I worked with Allison to develop an individualized treatment plan that addressed nutrition (she wanted to adopt the Mediterranean diet since it seemed sustainable), exercise (we identified several forms of physical activity she enjoyed that fit her schedule) and behavior modification (for example, we shifted her meal timing earlier and discussed techniques to avoid stress-eating). As part of this plan, we also started on metformin, a great option in cases like hers, because it can help with weight loss, it can help restore ovulation, and it is generally considered safe to take during pregnancy.

After a few months, Allison had lost 20 pounds and she began to ovulate; however, she had not yet conceived so she elected to start fertility treatment.

This meant her weight management program would be even more critical.

Weight gain associated with fertility treatment

Since hormones affect weight, hormonal therapy to enhance ovulation (whether pills or the multiple shots that the in vitro fertilization process entails) often leads to weight gain. This gain can be significant, especially for patients with insulin resistance and patients who, like Allison, have overweight or obesity.

While we don’t want to add to patients’ anxiety during the stress of fertility treatment, it is important for us as providers to be mindful of the potential for weight gain. Fertility-treatment-related weight gain can have a long-term impact because successful treatment means pregnancy — and thus pregnancy weight gain — and it’s often difficult to lose the cumulative excess pounds afterward. For women with multiple pregnancies, the extra weight can add up quickly. One of my patients, for example, gained 70 pounds with her first pregnancy and then lost only 20 pounds before conceiving again. She presented to me during her second pregnancy, and we’re working on strategies to avoid excessive weight gain this time.

Excess weight is associated with various health complications during pregnancy, including hypertension, diabetes, obstructive sleep apnea and preeclampsia, as well as an increase in the child’s risk of congenital anomalies. Women’s healthcare providers often hesitate to bring up the topic of weight, but both mother and baby could benefit significantly if more fertility specialists and OB-GYNs (nonjudgmentally) asked patients’ permission to discuss the issue — and then monitored their weight at appointments and took appropriate action as needed.

Managing weight during fertility treatment

Cases like Allison’s are extremely common, so it’s important for women’s healthcare providers of all kinds to be aware of the options and limitations of weight management during fertility treatment. Most anti-obesity medications are off the table for patients during this time, but there are still a number of steps practitioners can take to help their patients avoid excessive weight gain:

• Optimize lifestyle interventions. Dietary strategies, physical activity and recommended behavioral modifications may be more effective when tailored to the patient’s specific lifestyle. Referrals to outside resources, such as a dietitian or behavioral therapist, for instance, can be great options if additional support is needed.

• Address other contributors to weight gain. Stress, lack of sleep and many factors unrelated to the conventional diet-and-exercise combo contribute to weight gain, and all of these contributors may be in play during fertility treatment. Patients benefit from a personalized plan that addresses these as well.

• Assess for drug-induced weight gain. Many medications are known to promote weight gain, so consider pausing these medications or reducing the dose during fertility treatment, if possible, when substitution with weight-neutral agents isn’t an option. Critical medications obviously need to be maintained, but a risk-benefit analysis might suggest that others should be discontinued.

• Consider prescribing metformin. Some gynecologists and reproductive endocrinologists may be comfortable prescribing the diabetes medication, metformin, for patients with overweight, obesity or insulin resistance, or for those at high risk of weight gain. In addition to improving insulin sensitivity and helping to balance hormones, metformin is a weight-loss-promoting medication and can thus help decrease weight gain associated with fertility treatment.

• Refer to an obesity medicine specialist. While we generally can’t use anti-obesity medications during fertility treatment, patients may benefit from a comprehensive medical evaluation and a personalized treatment plan. A thorough plan is particularly important when a patient is unable to conceive quickly and undergoes fertility treatment for a prolonged period. (I currently have one patient, for example, who has gained 40 pounds over the course of seven months of fertility treatments and still isn’t pregnant.)

Supporting better outcomes for mother and child

Women with overweight or obesity who plan to become pregnant are often counseled to lose weight before trying to conceive, both to enhance fertility and to reduce the risk of health complications for themselves and their babies. This recommendation often becomes more explicit before a woman begins fertility treatment — and obesity medicine specialists like me receive many referrals at this juncture.

The more time we have to treat a patient’s obesity beforehand, the more we can do, of course, but we can still help even after treatment begins. While managing weight during fertility treatment is a challenge, it’s not a lost cause. Taking steps to counteract the potentially weight-promoting effects of hormone therapy can significantly impact the health of the woman and her future child. This is a challenge that impacts many generations to come. We can do this together!

The post Weight Management During Fertility Treatment: A Challenge But Not a Lost Cause appeared first on Medika Life.

She had never been diagnosed, but Jennifer’s symptoms immediately suggested polycystic ovarian syndrome (PCOS). PCOS is a common endocrine condition (affecting 4%–18% of women of reproductive age, depending on the diagnostic criteria used) involving changes in two types of hormones: androgens and insulin. Increased androgens can cause growth of excess body or facial hair, acne, and hair loss from the scalp, while increased insulin can lead to acanthosis nigricans and skin tags, weight gain (especially around the waist), and difficulty losing weight. Both hormones can cause menstrual irregularity, inhibit ovulation and reduce fertility. They can also increase risk of earlier onset type 2 diabetes, produce mood changes, and result in other negative psychological effects.

