IVF and intracytoplasmic sperm injection (ICSI) and with an impaired response to ovarian stimulation (9Fedorcsak P. Dale P.O. Storeng R. Ertzeid G. Bjercke S. Oldereid N. et al.Impact of overweight and underweight on assisted reproduction treatment.Hum Reprod. 2004; 19: 2523-2528Crossref PubMed Scopus (396) Google Scholar).On the other hand, obesity had no negative impact on ovarian stimulation for IVF in other data (10Ellenbogen A. Gidoni Y. Michaeli M. Rotfarb N. Spalter M. Ballas S. The role of obesity on the outcome of in vitro fertilization.Fertil Steril. 2005; 84: S271Abstract Full Text Full Text PDF Google Scholar). Some studies have shown that BMI has no adverse impact on implantation or reproductive outcome in donor oocyte recipients making obesity not a reason to exert a negative effect on endometrial receptivity (11Styne-Gross A. Elkind-Hirsch K. Scott Jr., R.T. Obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation.Fertil Steril. 2005; 83: 1629-1634Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar).Bariatric surgical procedures provide greater and more durable weight reduction than behavioral and pharmacologic interventions for morbid obesity. Although there are different techniques of bariatric surgery, gastric bypass and gastric banding procedures are the most widely used. The former, called Roux-en-Y gastric bypass, consists of the construction of a proximal gastric pouch (less than 30 mL in volume) whose outlet is a Y-shaped limb of small bowel. The proximal stomach is separated from the remaining part of the stomach with staples. In the gastric banding procedure, a band, which can be adjusted by the infusion of saline, is placed around the stomach near its upper end creating a small pouch (less than 30 mL in volume) and a restricted passage to the larger remaining part of the stomach. Both techniques can be performed either laparoscopically or via laparotomy.The estimated number of bariatric surgical procedures has been increasing dramatically with estimated incidence of 13,365 in 1998 to 72,177 in 2002 to approximately 103,000 in 2003, while the rates of in-hospital complications were stable, and length of stay has decreased averaging 3 to 4 days (12Santry H.P. Gillen D.L. Lauderdale D.S. Trends in bariatric surgical procedures.J Am Med Assoc. 2005; 294: 1909-1917Crossref Scopus (772) Google Scholar). Complications of bariatric surgery include but are not limited to gastrointestinal leaks, stomal obstruction or stenosis, ventral hernia, bleeding, pulmonary embolism, respiratory failure, and death (13Steinbrook R. Surgery for severe obesity.N Engl J Med. 2004; 350: 1075-1079Crossref PubMed Scopus (486) Google Scholar). Bariatric surgery is very effective in weight loss, accompanied by reduction or disappearance of comorbidities such as diabetes, hyperlipidemia, hypertension, and coronary artery disease, with considerable improvement in quality of life (14Buchwald H. Avidor Y. Braunwald E. Jensen M.D. Pories W. Fahrbach K. et al.Bariatric surgery: a systematic review and meta-analysis.J Am Med Assoc. 2004; 292: 1724-1737Crossref PubMed Scopus (5311) Google Scholar).A literature review was performed using the PubMed, the Cochrane Database, and MEDLINE using the terms “bariatric surgery” and “fertility.” The literature review revealed that relatively limited data exist on the subject. Although male fertility is beyond the scope of the paper, it is worthy to note that a case series of six healthy previously fertile male subjects showed that surgical treatments with Roux-en-Y gastric bypass operation was associated with long-term side effects in fertility status, probably due to the reduced absorption of nutrients (15di Frega A.S. Dale B. Di Matteo L. Wilding M. Secondary male factor infertility after Roux-en-Y gastric bypass for morbid obesity: case report.Hum Reprod. 2005; 20: 997-998Crossref PubMed Scopus (87) Google Scholar). Those subjects presented for secondary infertility after a Roux-en-Y gastric bypass operation for morbid obesity (weight loss of 60–80 kg), and reproductive function was assessed with a series of spermiograms and by testicular biopsy. Secondary azoospermy with complete spermatogenic arrest was diagnosed in all of them. These data suggested that this operation could result in secondary infertility in males (15di Frega A.S. Dale B. Di Matteo L. Wilding M. Secondary male factor infertility after Roux-en-Y gastric bypass for morbid obesity: case report.Hum Reprod. 