Sunday, August 12, 2018

The Turkey Awards: Obesity Eugenics via Fertility Treatment Denial


We've been talking about Obesity Eugenics, when authorities try to keep people of size from reproducing through negative media campaigns, scare tactics, risk hyperbole, apocryphal stories, push for normal BMI before conception, and pressure for sterilization or termination. This incredibly insensitive and discriminatory movement is the winner of not one, but two Turkey Awards. It's time to call out these egregious practices.

If you aren't familiar with them, the Turkey Awards are the "prizes" I hand out to highlight fat-phobic treatment of people of size from care providers, biased attitudes or studies from researchers, or troubling trends in the care of fat pregnant women these days.

Last year's Turkey Award was delayed so I'm doing two years in a row now. I've already done the first half; attention to the Obesity Eugenics Media Campaign. Now it's time to highlight the egregious lack of access to fertility treatment for people of size.

In past years, we've talked about:
We've already seen in the previous Turkey Award that many care providers believe that "obese" women have no business being pregnant. As a result, there has been a concerted public health campaign in recent years to reduce pregnancies in high BMI women. Today we talk about one of the most widely accepted and insidious ways the medical establishment promotes Obesity Eugenics ─ by denying access to fertility treatment.

Lack of Access to Fertility Treatment

Headline from The Hamilton Spectator, 2011
Denying access to fertility treatment via BMI restrictions is a widely-accepted practice in the medical community. It is driven by risk hyperbole, economics, and weight bias.
“Fat women only have babies because we can’t stop them; we’re certainly not going to help you conceive.” – Family Practice doctor to woman dealing with infertility
In many fertility clinics these days, women above a certain BMI are not permitted to access fertility treatments. In many clinics the cutoff is a BMI of 35, but in the U.K., the limit is usually a BMI of 30. Here is one story of a woman denied fertility treatment and pressured for bariatric surgery because of her weight.
The first thing out of the gynaecologist's mouth was “How much do you weigh”. 135kg [297 lbs]. “Do you realise how obese you are?” I then told her I have been working hard to lose weight through diet and exercise, thinking to cut her off before she got into her fat-bashing rant. As I explained that I had lost 15kg since January, was doing 90 minutes of cardio at the gym 5 times a week, and eating a low GI, low-fat, low-carb diet. She rolled her eyes at me in disbelief. Her reply was, “You are too fat for a baby. You need to get down to 65kg [143 lbs.] before I will help you”. At that point I should have stood up, told her to go f*** herself and walked out but I was stunned. I guess she took the stunned silence as agreement because then she whipped out the lapbanding pamphlet and told me I had to have weight loss surgery. 
Stories abound of women denied fertility treatment because of weight. One woman was told by her Reproductive Endocrinologist (RE):
Pregnancy is supposed to be beautiful and natural and it can be neither at your weight. I suggest you lose 100 pounds then come back.
Here is a story from the comments section of the defunct blog, My OB Said What?!?:
I...had an amazing RE last time, but she has since retired and the only one in town will not treat me due to my weight. He will not do any infertility treatment on you unless you have a BMI under 30!! Really? Because last time I got pregnant with injections and IUI [Intrauterine Insemination] I was 330!!! I had an amazing pregnancy and a healthy baby! Why is okay that...because I have a medical issue and disease I do not deserve to have children. UGH! I can’t even start on how this way of thinking pisses me off!!
Another woman in the same story wrote in the comments section:
We have a good ob/gyn...but we cannot find a reproductive endocrinologist who will even agree to see us.
BMI limits on fertility treatment is one of the most accepted ways doctors try to keep obese women from reproducing. It's another step on the path towards Obesity Eugenics.

The PCOS Conundrum

It's true that heavier women have higher rates of fertility problems. However, it's important to note that just because you are larger, it doesn't mean you will have trouble having a baby. Lots of plus-size women have babies without help. That includes me; I was told I would probably not conceive without fertility help, but conceived four children naturally with no problems. So don't just assume (or let your doctors tell you) that if you are fat you probably won't be able to have kids.

But it's important to acknowledge that some high BMI women do have more difficulty conceiving a pregnancy. Doctors often blame higher levels of estrogen, but the bottom line is that many fertility issues in women of size can be traced back to PolyCystic Ovarian Syndrome (PCOS), which leads to higher levels of estrogen.

