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In vitro fertilization after bariatric surgery

2010; Elsevier BV; Volume: 94; Issue: 7 Linguagem: Inglês

10.1016/j.fertnstert.2010.06.052

1556-5653

Manuel Doblado, Beth M. Lewkowksi, Randall R. Odem, Emily S. Jungheim,

Gestational Diabetes Research and Management

Few data exist regarding IVF in women who have undergone bariatric surgery. Our experience with five patients suggests that IVF is a safe and effective fertility treatment for these women, although special considerations should be made when treating patients who have undergone bariatric surgery. Considering the type of bypass procedure the patient underwent is particularly important should a patient develop concerning symptoms during her IVF cycle. Few data exist regarding IVF in women who have undergone bariatric surgery. Our experience with five patients suggests that IVF is a safe and effective fertility treatment for these women, although special considerations should be made when treating patients who have undergone bariatric surgery. Considering the type of bypass procedure the patient underwent is particularly important should a patient develop concerning symptoms during her IVF cycle. Obesity is a common problem among reproductive-age women in the United States, placing them at increased risk for problems such as cardiovascular disease, diabetes, and some cancers (1Holte J. Bergh T. Berne C. Lithell H. Serum lipoprotein lipid profile in women with the polycystic ovary syndrome: relation to anthropometric, endocrine and metabolic variables.Clinical endocrinology. 1994; 41: 463-471Crossref PubMed Scopus (193) Google Scholar). Furthermore, for obese women of reproductive age, fertility and pregnancy also may be affected (1Holte J. Bergh T. Berne C. Lithell H. Serum lipoprotein lipid profile in women with the polycystic ovary syndrome: relation to anthropometric, endocrine and metabolic variables.Clinical endocrinology. 1994; 41: 463-471Crossref PubMed Scopus (193) Google Scholar, 2Gosman G.G. King W.C. Schrope B. Steffen K.J. Strain G.W. Courcoulas A.P. et al.Reproductive health of women electing bariatric surgery.Fertil Steril. 2009; https://doi.org/10.1016/j.fertnstert.2009.08.028Abstract Full Text Full Text PDF Scopus (74) Google Scholar, 3Practice Committee of American Society for Reproductive MedicineObesity and reproduction: an educational bulletin.Fertil Steril. 2008; 90: S21-S29PubMed Google Scholar). Weight loss is often recommended to obese women desiring pregnancy to improve fertility and help decrease morbidity in pregnancy (3Practice Committee of American Society for Reproductive MedicineObesity and reproduction: an educational bulletin.Fertil Steril. 2008; 90: S21-S29PubMed Google Scholar, 4American College of Obstetricians and GynecologistsACOG Committee Opinion number 315, September 2005. Obesity in pregnancy.Obstet Gynecol. 2005; 106: 671-675Crossref PubMed Scopus (344) Google Scholar, 5Patel J.A. Colella J.J. Esaka E. Patel N.A. Thomas R.L. Improvement in infertility and pregnancy outcomes after weight loss surgery.Med Clin North Am. 2007; 91 (xiii): 515-528Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar). One increasingly common treatment option for severe obesity is bariatric surgery (2Gosman G.G. King W.C. Schrope B. Steffen K.J. Strain G.W. Courcoulas A.P. et al.Reproductive health of women electing bariatric surgery.Fertil Steril. 2009; https://doi.org/10.1016/j.fertnstert.2009.08.028Abstract Full Text Full Text PDF Scopus (74) Google Scholar). This type of surgery is recommended for patients with a body mass index (BMI) of ≥40 kg/m2, or 35 kg/m2 and high risk conditions such as severe sleep apnea, cardiac disease, or diabetes (6DeMaria E.J. Bariatric surgery for morbid obesity.N Engl J Med. 2007; 356: 2176-2183Crossref PubMed Scopus (328) Google Scholar). Two of the most common bariatric surgery procedures are laparoscopic adjustable gastric banding and the Roux-en-Y gastric bypass. Gastric banding limits intake by restricting the gastric reservoir and delaying emptying, whereas the Roux-en-Y procedure limits small intestine absorption of nutrients and also decreases the size of the gastric reservoir. Sleeve gastrectomy is another procedure that is increasing in popularity. This surgery is restrictive like the gastric band, but is thought to provide additional benefit by decreasing secretion of the appetite-stimulating hormone ghrelin (4American College of Obstetricians and GynecologistsACOG Committee Opinion number 315, September 2005. Obesity in pregnancy.Obstet Gynecol. 