Fertility After WLS

While obesity is a well-known contributor to female infertility, studies have also shown that weight loss "can restore ovulatory cycles, allowing for spontaneous pregnancy" in obese patients with PCOS.¹ Bariatric surgery has been proven to improve menstrual regulation and fertility², but there are nutritional complications one should consider before becoming pregnant after bariatric surgery. We will dive into the different potential complications and how you can navigate through pregnancy safely after bariatric surgery.

Potential Complications

Malnutrition and vitamin/mineral deficiencies are high-risk nutritional complications that can impact fetal growth. These complications are due to rapid weight loss and inability to eat large portions of food (adequate nutrients) in the first year after bariatric surgery. It's generally recommended to avoid pregnancy for at least 12-24 months after bariatric surgery to avoid these risks.³ Optimal care for women undergoing bariatric surgery planning on becoming pregnant include “pre-conception counselling, optimization of nutrition before, during and after pregnancy, and monitoring for complications.”⁴ 

Recommendations for a Safe Pregnancy Post-WLS 

In addition to following the ASMBS guidelines for nutrition supplementation post-bariatric surgery, there are a few modifications that are needed with pregnancy. It’s recommended that pregnant women have nutritional labs done every trimester to screen for deficiencies. As always, please be sure to consult with your bariatric team to ensure modifications and recommendations are appropriate for you and your body. The following are general guidelines:^3,4 

• Energy & Protein Intake
  • Energy & protein requirements will be best determined by your bariatric team to ensure adequate gestational weight gain and optimal fetal development and growth. 
  • Generally, it’s recommended to increase energy intake by 200 k/cal per day in the final three months of pregnancy.
  • Protein intake is recommended to be 1.2 g/kg of ideal body weight daily (with a minimum of 60 g/daily). 
• Folic Acid
  • An additional 5,000 mcg daily 2 months pre-conception and for the first 12 weeks of pregnancy. After the first 12 weeks, supplementation can return to the standard ASMBS guidelines of 400-800 mcg/daily.
• Calcium & Vitamin D
  • 1500 mg daily, the upper end of the ASMBS guidelines for RNY and VSG.
  • Outside of the ASMBS guidelines of 3,000 IU daily, additional Vitamin D may be required if deficiencies exist.
• Vitamin A
  • 5,000 IU Vitamin A daily, and do not exceed 10,000 IU daily of Vitamin A, as an excess in Vitamin A can lead to fetal malformation. Choose Vitamin A supplementation in the form of beta-carotene, as “a high intake of beta-carotene was not found to be associated with congenital defects”⁵ 
• Vitamin B12
  • 1000 mcg of B12 orally, daily. 
• Iron
  • At least 45-60 mg daily, and up to 100mg elemental iron daily, based on your individual needs. 
• Thiamine
  • Follow the ASMBS guidelines of at least 12mg/daily, unless prolonged vomiting is experienced. In this case, take an additional 200-300 mg/daily. 
• Biliopancreatic Diversion/Duodenal Switch (BPD/DS)
  • If you have undergone this surgery, get additional screening for your fat-soluble vitamins (Vitamins A,D,E,K) as these are at higher risk of deficiency. 

Other Considerations

While weight gain can seem daunting after bariatric surgery, it’s expected and encouraged when pregnant. For women with a pre-pregnancy BMI of 25-29, recommended total pregnancy weight gain is about 15-25 lbs. For women with a pre-pregnancy BMI of 30 or higher, recommended total pregnancy weight gain is about 11-18 lbs.³ While pregnant, your nutritional goals should promote healthy fetal growth, not weight loss. 

Dumping syndrome may be triggered by the oral glucose tolerance test used to test for gestational diabetes. While screening for gestational diabetes is recommended, “capillary blood glucose monitoring daily before and after meals for a week at 24 to 28 weeks’ gestation [is] a safer alternative to the oral glucose tolerance test.”⁶ 

Bottom Line

While there are potential complications and risks of becoming pregnant after bariatric surgery, it can absolutely be done in a safe and healthy way. It is of utmost importance to be open and honest with your bariatric and health care team before, during, and after pregnancy, so they can guide you through a healthy pregnancy.

References:

1. Crosignani PG, Colombo M, Vegetti W, Somigliana E, Gessati A, Ragni G. Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements in anthropometric indices, ovarian physiology and fertility rate induced by diet. Hum Reprod. 2003;18(9):1928-1932. doi:10.1093/humrep/deg367
2. Moran, L. J., and R. J. Norman. “The Effect of Bariatric Surgery on Female Reproductive Function.” The Journal of Clinical Endocrinology & Metabolism, vol. 97, no. 12, 2012, pp. 4352–4354., doi:10.1210/jc.2012-3606.
3. Cummings, Sue, and Kellene A. Isom. Academy of Nutrition and Dietetics Pocket Guide to Bariatric Surgery. Academy of Nutrition and Dietetics, 2015.
4. Slater, Christopher, et al. “Nutrition in Pregnancy Following Bariatric Surgery.” Nutrients, vol. 9, no. 12, 2017, p. 1338., doi:10.3390/nu9121338.
5. Bastos Maia, Sabina et al. “Vitamin A and Pregnancy: A Narrative Review.” Nutrients vol. 11,3 681. 22 Mar. 2019, doi:10.3390/nu11030681
6. Adam, S.; Ammori, B.; Soran, H.; Syed, A.A. Pregnancy after bariatric surgery: Screening for gestational diabetes. BMJ 2017, 356, j533.

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