2005; 20: 997-998Crossref PubMed Scopus (87) Google Scholar). A study from Israel by Sheiner et al. (16Sheiner E. Menes T.S. Silverberg D. Abramowicz J.S. Levy I. Katz M. et al.Pregnancy outcome of patients with gestational diabetes mellitus following bariatric surgery.Am J Obstet Gynecol. 2006; 194: 431-435Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar) showed that 21.4% of 28 women who had bariatric surgery needed fertility treatments versus only 5.5% of 7,986 controls; odds ratio 4.7, 95% confidence interval 1.9–11.6 (both cases and controls had gestational diabetes) ascribing higher rates of infertility to the bariatric surgery.On the other hand, several other studies revealed that weight loss by bariatric surgery might have a beneficial effect on infertility. Twenty-nine percent of 109 reproductive-age female patients had an infertility problem before undergoing bariatric surgery for morbid obesity; nine of those patients conceived postoperatively (the mean weight before and after weight loss was 124 kg and 79 kg, respectively) (17Deitel M. Stone E. Kassam H.A. Wilk E.J. Sutherland D.J. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery.J Am Coll Nutr. 1988; 7: 147-153Crossref PubMed Scopus (206) Google Scholar). Whether the weight loss from the bariatric surgery was the reason is unclear.Bilenka et al. (18Bilenka B. Ben-Shlomo I. Cozacov C. Gold C.H. Zohar S. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity.Acta Obstet Gynecol Scand. 1995; 74: 42-44Crossref PubMed Scopus (94) Google Scholar) presented a series of nine patients where five (out of six who attempted conception) who needed ovulation induction to conceive prior to vertical banded gastroplasty (VBG) became pregnant spontaneously postoperatively (mean weight loss was 36 kg). Although a small number of cases was presented, that article demonstrated an improvement of fertility status after VBG. Additionally, in a study by Martin et al. (19Martin L.F. Finigan K.M. Nolan T.E. Pregnancy after adjustable gastric banding.Obstet Gynecol. 2000; 95: 927-930Crossref PubMed Google Scholar) of 265 fertile women who underwent adjustable gastric banding, 20 became pregnant of whom 5, failing to conceive at heavier weights, conceived after weight loss (mean weight loss 10.6 kg).A study by Marceau et al. (20Marceau P. Kaufman D. Biron S. Hould F.S. Lebel S. Marceau S. et al.Outcome of pregnancies after biliopancreatic diversion.Obes Surg. 2004; 14: 318-324Crossref PubMed Scopus (182) Google Scholar) of women who underwent biliopancreatic diversion (BPD) between 1984 and 1995 revealed that 47% (15 of 32) who were unable to become pregnant preoperatively (mean BMI = 47 kg/m2) were successfully pregnant postoperatively (mean BMI = 30 kg/m2). Despite the use of the same oral contraceptives before and after BPD, two of nine patients had unforeseen pregnancy after surgery in one of the studies (21Gerrits E.G. Ceulemans R. van Hee R. Hendrickx L. Totte E. Contraceptive treatment after biliopancreatic diversion needs consensus.Obes Surg. 2003; 13: 378-382Crossref PubMed Scopus (85) Google Scholar).In broader terms, the role of weight loss by bariatric surgery on infertility is understudied and not coincidentally remains uncertain in the management of the morbidly obese infertile patient. With almost contentious evidence of efficacy and until clinical trials prove its benefit, a recommendation to a morbidly obese infertile patient to undergo such major surgery solely for the sake of infertility should be approached with caution in clinical practice, weighing a 1-year mortality rate up to 4.6% against the anticipated benefits of the procedure (22Flum D.R. Salem L. Elrod J.A. Dellinger E.P. Cheadle A. Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures.J Am Med Assoc. 