In PCOS, women have a hormonal imbalance, probably because of underlying insulin resistance due to impaired insulin signaling. They have too much estrogen and testosterone, but not enough progesterone. As a result, the body ovulates sporadically, weakly, or sometimes only rarely. Ovarian follicles containing eggs either don't finish ovulating or ovulate only weakly. The ovarian cysts that are a byproduct of this process give off excess hormones, and can cause distressing symptoms like excess facial and body hair, thinning scalp hair, cystic acne, body tags, darkened skin around the back of the neck, armpits, etc. It also leads to reduced fertility.

In PCOS, the woman often experiences erratic menstrual cycles, which make it difficult to become pregnant. She may not ovulate regularly, or if she does, she may ovulate only weakly. If she does manage to conceive, she may have difficulty sustaining the pregnancy because of low levels of progesterone to support the the early weeks of pregnancy. In other words, the problem may be conceiving a pregnancy, or a high miscarriage rate afterwards, or both. While there are some women with PCOS who have the ovulatory phenotype and do not have problems conceiving (I'm one of these), many women with PCOS have fertility issues.

PCOS is one of the most common cause of fertility issues. Australian research suggests that up to 72% of women with PCOS have fertility issues, and PCOS often leads to long-term weight gain due to insulin resistance. While many people with PCOS are heavy, not all are, but the fertility effects of PCOS are independent of BMI. Thin women with PCOS experience fertility problems too, but they are able to access fertility help more easily than their heavier sisters.

There is an erroneous belief among some doctors that being fat or gaining weight can cause PCOS. This is an unproven assumption based on fatphobia and allows doctors to blame women with PCOS for their condition. It is far more likely to be the opposite ─ PCOS is most likely an inherited underlying metabolic condition that then triggers weight gain. One review states:
Familial aggregation of PCOS strongly supports a genetic susceptibility to this disorder.
Weight gain does tend to make PCOS symptoms worse, but it is likely the underlying condition that causes weight gain in the first place. Although it is not impossible to lose weight with PCOS, it is much harder. And not everyone who loses weight with PCOS finds that it helps their symptoms. Many people spend years yo-yo dieting because it is so difficult to lose weight with PCOS.

It is a cruel irony to then deny heavy women with PCOS access to fertility treatment. It is a double blow because they are the very ones who need help the most. It's simply a genetic condition that is inherited through no fault of their own, but they are being punished for that genetic inheritance.

Treatment Success Rates

Headline from The Globe and Mail, 2011
Many infertility doctors justify denying fertility treatment to obese people because they contend it is less likely to succeed at high BMIs, and the risk for complications if pregnancy occurs is too high. Let's take a look at these arguments and see if they hold up.

To be fair, there is considerable research that suggests lower rates of Assisted Reproductive Technology (ART) ) success in heavier women and a higher rate of miscarriage after fertility treatment, although not all studies agree. These results seem to confirm that health issues like PCOS play a strong role in infertility in obese women. But it doesn't mean that these women should be penalized for their genetic vulnerabilities.

It's probably true that a higher BMI has a generally lower success rate of fertility treatment to regulate menstrual cycles and help ovulation occur, but that doesn't always translate to actual live birth rates. When looking at live birth rates, some research has found very similar rates of ART success in obese women. One recent Israeli study found similar pregnancy and live-birth rates between all BMI groups and concluded:
The results of our relatively large retrospective study did not demonstrate a significant impact of BMI on the ART cycle outcome. Therefore, BMI should not be a basis for IVF [In Vitro Fertilization] treatment denial.
When funds are limited, doctors argue that fertility treatment should be limited to those most likely to achieve a pregnancy. However, even when funds are available or people pay for their own treatment, many fertility doctors withhold treatment for people of size. It's not just about saving money.

Most tellingly, doctors do not deny fertility treatments to other groups (like older women) who may have lower success rates. Only obese people are penalized like this. 

This is a form of selective discrimination. If older women have access to fertility treatment, so should high BMI people.

What About Weight Loss Before Fertility Treatment?