2005; 106: 671-675Crossref PubMed Scopus (344) Google Scholar). Studies have shown these procedures lead to more rapid, significant, and persistent weight loss than conventional treatment such as diet and exercise, leading to greater improvements in obesity-related morbidity and possibly reduced mortality (6DeMaria E.J. Bariatric surgery for morbid obesity.N Engl J Med. 2007; 356: 2176-2183Crossref PubMed Scopus (328) Google Scholar, 7Sjostrom L. Narbro K. Sjostrom C.D. Karason K. Larsson B. Wedel H. et al.Effects of bariatric surgery on mortality in Swedish obese subjects.N Engl J Med. 2007; 357: 741-752Crossref PubMed Scopus (3481) Google Scholar). Whereas there are data on pregnancy outcomes after bariatric surgery (4American College of Obstetricians and GynecologistsACOG Committee Opinion number 315, September 2005. Obesity in pregnancy.Obstet Gynecol. 2005; 106: 671-675Crossref PubMed Scopus (344) Google Scholar), there are few data on outcomes in bariatric patients requiring assistive reproductive technology to conceive. We discuss five patients (Table 1) from our center who underwent bariatric surgery followed by in vitro fertilization (IVF). Appropriate institutional review board approval for presentation of this data was obtained.Table 1Patient characteristics.PatientAge (y)Bariatric procedureWeight loss (lbs.)Length of infertilityInfertility diagnosisBMI (kg/m2) at time of IVFNo. of IVFcyclesIVF complicationsIVF outcome137Roux-en-Y15046 moMale factor26.81NoneTerm singleton237Roux-en-Y10024 moMale factor, fibroids363NoneCycle 1, failed; 2, biochemical pregnancy; 3, term twins331Roux-en-Y10010 yMale factor, PCOS22.81Mild OHSSPreterm labor and delivery of twins at 24 wk; 0/2 survived429Roux-en-Y10036 moMale factor, PCOS39.23Twin gestation spontaneously reduced to singletonCycle 1, failed fertilization; 2, failed; 3, FET-term singleton529Gastric banding6036 moMale factor, PCOS29.91NoneTerm singleton Open table in a new tab Patient 1 is a 37 year old with a 46-month history of infertility owing to male factor. The patient underwent a Roux-en-Y gastric bypass procedure 2 years before starting IVF. The patient lost 68 kilograms and had a BMI of 26.8 kg/m2 at the start of her single IVF cycle. Twelve oocytes were retrieved and subjected to intracytoplasmic sperm injection (ICSI). Seven oocytes were fertilized and three cleavage stage embryos were transferred, resulting in delivery of a term singleton. The patient did not experience any complications. Patient 2 is a 37 year old with a 24-month history of infertility owing to male factor and uterine fibroids. The patient underwent a Roux-en-Y gastric bypass procedure 2 years before her first IVF cycle, at which time she had lost 45 kilograms and her BMI was 36 kg/m2. The patient underwent three IVF cycles. In the first cycle, three oocytes were retrieved and all were fertilized after ICSI. Two cleavage-stage embryos were transferred, but no pregnancy resulted. In the second cycle, seven of 13 oocytes fertilized after ICSI and two cleavage-stage embryos were transferred, resulting in a chemical pregnancy. In the third cycle, the patient had five of seven oocytes fertilized after ICSI. Three cleavage-stage embryos were transferred, and the patient delivered twins at term. The patient experienced no complications during her IVF cycles or pregnancy. Patient 3 is a 31 year old with a 10-year history of infertility owing to a tubal factor. The patient underwent a Roux-en-Y gastric bypass procedure 5 years before IVF and lost 45 kilograms. Her BMI at the time of IVF was 23 kg/m2. The patient underwent one cycle of IVF. Four of 10 oocytes were fertilized by conventional insemination and nine of 11 oocytes were fertilized by ICSI. She had two day-five embryos transferred, resulting in a twin gestation. Her IVF cycle was complicated by mild ovarian hyperstimulation syndrome with ascites, increased abdominal girth, shortness of breath, and chest pain. She responded well to supportive care, but unfortunately experienced preterm labor and delivered nonviable twins at 24 weeks' gestation. Patient 4 is a 29 year old with a 36-month history of infertility owing to male factor and polycystic ovary syndrome (PCOS). The patient underwent a Roux-en-Y gastric bypass 2 years before