2005; 294: 1903-1908Crossref Scopus (498) Google Scholar). Obesity, defined as a body mass index (BMI) of 30 kg/m2 or greater, is one of the fastest-growing health problems in the United States. Its prevalence has been increasing strikingly during the past two decades (1Hedley A.A. Ogden C.L. Johnson C.L. Carroll M.D. Curtin L.R. Flegal K.M. Prevalence of overweight and obesity among U.S. children, adolescents, and adults, 1999–2002.J Am Med Assoc. 2004; 291: 2847-2850Crossref PubMed Scopus (3539) Google Scholar). The increasing prevalence and associated sociodemographic disparities of morbid obesity are serious public health concerns. It is estimated that about one third of all U.S. women are obese (1Hedley A.A. Ogden C.L. Johnson C.L. Carroll M.D. Curtin L.R. Flegal K.M. Prevalence of overweight and obesity among U.S. children, adolescents, and adults, 1999–2002.J Am Med Assoc. 2004; 291: 2847-2850Crossref PubMed Scopus (3539) Google Scholar). The majority of those are women of reproductive age, and many of the risk factors that are linked to obesity may also predispose them to infertility (e.g., anovulation) (2The ESHRE Capri Workshop GroupNutrition and reproduction in women.Hum Reprod Update. 2006; 12: 193-207Crossref PubMed Scopus (162) Google Scholar, 3Pasquali R. Pelusi C. Genghini S. Cacciari M. Gambineri A. Obesity and reproductive disorders in women.Hum Reprod Update. 2003; 9: 359-372Crossref PubMed Scopus (364) Google Scholar). Because weight loss can correct ovulatory dysfunction, it is not uncommon for an infertility doctor to recommend a morbidly obese patient to lose a massive amount of weight before proceeding with the fertility treatment. Very commonly, that morbidly obese patient, especially if she is late in her reproductive age, is educated about all the methods of rapid weight loss. Of those options, bariatric surgery is becoming popular. Several studies of nonsurgical weight loss in obese women have shown improved fertility (4Crosignani P.G. Colombo M. Vegetti W. Somigliana E. Gessati A. Ragni G. Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements in anthropometric indices, ovarian physiology and fertility rate induced by diet.Hum Reprod. 2003; 18: 1928-1932Crossref PubMed Scopus (247) Google Scholar, 5Clark A.M. Thornley B. Tomlinson L. Galletley C. Norman R.J. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment.Hum Reprod. 1998; 13: 1502-1505Crossref PubMed Scopus (557) Google Scholar). The purpose of this article is to appraise the literature to ascertain whether the use of bariatric surgery should have a role in the contemporary management of the morbidly obese infertile patient before proceeding with infertility treatment. Data about the effect of obesity on fertility outcome has been controversial. In some studies, it has been reported to be associated with unfavorable outcome. For instance, one study revealed that increased BMI was associated with higher cancellation rate, lower mature oocyte yield, and lower number of cryo cycles (6Esinler I. Bozdag G. Yarali H. Does obesity have an adverse effect on conception rates with ICSI?.Fertil Steril. 2005; 84: S256Abstract Full Text Full Text PDF PubMed Google Scholar). In a study on mice, dietary-induced obesity was associated with reduced fertility. The mechanism, though not definite, was likely to be due to chronic hyperleptinemia caused by the accumulation of excess adipose tissue, leading to central leptin resistance as manifested by the reduction in leptin receptor expression in the hypothalamus. Additionally, subfertility in those female mice appeared reversible through dietary modification (7Wang J.G. Tortoriello D.V. Subfertility associated with dietary-induced obesity in female Dba/2j mice can be reversed by diet modification.Fertil Steril. 2005; 84: S382-S383Abstract Full Text Full Text PDF Google Scholar). Additionally, other data demonstrated that women with a BMI more than 27 kg/m2 had a significantly lower delivery rate (8Lintsen A.M. Pasker-de Jong P.C. de Boer E.J. Burger C.W. Jansen C.A. Braat D.D. et al.Effects of subfertility cause, smoking and body weight on the success rate of IVF.Hum Reprod. 