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Physicians' perspectives and practices regarding the fertility management of obese patients
MENTAL HEALTH, SEXUALITY, AND ETHICS Physicians’ perspectives and practices regarding the fertility management of obese patients Isiah D. Harris, M.D., Johanne Python, M.D., Lauren Roth, M.D., Ruben Alvero, M.D., Shona Murray, M.D., and William D. Schlaff, M.D. Division of Advanced Reproductive Medicine, Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, Colorado
To assess the practice patterns and personal beliefs of fertility physicians who care for obese patients seeking assisted reproduction, we conducted a national survey of fertility program directors from both private and academic practices and discovered that although few practices have firm guidelines regarding the management of obese patients, the overwhelming majority of providers believe that body mass index guidelines or cutoffs should exist. (Fertil Steril 2011;96:991–2. 2011 by American Society for Reproductive Medicine.) Key Words: Fertility management, obesity
Obesity continues to be an international concern, and recent estimates highlight the epidemic of obesity in the United States, with >64% of women being overweight and >35% being obese (1, 2). The Centers for Disease Control and Prevention estimate that obesity-related illness accounted for $147 billion in medical care costs in 2008. This figure includes a plethora of deleterious reproductive consequences, including menstrual disorders, infertility, increased miscarriage rates, and elevated risks for a myriad of maternal complications (3–6). The adverse impact of obesity on the success of assisted reproductive technologies (ART) has also been well documented (7–9), and there is recent, though unpublished, Society for Assisted Reproductive Technology data which evaluated >50,000 patients and confirm that severe obesity reduces IVF success by 45% (personal communication). Despite this extensive body of literature, there are as yet no guidelines for fertility physicians regarding the management of obese patients, and there is limited guidance in the literature about how to approach restricting ART services to obese patients (10). Therefore, we conducted a survey to characterize physicians’ personal beliefs and practice patterns regarding the management of obese patients seeking ART. We distributed a survey to the medical directors of infertility programs throughout the United States. The survey was initially distributed to physicians at 41 university-based clinics and 65 private clinics. There were 43 total respondents, 22 from university-based practices and 21 from private practices. The majority of respondents reported that their clinics performed <300 cycles per year and had <100 cycles with patients whom had a body mass index (BMI) greater than 30 kg/m2 (67.8% and 73.8%, respectively).
Received June 30, 2011; revised and accepted July 19, 2011; published online August 15, 2011. I.D.H. has nothing to disclose. J.P. has nothing to disclose. L.R. has nothing to disclose. R.A. has nothing to disclose. S.M. has nothing to disclose. W.D.S. has nothing to disclose. Reprint requests: Isiah D. Harris, M.D., 12631 East 17th Avenue, Room 4411, Aurora, CO 80045 (E-mail: [email protected]).
0015-0282/$36.00 doi:10.1016/j.fertnstert.2011.07.1111
When asked about the existence of a BMI cutoff for performing controlled ovarian hyperstimulation for intrauterine insemination, only 42.9% of clinics had a cutoff, although 73.2% of program/medical directors personally thought that a cutoff should exist. For IVF, 54.8% of clinics had a BMI cutoff, and 82.9% of program/medical directors stating that they believed such a cutoff should exist. The specific cutpoints recommended varied from a BMIs of 30 to 55 kg/m2; the responses came in a normal distribution with a mode and median of 40 kg/m2 (Fig. 1). When asked about specific recommendations for weight loss and preconception management, 36.6% of respondents stated that they typically recommend a 5%–10% weight loss for their obese patients, whereas 58.5% recommend weight loss until a specific BMI cutoff is reached. The remainder of the respondents recommended >10% weight loss for their obese patients. We also asked physicians about their counseling habits for obese patients. The overwhelming majority of respondents recommended that patients consider diet and exercise as well as consultation with a nutritionist (>95.2% and 90.5%, respectively). However, only about two-thirds of respondents discussed maternal fetal medicine consultation or bariatric surgery with their obese patients, and very few discussed the possibilities of gestational carrier or adoption (11.9% and 9.5%, respectively). When counseling patients on the pregnancyrelated risks of obesity, the vast majority of respondents discussed the reduced success rates of ART and the increased risks of gestational diabetes, but only about one-half counseled patients about the increased risk of miscarriage, thromboembolic disease, preeclampsia, need for cesarean delivery, or fetal macrosomia. Furthermore, fewer than one-third of respondents counseled patients regarding their increased risk of fetal anomalies. Finally, respondents were asked to describe how they counsel obese patients regarding the number of embryos to transfer compared with a normal-weight women, given that all other demographic and cycle parameters were equal. Seventy-eight percent of respondents stated that they would recommend the same number of embryos regardless of BMI. The remainder of respondents said
Fertility and Sterility Vol. 96, No. 4, October 2011 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.
