Obesity and Reproduction

1. Obesity and
Reproduction
Aboubakr Elnashar
Benha university, Egypt
Email: elnashar53@hotmail.com
ABOUBAKR ELNASHAR

2. ABOUBAKR ELNASHAR

3. ABOUBAKR ELNASHAR

4. ABOUBAKR ELNASHAR

5. ABOUBAKR ELNASHAR

6. •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
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7. 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
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8. Precocious menarche (<9 y).
Irregular cycles
Oligo/amenorrhoea
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9.  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.
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10. Difficulty of
performance.
Male:
ED
Female:
Impairment of
Desire
Arousal
Orgasm
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11. Male Female Best position
Thin Obese Side to side
Obese Thin Female
superior
Obese Obese Rear entry
Difficulty of performance
Obese women reported more
impairment in sexual quality of life
than obese men
(Kolotkin et al, 2005).
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12. 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: significant impairment of
desire, arousal, lubrication, orgasm, and
satisfaction
(Kolotkin et al, 2005; Assimakopoulos et al, 2006)
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13. Male:
•ED
40-70 yrs: 50%.
increased in obese men,
{complications of metabolic syndrome}.
Management of obesity: reduced risk for ED.
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14. Male:
Reduced semen quality
Reduced testicular
volume
ReducedT/E2 &
Decreased sperm
concentration
Infertility
Female:
Anovulation
Increased androgenization
 PCOS
Infertility
Poor response to fertility drugs
 Poor results to ART
DVT {Drugs containing E}
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15. Female:
PCOS:
• Insulin resistance:
 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.
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16. HAIR-AN syndrome (hyperandrogenism,
insulin resistance, acanthosis nigricans).
Obesity, hirsutism, acne, and acanthosis
nigricans are seen.
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17. •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
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18. •Poor outcome from Gnt ov induction
The most clinically useful predictors:
obesity & insulin resistance.
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19. Male:
1. Reduced testicular vol
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). }
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20. 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)
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21. •Early
Foetal anomalies
Miscarriage
Difficult US exam
•Late
PIH
GDM
Induction of lab
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22. •Intrapartum
Failure to progress
Failure VBAC
Shoulder dystocia
CS
Operative problems
Anesthetic problems
•Postpartum
Hge
Infection
DVT
•Foetal
Macrosomia
Birth injury
PNM/ PNM
V. Labour
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23. 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.
ABOUBAKR ELNASHAR

24. PIH
2-3 fold increase
US in morbidly obese:
difficult.
{Adipose tissue
attenuates the US signal}.
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25. Diabetes
4 fold increase in risk of GDM.
•Appropriate management:
reduce f macrosomia & perinatal morbidity.
•Women with GDM
much more likely to develop diabetes, and this risk
is greatest in obese women.
•Therefore,
1. Wt loss & exercise.
2. Regular screening for T2DM.
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26. Venous thromboembolism.
•Pregnancy
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}
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27. Increased rates of intrapartum complications
•Increased rate of CS:
Anaesthesia services need to be effective.
•Failure of VBAC:
Success < 15% .
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28. 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%.
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29. Admission to a NICU
Significantly higher
{increased rates of
antenatal complications
complications secondary to macrosomia}.
Breast feeding
less likely.
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30. 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.
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31. BMI Lean
<20
Normal
20-25
Over weight
25-30
Obese
>30
Weight gain, Kg 12-18 12-16 7-12 7
II. During pregnancy
1. Exercise in pregnancy:
a. Exercise that uses upper or lower extremity ms while
recumbent do not increase ut 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
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32. ABOUBAKR ELNASHAR

33. 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
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34. III. During labour
1. Anaesthetic consultation before delivery
2. Plan delivery to allow optimum management by
experienced obstetricians
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35. VI. Postpartum
1. Prophylactic antibiotics
if delivery is complicated
2.Thromboprophylaxis if indicated
Consider extended thromboprophylaxis after
discharge
3. Postnatal review at 6w
Discuss: any problems
future intervention
Best targeted at women with BMI > 35.
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36. Pregnancy after Bariatric surgery
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37. •Effects
1. No adverse
on perinatal outcome
2. Complications are less:
GDM, PIH, macrosomia,CS
3. Deficiency
of iron, vit B12, folate,
calcium
LAPAROSCOPICADJUSTABLEGASTRIC BANDING
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38. 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
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39. (‫ال‬ ‫إنه‬ ‫تسرفوا‬ ‫وال‬ ‫واشربوا‬ ‫وكلوا‬
‫المسرفين‬ ‫يحب‬)
-‫األعراف‬ ‫سورة‬31-
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40. Thank You
ABOUBAKR ELNASHAR