Fertility Advice for Overweight and Obese Women

by Rebecca Smith Waddell

Here's What You'll Find Below:Most common weight-related reasons for infertility
Affects of weight on conception and pregnancy
Finding a weight-friendly health care provider
Test you can expect
Concerning medication
Improving the chance of getting pregnant
Controlling weight while making a baby

Does extra weight alone compromise fertility?

No, one should not assume weight alone is a problem. It can be, but it is not a given. In fact, weight is probably only a factor less than 10 percent of the time. The primary obstacle for overweight women is ovulation. If your physician suggests all your problems will be solved simply by losing weight, seek a second opinion because even if your weight is an issue, it is something medications can work around.

What are the most common weight-related reasons for infertility?

The two most common problems are excess estrogen and polycystic ovaries (PCOS). Along with both of these is a greater chance of a luteal phase defect (LPD).

Estrogen: Fat cells produce estrogen. The problem is that if you get too much estrogen your body reacts as if it is on birth control. Ovulation may not occur or it may be inadequate. An inadequate ovulation contributes to LPD, mentioned below.

PCOS: This is a endocrine disorder with any combination of several symptoms. These symptoms include irregular cycles, cysts in the ovaries, ovulatory pain, anovulation, acne, excess body hair (face, chest, below navel, toes), heavy and painful periods, as well as a high LH-FSH ratio (>3:1). Diagnosis involves both a physical exam, usually including an ultrasound to check ovaries, and blood work. Recommended blood tests will be addressed later in this document. See web sites and medical journal abstracts for more information.

LPD: The luteal phase in the time between ovulation and menses. The ideal length is 14 days, 12-16 being normal. There are a number of ways to diagnose the problem, including serum progesterone tests 7 days post-ovulation, endometrial biopsies, and the length of the luteal phase can be observed by charting basal body temperatures and/or being aware of when ovulation occurred. LPD can be caused by inadequate ovulation, so improving the quality and perhaps quantity of follicles produced will help straighten things out so that the lining is properly supported.

Does weight effect conception rates? What about body fat distribution?

There was a study published in the British Medical Journal that found that very lean women and very obese women (BMI >38) had lower conception rates. However, body fat distribution was found to have a greater impact. Women with a high waist-hip ratio had greater trouble conceiving -- so being shaped like an apple is not as good for conception as being shaped like a pear. PCOS women may be more likely to have the apple shape.

Does the extra weight put me at risk for pregnancy complications?

Extra weight can be related two pregnancy problems: gestational diabetes and pre-eclampsia. Generally speaking, gestational diabetes is very controllable. One thing that is very important to remember is that even though you may be at higher risk for something, it doesn't mean you are at a high risk. It also doesn't mean that you are not entitled to have a baby.

There used to be some trouble is gauging the size of a baby being carried by a large woman, but with the use of transvaginal ultrasounds dating a pregnancy isn't as hard as it used to be. Large women are at higher risk of having babies with neural tube defects, but it still isn't a high risk. It is possible that folic acid supplements will reduce the risks, though there is one study that disagrees with that.

Does the extra weight put me at greater risk of a miscarriage?

Women who have PCOS may be have a higher statistical chance of miscarriage than the general population. The reason for this increased risk is that many PCOS women have elevated LH, and that kind of hormone imbalance appears to effect some pregnancies. There is research in progress to determine how this can be better managed and lower the risk. Excess weight does not contribute to miscarriage; however, PCOS, which is common in overweight women, does create a higher statistical chance of pregnancy loss than in the general population. The reason is related to hormone imbalance. Both elevated LH and testosterone are linked to miscarriage. There are treatments available that help to minimize these risks.

What are the potential problems of being large and seeking fertility help?

Some of the tests may be harder to run, but not enough so that you should be frightened. BBWs make higher risk patients for laparoscopy, for example, but it usually can be done by a skilled surgeon. Make sure your doctor is comfortable in doing the surgery on you -- confidence goes a long way!

There is also the potential of having trouble seeking medical care from a qualified reproductive endocrinologist or OB/GYN. Sometimes you have to put up with some rudeness before you find the right place to be treated, but it really should be possible to find a doctor to treat your fertility problem no matter how overweight you are.

How do I deal with a fat-phobic doctor?

You don't! You find yourself a good doctor. It's a pretty horrible feeling when a doctor refuses to treat you because you are large, or suggests you have to lose weight before you will be helped. There is always a smarter, more compassionate doctor out there. What you need to do is not let the monster doctor get to you and find yourself someone better.

What should I expect from a good doctor who is willing to help me?

You should expect to be treated with respect and tested in the same manner a thinner woman would be. Probably the first things a large woman should be tested for are PCOS and LPD. Check out some of the infertility sites and see what normal testing involves.

How do I find a fat-friendly physician?

