Medical and surgical interventions to improve fertility outcomes

10.1 Introduction

1.
The prevalence of obesity is increasing worldwide with more than 600 million obese adults, including 15% of women, in 2014.
2.
Being overweight in early adulthood increases the risk of menstrual irregularities, ovulatory dysfunction, and consequently subfertility.
3.
An increasing number of men and women with high body mass index (BMI) are being referred for the evaluation and treatment of subfertility across the country.
4.
Identifying and developing effective long-term reproductive health strategies for overweight and obese men and women is of paramount importance.
5.
Only one-third of obese patients are found to receive advice from healthcare providers regarding weight reduction.
6.
Prospective studies have demonstrated that high levels of central and overall adiposity are associated with decreased fecundability, even when adjusting for confounders.
7.
Obesity’s established negative impact on reproductive potential is multifactorial, and increased adiposity can influence almost every stage of fertilisation from ovulation to successful implantation and development of the embryo.

1.
Weight loss is recommended for men and women with high BMI before attempting natural conception or fertility treatments to improve fertility outcomes, assist with fertility treatment funding, and to reduce the risks of obstetric complications.
2.
Reduced calorie intake and increased physical activity are the two essential pillars of any weight-loss program.
3.
Most guidelines recommend a target of 5%–10% body weight loss in overweight/obese women with long-term goals of 10%–20% weight loss and waist circumference <80–88 cm tailored to the ethnicity.
4.
Maintaining long-term weight loss can prove challenging and attention needs to be given to other areas of lifestyle, such as alcohol intake, smoking cessation, and stress-reduction techniques.
5.
Strategies to promote sustained weight loss include self-monitoring techniques such as food diaries, pedometers, time management advice, relapse prevention techniques, engagement of social support, and goal setting.
6.
There is some evidence that intensive weight loss immediately prior to in vitro fertilisation (IVF) is associated with adverse outcomes, including increased cycle cancellation and decreased rates of fertilisation, implantation, ongoing pregnancy, and live births in women with polycystic ovary syndrome (PCOS).
7.
Weight-loss strategies should be encouraged well in advance of pregnancy planning by the individual woman.

1.
Dietary interventions in overweight or obese men and women should consider the degree of obesity, dietary preferences, and food availability.
2.
If an eating disorder is suspected, referrals to the dietitian and clinical psychologist should be considered.
3.
Strategies such as face-to-face education sessions and practical advice on approaches to healthy eating tailored to the patient should be incorporated.
4.
It is currently recommended that women with BMI >25 should aim for weight loss via caloric restriction through balanced dietary approaches irrespective of diet composition.
5.
In the general adult population, a target energy deficit of 2500 kJ daily is recommended for weight loss.

1.
An individualised approach works best.
2.
The aim should be to lose weight at a safe and sustainable rate of 0.5–1 kg a week, and for most women, the initial advice should be to reduce their energy intake by 600 cal a day.
3.
To consider swapping unhealthy and high-energy food choices (fast food, processed food, sugary drinks, and alcohol) for healthier choices.
4.
Very low-calorie diet which involves consumption of less than 800 cal a day, can lead to rapid weight loss, but may not be suitable for everyone. Such diets should not be followed for longer than 12 weeks at a time. They should only be recommended under the supervision of a suitably qualified healthcare professional.

1.
Evidence shows that exercise benefits overweight women even in the absence of significant weight loss.
2.
Thrice-weekly moderate exercise for at least 30 minutes has been demonstrated to reduce BMI, waist circumference, and insulin resistance (IR) in young PCOS women.
3.
A recent meta-analysis found that weight-loss interventions, particularly diet and exercise, improved pregnancy rates and ovulatory status.
4.
Miscarriage rates remained unchanged by weight-loss interventions.
5.
The meta-analyses also showed that weight loss had a nonsignificant advantage over weight loss medications such as metformin with respect to achievement of pregnancy or improvement of ovulation rates.

1.
Pharmacological agents are mainly indicated when patients fail to lose significant weight despite lifestyle changes and a low-calorie diet.
2.
These agents have been shown to induce modest weight loss but are not suitable for long-term weight maintenance.
3.
These have mainly included metformin (an insulin sensitiser), orlistat (a lipase inhibitor), sibutramine (a selective serotonin and norepinephrine reuptake inhibitor), and liraglutide [a glucagon-like peptide-1 (GLP-1) receptor agonist].
4.
When prescribing the appropriate weight-losing drug, it is paramount to consider the safety of these drugs should a woman conceive while taking them.
5.
The safety of acarbose in pregnancy is not established.
6.
The use of weight-loss medications is contraindicated during pregnancy.
7.
Out of all the drugs mentioned previously, pharmacokinetics of the orlistat places it in a favourable position due to its low absorption and first-pass metabolism resulting in a bioavailability of less than 1%.
8.
Lifestyle interventions should still be considered the first-line therapy, with drug use largely reserved for monitored trials.

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