Image from The Unnecessarean
One of the arguments for BMI limits in fertility treatment is that losing weight first improves outcomes. The British NHS Guidelines state that "most overweight women would only need to lose 5 to 10 per cent of their body weight before they would be able to conceive without needing treatment." The advantage of this is that it could save lots of money and increase success rates. However, the evidence is not so clear.

Some research does suggest higher rates of ovulation in obese women with PCOS who lose weight before fertility treatment. This is why many doctors require that high BMI people lose weight before treatment is permitted. They figure a low-cost intervention like this is worth trying before resorting to high-cost ones. That is a logical argument.

However, while weight loss may improve ovulation and pregnancy rates, does it really result in more babies? What is most important is the final outcome, i.e. live-birth rates. And not all studies agree that weight loss improves actual live-birth rates. A 2017 review found:
The existing data from randomized trials...have failed to document improved live-birth rates after the [weight loss] intervention compared with control groups.
A study in infertility clinics across several Nordic countries found statistically similar live birth rates among obese women (BMI 30-35) who were subjected to a very-low-calorie liquid diet for 3 months before In Vitro Fertilization (IVF). Another study found that an intensive weight loss intervention before IVF actually resulted in decreased IVF success.

An important 2016 study in the New England Journal of Medicine found that live birth rates were actually slightly better in the non-weight loss group that proceeded directly to fertility treatment than in the group subjected to a 6 month "lifestyle intervention" program (i.e. weight loss) before treatment:
...The primary outcome [live births] occurred in 27.1% of the women in the intervention [weight loss] group and 35.2% of those in the control group..In obese infertile women, a lifestyle intervention preceding infertility treatment, as compared with prompt infertility treatment, did not result in higher rates of a vaginal birth of a healthy singleton at term within 24 months after randomization.
A follow-up of this study found that the lifestyle intervention in anovulatory women resulted in more spontaneous conceptions but made no difference in live birth rates.

The benefits of weight loss before fertility treatment are mixed. While some people of size do find increased success with spontaneous conception with a modest weight loss, other people of size do not. To blithely suggest that a 5-10% weight loss is all it takes to conceive is insensitive and unrealistic. It may help some; for others it may be a waste of valuable time. Weight loss can be offered to larger women if they are interested since it helps some achieve pregnancy, but the choice must be left up to them, not mandated.

Furthermore, time is a complicating issue. If women put off pregnancy to pursue weight loss, they are losing some of their most fertile years. It can take a long time to lose weight down to required BMI cutoffs. As one critic noted:
Restricting fertility treatment on the grounds of BMI would cause stigmatization and lead to inequity...Time lost and poor success of conventional weight loss strategies would jeopardize the chances of conception for many women.
Surveys suggest that very few women in their 30s are willing to delay seeking fertility treatment in order to pursue weight loss. They know that advancing age is a far more important risk factor than weight.

Others are unwilling to pursue weight loss because even a small loss often results in long-term weight gain rebound and they are unwilling to risk that, especially in pregnancy. A high drop-out rate in weight-loss-for-fertility programs is an additional problem, suggesting that many of these programs are not sustainable or practical.

As a result, there are some doctors who suggest an emphasis on good nutrition and exercise a few months before treatment is more effective than a weight loss emphasis.:
Lifestyle modifications, in particular a healthy diet and exercise during the 3-6 months before conception and during treatment, should result in better outcomes than requiring weight loss before fertility treatments.
This is compatible with a Health At Every Size® approach. Focus on lifestyle and habits, not the scale. Healthy habits are very important before pregnancy but they doesn't necessarily result in weight loss.

Perceived Risks of Obese Pregnancies

Headline from The National Post, 2016
Many fertility docs justify denying treatment to high BMI women because of the perceived risks of pregnancy at larger sizes. They are concerned that the risks of an Assisted Reproduction Technology pregnancy will magnify the risks of a high BMI pregnancy, creating an extremely unhealthy outcome. However, research shows that the two risks are generally not synergistic.

