Preconception counseling and expectation management are key to optimizing in vitro fertilization (IVF) and pregnancy outcomes, and providers should pay special attention to the workup of certain patient populations, including women who are older than 35 years, those who have uterine abnormalities, and those with comorbidities, including hypertension, diabetes, thrombophilias, and obesity.

A June 2020 article published in Obstetrical and Gynecological Survey summarizes current guidelines and recommendations for addressing more than 10 environmental and lifestyle factors that have been shown to impact IVF outcomes in treating infertility, including obesity, smoking, illicit drug use, and inadequate nutrition.

Obesity poses a significant challenge for providers caring for women of reproductive age across the United States. According to the WHO, nearly 60% of all women are overweight, with up to 30% of them considered to be obese (BMI of 25 to 29.9).

“Preconception evaluation is an extremely important step in optimizing people’s health before they conceive, and if assisted reproductive technology is required, the counseling may differ slightly,” says Benjamin Harris, MD, MPH, a board-eligible OB/GYN Fellow in Duke’s Division of Reproductive Endocrinology and Infertility, and co-author of the article. “In the context of fertility treatment and obesity, even a modest weight loss of 5% of total body weight can improve pregnancy rates and overall maternal health.”

At the Duke Fertility Center, patients with a BMI above 40 are referred to the Duke Divisions of Maternal-Fetal Medicine (MFM) and Anesthesia prior to conception to discuss lifestyle modifications that promote maternal and fetal health. IVF is not generally available to individuals with a BMI above 44 due to the increased risk of anesthesia-related morbidity and pregnancy complications.

“Every infertility group makes its own guidelines as to when they will perform IVF, and they oftentimes will not perform IVF or other assisted reproductive technologies for a patient who is obese because they feel the risks are too high,” says Jeffrey A. Kuller, MD, a Duke MFM specialist and a co-author of the article. “In my experience, the risks come as a bit of a shock to even well-educated patients, and it can be overwhelming for them to learn about their potential for hypertensive disorders, diabetes, and deep vein thrombosis, as well as fetal birth defects.”

Duke’s multidisciplinary approach helps provide individualized care plans that ensure patients with high-risk conditions are not taking on undue risk, Kuller says: “We have very adept teams that provide preconception counseling and an expert labor and delivery site for these patients who often require delivery in a tertiary care center.”

Kuller emphasizes the importance of referring patients who are obese for weight management interventions. “This may include a discussion of the role of bariatric surgery, which typically delays attempts to conceive by one to two years,” he says. “We've seen patients do very well with IVF after bariatric surgery, and some of their comorbidities often become easier to manage or are resolved.”

Appropriate preconception counseling is essential in patient-centered decision-making, Harris adds. “For those with an identifiable risk factor, early intervention and education to help guide patients toward subspecialty care is important for healthy reproductive outcomes,” he notes. “We involve the entire family from the beginning to counsel them about the potential successes and challenges with fertility treatment and pregnancy.”