There isn't a set way to do this -- no database hiding somewhere -- but here are some suggestions:

  • Ask some of your overweight friends who they see as a doctor, especially women who are large and pregnant or have children. This may lead you to a good OB/GYN, which is a reasonable place to start infertility treatment, even though a reproductive endocrinologist is desirable (that's the real infertility specialist).
  • Compile a list of infertility doctors. You can get names from your local Resolve chapter as well as from friends and people online. Once you get the names, phone numbers and address, decide on your next approach. Your options are:

Make an appointment and see what happens. If you do this, try to set it up so that you will meet the doctor fully clothed. You don't want to be undressed and feeling vulnerable.

Call and ask to speak with the doctor or one of his nurses. Be blunt and ask about the doctor's feelings toward treating large women. If there is any hesitation or doubt, keep calling around.

Write to all the doctors on your list and explain your situation, including your weight (be honest!). Ask if s/he would be willing to help you find out what is wrong and then help you to get pregnant. Not all of the doctors will respond, but most likely you will find someone who will treat you with respect and really want to help you.

What tests should I expect?

Ideally you should start out with a consultation, fully clothed, to discuss what tests should be done in what order. Generally speaking the first step is a physical exam that include checking your breasts, lymph nodes, and pressing on your abdomen to feel ovaries and uterus. After that an internal exam is done to check your cervix for signs of infection. A pap smear will be done if it's been over a year since you had one, and depending how things look, cultures may be taken. If the doctor's office is properly equipped, you should also have an ultrasound to look for cysts and any abnormalities which may be visible. Sometimes both an abdominal and a transvaginal ultrasound will be done.

Usually the next step is blood work. Many OB/GYNs will do all the tests at once, while REs will do specific levels on different days of the cycle.

Day, Test Normal Result
Day 3 FSH (follicle stimulating hormone) range 3-20 mlU/ml
Day 3 E2 (estradiol or estrogen) range 25 - 75 pg/ml
Day 3 LH (luteinizing hormone) range 5 - 20 mlU/ml
Day 3 Prolactin less than 25 ng/ml
Day 10 FSH range 9-28 mlU/ml
(about twice day 3 level)
Day 12-14 E2 200-600 pg/ml for 1 follicle at about 18mm
Surge Day LH range 25-40 mlU/ml
Day 21 Progesterone (or 7 days post-ov) greater than 14 ng/ml
TSH (thyroid stimulating hormone) 0.4-3.8 uIU/ml
Free T3 1.4-4.4 pg/ml
Free Thyroxine (T4) 0.8-2.0 ng/dl
Total Testosterone 6.0-86 ng/dl
Free Testosterone 0.7-3.6 pg/ml
HEAS 35-430 ug/dl
Androstenedione 0.7-3.1 ng/ml

After the hormone levels comes some of the more invasive tests. An endometrial biopsy happens toward the end of you cycle. Some doctors do this in place of, or in addition to, blood progesterone levels. It's done by threading a small catheter through the cervix and up into the uterus to take a sample of the endometrium. It's usually a few days before you get the pathology report back.

Usually the next test is a hysterosalpingogram. Some people call this the dye test. Dye in injected through the cervix while the uterus is being x-rayed -- usually both as a video and as a few stills. hysteroscopy is done for some patients -- where a scope is inserted through the cervix to view the inside of the uterus -- but more commonly patients have a laparosopy. This gives a view of the uterus, ovaries and tubes.

If I go on fertility drugs, will I need more meds because of my size?

You might, but fertility treatment is very individual. There is a study on clomiphene citrate that indicates that higher doses are needed for women with a larger body mass index, and a similar finding for gonadatropins.

Will I need a longer needle for intramuscular shots?

Again, you might. It depends how overweight you are, how you carry your weight, and where you are doing the shots. I think a common change is from a 1½" needle to a 3"needle. Also, Metrodin, one of the more common injectables, is now available in a subcutaneous version called Fertinex, and that is a shorter needle. Will I have problems with medications that are for subcutaneous injection?

Some overweight women do not appear to respond as well to subcutaneous injections. Fertinex, for example, seems to be less effective in people as little as 20 pounds overweight if given with a very short needle. Follistim seems to do better, one of the new recombinant FSH medications, but the manufacturer, Organon, had it FDA approved for intramuscular injections in obese women. There is always the option of getting a slightly longer needle to get under the fat layer better, or doing the shot IM. Choosing a part of your body that is less fat usually helps as well -- arms, thighs and stomach are common injection sites. Discuss the options with your doctor.

If I need some of the invasive tests, like a laparoscopy, how will that be effected by my size?

Some doctors won't do a laparoscopy on a heavy patient, though there are some who will. The risks here are with anesthesia and a slightly elevated chance of perforating something while trying to look around with the scope. A hysteroscopy could be a potential anesthesia problem also, but an IV or a local anesthetic might work out fine.

With a hysterosalpingogram there is a chance that the x-ray machine may have to crowd you a bit, or even touch you, in order to get a good picture. This isn't a big deal, and it doesn't add pain or risk to the test.

