Obesity and Reproduction

Obesity and Reproduction Prof. Aboubakr Elnashar Email: elnashar53@hotmail.com •Obesity can affect every aspect of reproductive life, whether Metabolic, Clinical or Technical •Obesity can affect I. Menstruation II. Sexual function: Female & Male III. Fertility: Female & Male IV. Pregnancy The cost of management obese pregnant is 5 times higher than the average (Ramsay et al, 2006). Increased use of US: for difficult anomaly scans & fetal assessment Increased risk of: Hospital admission for complications: PET Operative delivery Postpartum complications: infection, haemorrhage, DVT Neonatal admission Precocious menarche (<9 y). Irregular cycles Oligo/amenorrhoea Critical body weight of 47.8 Kg (Frisch hypothesis). A greater percentage of body fat (16% to 23.5%) may serve as initiating signal. Moderately obese: earlier menarche. Morbid obesity: delayed menarche Leptin: a peptide secreted by adipose tissues acts on CNS neurons, regulating eating behavior & energy balance. Higher levels: earlier menarche. Difficulty of performance. Female: Impairment of Desire Arousal Orgasm Male: ED Difficulty of performance Obese women reported more impairment in sexual quality of life than obese men (Kolotkin et al, 2005). Male Thin Female Obese Best position Side to side Obese Obese Thin Obese Female superior Rear entry Female: •FSFI strongly correlated with BMI (Esposito et al, 2007). Of the 6 sexual function parameters, desire and pain did not correlate with BMI Arousal, lubrication, orgasm& satisfaction did. •Obese women reported significant impairment of desire, arousal, lubrication, orgasm, and satisfaction, compared to healthy controls (Kolotkin et al, 2005; Assimakopoulos et al, 2006) Male: ED in men aged 40-70 yrs is 50%. ED are increased in obese men, {complications of metabolic syndrome}. •Management of obesity: reduced risk for ED. Female: Anovulation Increased androgenization  PCOS Infertility Poor response to fertility drugs  Poor results to ART DVT {Drugs containing E} Male: Reduced semen quality Reduced testicular volume Reduced T/E2 & Decreased sperm concentration Infertility Female: PCOS: • Insulin resistance is an integral part, especially in obese women. • Hyperinsulinaemia revealed by excess wt gain promotes ovarian androgen secretion & abnormal follicular development: ovarian& menstrual dysfunction. •Androgens are carried in the circulation bound to SHBG. Conditions of high androgen & insulin concentrations: lower levels of SHBG: high free androgen activity. Clinical manifestation: 2 of 3 1. Irregular or absent ovulation 2. Hyperandrogenism (clinical or biochemical) &/or 3. Polycystic ovaries. HAIR-AN syndrome (hyperandrogenism, insulin resistance, acanthosis nigricans). Obesity, hirsutism, acne, and acanthosis nigricans are seen. •DVT {Medications that contain E (COCs) or resulting in high levels of endogenous E (ovulating drugs)} The combined effect of obesity & COCs: 10-fold increase of DVT •Poor outcome from gonadotrophin ovulation induction The most clinically useful predictors: obesity & insulin resistance. Male: 1. Reduced testicular volume 2. Reduced semen quality In both extremes of BMI (< 19 or > 30 kg/m2) suggesting impairment of spermatogenesis (Jensen et al, 2004). 3. Reduced T/E2 & Decreased sperm concentration: {Excessive conversion of T into E2 by aromatase enzyme in peripheral body fat [Fejes et al, 2006]. Disturbed testicular thermoregulation (Baker, 1998). } 4. Infertility A dose–response relationship Association between BMI & infertility was similar for older & younger men, suggesting that ED in older men does not explain the association (Sallmen et al, 2006) •Early Foetal anomalies Miscarriage Difficult US exam •Intrapartum Failure to progress Failure VBAC Shoulder dystocia CS Operative problems Anesthetic problems •Late PIH GDM Induction of lab •Postpartum Hge Infection DVT •Foetal Macrosomia Birth injury PNM/ PNM Fetal anomalies Spina bifida or omphalocele: 3 times Heart defect or multiple anomalies: Twice Miscarriage: •3 times more. •Encourage wt loss to maximize the chance of a successful pregnancy before treatment of infertility. PIH 2-3 fold increase US in morbidly obese: difficult. {Adipose tissue attenuates the US signal}. Diabetes 4 fold increase in risk of GDM. •Appropriate management: reduce the incidence of f macrosomia & perinatal morbidity. •Women with GDM are much more likely to develop diabetes, and this risk is greatest in obese women. •Therefore, 1. Wt loss & exercise. 2. Regular screening for T2DM. Venous thromboembolism. •Pregnancy is a prothrombotic state {increase in coagulation factors decrease in natural anticoagulants inhibition of fibrinolysis}. •Obesity treble the risk of thrombosis: pul embolism {Obese individuals: higher levels of factor VIII & factor IX} Increased rates of intrapartum complications •Increased rate of CS: Anaesthesia services need to be effective. •Failure of VBAC: Success < 15% . Fetal macrosomia is a risk factor for: 1. lower Apgar score at 1 min 2. lower umbilical artery pH level 3. Severe injuries to the baby. Morbidity is increased by 8%. Admission to a NICU Significantly higher {increased rates of antenatal complications and complications secondary to macrosomia}. Breast feeding less likely. Management of obese pregnant I. Before pregnancy 1. Healthy lifestyle, healthy diet , exercise, lose weight, folic acid supplements, to use contraception while aiming for target wt Gynecology & Prepregnancy clinics. 2. Surgical treatment of obesity in young women have been suggested by some authors. II. During pregnancy 1. Exercise in pregnancy: a. Exercise that uses upper or lower extremity ms while recumbent do not increase uterine contractions, PTL or poor Apgar scores (de Veciana & Mason, 2000). b. Gentle aerobic exercise c. Walking (Homko et al, 1998). • Significantly higher birth wt. Reduce pregnancy complications e.g. GDM 2. Healthy diet, avoid excess wt gain BMI Weight gain, Kg Lean <20 12-18 Normal 20-25 12-16 Over weight 25-30 7-12 Obese >30 7 3. Thromboprophylaxis if needed (graduated compression stockings, hydration, early mobilization, heparin) 4. low dose aspirin in the presence of additional risk factors (obesity is associated with increased risk of PET) 5. Screening for congenital abnormality: anomaly scan, serum 6. Screening for GDM III. During labour 1. Anaesthetic consultation before delivery 2. Plan delivery to allow optimum management by experienced obstetricians VI. Postpartum 1. Prophylactic antibiotics if delivery is complicated 2. Thromboprophylaxis if indicated Consider extended thromboprophylaxis after discharge 3. Postnatal review at 6w To discuss any problems and future intervention Best targeted at women with BMI > 35. Pregnancy after Bariatric surgery •Effects 1. No adverse on perinatal outcome 2. Complications are less: GDM, PIH, macrosomia,CS 3. Deficiency of iron, vit B12, folate, calcium LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING Counseling Before pregnancy 1. Unexpected pregnancy can occur after wt loss following surgery 2.Delay pregnancy for 12-18 ms {avoid pregnancy during the rapid wt loss phase} During pregnancy 1.Surgical monitoring {adjustment of the band may be necessary} 2.Evaluate nutritional deficiencies: vitamins supplementation when necessary Thank You Aboubakr Elnashar