One of the many benefits of weight-loss surgery is that it can boost fertility rates for people who are otherwise struggling to conceive a child because of weight-related health problems. Bariatric procedures are on the rise as a surgical treatment for morbid obesity. In reproductive age of women, bariatric surgeries will improve factors related to anovulation and lead to spontaneous fertility. As the prevalence of adult obesity increases in the United States, physicians are more often caring for patients who have undergone or who are considering bariatric surgery. Counseling and treating women who become pregnant after bariatric surgery present unique challenges. Although outcomes are generally good, nutritional and surgical complications can arise. Given that the majority of patients are female and of reproductive age, it is important for clinicians who manage women’s health issues to be aware of the surgery, its long term goals, and the potential effect on future pregnancies.
The Link Between Weight, Fertility, and Bariatric Surgery
There's an intricate relationship between excess weight and fertility. Obesity is associated with reduced fertility, primarily because of oligo-ovulation and anovulation. A higher-than-healthy weight may trigger hormonal imbalances that affect ovulation cycles and increase the risk of developing conditions like polycystic ovary syndrome (PCOS). It may also increase the risk for other health problems, like diabetes or metabolic syndrome. These weight-related conditions can make it harder to get pregnant.
Bariatric surgery is one option for weight loss in patients with a body mass index (BMI) of at least 40 kg per m2, or in those with a BMI of at least 35 kg per m2 who have comorbidities. There are two approaches to bariatric surgery: restrictive and restrictive/malabsorptive surgeries. The most common restrictive procedure is adjustable gastric banding, and the most common restrictive/malabsorptive procedure is the Roux-en-Y gastric bypass. Bariatric surgery promotes weight loss via restriction (limits the amount of food ingested), malabsorption (bypasses parts of the small intestine) or a combination of both. In the United States, the most common procedures performed today are the Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), vertical sleeve gastrectomy (VSG), and biliopancreatic diversion (BPD). These can be performed either via laparoscopy or laparotomy.
Rapid weight loss is typical after either procedure, resulting in improvement of polycystic ovary syndrome, anovulation, and irregular menses, thus leading to higher fertility rates. Spontaneous pregnancy can happen within a year after bariatric surgery due to higher level of sex hormone binding globulin and follicular stimulating hormone and reduction in androgens level.
Assembling Your Expert Care Team
It’s important to work with experts who understand the effect of bariatric surgery on pregnancy. Many of the bariatric surgery patients are people of reproductive age. I continue to oversee the care of my patients post-surgery, including when they become pregnant. I also typically recommend seeing an obstetrician who has experience caring for patients who have had weight-loss surgery. In some cases, a maternal-fetal medicine specialist may be preferred. Many patients also benefit from working with a registered dietitian who specializes in weight-loss surgery. The bariatric team is multidisciplinary and includes surgeons, psychologists, nutritionists, nurses, patient educators, endocrinologists, and cardiologists.
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The Recommended Waiting Period After Bariatric Surgery
Patients who have had bariatric surgery should consult with members of their care team before trying to get pregnant to ensure that their bodies are ready for pregnancy. The Obesity Society and the American Society for Metabolic & Bariatric Surgery recommended that conception should be avoided for 12-18 months after bariatric surgery. However, other professional bodies such as American College of Obstetrician and Gynaecologists recommends duration of 12-24 months before conception whereas the Royal College of Obstetricians and Gynaecologists suggests individualised approach which depend on the age of women and its effect in delaying pregnancy for older women.
This wait period can be challenging - especially for patients who sought out bariatric surgery to improve their chances of getting pregnant - but it's worth it: Delaying pregnancy is necessary to help maximize someone’s weight loss after surgery, and to reduce the risk of potential complications. The wait allows their body's vitamin levels and weight to stabilize. It can also help encourage healthy weight gain during pregnancy, which is important for the health of the baby.
Nutritional Considerations and Supplementation
Not getting enough vital nutrients typically poses the biggest challenge for bariatric patients who have become pregnant. Because of their surgery, they're taking in fewer calories overall, and it may also be harder for their bodies to absorb nutrients from foods. These factors can affect a person's ability to take in the calories needed to gain weight during pregnancy. For these reasons, I closely monitor my patients' nutrition status with regular screenings - ideally before they become pregnant - but if not, starting at their first prenatal visit.