Some doctors believe that fat women are at SUCH high risk that they can't possibly have a healthy pregnancy or a healthy baby. While that's simply not true, it is a strongly held belief of many fertility doctors. Toronto fertility specialist Dr. Carl Laskin says:
“To me, it’s a medical issue. It is not a discrimination issue. [Obese] women are running risks in pregnancy, and if they’re running risks in pregnancy, why should you be helping them get pregnant?” Dr. Laskin has a BMI cut off of 35. “Mine is a brick wall,” he said. "Other clinics will go as high as 40. Some have no cut off."
Bill Ledger, a professor of Reproductive Medicine at Sheffield University in the U.K., reflects the extremism of some doctors' beliefs:
Doctors shouldn't be helping women have a pregnancy that's at a high risk of going horribly wrong. 
Many reproductive endocrinologists (REs) feel that "it would be unethical to help a fat woman get pregnant."  From a comment left on my blog in a past post:
I just went to a gynecologist this past week ...I was told, quite directly, that she would not and nor would any doctor in my HMO take me on since my BMI would make the pregnancy too high risk to myself and a fetus.
An article from 2016 has the doctor throwing down the Fat Death Card (if you get pregnant you'll probably die so we mustn't help you):
One woman recounted a fertility doctor telling her, “Gals your size, OK, mortality rates are higher. So I go ahead and intervene, help you get pregnant here. Then you go down to (a birthing ward). And then, boom! Pulmonary embolism.”
Again, this goes back to risk hyperbole. People of size are more at risk for blood clots, some of which can go to the lung (pulmonary embolism), and that is potentially lethal. But the actual incidence of such incidents is quite low. Furthermore the risk can be lowered with good care by using blood thinners when indicated, not doing cesareans unless truly needed, keeping women as mobile as possible all throughout pregnancy and afterwards, and increasing postpartum surveillance for blood clots in women at increased risk.

Furthermore, the argument about risk is a spurious argument because it is not applied equally. 

Doctors justify denying fertility treatment because women of size do have a higher rate of pregnancy and birth complications, but they weaken their argument by not applying it equitably:
...the objection is that it excludes a specific patient category on grounds that are not applied to treatment of others with comparable risks.
In other words, there are many other groups (like older women, people with certain medical conditions) that have similar or higher risks for complications but these groups are NOT denied access to fertility treatment. Only fatness is penalized in such an across-the-board way. As one review put it:
...a higher risk than the mean IVF population does not mean that it is irresponsible to take that risk. It is a question of proportionality: a higher risk can still be acceptable in light of the gain a woman can expect from treatment. Through the same reasoning IVF is thought acceptable in other women who are at increased risk of pregnancy complications because of medical conditions. Women with diabetes mellitus have an increased risk of hypertensive disorders and congenital abnormalities, macrosomia, stillbirth and premature labour...Diabetes mellitus is, however, not an exclusion criterion for fertility treatment.
Another recent review agreed:
Given that patients with, for example, diabetes or previous pre-eclampsia, who are at higher risks than many obese women, are allowed treatment on the basis of individualized and well-informed decision-making, we think there is no justification for taking a different line with regard to BMI.
Although fertility doctors like to pretend that denial of treatment is based on their concern for risks, they don't apply these rules equally among groups. The same standards are not applied to other women at higher risk for complications; only the obese are targeted. 

Research also shows that while some risks are increased in people of size, the increase in risk is moderate, and many women of size actually have perfectly healthy pregnancies and births. Furthermore, group statistics cannot predict any one person's outcome. Denying fertility treatment based only on weight limits or BMI means that many pregnancies that would have had normal and healthy outcomes will never occur.

 Some experts refute the idea that BMI should be used as a surrogate for unacceptable risk levels:
Dr. Cheung plans to argue that studies also show IVF does not pose unacceptable risks for heavy women, and that BMI alone is not a good measure of which patients face the highest risks. Age, he said, is "by far the strongest indicator" of success and dangers.
An article highlighting the Canadian debate agrees:
But to Dr. Yoni Freedhoff, a specialist in weight control at the Ottawa Bariatric Medical Institute, that’s part of an “insidious” health care practice. 
“It would seem to me that this ‘you’re too fat to have IVF’ policy probably is in part started as patient safety, but ultimately it reflects weight bias,” he said. 
Freedhoff, who’s advised assisted reproduction patients needing to lose weight, doesn’t dispute that excess pounds can cause additional risks. What he doesn’t understand is why weight might exclude women from fertility treatment, but other factors that have been shown to adversely affect pregnancy — such as smoking or advanced age — are not perceived as equally damaging.
Ethics and Eugenics Questions