starting IVF and lost 45 kilograms. Her BMI was 39 kg/m2 at the time of her first IVF cycle. She underwent two fresh IVF cycles followed by two cycles with frozen embryos. In her first fresh IVF cycle, conventional insemination resulted in fertilization of only one of 10 oocytes. The resulting zygote failed to progress, and transfer was not performed. ICSI was used to inseminate oocytes in the second cycle, resulting in fertilization of seven of 11 oocytes. The patient failed to conceive after transfer of two cleavage-stage embryos. Three cryopreserved embryos from the second cycle were thawed and transferred, resulting in a twin conception. The conception spontaneously reduced to a singleton pregnancy. She had an uncomplicated term delivery. Patient 5 is a 29 year old with a 36-month history of infertility owing to male factor and PCOS. The patient underwent a gastric banding procedure 1 year before IVF and lost 27 kilograms with a BMI of 30 kg/m2. The patient underwent one cycle of IVF-ICSI. Eleven of 13 oocytes fertilized and two day-five embryos were transferred resulting in an uncomplicated singleton pregnancy and delivery. Overall, these patients tolerated IVF well, and four of the five went on to have term deliveries. Although these patients did well, our experience demonstrates special considerations should be taken. It is not clear whether weight loss owing to bariatric surgery improves IVF outcomes, although weight loss may help obese women conceive naturally, particularly women with PCOS (8Teitelman M. Grotegut C.A. Williams N.N. Lewis J.D. The impact of bariatric surgery on menstrual patterns.Obes Surg. 2006; 16: 1457-1463Crossref PubMed Scopus (136) Google Scholar, 9Escobar-Morreale H.F. Botella-Carretero J.I. Alvarez-Blasco F. Sancho J. San Millan J.L. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery.J Clin Endocrinol Metab. 2005; 90: 6364-6369Crossref PubMed Scopus (281) Google Scholar). In addition, studies have shown that obesity may be associated with decreased pregnancy and live birth rates after IVF (3Practice Committee of American Society for Reproductive MedicineObesity and reproduction: an educational bulletin.Fertil Steril. 2008; 90: S21-S29PubMed Google Scholar, 10Jungheim E.S. Lanzendorf S.E. Odem R.R. Moley K.H. Chang A.S. Ratts V.S. Morbid obesity is associated with lower clinical pregnancy rates after in vitro fertilization in women with polycystic ovary syndrome.Fertil Steril. 2009; 92: 256-261Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 11Fedorcsak 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 (389) Google Scholar). Obesity has also been associated with increased dose and duration of gonadotropin stimulation, lower peak E2 levels, and increased oocyte retrieval time (3Practice Committee of American Society for Reproductive MedicineObesity and reproduction: an educational bulletin.Fertil Steril. 2008; 90: S21-S29PubMed Google Scholar, 10Jungheim E.S. Lanzendorf S.E. Odem R.R. Moley K.H. Chang A.S. Ratts V.S. Morbid obesity is associated with lower clinical pregnancy rates after in vitro fertilization in women with polycystic ovary syndrome.Fertil Steril. 2009; 92: 256-261Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 12Dokras A. Baredziak L. Blaine J. Syrop C. VanVoorhis B.J. Sparks A. Obstetric outcomes after in vitro fertilization in obese and morbidly obese women.Obstet Gynecol. 2006; 108: 61-69Crossref PubMed Scopus (204) Google Scholar, 13Egan B. Racowsky C. Hornstein M.D. Martin R. Tsen L.C. Anesthetic impact of body mass index in patients undergoing assisted reproductive technologies.J Clin Anesth. 2008; 20: 356-363Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar). Three of the five bariatric surgery patients in our series conceived with their first IVF cycle, and the other two required additional cycles. None of these patients experienced IVF complications attributable to prior bariatric surgery, but one patient had a mild case of ovarian hyperstimulation syndrome (OHSS). While there is no evidence that previous gastric bypass predisposes patients to OHSS, the presence of OHSS in postgastric bypass surgery patients could lead to serious complications. OHSS can lead to ascites and increased intraabdominal pressure, potentially increasing the risk of two late complications of gastric bypass surgery, intestinal obstruction, and internal hernia (6DeMaria E.J. Bariatric surgery for morbid obesity.N Engl J Med. 2007; 356: 2176-2183Crossref PubMed Scopus (328) Google Scholar). Internal hernia is a late complication of gastric bypass surgery, which can present clinically with vague abdominal complaints such as nausea and abdominal pain. This clinical presentation can also occur in patients with OHSS. However, internal hernia requires surgical intervention to prevent bowel necrosis and perforation, so prompt diagnosis with an upper gastrointestinal series and computed tomography scan is important to prevent further complications (14Iannelli A. Facchiano E. Gugenheim J. