Gastric Bypass, LAP-BAND® and REALIZE® Band Surgery Increases Fertility in Morbidly Obese Women

By Ajay Goyal, MD, FACS, New Jersey Bariatric Center

One of the first questions many of my female patients in their twenties and thirties ask me when contemplating gastric bypass or LAP-BAND® surgery is how the procedures will affect their ability to get pregnant. Many have tried to conceive in the past, and have been unsuccessful. The good news is that in addition to improving ones overall health, both procedures can have a positive effect on fertility. While they can’t overcome serious fertility issues, research shows both gastric bypass and LAP-BAND® surgery can improve many factors related to infertility for those who are obese.

Obesity’s Toll on Fertility and Pregnancy
Obesity takes a toll on the body, as many people know it’s often the cause of diabetes, heart disease, high blood pressure and sleep apnea. What many don’t realize is the toll carries over to fertility too. Being seriously overweight causes an increase in the level of two key hormones related to fertility – estrogen and testosterone.  While an increase in these two hormones result in excess body hair and risk in breast and uterine cancer, it’s also directly related to infertility, causing irregular or heavy periods.   Weight loss after gastric bypass or LAP-BAND® surgery results in normalization of estrogen and testosterone, and a return to normal menstrual cycle and improved fertility.
For those who are able to conceive, obesity also takes a toll on the pregnancy increasing the risk for gestational diabetes, hypertension and spontaneous abortions. There is also an increased rate of cesarean sections due to large weight fetus that results from gestational diabetes. Weight loss surgery prior to pregnancy can help resolve the pregnancy-related medical conditions obese woman are at risk for, often resulting in a safe and healthier birth.

Pregnancy after Gastric Bypass or LAP-BAND® Surgery
After patients learn about the benefits to weight loss on fertility, they quickly ask how gastric bypass or LAP-BAND® surgery will affect pregnancy. Is pregnancy safe after surgery? Will I be able to take in enough nutrients for both me and the baby?  Multiple studies show that pregnancy is safe after bariatric surgery provided you follow a couple of key guidelines. To start, for your safety and the safety of the baby it’s very important to avoid becoming pregnant for one year after gastric bypass surgery as this is the time where one’s weight loss will be most significant. Contraception is a must for the first year after both procedures, and for gastric bypass in particular oral contraceptives (OCP) might not be adequately absorbed after the procedure so it’s important to use an additional form of contraception.
With LAP-BAND® surgery, one can safely conceive six months after the procedure but might not have lost enough weight yet to avoid pregnancy related health conditions. 
As with any patients who have had weight loss surgery, nutritional supplements need to be taken religiously before, during and after pregnancy. This is because gastric bypass surgery is both a restrictive and mal-absorptive procedure. It results not only in a decreased intake of food – four to six ounces of food per meal - but it also decreases the absorption of calories and nutrients you have consumed.
LAP-BAND® and the new REALIZE® band surgery is a restrictive procedure, resulting in only decreased amount of solid food one can consume at one setting. The decrease in calories, means a decrease of nutrients you take in, so it’s important to add nutritional supplements to your diet. 
Key supplements to increase include iron to form new red blood cells, calcium for mineralization of fetal skeleton, folic acid to prevent birth defects, vitamin B1 (thiamine), vitamin B12 and vitamin A. Women should also take protein supplements in the form of protein shakes (Table1) or protein bars as one cannot take the recommended daily allowance of 60 grams of proteins per day from foods. I recommend taking at least half or 30 grams in supplements and the rest from foods rich in proteins. (Table 2)
For women who have undergone gastric bypass or LAP-BAND® procedure pregnancy can be safe for them and even healthier for the baby with regular follow-up visits to your bariatric surgeon and obstetrician. Below are ten guidelines to help you along the way.

Ten Guidelines to follow for a safe pregnancy:

• Avoid pregnancy for one year after weight loss surgery

• Take multivitamins (Vitamin A, B1, B12, Iron, Folic Acid)

• Make regular appointments with your bariatric surgeon and obstetrician

• Obtain regular blood test to check for vitamin deficiency

• Eat multiple small meals a day (at least four meals per day) and  spend 30 minutes to eat each meal

• Eat high-protein, low-carbohydrates and a low fat diet

• Take 30 grams of proteins in supplements

• Drink plenty of water (40 – 60 ounces per day)

• Continue regular low impact exercise for both body and mind

• For LAP-BAND® or realize band patients, one can remove the restriction by an adjustment if patients develop pregnancy related nausea.  

Table 1 High-protein and low-carbohydrates shakes
Protein supplement shakes are best mixed with skim milk or lactaid milk as lactose intolerances can occur after surgery.  Another option is to mix in the blender the protein powder with sugar-free yogurt or sugar-free beverages. You may split your protein shake into 2 or 3 servings, as long as you take 30 -40 grams of protein in 100-150 calories. Suggested supplements include:

• Designer Protein (90kcal/17.5g pro per scoop)

• Isopure (210kcal/50g pro per 2 scoops)

• Pro-stat 64 (15g proteins and 1g Carbohydrate per2 tablespoon)

• ISS Whey Protein (96kcal/17g pro per scoop)

• Twinlabs Triple Whey Fuel (100kcal/21g pro per scoop)

Table 2 Foods Rich in Protein
Our bodies need the amino acids and other nutrients found in protein-rich foods. Protein builds and repairs muscle, and is the fuel that gives our body energy. Patients should attempt to get at least 60 grams of protein a day. Good sources of protein include:

• Turkey, chicken, or beef - purchase 97% lean meat

• Baked, broiled, or BBQ skinless chicken, white turkey meat, or fish

• Ground or chopped chicken or turkey (white meat) for salads (use nonfat, non-dairy based dressing)

• Water packed tuna (1/4 cup = 1 oz meat)

• Egg whites or egg substitute. (Yolk has all the cholesterol and fat, whites are pure protein)

• Nonfat yogurt

• Cereals: oatmeal or cream of wheat with nonfat milk

• Kidney beans, navy beans, lima beans, pinto beans

• Baked potato

• Nonfat cottage cheese (great on a baked potato)

• Cereals (read labels for those high in protein and fat free or low fat)

• Fish baked or broiled