Headline from The Independent, 2018
Infuriatingly, in some areas, helping an obese woman with fertility is seen as malpractice and authorities forbid or strongly discourage allowing fertility docs to treat women of size. According to guidelines in the UK:
Fertility clinics should defer treating obese women until they have lost weight through dieting, exercise or surgery, according to guidelines published today. Under the recommendations, clinics are advised to begin treatment on severely overweight women only once they have reduced their body mass index (BMI) to below 35. Women under 37 years of age should reduce their weight further, to a BMI of less than 30, the guidelines state.
Here's a story from a woman in Australia:
I’ve been to two fertility specialists and neither of them will give us any fertility treatment until I have a BMI of under 35 (99kg). Nothing to do with my chances of getting pregnant; they say it’s an ethical matter, that obesity itself is enough of a health challenge for the body without adding the impact of pregnancy. Getting an obese woman pregnant would be seen as doing harm. The second OBGYN informed me it’s a state-wide guideline according to the Fertility Council which covers public & private health.
Although there are fertility docs out there who believe that it's wrong to deny fertility treatment to fat women, BMI restrictions are common in many fertility practices and some government healthcare.

In New Zealand, Australia, and Canada, there are guidelines in place/ being proposed to prevent women over a BMI of 35 from accessing fertility treatment. In the U.K., women under the age of 37 must have a BMI of no more than 30. In the U.S., guidelines are more individualized, but many clinics have policies in place that bar fertility treatment above a certain BMI, usually 35.

And now things are going even further. Some areas of the U.K. are proposing limiting fertility treatments to women whose male partners have a BMI over 30. The woman can have a "normal" BMI which would ordinarily get her IVF, but if her partner is fat, she doesn't qualify anymore. So not only can they deny treatment to fat women, but to fat men and any woman with a fat male partner.

Some fertility experts  recognize the major ethical problems with denying heavier people access to fertility treatment. An article about proposed BMI limitations on fertility treatment in Canada notes:
...It's ethically troubling," said the University of Manitoba's Arthur Schafer, director of the Centre for Professional and Applied Ethics. "In our society, the decision to procreate is left to the individual – so why would it be appropriate for the doctors to usurp those rights for women who are obese." 
Doctors would only be justified, he says, if they could "honestly, hand-on-heart say," that the safety risks are so great "that no reasonable fat woman would want to conceive a baby in this way." 
"I'm not sure the fertility industry or association can really defend a blanket exclusion on obese women having access to assisted reproduction."
Intersectional stigma applies here too. Another article from Australia notes that the impact of these policies is often discriminatory towards various racial groups and poorer people:
"They need to recognise that there's harm in doing nothing. Women who are unable to have children, there's a much higher risk of depression and anxiety and a doubling in the suicide rate. So doing nothing is not necessarily doing the best thing." 
The guidelines, he claims, can be classified as discrimination."Especially when you consider the low socio-economic group," he said. 
"The Indigenous patients have a lot higher incidents of obesity than the general population, so you're almost discriminating against those two disadvantaged groups in this particular policy. "Obviously that wasn't the original intent, but that is a potential end product of that."
Here is what one group of experts argues in response to the usual excuses for denying fertility treatment based on BMI (my emphasis):
Obesity is associated with a reduction in fertility treatment success and increased risks to mother and child. Therefore guidelines of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) suggest that a body mass index exceeding 35 kg/m2 should be an absolute contraindication to assisted fertility treatment such as in vitro fertilisation IVF. 
In this paper we challenge the ethical and scientific basis for such a ban. Livebirth rates for severely obese women are reduced by up to 30%, but this result is still far better than that observed for many older women who are allowed access to IVF. This prohibition is particularly unjust when IVF is the only treatment capable of producing a pregnancy, such as bilateral tubal blockage or severe male factor infertility. 
Furthermore, the absolute magnitude of risks to mother or child is relatively small, and while a woman has a right to be educated about these risks, she alone should be allowed to make a decision on proceeding with treatment. We do not prohibit adults from engaging in dangerous sports, nor do we force parents to vaccinate their children, despite the risks. Similarly, we should not prohibit obese women from becoming parents because of increased risk to themselves or their child. 
Finally, prohibiting obese women's access to IVF to prevent potential harms such as 'fetal programing' is questionable, especially when compared to that child never being born at all. As such, we believe the RANZCOG ban on severely obese women's access to assisted reproductive treatment is unwarranted and should be revised.
Amen to that. Now if only the health authorities would listen. Unfortunately, they seem to be going in the opposite direction, getting more stringent in their weight-related restrictions, as seen in the U.K. limits on male partners too.

