Should obese women's access to assisted fertility treatment be limited? A scientific and ethical analysis

Abstract

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/m 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.

Irresponsibly Infertile? Obesity, Efficiency, and Exclusion from Treatment

“…The approach in the UK is comparable to a number of overseas contexts. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists have published guidance that a BMI over 35 should be regarded as an absolute contraindication for IVF [ 56 , 57 ]. In the absence of professional body guidelines, a 2016 survey of providers of fertility services in the United States found that the majority of responding centres have a formal policy of setting a maximum BMI threshold for IVF [ 18 ].…”

“…Obesity is a risk factor for subfertility, and obese pregnancies are associated with higher risk of complications that threaten the health of the mother as well as reduce the likelihood of a live birth and potentially the longer term health of the child born [ 24 , 34 , 51 ]. However, it seems unlikely to be appropriate to describe IVF treatment as futile in obese women but not non-obese women: as described by Tremellen et al [ 57 ], analysis of a large sample of cycles in North America showed live birth rates in morbidly obese women (those with a BMI over 35) were not much lower than in women in the healthy weight range (26.3% as opposed to 31.4%).…”

“…This is not to say that there is no way of estimating how obesity could affect the cost-effectiveness of IVF. Papers by Pandey and Bhattacharya [ 40 ], Pandey et al [ 41 ], Koning et al [ 21 ], Tremellen et al [ 57 ] and Mahutte et al [ 24 ] all argue that there is insufficient evidence showing the detrimental effect of obesity on the success of IVF compared to non-obese recipients to justify restricting treatment to obese women. This does not mean that obesity has no impact on cost-effectiveness of IVF treatment, nor that weight loss is not a desirable occurrence in obese women prior to pregnancy/IVF treatment.…”

Successful weight loss interventions before in vitro fertilization: fat chance?

“…Limited resources have also led to health care providers clamping down on subsidised treatment of patients going through IVF. This approach has been criticized on ethical and medical grounds (12,15), although it is defended by others (16).…”

“…Koning et al (26) showed only a slightly lower rate for overweight women. Given that obesity is increasing in many populations, women are seeking pregnancy at later ages, patients are demanding more rapid treatment, and pressure is being placed on medical providers to institute therapy quickly, there have been suggestions that placing a weight loss delay on women who are overweight and need fertility treatment is unethical (15).…”