SART Fertility Experts: Can Your Weight Affect Your Fertility?

Struggling with weight and planning for pregnancy? Dr. Mark Trolice and Dr. Lindsay Maggio reveal how BMI impacts fertility, the truth about obesity as a disease—not a failure of willpower—and how small, realistic changes can lead to big wins. From lifestyle tips to when to pause medications or surgery before conceiving, this episode is packed with insights every hopeful parent needs to hear.

Hi everyone, I'm Dr. Mark Trolice, Director of the IVF Center in Orlando, Florida and Professor at the University of Central Florida College of Medicine. Today we're going to be speaking about optimizing your health prior to pregnancy and with a focus actually on your body mass index, which we'll go into shortly. With me is a wonderful, wonderful colleague and an expert in the area she's boarded in Lifestyle Medicine and Obesity Medicine.

Dr. Lindsay Maggio did a residency in Houston and then a fellowship in Maternal Fetal Medicine at Brown and now she is the Director of Maternal Fetal Medicine at Hackensack Medial Health. I was from New Jersey as well and she is practicing there and helping the community where she used to be in Florida and we miss her tremendously. Lindsay, thank you so much for joining us in the podcast.

Thanks for inviting me. I'm really happy to be here talking about this with you. Yeah, a vital topic.

I mean, when we look at the numbers, the latest CDC report showed that nearly 40% of the population in the United States are obese and they're predicting by 2030 nearly half the country. So we see patients for fertility mostly and I know you see patients who are high risk for pregnancy and what we share with the patients with fertility is that the higher your body mass index, which is based on your height and weight, the higher that is the decline in fertility, increasing risks of miscarriage and poor pregnancy outcomes. So just to preface what you're going to be saying is that there was a study just came out in the Journal of Osteopathic Medicine and it looked at as BMI increases, so does the decline in pregnancy outcomes as it relates to hypertension in pregnancy, gestational hypertension and even more severe called preeclampsia, preterm delivery, macrosomia, which is large infants and also even postpartum hemorrhage.

They also looked at neonatal issues and so when we are seeing these patients, how do we counsel them to optimize their health going into pregnancy and what do you share with them are the risks in pregnancy, Lindsay? Yes, this is such an important topic as you mentioned, there's such a large percentage of people that are coming to you and coming to me that do have obesity and they do have sometimes other medical complications as a result of that and getting them before pregnancy and having the opportunity to optimize as much of their health as we can is wonderful. It doesn't always happen, but fortunately in your world, you have that opportunity and then we get to work together in helping these patients. But a lot, obesity is so multifaceted, having these conversations with people sometimes can be really challenging because their stigma and their shame and traditionally, our medical nutrition communities have basically told people this is a problem of willpower or a problem of moral integrity when really obesity is just a disease like any other disease like asthma.

I can't run in 30 degree weather without taking my albuterol inhaler. So, obesity is a disease just the same and there are some wonderful, powerful treatments out there, but recognizing what we can and can't do prior to pregnancy or in pregnancy and how to help people get from where they are to where they need to be prior to their pregnancy involves sometimes a team approach in how can we best get them where they need to be and then in our worlds too, sometimes we're limited by time. People can't get pregnant for the entire duration of their life too.

So, sometimes we're trying to optimize in a very short window of time to improve outcomes, but also sort of up against a biological clock. So, what do you think the OB-GYN and the fertility specialist, how should we approach the issue? I should preface this by saying that there are categories of a body mass index and normal BMI is 18.5 to right before 25 and then you'll have overweight which is 25 to right below 30, but then you'll get into classes of obesity. Class 1 obesity 30 to 35 and class 2 obesity is 35 to nearly 40 and then class 3 which is the most severe is above 40 and higher.

So, Lindsay, what does the OB-GYN and reproductive endocrinologist have as a means of approaching women with obesity to not have them feel self-conscious, shaming issue and or blaming? What do you see in your practice as the best approach to facilitate their understanding and potentially addressing the problem to optimize their health prior to pregnancy? Yeah, one of the first things I do because I know this can be so sensitive for so many people is I ask permission. Can we talk about this? Because some people they don't want to and for those people that sort of ends the conversation in that moment. Like if they're not ready or they don't want to and that's okay, but forcing it is just going to further ostracize them and further push them away.

