Interview with Oleksandr Ioffe, Professor, Doctor of Medical Sciences, Board-certified surgeon of the highest qualification category.
Overweight is primarily an aesthetic problem for most women. But in fact, extra kilos are also a big health problem, including reproductive health issues, especially when it comes to morbid obesity with the body mass index above 35 kg/m2 or more. We are talking with Oleksandr Ioffe, Professor, Doctor of Medical Sciences, Board-certified surgeon of the highest qualification category, about the connection between the excess weight and fertility in women, as well as the possibility to normalize body weight and restore the ability to conceive.
— Could you explain how overweight affects a woman’s ability to get pregnant?
— Morbid obesity, as experts call it, triggers processes in the body which lead to impaired hormonal balance. In particular, estrogens (female sex hormones) accumulated in fatty tissue affect the production and level of sex hormones, on which the ovarian function depends. Frequent pathologies in morbid obesity are polycystic ovary syndrome, menstrual disorders and anovulation which make conception impossible. Moreover, excess weight complicates not only the natural course of the process, but also the infertility treatment with the use of assisted reproductive technologies (ART). Compared to women with normal body weight and polycystic ovary syndrome, the success of treatment with ART is 27 % lower for women with BMI of 30-34.9 35 kg/m2 and 50 % lower for women with BMI of more than 35 kg/m2. It is much easier to achieve ovulation in women with polycystic ovary syndrome and normal weight than in those who are obese (79 % of women with normal BMI undergoing appropriate treatment have ovulation within six months, while women with varying degrees of obesity have ovulation after treatment only in 11.8-15.3 % of cases). There is also evidence of the relative risk of anovulation (i.e., menstrual cycles with no ovulation) in women of different weights: the higher the weight, the more likely anovulatory cycles are, and consequently, the less likely to become pregnant. It means there is a direct connection between a woman’s body weight and her ability to conceive. Moreover, there is a good deal of evidence indicating an increased risk to the mother and child in cases where pregnancy occurred in an obese woman. Therefore, normalizing body weight before conception is an absolutely justified process which is worth taking your time to minimize the risks in the future.
— In general, morbid obesity is the cause of many health problems. In your opinion, would it be advisable to solve weight problems within the integrated approach to the disease treatment — not only gynaecological issues, like the already mentioned PCOS, but also cardiovascular and endocrinological ones?
— This approach (to normalize body weight before active treatment of any disease) is generally accepted in the Western countries. But in Ukraine, bariatric surgery, which is the most effective method to combat obesity, is perceived as a measure of last resort. In particular, obese women have been treated for years by endocrinologists and gynaecologists without any success. At the same time, the weight normalization, which occurs within a year after bariatric surgery, gradually leads to the normalization of hormonal levels, as a result of which the ovarian function also normalizes. After that, the standard treatment leads to the desired outcome — pregnancy.
— Perhaps, the desire to postpone bariatric surgery as long as possible is associated not only with the lack of information in female patients, but also with a psychological factor: after all, we are talking about surgical intervention. What exactly is bariatric surgery?
— There are a number of bariatric surgeries, regulated and recognized as effective for alimentary obesity, that is, for morbid obesity which is associated with the nutritional factor. This is 97 % of all cases of obesity in the world, as only 3 % have primary hormonal causes and are associated with thyroid or adrenal disorders. The first group of bariatric surgery aims to reduce the volume of the stomach. The most popular among them are gastric banding, when a band is applied to the stomach, and partial gastrectomy, when the stomach volume is surgically reduced. There are also surgeries which combine a reduction in the stomach volume and a reduction in the food absorption. The gold standard here is a gastric bypass surgery when nothing is removed, but the anatomy of the stomach and small intestine changes. After such a surgery, not only the stomach volume is reduced, but also the eating habits change due to the activation of certain areas in the brain. Bariatric surgeries are performed laparoscopically. The patient can get up and walk a few hours after the surgery. He/she may be discharged in 4 to 5 days and then start eating independently. At first, liquid and semi-liquid food is recommended. The person returns to a normal diet after a few weeks. At the same time, he/she eats much less than before, feels full very quickly, does not feel extreme hunger, and his/her cravings for eating unhealthy food, such as sweets, reduce. That is, such a process of losing weight does not cause any moral distress. And more importantly, excess weight does not come back.
— How long does it take to normalize weight after bariatric surgery? How much can a woman lose? And how long before planning a pregnancy is it advisable to seek such help for obese women?
— Weight normalization occurs within a year, sometimes a little faster. However, we recommend a bariatric surgery at least one year before planning your pregnancy. During this time, you can lose up to 100 % of your excess weight. For example, a woman of 170 cm height and 170 kg weight can weigh 70 kg a year after, that is, she can have an absolutely normal weight. If there are no other pathologies, it is likely that the hormonal balance will also normalize during this period, the menstrual cycle will become regular, there will be ovulation. It means that infertility treatment will not necessarily be required. But if there is a need for such treatment, the efficiency will be much higher with a normal body weight. It is advisable to have the surgery performed at least a year before your start your pregnancy planning.
— Will you have the opportunity to perform bariatric surgeries at the Leleka Maternity Hospital?
— Yes, there is everything necessary for such interventions. Obesity treatment and infertility treatment are the aspects where the interests of bariatric surgery and reproductive medicine coincide. I think the cooperation will be fruitful. And together we will help women to get closer to the desired motherhood.