Summary
Headline from abc.news.au, 2017
A few brave medical professionals are speaking out about the discrimination happening in fertility treatment despite tremendous pressure from their colleagues. There have been a number of articles published recently in OB journals questioning the ethics of BMI restrictions but so far, none of the national guidelines have changed. And as noted in the U.K., things seem to have gotten even worse.

Bottom line, denying fat people access to fertility treatment is another form of keeping fat people from having children, but many doctors resist acknowledging the implications of these restrictions. They tell themselves they are protecting their patients with these guidelines. They tell themselves it's all about the risks, yet other groups with similar risks are not penalized. They refuse to acknowledge that they are infantilizing larger-bodied people and taking away their personal autonomy over crucial life decisions.

Authorities think that they are doing fat women a favor by insisting they lose weight before pregnancy, yet by insisting on such weight loss they deny women timely intervention when fertility treatments are most likely to succeed. The number of people who lose weight to a "normal" BMI and keep it off is quite small. When authorities insist on a much lower BMI as a requirement for treatment, they basically are keeping fat people from having children. Intentional or not, this is Eugenics.

Denial of treatment is based on weight bias, the assumption that all fat people voluntarily brought on their weight through poor health habits, sloth, and gluttony, and would perpetuate those bad habits to the next generation. Doctors assume that fatness is easily solved through altering health habits and exercising a little more willpower, but this argument does not hold up under scrutiny.

Research is very clear that most people are unable to lose weight and keep it off long-term, so denying treatment until someone reaches an "ideal BMI" or even a 5-10% reduction is unrealistic and delays fertility treatment until it may be too late. As some experts note;
Age trumps everything, so if your plan is going to make these women lose weight, the time that might take them if they’re older is going to be way more significant than any potential benefit in terms of weight loss.
Weight loss surgery does reduce BMI, but research shows significant trade-offs. There are reduced risks for gestational diabetes and large babies, but also increased risks of prematurity, too-small babies, and possibly neonatal mortality. There are no easy answers here.

Potential health complications is a red herring argument. The underlying reason weight has been made an automatic disqualifier is because doctors see people of size as unfit parents who will create more fat people. Sure, there are some fat people who do have poor health habits but so do many thinner women, yet they are not kept from fertility treatment. If health habits were the main concern then EVERY patient should be screened for this and used as a barrier to treatment for all sizes, yet it's only targeted to obese people.

Furthermore, many fat people have medical causes for their weight such as Polycystic Ovarian Syndrome, lipedema, hypothyroidism, etc., and these conditions can impact fertility as well. To deny people with conditions like PCOS treatment is to penalize them for their genetics. People should not be punished for their genetic vulnerabilities.

People of size should be informed of the potential risks of pregnancy at larger sizes, but in a realistic way, not through scare tactics. People of ALL sizes should be encouraged to practice healthy habits and have great nutrition, and should be counseled about their individual risks. In most cases, though, the decision on whether to proceed with fertility treatment must be the person's. The government or a group of doctors has no business controlling whether or not a person has children. It infantilizes women and takes away personal autonomy to impose such rigid guidelines.

Denying fertility treatment based on weight basically keeps a whole group of people from having children and that's always a suspicious restriction that smacks of eugenics.

Those who would deny fertility treatment based on BMI are trying to be the gatekeepers of who are "allowed" to reproduce; this is another insidious form of eugenics and must STOP.


Resources

If you are experiencing fertility issues, here is a brief set of links to resources that might be helpful:
References

*The full list of references for this post are far too long to include. Instead, here are a few key references and quotes. The other references are scattered throughout the article and have links to the original sources and studies. 