Endometrial biopsies shouldn't be any problem, though they aren't very comfortable.

What are some suggestions for dealing with people who suggest my problems are purely weight-related and that I should diet before trying to get pregnant?

I think the biggest argument against losing weight first is that 95% of people who diet to lose weight gain it back with interest. It would be worse to gain a large amount of weight while pregnant than it would be to start out large.

The other thing is that there is no way to know for sure if you aren't getting pregnant because of your weight or because of something else. Plenty of big women have babies, so it stands to reason that weight alone doesn't disallow pregnancy. You have to decide whether it would be better for you to concentrate on losing weight or finding out what the problem is. If you do opt for losing weight, calculate how long it will take you to reach your goal, and then add a year -- it's a good idea to keep the weight off for a year before getting pregnant. If you decide to move ahead at your current weight, make sure you are eating sensibly and get good medical care.

What can I do to improve my chances of getting pregnant?

There are some things you can do for yourself without the help of a doctor.

Chart your basal body temperature (BBT). You need to buy a basal thermometer. A glass one costs about $5, but you have to wait 5 minutes before you get out of bed. For that reason, it is probably better to invest $10 and a B-D digital basal thermometer. These thermometers are more accurate than ones for fever, and accuracy counts for a lot! Once you have one, you should start taking your temp each morning at the same time, before you do any activity (speak, move around, get up, etc.).

Along with this, it is a good idea to chart your other fertility signals such as cervical mucus and cervical position. A wonderful book on the subject is Taking Charge of Your Fertility by Toni Weschler. There is a BBTchart spreadsheet available for download that is tailored toward conception (some fertility awareness charts are geared also toward contraception).

Next, invest in some ovulation predictor kits. OPKs let you know ovulation is about to happen, while BBTs only confirm it after the fact.

Take prenatal vitamins or the equivalent. A multi such as Centrum, combined with additional folic acid (make sure to get at least 800mcg) and calcium should be good.

Think about how you would eat if you were pregnant. Not so much in quantity, but in quality. Try changing your eating plan to be as healthy as you'd want it if your were pregnant, whether or not you are trying to lose weight.

Get informed. Check the web and newsgroups. Be an informed concern and an advocate in your health plan. Not only will you help yourself, you'll be better able to speak with your doctor.

What about the concern that I will gain a lot of weight while I am pregnant?

Overweight women often gain less weight than our leaner counterparts during pregnant and that's fine. The main concern is eating properly - not over-eating, and definitely not dieting. Pregnancy is not the time to try to lose weight.

Should I try to lose weight before trying to get pregnant?

If it makes you feel more comfortable, yes, but only if you are doing it for yourself. It is not something you should feel as if you have to do. Some information out there suggests one should only attempt a 20-pound loss because of the gain-back potential, while others suggest getting down to your goal weight and staying there for a year.

Keep in mind that rapid weight loss can cause fertility problems such as a reduction in progesterone, a slow down in follicle growth, and ovulatory dysfunction. It is certainly more important to have a balanced diet then to be the perfect weight.

Can I try to lose weight while I try to get pregnant?

You can try to do both together if you do it sensibly. Eating an adequate diet in necessary regardless of what supplements you are taking. The goal should be to lose weight slowly and intelligently using an eating plan that would be good for pregnancy, and actually for the rest of your life! If it isn't a life-plan change, it won't work. Be sure to get plenty of folic acid and calcium. One should start taking pre-natal vitamins, or the equivalent, at least 3 months before trying to get pregnant.

Can I take diet drugs while trying to get pregnant?

No. Diet drugs have not been fully tested in pregnancy, for one thing, but more importantly such dieting can lead to poor nutrition. You want a healthy baby, so it is best to keep your system as drug free as possible. Some literature suggests one should try to be drug free -- including over the counter medications, for 3 months prior to seeking pregnancy. See medical journal abstracts.

What happens if I get pregnant while on diet drugs?

Stop taking the diet drugs as soon as you know you are pregnant. Tell your physician you were on the drugs so that s/he is aware. Chances are your baby will be fine. You need to start eating a balanced diet as soon as you learn you are expecting.

I'm anovulatory. How much weight would I need to lose to get my cycle back to normal?

It may not take that much weight loss to get your cycle back. There are studies showing improved cycling with the loss of 12-20 pounds, while other information says losing 20 percent of your body weight may help if you are 100 percent or more over your "ideal" weight (i.e., if you weigh 300 pounds, lose 60 pounds and your cycles may return to normal).

My period is very irregular. How long can I let it go without seeing a doctor?

It's best not to go more than 3 cycles without having a period, definitely no longer than six months. You should see your physician to have your period induced, usually with a drug called Provera, or sometimes Megace.

Copyright © by Rebecca Smith Waddell, FertilityPlus.org. Permission to publish granted to Pregnancy.org, LLC.