Naturally, not all women with PCOS experience every potential sign and symptom, but the wide variety of manifestations means that a range of health providers — primary care physicians, OB-GYNs, endocrinologists, dermatologists and obesity medicine specialists, for example — may care for patients with PCOS.

The condition frequently goes undiagnosed, though, especially in women who are on birth control and thus don’t have irregular periods. When PCOS is diagnosed, treatment often focuses on relieving specific symptoms (for example, regulating menstruation or eliminating excess hair) without addressing underlying or exacerbating factors — including, more often than not, excess weight.

The need for a weight-centric approach

While obesity’s role in the development of PCOS varies among patients, the two conditions are closely correlated. Some studies suggest that up to 80% of women with PCOS in the U.S. have overweight or obesity. Furthermore, obesity exacerbates many of the signs and symptoms associated with PCOS, as well as the underlying hormonal abnormalities. Obesity also impacts the progression of insulin resistance and development of metabolic syndrome. For this reason, treating the patient’s obesity is often an early step in managing PCOS.

Many providers are aware of the nexus between obesity and PCOS, but they either don’t realize the extent to which weight loss can improve outcomes — restoring regular menstruation, enhancing response to ovulation-inducing medications, and improving androgen levels as well as metabolic markers — or they assume their patients have already tried to lose weight so there’s no point in bringing it up. Unfortunately, many providers don’t feel comfortable talking to their patients about their weight, let alone treating it.

This hesitancy to address obesity is a disservice to patients, though, and the benefits of weight management in the treatment of PCOS need to be more widely recognized, just as they are in the treatment of type 2 diabetes. Since weight loss can lead to significantly improved health outcomes for individuals with type 2 diabetes, weight management is incorporated regularly into diabetes and pre-diabetes care. There’s also a growing focus on substituting medications that promote weight gain.

“The push in the field of endocrinology is to practice weight-centric rather than glucose-centric diabetes management,” says my endocrinologist colleague Dr. Leon I. Igel. “While controlling glucose levels remains paramount, doing so via medications that cause weight gain should be avoided, as this can lead to patients not following the treatment plan, as well as worsening of obesity-related health complications. Practitioners are encouraged to prioritize weight-loss-promoting or weight-neutral medications as first-line treatment in type 2 diabetes. We should take a similar approach in PCOS management, where certain weight-gain-promoting oral contraceptives, for example, are sometimes prescribed.”

Pharmacotherapy steps up

Not all patients with PCOS have overweight or obesity, but for the many who do, the diabetes medication metformin can be an effective first-line treatment to promote weight loss (in combination with a healthy diet and physical activity) while helping to balance hormones. A glucagon-like peptide 1 (GLP-1) receptor agonist, such as liraglutide or semaglutide, can be considered as a second-line treatment if metformin is ineffective. We have a growing armamentarium of pharmacotherapy options to support weight management, including medications approved specifically for obesity treatment and medications that treat both weight and insulin resistance that can be prescribed off-label. Finally, I couldn’t be more excited about the promising new medications in the pipeline.

Jennifer expressed relief when I suggested a potential diagnosis of PCOS because it provided an explanation for all her signs and symptoms, and it allowed her to stop blaming herself for her inability to lose weight. She responded well to metformin, which we introduced together with a low-glycemic diet and increased physical activity. Within a few months, not only had Jennifer begun to lose weight, but her periods normalized and her skin conditions improved as well.

Weight loss for better patient outcomes

Obesity is a complex multifactorial disease, and the fact that it affects so many body systems and it is linked to so many other conditions (PCOS is just one of 200 medical conditions associated with obesity!) can feel daunting. But the flipside is that effectively treating obesity can have a tremendously positive impact on many of these correlated conditions, even if we don’t understand all of the physiological mechanisms or causal pathways in every case.

And sometimes it doesn’t take much, because even a small amount of weight loss can lead to better clinical outcomes. For example, we can see improved glucose tolerance with a loss of just 2.5% of body weight. Improvements in menstrual irregularities and a subsequent successful pregnancy are more likely with a loss of 2%–5%, with more weight loss leading to a greater benefit.

Jennifer’s story is not at all unusual. Weight loss, especially with the help of a medication that simultaneously combats insulin resistance and hormone imbalance, is one of the most effective ways to treat PCOS in women with obesity — though it’s not a silver bullet, of course.

Providers who don’t feel comfortable counseling about diet and exercise or prescribing metformin or other weight-loss-promoting medications can refer their patients to an obesity specialist. An important first step is to recognize the correlation between PCOS and obesity, and start thinking about weight loss as a way to help patients achieve the outcomes that matter to them — whether that means getting pregnant, alleviating distressing acne, or reducing the long-term risk of developing type 2 diabetes and cardiovascular disease.

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