Often that means taking prenatal vitamins along with additional supplements for protein, calcium, iron, folate, and vitamin B12. These supplements can typically be taken orally, but some patients may require intravenous iron. Important micronutrient such as iron, calcium, vitamin B12 and folate can be affected from bariatric procedures. These micronutrients are essential during pregnancy and severe deficiency can lead to adverse pregnancy outcome such as anaemia, congenital anomaly such as neural tube defect and megaloblastic anaemia.
Protein, iron, folate, calcium, and vitamins B12 and D are the most common nutrient deficiencies after gastric bypass surgery. A broad evaluation for deficiencies in micro-nutrients should be considered at the beginning of pregnancy in women who have had bariatric surgery, and treatment should be initiated if any deficits are present. Nutrient deficiencies can also occur after restrictive surgical procedures, such as adjustable gastric banding, because of decreased food intake or food intolerances.
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Weight Gain During Pregnancy
Weight gain is crucial for a healthy pregnancy, so patients shouldn't try to restrict calories once they've conceived. This can obviously be a big shift for patients who recently had surgery to lose weight, but it's important to not restrict yourself, as eating enough food is crucial for a baby’s growth.
Potential Obstetric Outcomes
Most pregnancies after bariatric surgery have successful outcomes with decreased occurrences of gestational diabetes and hypertension and lower birth weight compared with controls. Spontaneous miscarriages are more common in women with obesity compared to pregnant women with normal BMI. Whether the pregnancy is natural or conceived via assisted reproductive technique, obesity itself or with combination of other factors such as PCOS will increase miscarriage rates.
Gestational Diabetes and Preeclampsia
Risk of developing gestational diabetes mellitus and preeclampsia reduced among post bariatric surgery compared to no surgery. However, Maggard MA et al. (2008) in a systematic review of pregnancy following bariatric surgery had shown that risk of developing gestational diabetes mellitus and preeclampsia were lower in women undergone bariatric surgery compared to obese women without bariatric surgery [26]. Since the sudden surge of increasing number of reproductive obese women undergone bariatric surgeries in the 2000's, it is normal to predict their risk of developing preeclampsia is very much reduced after bariatric surgery.
Mode of Delivery
Another benefit observed are reduction in the risk of caesarean section and admission to neonatal intensive care unit. Bariatric surgery is not a contraindication for trial of vaginal delivery unless absolute obstetrics factors come into play such as presence of placenta praevia, macrosomia and abnormal foetal lie. Earlier systematic review by Vrebosch L et al. (2012) reported that lower rate of caesarean section in the post bariatric surgery group [31] whereas a meta-analysis involving 11 studies by Yi X et al. (2015) have shown no significant difference in Caesarean delivery [48].
Infant Birth Weight
The major impact to pregnant women is development of small for gestational age babies due to persistent weight loss but this can be minimized by avoiding pregnancies too soon after bariatric surgery and good nutrition supplement. Most studies about bariatric surgeries and its impact to pregnancy will also include foetal outcome of it. A small for gestational age baby (SGA) is defined as estimated fetal weight or birth weight of less than 10th centile for gestational age [46].
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Breastfeeding
Many of my pregnant patients ask whether it's OK to breastfeed their baby. I tell them that breastfeeding is encouraged and that their ability to do so isn't usually affected by their surgery. Breastfeeding is an essential part in newborn and provide various health benefits to both mother and her newborn. In a small multicenter prospective study reported by Jans G et al. (2018) the composition of breastmilk from women after bariatric surgery was found to be comparable with women without bariatric surgery [49]. Thus, it is recommended to continue nutritional supplement during breastfeeding period and to practice breastfeeding for at least six months after delivery.
Special Considerations and Potential Complications
Because of the risk of delayed postoperative complications, gastrointestinal problems that are common in pregnancy (e.g., nausea, vomiting, abdominal pain) require thorough evaluation in women who have undergone bariatric surgery. Dumping syndrome can occur after ingestion of refined sugars and high-glycemic carbohydrates in patients who have had gastric bypass surgery. Symptoms include abdominal cramping, bloating, nausea, vomiting, and diarrhea. Hyperinsulinemia and hypo-glycemia can occur later, resulting in tachycardia, palpitations, anxiety, and diaphoresis. Women with dumping syndrome may not tolerate the 50-g glucose solution typically administered to screen for gestational diabetes.
Modified guidelines from Mechanick et al for supplementation in the pregnant population are summarized in Table 1.45 Of note, the majority of the supplements are contained within a single prenatal vitamin.