So, I try and always start these conversations with, you know, can we talk about this? Your doctor sent you to me to talk about this today. Do I have your permission? What is your understanding? And kind of really diving in because most people who suffer from obesity know that they have obesity. This is not a new fact to them.

But again, because of all the shame and stigmatism, sometimes they're closed off and don't talk about it. So, I always approach with permission. And then once I've sort of opened that, once they've opened it, I should say they opened that door, then I, you know, go into figuring out other comorbidities that they're suffering from and how we can work on addressing those.

You know, what their short-term and long-term goals are is also important. You know, how soon are you looking to become pregnant? Because if somebody's not looking for another year or two, then we have a lot more options for optimizing their health with either medications and or bariatric surgery and really getting them healthy prior to conceiving, as opposed to the people that would like to be pregnant in the next three to six months. That sort of limits what we can do from a pharmacological and surgical standpoint.

Do you see patients strictly because of their body mass index as a preconception consult? I have for some patients. That's solely what it is. Body mass index is interesting.

I mean, it's a crude tool, but you sort of have to look at the entire metabolic profile because you can have someone with a high body mass index who has no comorbidities, or you can have someone with a lower but still in the obese category, but is also has like type two diabetes and also has chronic hypertension. And so those patients may be a little bit more, I don't want to say sick, but have a lot more things that need to be optimized than someone who's just looking at their weight. And then also, you know, there's in the obesity medicine community, there's a lot of talk of other metrics of obesity, you know, visceral fat measurements, abdominal circumference, like insulin resistance, and sort of determining that.

So the body mass index, while it's, it's what most of our research and studies are based off of sort of have to look at the patient as an entire, entire package, and not just what that actual number is to really identify what are some of the best things that can be done to help improve your entire metabolic picture. So what's your lifestyle approach to these patients? You know, we're, as repetitive endocrinology and infertility specialists, we were sort of faced with pressure in terms of the patient by the time they get to see us, they really don't want to be counseled as to, well, maybe we should take some time off and get your get your health more optimal. How do you approach that? And if they are going to have some delay, do you use the GOP ones, like the ozempics and the manjaros, or the brand names? Or do you look at bariatric? When do you choose one? And then how long would it take after they've had some resolution or improvement? Can they conceive? Yeah, so that's, so I mean, starting with lifestyle is always sort of the first answer.

But we do know in the grand scheme of obesity treatment, lifestyle changes, work in a very, very, very small percentage of people, most people who make these lifestyle changes will ultimately have weight regain in the future. So but absolutely talking about, you know, good nutrition, and what what should you eat, not eat? I mean, that is a very complicated, nuanced conversation, making sure that physical activity is incorporated as well. Sleep, I mean, I think sleep is one of the most overlooked things, but so important when we start talking about cortisol levels and insulin resistance and ghrelin levels.

And if we are not getting good sleep, all of those things are working against us as well. So, you know, covering all these lifestyle things is really important. But then we start talking about pharmacologic and surgical approaches, like you mentioned, some, well, some of this is sort of a gray area, in that a lot of the pharmacological, pharmacologic medicine medications are not, pregnant women were excluded in those studies.

So we don't really know what they do or don't do in pregnancy and what that risk profile is like. We have some animal studies, there's, you know, data collection going on with the pharmaceutical companies that have made these drugs. But a lot, most of them say don't use during pregnancy.

We do know that when women start to lose weight, they start ovulating and the chance of natural conception also will increase. So if they're on these medications, and then they get pregnant, you know, what do we do? And how are these medications going to impact their pregnancy? If we're actively treating, when do we tell women to stop these medications before, you know, they're back in your office getting pregnant. And it's all varied as to it can be anywhere from one to three months coming off these medications.

And we know that when people stop obesity treatment, the likelihood that they are going to regain all their weight also increases. So are we doing this temporarily to meet a certain goal, but then we know that it's going to then have, you know, negative impacts in the future. And truly, we don't know, we don't know the answers to a lot of these questions, what is the best thing to do? Because it's just we haven't looked at it, we haven't studied it.