991
FIGURE 1 Body mass index (BMI) cutoffs at which point program directors report that their practice policy mandates (A and C) or that they personally think (B and D) that assisted reproduction services should be restricted owing to obesity. COH ¼ controlled ovarian hyperstimulation; IUI ¼ intrauterine insemination.
Harris. Fertility management of obese patients. Fertil Steril 2011.
that they would recommend that fewer embryos be transfered to the obese patient, and no respondents would recommend that the obese woman have more embryos transfered. It is clear from this survey that there are varying opinions and practices throughout the country regarding the management of obese patients seeking ART. However, there appears to be consensus that a set of guidelines should exist, and it would behoove the American Society for Reproductive Medicine and Society for Reproductive Endocrinoloty and Infertility to make such recom-
mendations. There continues, however, to be some national disagreement regarding what level of obesity should be considered ‘‘too obese’’ to receive ART treatments. Therefore, the specific recommendations will need to consider the available clinical outcomes data, as well as the basic principles of beneficence, nonmaleficence, respect, and justice. Until national recommendations are available, however, physicians and practices may remain hesitant to develop their own BMI restrictions for fear that they will be considered discriminatory.
REFERENCES 1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA 2010;303:235–41. 2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006;295:1549–55. 3. Bhattacharya S, Campbell DM, Liston WA. Effect of body mass index on pregnancy outcomes in nulliparous women delivering singleton babies. BMC Public Health 2007;7:168. 4. Chu SY, Callaghan WM, Kim SY, Schmid CH, Lau J, England LJ, et al. Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care 2007;30:2070–6.
992
Harris et al.
5. Chu SY, Kim SY, Schmid CH, Dietz PM, Callaghan WM, Lau J, et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obes Rev 2007;8:385–94. 6. Pasquali R. Obesity, fat distribution and infertility. Maturitas 2006;54:363–71. 7. Jungheim ES, Lanzendorf SE, Odem RR, Moley KH, Chang AS, Ratts VS. Morbid obesity is associated with lower clinical pregnancy rates after in vitro fertilization in women with polycystic ovary syndrome. Fertil Steril 2009;92: 256–61.
Fertility management of obese patients
8. Sneed ML, Uhler ML, Grotjan HE, Rapisarda JJ, Lederer KJ, Beltsos AN. Body mass index: impact on IVF success appears age-related. Hum Reprod 2008;23:1835–9. 9. van der Steeg JW, Steures P, Eijkemans MJ, Habbema JD, Hompes PG, Burggraaff JM, et al. Obesity affects spontaneous pregnancy chances in subfertile, ovulatory women. Hum Reprod 2008; 23:324–8. 10. Vahratian A, Smith YR. Should access to fertilityrelated services be conditional on body mass index? Hum Reprod 2009;24:1532–7.
Vol. 96, No. 4, October 2011
To assess the practice patterns and personal beliefs of fertility physicians who care for obese patients seeking assisted reproduction, we conducted a national survey of fertility program directors from both private and academic practices and discovered that although few practices have firm guidelines regarding the management of obese patients, the overwhelming majority of providers believe that body mass index guidelines or cutoffs should exist. (Fertil Steril 2011;96:991–2. 2011 by American Society for Reproductive Medicine.) Key Words: Fertility management, obesity
Obesity continues to be an international concern, and recent estimates highlight the epidemic of obesity in the United States, with >64% of women being overweight and >35% being obese (1, 2). The Centers for Disease Control and Prevention estimate that obesity-related illness accounted for $147 billion in medical care costs in 2008. This figure includes a plethora of deleterious reproductive consequences, including menstrual disorders, infertility, increased miscarriage rates, and elevated risks for a myriad of maternal complications (3–6). The adverse impact of obesity on the success of assisted reproductive technologies (ART) has also been well documented (7–9), and there is recent, though unpublished, Society for Assisted Reproductive Technology data which evaluated >50,000 patients and confirm that severe obesity reduces IVF success by 45% (personal communication). Despite this extensive body of literature, there are as yet no guidelines for fertility physicians regarding the management of obese patients, and there is limited guidance in the literature about how to approach restricting ART services to obese patients (10). Therefore, we conducted a survey to characterize physicians’ personal beliefs and practice patterns regarding the management of obese patients seeking ART. We distributed a survey to the medical directors of infertility programs throughout the United States. The survey was initially distributed to physicians at 41 university-based clinics and 65 private clinics. There were 43 total respondents, 22 from university-based practices and 21 from private practices. The majority of respondents reported that their clinics performed <300 cycles per year and had <100 cycles with patients whom had a body mass index (BMI) greater than 30 kg/m2 (67.8% and 73.8%, respectively).
Received June 30, 2011; revised and accepted July 19, 2011; published online August 15, 2011. I.D.H. has nothing to disclose. J.P. has nothing to disclose. L.R. has nothing to disclose. R.A. has nothing to disclose. S.M. has nothing to disclose. W.D.S. has nothing to disclose. Reprint requests: Isiah D. Harris, M.D., 12631 East 17th Avenue, Room 4411, Aurora, CO 80045 (E-mail: [email protected]).