2005; 20: 1867-1875Crossref PubMed Scopus (206) Google Scholar) and that obesity was associated with lower chances for live birth after IVF and intracytoplasmic sperm injection (ICSI) and with an impaired response to ovarian stimulation (9Fedorcsak P. Dale P.O. Storeng R. Ertzeid G. Bjercke S. Oldereid N. et al.Impact of overweight and underweight on assisted reproduction treatment.Hum Reprod. 2004; 19: 2523-2528Crossref PubMed Scopus (396) Google Scholar). On the other hand, obesity had no negative impact on ovarian stimulation for IVF in other data (10Ellenbogen A. Gidoni Y. Michaeli M. Rotfarb N. Spalter M. Ballas S. The role of obesity on the outcome of in vitro fertilization.Fertil Steril. 2005; 84: S271Abstract Full Text Full Text PDF Google Scholar). Some studies have shown that BMI has no adverse impact on implantation or reproductive outcome in donor oocyte recipients making obesity not a reason to exert a negative effect on endometrial receptivity (11Styne-Gross A. Elkind-Hirsch K. Scott Jr., R.T. Obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation.Fertil Steril. 2005; 83: 1629-1634Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar). Bariatric surgical procedures provide greater and more durable weight reduction than behavioral and pharmacologic interventions for morbid obesity. Although there are different techniques of bariatric surgery, gastric bypass and gastric banding procedures are the most widely used. The former, called Roux-en-Y gastric bypass, consists of the construction of a proximal gastric pouch (less than 30 mL in volume) whose outlet is a Y-shaped limb of small bowel. The proximal stomach is separated from the remaining part of the stomach with staples. In the gastric banding procedure, a band, which can be adjusted by the infusion of saline, is placed around the stomach near its upper end creating a small pouch (less than 30 mL in volume) and a restricted passage to the larger remaining part of the stomach. Both techniques can be performed either laparoscopically or via laparotomy. The estimated number of bariatric surgical procedures has been increasing dramatically with estimated incidence of 13,365 in 1998 to 72,177 in 2002 to approximately 103,000 in 2003, while the rates of in-hospital complications were stable, and length of stay has decreased averaging 3 to 4 days (12Santry H.P. Gillen D.L. Lauderdale D.S. Trends in bariatric surgical procedures.J Am Med Assoc. 2005; 294: 1909-1917Crossref Scopus (772) Google Scholar). Complications of bariatric surgery include but are not limited to gastrointestinal leaks, stomal obstruction or stenosis, ventral hernia, bleeding, pulmonary embolism, respiratory failure, and death (13Steinbrook R. Surgery for severe obesity.N Engl J Med. 2004; 350: 1075-1079Crossref PubMed Scopus (486) Google Scholar). Bariatric surgery is very effective in weight loss, accompanied by reduction or disappearance of comorbidities such as diabetes, hyperlipidemia, hypertension, and coronary artery disease, with considerable improvement in quality of life (14Buchwald H. Avidor Y. Braunwald E. Jensen M.D. Pories W. Fahrbach K. et al.Bariatric surgery: a systematic review and meta-analysis.J Am Med Assoc. 2004; 292: 1724-1737Crossref PubMed Scopus (5311) Google Scholar). A literature review was performed using the PubMed, the Cochrane Database, and MEDLINE using the terms “bariatric surgery” and “fertility.” The literature review revealed that relatively limited data exist on the subject. Although male fertility is beyond the scope of the paper, it is worthy to note that a case series of six healthy previously fertile male subjects showed that surgical treatments with Roux-en-Y gastric bypass operation was associated with long-term side effects in fertility status, probably due to the reduced absorption of nutrients (15di Frega A.S. Dale B. Di Matteo L. Wilding M. Secondary male factor infertility after Roux-en-Y gastric bypass for morbid obesity: case report.Hum Reprod. 2005; 20: 997-998Crossref PubMed Scopus (87) Google Scholar). Those subjects presented for secondary infertility after a Roux-en-Y gastric bypass operation for morbid obesity (weight loss of 60–80 kg), and reproductive function was assessed with a series of spermiograms and by testicular biopsy. Secondary azoospermy with complete spermatogenic arrest was diagnosed in all of them. These data suggested that this operation could result in secondary infertility in males (15di Frega A.S. Dale B. Di Matteo L. Wilding M. Secondary male factor infertility after Roux-en-Y gastric bypass for morbid obesity: case report.Hum Reprod. 