We do know that with bariatric surgery, if someone's going to take a surgical approach to weight loss, outcome, pregnancy outcomes are best if they delay pregnancy for at least 12 months after surgery, even up to 18 months to two years with some data suggests. So it's really challenging to help people with the tools that we know that work really well, because we often have to stop those tools to prepare for pregnancy. So what I've always gone by is six to eight weeks after stopping the Ozempics and the Manjaros, and then one year following bariatric surgery.

But in women of advanced representative age, I've seen data that suggests six months, as long as all vitamins levels are appropriate and chemistries. Do you ascribe to that? Is that something that you think is reasonable? I think it's really patient dependent. If somebody's still rapidly losing weight, which many are in that first like six month period, I think introducing pregnancy too soon can certainly has an increase the risk of some other adverse outcomes beyond just some of the nutritional deficiencies.

If somebody is really sort of plateaued and is stabilized, I think it's absolutely something that could be considered. But I think you have to kind of look at the whole picture and really individualize that than just a blanket, you know, six months kind of. So do you agree with that study about the risks in pregnancy, the hypertensive and the diabetes? And was there anything that you wanted to add in terms of the complications of obesity and pregnancy? Um, yeah, I mean, just a couple things that you hadn't mentioned is, you know, I also I will also think of obesity as a teratogen, we do see higher rates of birth defects, just purely attributed to obesity, once other factors are controlled for.

And sometimes it's harder to detect some of those birth defects. So I think sometimes thinking of this, like a true condition can really help not only patients understand what what is at risk and why they might want to improve some of this or modify some of their health prior to their pregnancy. But also, you know, just an understanding kind of what what to expect and why we we do and recommend and manage pregnancies for women with BMIs that are higher the way we do.

We also know that there's much higher rates of stillbirth as well, and we start talking about the back end of pregnancy. So making sure they get monitored closely later on in the third trimester is really important to understand that too. It seems at least in my experience that the key is to demonstrate to the patient your empathy, you certainly understand their challenge.

I also try to get across the fact that this is a disease, as you mentioned, it's not a judgment. And weight loss is not a punishment, but a prescription. And we just have and there's not one size fits all, literally, you know, we have to adjust to what works best for the individual and have them realize you're taking ownership in their problem.

And you want to work with them as opposed to the unfortunate stories of dismissiveness because of a particular BMI cut off. I think it's it's an art and you and you put the whole picture together, as opposed to just having a strict cut off. Any pearls that you wanted to share with our listeners in terms of their approach to optimizing their health, particularly their weight prior to pregnancy? I think probably one of the biggest take homes is that you have to meet people where they are.

So, you know, assessing their readiness for change and in what stage are they in? Are pre-contemplation stage and working with them? And it's one thing to say, oh, you should only eat 1800 calories and you need to exercise 30 minutes a day. I mean, great. Like most people know this, but but really focusing down on like goals that are attainable, because when you when you make these big, huge goals and send somebody off, it most likely it's not going to happen.

I mean, data shows that's not going to happen. So like, what what can you do? Okay, so can you maybe increase your physical activity from one day to two days for the next three weeks and trying to help people anticipate what barriers they may have and helping them kind of come up with workarounds and and all that takes time and it takes patience and, you know, Rome isn't built in a day and making lifestyle changes and weight loss isn't something that's going to happen overnight. But recognizing that small little steps every single day will ultimately lead to big challenges, but really meeting people where they are so that you can work with them in a way that, like you said, it's individualized and in a way that's going to be successful for them.

Yeah, the journey toward a baby with the the challenge of obesity is really baby steps, but still moving forward. So inch by inch, life is a cinch. I always say yard by yard, life is hard.

So you don't look too far down the road. It's just really a little bit each day, but as long as there's consistency and progress. Yeah, and focusing on the small wins, you know, begets the next win, so.

Well, Lindsay, thank you so much. You're just a plethora of sage advice and I thank you for your contributions to the community for high-risk obstetrics and lifestyle medicine. I thank you all for listening.

Until next time, I'm Dr. Mark Trolice. Good luck to you all. Take care.

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates. These are provided as a source of general information and are not a substitute for consultation with a physician.