Obesity Could Hurt Your Chances With Assisted Reproductive Technology
Assisted reproductive technology (ART) has been a blessing for many couples and individuals who aren't able to conceive children by traditional means. From the days when a "test-tube baby" led nightly newscasts to today, when such procedures attract notice only when five, six or more babies are born to a mother who underwent in vitro fertilization (IVF), the technology behind ART has advanced to a tremendous degree.
Even so, ART doesn't always work. Sometimes, the odds are just stacked against the couple or individual. Other times, it comes down to someone's health, and obesity plays a part. Obesity can become a chronic condition leading to a number of other persistent health problems, including heart issues, chronic pain, breathing problems and trouble with mobility.
Body mass has an impact on sexual and reproductive health, too. Being overweight or obese is sometimes linked to erectile dysfunction (ED), and obesity can cause virility and childbearing problems for men and women for a number of reasons.
Individuals or couples who want to use ART may be surprised to find out obesity can be an impediment. Specifically, sperm harvested from an obese man may not be successful in achieving ART-induced childbirth.
More research is needed
The medical community is working rapidly to advance reproductive technologies and increase options for obese patients looking to use ART. Obesity and cardiovascular health influence sexual and reproductive function in men, but we generally understand this to be influential in terms of erectile performance rather than reproductive effects—burgeoning sperm knowledge aside.
Ron Blankstein, M.D., is a cardiologist and professor of medicine at Harvard Medical School who specializes in cardiovascular imaging and spends significant time observing the heart and conditions associated with the risk of heart disease and heart attack. He said it's difficult to create a distinct link between cardiovascular health and male sexuality, except in the well-established areas of erectile dysfunction and sperm quality.
Obesity can become a chronic condition leading to a number of other persistent health problems, including heart issues, chronic pain, breathing problems and trouble with mobility.
"The one relationship of [cardiovascular health] with sexual function is that men who have erectile dysfunction, in general, have a higher risk of cardiovascular disease," he said. "So when men think about their risk factors for heart disease, if they have erectile dysfunction, that needs to be regarded as a risk factor for having heart disease."
Unfortunately, there's not a lot of data on male reproductive capacity and how obesity affects whether conception through ART is possible. In men, success typically boils down to the overall health of the sperm.
Outlook is promising
A 2021 study observed that ART helps facilitate child conception for men suffering from metabolic conditions, of which diabetes and obesity are the two most common. It also found, however, that sperm taken from men with metabolic conditions tends to suffer a higher rate of DNA fragmentation, and that other naturally occurring modifications to sperm from this type of subject prevent successful embryo development more frequently than counterpart sperm taken from subjects without metabolic disorders.
In other words, sperm from metabolically impaired subjects is less successful during ART attempts than sperm from metabolically healthy subjects.
Fortunately, assisted reproduction techniques are constantly advancing and evolving, so it is likely sperm selection procedures will one day be capable of harvesting only the healthiest spermatozoa, even from obese patients or those suffering other metabolic conditions.
In the meantime, obese patients may have a preliminary option for improving their overall health, dropping body weight and possibly even improving the probability of reproductive success through ART: surgery.
The possibility of surgical intervention
Shanu Kothari, M.D., is the president of the American Society for Metabolic and Bariatric Surgery (ASMBS). The word "bariatric" emphasizes weight loss, but Kothari notes bariatric surgeons and metabolic health professionals deal with a broad range of health conditions beyond obesity.
Kothari listed diabetes, high blood pressure, sleep apnea, reflux disease, stress-urinary incontinence and joint pain as maladies that can improve after bariatric surgery, which are procedures that make changes to a patient's digestive system—gastric bypass is probably the best-known such surgery. Some limit how much a person can eat; others inhibit the ability of the body to absorb nutrients.
He blames lack of access—many health plans don't cover the surgeries—and misconceptions about the procedures for the fact that less than 1 percent of the eligible population received bariatric surgery in 2019.
Kothari said the other 99 percent of the eligible population could be missing out on the potential sexual and/or reproductive benefits of bariatric surgery.
"Studies have been done on patients seeking bariatric surgery, looking at their sexual health before and after surgery, and there was actually a biologic or metabolic component to seeing those improvements as well in sexual health after bariatric surgery in both men and women," he said.
Surgery often gets treated as a last resort by doctors and patients alike, but Kothari suggested such thinking can be a disservice to the patient (in narrow circumstances), and that surgery with a more interventionist approach could improve how patients live with a variety of chronic conditions.
The types of eligible patients he is talking about are typically those who are 75 to 100 pounds over their ideal body weight. He said successful weight loss occurs through "conventional means" in only about 5 percent of those patients.
On the other hand, weight loss that is often impossible for some people through diet and exercise can be regularly expected and achieved through surgery.
"They shouldn't see bariatric surgery as a last resort," Kothari said. "We should be intervening sooner in their health when we have multiple studies, prospective randomized trials, that show the sooner that we intervene, the more the likelihood is that these medical conditions are going to improve or potentially even go into remission.
"So we shouldn't wait until the diabetes has been present for 15 years, the high blood pressure has been present for 15 years," he continued. "These things now are causing end-organ damage. Now you're at even higher risk for surgery, in terms of risks, when you are least likely to benefit. We should be intervening within a couple of years of the [onset of] diabetes."
Surgery as an intervention for obesity and other metabolic health issues could help individuals and couples looking to make use of assisted reproductive measures, Kothari suggested.
Obesity and infertility are treatable
"After metabolic surgery, testosterone tends to rise in men and it tends to decrease in women, which is where you have a biologic reason for improvements in patients' sexual function and well-being," Kothari said.
Based on what the medical community knows about generalized men's health as a primary driver of male reproductivity, this idea tracks. By giving men more of an opportunity to successfully manage their own health through the surgical elimination of a fair amount of body weight, you are also improving the chances of the person producing healthy sperm after other potentially contributive health issues are resolved.
"We [ASMBS] wrote a paper together with the American Society for Reproductive Medicine, a guideline, looking at this years ago," Kothari said. "The document stopped short of recommending metabolic and bariatric surgery as a treatment option for couples with an inability to conceive, but there's growing evidence out there that it is, in fact, something that couples could at least consider."
When obesity and reproductive issues overlap, it's important to know there are options, and that new advancements are being made in the areas of reproductive health and weight-loss science.
Kothari pointed out that couples and individuals often have to pay for ART procedures out of their own pocket, and it sometimes takes multiple attempts for success, even in optimal conditions. So it stands to reason that a procedure with potential multidisciplinary benefits, including those related to sexual and reproductive function, may be beneficial prior to accessing options involving ART.
The physical and financial benefits of these procedures have to be measured on an individual basis. The big takeaway here is that healthy bodies tend to be better suited to create more healthy bodies. But people struggle with obesity for a number of reasons, and some of those struggles are more difficult to overcome than others.
When obesity and reproductive issues overlap, it's important to know there are options, and that new advancements are being made in the areas of reproductive health and weight-loss science. Science is also learning more about sperm and male fertility with each passing year, so it's difficult to say what assisted reproductive technologies will be capable of in the decades ahead.