2005; 20: 997-998Crossref PubMed Scopus (87) Google Scholar). A study from Israel by Sheiner et al. (16Sheiner E. Menes T.S. Silverberg D. Abramowicz J.S. Levy I. Katz M. et al.Pregnancy outcome of patients with gestational diabetes mellitus following bariatric surgery.Am J Obstet Gynecol. 2006; 194: 431-435Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar) showed that 21.4% of 28 women who had bariatric surgery needed fertility treatments versus only 5.5% of 7,986 controls; odds ratio 4.7, 95% confidence interval 1.9–11.6 (both cases and controls had gestational diabetes) ascribing higher rates of infertility to the bariatric surgery. On the other hand, several other studies revealed that weight loss by bariatric surgery might have a beneficial effect on infertility. Twenty-nine percent of 109 reproductive-age female patients had an infertility problem before undergoing bariatric surgery for morbid obesity; nine of those patients conceived postoperatively (the mean weight before and after weight loss was 124 kg and 79 kg, respectively) (17Deitel M. Stone E. Kassam H.A. Wilk E.J. Sutherland D.J. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery.J Am Coll Nutr. 1988; 7: 147-153Crossref PubMed Scopus (206) Google Scholar). Whether the weight loss from the bariatric surgery was the reason is unclear. Bilenka et al. (18Bilenka B. Ben-Shlomo I. Cozacov C. Gold C.H. Zohar S. Fertility, miscarriage and pregnancy after vertical banded gastroplasty operation for morbid obesity.Acta Obstet Gynecol Scand. 1995; 74: 42-44Crossref PubMed Scopus (94) Google Scholar) presented a series of nine patients where five (out of six who attempted conception) who needed ovulation induction to conceive prior to vertical banded gastroplasty (VBG) became pregnant spontaneously postoperatively (mean weight loss was 36 kg). Although a small number of cases was presented, that article demonstrated an improvement of fertility status after VBG. Additionally, in a study by Martin et al. (19Martin L.F. Finigan K.M. Nolan T.E. Pregnancy after adjustable gastric banding.Obstet Gynecol. 2000; 95: 927-930Crossref PubMed Google Scholar) of 265 fertile women who underwent adjustable gastric banding, 20 became pregnant of whom 5, failing to conceive at heavier weights, conceived after weight loss (mean weight loss 10.6 kg). A study by Marceau et al. (20Marceau P. Kaufman D. Biron S. Hould F.S. Lebel S. Marceau S. et al.Outcome of pregnancies after biliopancreatic diversion.Obes Surg. 2004; 14: 318-324Crossref PubMed Scopus (182) Google Scholar) of women who underwent biliopancreatic diversion (BPD) between 1984 and 1995 revealed that 47% (15 of 32) who were unable to become pregnant preoperatively (mean BMI = 47 kg/m2) were successfully pregnant postoperatively (mean BMI = 30 kg/m2). Despite the use of the same oral contraceptives before and after BPD, two of nine patients had unforeseen pregnancy after surgery in one of the studies (21Gerrits E.G. Ceulemans R. van Hee R. Hendrickx L. Totte E. Contraceptive treatment after biliopancreatic diversion needs consensus.Obes Surg. 2003; 13: 378-382Crossref PubMed Scopus (85) Google Scholar). In broader terms, the role of weight loss by bariatric surgery on infertility is understudied and not coincidentally remains uncertain in the management of the morbidly obese infertile patient. With almost contentious evidence of efficacy and until clinical trials prove its benefit, a recommendation to a morbidly obese infertile patient to undergo such major surgery solely for the sake of infertility should be approached with caution in clinical practice, weighing a 1-year mortality rate up to 4.6% against the anticipated benefits of the procedure (22Flum D.R. Salem L. Elrod J.A. Dellinger E.P. Cheadle A. Chan L. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures.J Am Med Assoc. 2005; 294: 1903-1908Crossref Scopus (498) Google Scholar). The author thanks Dr. David Seifer for his comments on the manuscript.