IVF outcomes in patients with a history of bariatric surgery: a multicenter retrospective cohort study

Abstract

STUDY QUESTION How does a history of dramatic weight loss linked to bariatric surgery impact IVF outcomes? SUMMARY ANSWER Women with a history of bariatric surgery who had undergone IVF had a comparable cumulative live birth rate (CLBR) to non-operated patients of the same BMI after the first IVF cycle. WHAT IS KNOWN ALREADY In the current context of increasing prevalence of obesity in women of reproductive age, weight loss induced by bariatric surgery has been shown to improve spontaneous fertility in obese women. However, little is known on the clinical benefit of bariatric surgery in obese infertile women undergoing IVF. STUDY DESIGN, SIZE, DURATION This exploratory retrospective multicenter cohort study was conducted in 10 287 IVF/ICSI cycles performed between 2012 and 2016. We compared the outcome of the first IVF cycle in women with a history of bariatric surgery to two age-matched groups composed of non-operated women matched on the post-operative BMI of cases, and non-operated severely obese women. PARTICIPANTS/MATERIALS, SETTING, METHODS The three exposure groups of age-matched women undergoing their first IVF cycle were compared: Group 1: 83 women with a history of bariatric surgery (exposure, mean BMI 28.9 kg/m2); Group 2: 166 non-operated women (non-exposed to bariatric surgery, mean BMI = 28.8 kg/m2) with a similar BMI to Group 1 at the time of IVF treatment; and Group 3: 83 non-operated severely obese women (non-exposed to bariatric surgery, mean BMI = 37.7 kg/m2). The main outcome measure was the CLBR. Secondary outcomes were the number of mature oocytes retrieved and embryos obtained, implantation and miscarriage rates, live birth rate per transfer as well as birthweight. MAIN RESULTS AND THE ROLE OF CHANCE No significant difference in CLBR between the operated Group 1 patients and the two non-operated Groups 2 and 3 was observed (22.9%, 25.9%, and 12.0%, in Groups 1, 2 and 3, respectively). No significant difference in average number of mature oocytes and embryos obtained was observed among the three groups. The implantation rates were not different between Groups 1 and 2 (13.8% versus 13.7%), and although lower (6.9%) in obese women of Group 3, this difference was not statistically significant. Miscarriage rates in Groups 1, 2 and 3 were 38.7%, 35.8% and 56.5%, respectively (P = 0.256). Live birth rate per transfer in obese patients was significantly lower compared to the other two groups (20%, 18%, 9.3%, respectively, in Groups 1, 2 and 3, P = 0.0167). Multivariate analysis revealed that a 1-unit lower BMI increased the chances of live birth by 9%. In operated women, a significantly smaller weight for gestational age was observed in newborns of Group 1 compared to Group 3 (P = 0.04). LIMITATIONS, REASONS FOR CAUTION This study was conducted in France and nearly all patients were Caucasian, questioning the generalizability of the results in other countries and ethnicities. Moreover, 950 women per group would be needed to achieve a properly powered study in order to detect a significant improvement in live birth rate after bariatric surgery as compared to infertile obese women. WIDER IMPLICATIONS OF THE FINDINGS These data fuel the debate on the importance of pluridisciplinary care of infertile obese women, and advocate for further discussion on whether bariatric surgery should be proposed in severely obese infertile women before IVF. However, in light of the present results, infertile women with a history of bariatric surgery can be reassured that surgery-induced dramatic weight loss has no significant impact on IVF prognosis. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by unrestricted grants from FINOX—Gédéon Richter and FERRING Pharmaceuticals awarded to the ART center of the Clinique Mathilde to fund the data collection and the statistical analysis. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER NCT02884258

The effects of bariatric surgery on periconception maternal health: a systematic review and meta-analysis

“…While Goldman et al (2016) reported that miscarriage occurred more often after RYGB (OR 9.81, 95% CI 1.12–85.71), two other articles observed no change in either miscarriage rate (38.7% vs 56.5%, P = 0.256) or recurrent miscarriages (OR 1.8 95% CI 0.6–5.2, P = 0.208) ( Sheiner et al , 2006 ; Grzegorczyk-Martin et al , 2020 ).…”

“…One article reported no significant difference in AMH between bariatric surgery patients and non-operated obese patients (mean ± SD 4.6 ± 5.4 vs 3.9 ± 4.0 ng/ml, P = 0.08) ( Grzegorczyk-Martin et al , 2020 ). On the other hand, Nilsson-Condori et al (2018) did find a significant decrease in AMH, free androgen index, androstenedione and testosterone 12 months postoperatively ( P < 0.05), whereas SHBG and oestradiol increased significantly ( P < 0.05) and LH and FSH did not change ( P > 0.05).…”

“…Moreover, there was no significant difference in the need for ART between their post-bariatric patients and controls ( Goldman et al , 2016 ). Live birth rate per transfer was higher in post-bariatric women than in non-operated obese controls (20.0% vs 9.3%, P = 0.017) ( Grzegorczyk-Martin et al , 2020 ). Menke et al (2019) reported that post-bariatric women with a history of infertility showed a higher conception rate (121.2, 95% CI 102.3–143.5 per 1000 woman-year) than women without previous infertility (47.0, 95% CI 34.2–62.9 per 1000 woman-year), P < 0.001.…”

Lifestyle intervention prior to IVF does not improve embryo utilization rate and cumulative live birth rate in women with obesity: a nested cohort study

“…Moreover, our intervention protocol also aimed to increase moderate physical activity ( van Elten et al , 2018 ), while no intervention on physical activity was included in the RCT reported by Einarsson. Additionally, a recent exploratory retrospective study illustrated that the number of good-quality embryos did not significantly differ between women who underwent bariatric surgery resulting in a mean BMI of 28.9 kg/m 2 and women with a mean BMI of 37.7 kg/m 2 who did not have surgery ( Grzegorczyk-Martin et al , 2020 ). Although the differences between these studies complicate comparisons of the results, all studies point in the same direction: after intervention with diet in combination with exercise, or LCD, or bariatric surgery to reduce body weight in women with obesity, no improvement was found regarding embryo quality or EUR as proxy for embryo quality.…”

The threshold effect of factors associated with spontaneous abortion in human-assisted reproductive technology

“…However, given that aging is a complex process, it is difficult to define the threshold point to make it clear that all events have the same result. In addition, ART patients are usually older and more likely to have some reproductive endocrine and pelvic diseases as well as immune system abnormalities 10 , 11 . Patients receiving ART-assisted pregnancy also require large doses of ovarian stimulation drugs, which further increase the possibility of fetal growth restriction and abortion 6 .…”