0015-0282/$36.00 doi:10.1016/j.fertnstert.2011.07.1111
When asked about the existence of a BMI cutoff for performing controlled ovarian hyperstimulation for intrauterine insemination, only 42.9% of clinics had a cutoff, although 73.2% of program/medical directors personally thought that a cutoff should exist. For IVF, 54.8% of clinics had a BMI cutoff, and 82.9% of program/medical directors stating that they believed such a cutoff should exist. The specific cutpoints recommended varied from a BMIs of 30 to 55 kg/m2; the responses came in a normal distribution with a mode and median of 40 kg/m2 (Fig. 1). When asked about specific recommendations for weight loss and preconception management, 36.6% of respondents stated that they typically recommend a 5%–10% weight loss for their obese patients, whereas 58.5% recommend weight loss until a specific BMI cutoff is reached. The remainder of the respondents recommended >10% weight loss for their obese patients. We also asked physicians about their counseling habits for obese patients. The overwhelming majority of respondents recommended that patients consider diet and exercise as well as consultation with a nutritionist (>95.2% and 90.5%, respectively). However, only about two-thirds of respondents discussed maternal fetal medicine consultation or bariatric surgery with their obese patients, and very few discussed the possibilities of gestational carrier or adoption (11.9% and 9.5%, respectively). When counseling patients on the pregnancyrelated risks of obesity, the vast majority of respondents discussed the reduced success rates of ART and the increased risks of gestational diabetes, but only about one-half counseled patients about the increased risk of miscarriage, thromboembolic disease, preeclampsia, need for cesarean delivery, or fetal macrosomia. Furthermore, fewer than one-third of respondents counseled patients regarding their increased risk of fetal anomalies. Finally, respondents were asked to describe how they counsel obese patients regarding the number of embryos to transfer compared with a normal-weight women, given that all other demographic and cycle parameters were equal. Seventy-eight percent of respondents stated that they would recommend the same number of embryos regardless of BMI. The remainder of respondents said
Fertility and Sterility Vol. 96, No. 4, October 2011 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.
991
FIGURE 1 Body mass index (BMI) cutoffs at which point program directors report that their practice policy mandates (A and C) or that they personally think (B and D) that assisted reproduction services should be restricted owing to obesity. COH ¼ controlled ovarian hyperstimulation; IUI ¼ intrauterine insemination.
Harris. Fertility management of obese patients. Fertil Steril 2011.
that they would recommend that fewer embryos be transfered to the obese patient, and no respondents would recommend that the obese woman have more embryos transfered. It is clear from this survey that there are varying opinions and practices throughout the country regarding the management of obese patients seeking ART. However, there appears to be consensus that a set of guidelines should exist, and it would behoove the American Society for Reproductive Medicine and Society for Reproductive Endocrinoloty and Infertility to make such recom-
mendations. There continues, however, to be some national disagreement regarding what level of obesity should be considered ‘‘too obese’’ to receive ART treatments. Therefore, the specific recommendations will need to consider the available clinical outcomes data, as well as the basic principles of beneficence, nonmaleficence, respect, and justice. Until national recommendations are available, however, physicians and practices may remain hesitant to develop their own BMI restrictions for fear that they will be considered discriminatory.
REFERENCES 1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA 2010;303:235–41. 2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006;295:1549–55. 3. Bhattacharya S, Campbell DM, Liston WA. Effect of body mass index on pregnancy outcomes in nulliparous women delivering singleton babies. BMC Public Health 2007;7:168. 4. Chu SY, Callaghan WM, Kim SY, Schmid CH, Lau J, England LJ, et al. Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care 2007;30:2070–6.
992
Harris et al.
5. Chu SY, Kim SY, Schmid CH, Dietz PM, Callaghan WM, Lau J, et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obes Rev 2007;8:385–94. 6. Pasquali R. Obesity, fat distribution and infertility. Maturitas 2006;54:363–71. 7. Jungheim ES, Lanzendorf SE, Odem RR, Moley KH, Chang AS, Ratts VS. Morbid obesity is associated with lower clinical pregnancy rates after in vitro fertilization in women with polycystic ovary syndrome. Fertil Steril 2009;92: 256–61.
Fertility management of obese patients
8. Sneed ML, Uhler ML, Grotjan HE, Rapisarda JJ, Lederer KJ, Beltsos AN. Body mass index: impact on IVF success appears age-related. Hum Reprod 2008;23:1835–9. 9. van der Steeg JW, Steures P, Eijkemans MJ, Habbema JD, Hompes PG, Burggraaff JM, et al. Obesity affects spontaneous pregnancy chances in subfertile, ovulatory women. Hum Reprod 2008; 23:324–8. 10. Vahratian A, Smith YR. Should access to fertilityrelated services be conditional on body mass index? Hum Reprod 2009;24:1532–7.
Vol. 96, No. 4, October 2011