Studies Critical of BMI Limits on Fertility Treatment

Should obese women's access to assisted fertility be limited? A scientific and ethical analysis. Tremellen et al. 2017 Aust N Z J Obstet Gynaecol https://www.ncbi.nlm.nih.gov/pubmed/28299785
Quote: "The absolute magnitude of the risks to mother or child is relatively small, and while a woman has a right to be educated about these risks, she alone should be allowed to make a decision on proceeding with treatment...we should not prohibit obese women from becoming parents because of the increased risk to themselves or their child...."
Should access to fertility treatment be determined by female body mass index? Pandey et al., 2010 Human Reproduction.  www.pubmed.gov/20129994
Quote: "Restricting fertility treatment on the grounds of BMI would cause stigmatization and lead to inequity...Time lost and poor success of conventional weight loss strategies would jeopardize the chances of conception for many women."
It is not justified to reject fertility treatment based on body mass index. Koning et al., 2017. Human Reproduction Open. https://academic.oup.com/hropen/article/2017/2/hox009/4049574
Quote: "Given that patients with, for example, diabetes or previous pre-eclampsia, who are at higher risks than many obese women, are allowed treatment on the basis of individualized and well-informed decision-making, we think there is no justification for taking a different line with regard to BMI."
Should overweight or obese women be denied access to ART?: Comment by: Ahmed Badawy, Middle East Fertility Society Journal, 2013. https://www.sciencedirect.com/science/article/pii/S1110569013001106
Quote: "Those who are choosing to postpone childbearing for the weight reduction should balance the negative effects of aging versus obesity on fertility and perinatal outcomes... there is no strong evidence for the association between obesity and live birth in infertile women. Thus, there is insufficient proof to refute women fertility treatment on grounds of BMI."
We need to stop discriminating against plus-size pregnant women. Raina Delisle, Today's Parent, 2017.  https://www.todaysparent.com/pregnancy/pregnancy-health/we-need-to-stop-discriminating-against-plus-size-pregnant-women/

Women with obese male partners will be denied IVF treatment, rules NHS group. Tom Embury-Dennis. Independent, 2018. https://www.independent.co.uk/news/health/women-obese-men-denied-ivf-treatment-bmi-30-bath-north-east-somerset-ccg-a8248061.html

Should high BMI be a reason for IVF treatment denial? Friedler et al., 2017 Gynecological Endocrinology  https://www.ncbi.nlm.nih.gov/pubmed/28531369 
Quote: "The results of our relatively large retrospective study did not demonstrate a significant impact of BMI on the ART cycle outcome. Therefore, BMI should not be a basis for IVF treatment denial."
Randomized Trial of a Lifestyle Program in Obese Infertile Women. Mutsaerts et al., 2016 New England Journal of Medicine https://www.ncbi.nlm.nih.gov/pubmed/27192672
...The primary outcome [live birth rate] occurred in 27.1% of the women in the intervention [weight loss] group and 35.2% of those in the control group (rate ratio in the intervention group, 0.77; 95% confidence interval, 0.60 to 0.99). CONCLUSIONS: In obese infertile women, a lifestyle intervention preceding infertility treatment, as compared with prompt infertility treatment, did not result in higher rates of a vaginal birth of a healthy singleton at term within 24 months after randomization.
Mr. Fertility Authority, Tear Down That Weight Wall! Hum Reproduction 2016 Dec;31(12):2662-2664. Epub 2016 Oct 19. Legro RS1. PMID: 27798043  Full text here
Discussion of the 2016 NEJM study above and subsequent subanalysis. Quote: "The impression from these epidemiologic studies and the smaller interventional trials is that obese women are damned if they do lose weight prior to pregnancy and damned if they don't. As the LIFEstyle study indicates, dropout rates with lifestyle modification are high (20%), the average amount of weight lost is modest (4.4 kg) and most women will not achieve the targeted weight loss (62%). Furthermore, women who participate, regardless of age, initial BMI and ovulatory status, will experience cumulative lower rates of a healthy baby... pending further studies, these cumulative data suggest that weight limits used to deny women access to fertility care are not only arbitrary, but discriminatory, and clearly not evidence-based.
  
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