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity.Obes Surg. 2006; 16: 1265-1271Crossref PubMed Scopus (151) Google Scholar). Physicians should closely monitor for signs and symptoms of OHSS and maintain a high index of suspicion for internal herniation in gastric bypass patients with OHSS, because of the possible difficulty in distinguishing between the two conditions and the morbidity associated with internal hernias. Another issue for gastric bypass patients undergoing IVF is timing of the procedures. Rapid weight loss and increased risk of nutritional deficiencies in the first year after bariatric surgery have led to recommendations suggesting that gastric bypass surgery patients wait at least 12 months before attempting pregnancy (4American College of Obstetricians and GynecologistsACOG Committee Opinion number 315, September 2005. Obesity in pregnancy.Obstet Gynecol. 2005; 106: 671-675Crossref PubMed Scopus (344) Google Scholar, 15Maggard M.A. Yermilov I. Li Z. Maglione M. Newberry S. Suttorp M. et al.Pregnancy and fertility following bariatric surgery: a systematic review.J Am Med Assoc. 2008; 300: 2286-2296Crossref Scopus (370) Google Scholar, 16Beard J.H. Bell R.L. Duffy A.J. Reproductive considerations and pregnancy after bariatric surgery: current evidence and recommendations.Obes Surg. 2008; 18: 1023-1027Crossref PubMed Scopus (89) Google Scholar). Because age is a strong predictor of IVF outcome, older obese women desiring pregnancy may wish to consider this delay before deciding on gastric bypass surgery. Of note, two of the patients described here were of advanced maternal age and had successful outcomes. Nutrition is another important issue in women attempting to conceive after gastric bypass surgery (4American College of Obstetricians and GynecologistsACOG Committee Opinion number 315, September 2005. Obesity in pregnancy.Obstet Gynecol. 2005; 106: 671-675Crossref PubMed Scopus (344) Google Scholar). Whereas nutritional deficiencies can occur after both restrictive and malabsorptive procedures, more serious deficiencies are usually associated with the malabsorption-producing procedures (17Guelinckx I. Devlieger R. Vansant G. Reproductive outcome after bariatric surgery: a critical review.Hum Reprod Update. 2009; 15: 189-201Crossref PubMed Scopus (193) Google Scholar). Gastric bypass surgery can lead to deficiencies in iron, folate, vitamin B12, calcium, and vitamin D. These deficiencies can increase the risk of fetal complications such as low birthweight, neonatal hypocalcemia, and neural tube defects (16Beard J.H. Bell R.L. Duffy A.J. Reproductive considerations and pregnancy after bariatric surgery: current evidence and recommendations.Obes Surg. 2008; 18: 1023-1027Crossref PubMed Scopus (89) Google Scholar). Testing for nutritional deficiencies, and correction if necessary, should be performed before IVF or in any woman considering pregnancy who has undergone gastric bypass surgery (4American College of Obstetricians and GynecologistsACOG Committee Opinion number 315, September 2005. Obesity in pregnancy.Obstet Gynecol. 2005; 106: 671-675Crossref PubMed Scopus (344) Google Scholar). All the patients described had adequate nutritional supplementation, and none of the children born had any signs of neural tube defects or growth restriction. IVF after bariatric surgery can be safe and successful as demonstrated in our case series. Women and their care team should be aware of issues such as complications of IVF and gastric bypass surgery, the importance of delaying pregnancy after bariatric surgery, and the special nutritional requirements of bariatric surgery patients. Whereas our data support the safety of IVF for women who have undergone bariatric procedures, future research following this patient population is warranted as surgical approaches to weight loss are evolving.