EXECUTIVE SUMMARY

Just-published research indicates that while women should avoid conception for the first 18 months following bariatric surgery, 42% of women participating in the 10-site study reported having unprotected intercourse during the 18-month at-risk, post-surgical timeframe.

  • Recommendations call for women to avoid conception for the first year and a half following weight-loss surgery so that the fetus is not affected by the woman’s quick weight loss and so that the patient can reach her weight-loss goals. However, 4% of women in the current study were actively trying to become pregnant and an additional 42% reported having unprotected intercourse during the post-surgical timeframe.

Just-published research indicates that although women should avoid conception for the first 18 months following bariatric surgery, 42% of women participating in the 10-site study reported having unprotected intercourse during this at-risk post-surgical timeframe.1

The Centers for Disease Control and Prevention estimate that 36.4% of U.S. women 20 years of age and older are obese (body mass index [BMI] of 30 or higher).2 Bariatric surgery is considered for those patients who have one of the following:

  • BMI at or above 40;
  • BMI 35 and up in association with major co-morbidities, such as severe sleep apnea, Pickwickian syndrome, or obesity-related cardiomyopathy;
  • BMI of 35 and up in association with obesity-induced physical problems with lifestyle, including joint disease or body size problems interfering with employment, family function, and ambulation.3

The Gainesville, FL-based American Society for Metabolic and Bariatric Surgery recommends that women avoid conception for the first year and a half following weight-loss surgery so that the fetus is not affected by the woman’s quick weight loss and so that the patient can reach her weight-loss goals.4 However, in the current study, which used data collected through the National Institutes of Health-funded Longitudinal Assessment of Bariatric Surgery consortium, 4% of women were actively trying to become pregnant and an additional 42% reported having unprotected intercourse during the post-surgical timeframe.

Lead author Marie Menke, MD, assistant professor of obstetrics, gynecology, and reproductive sciences at the University of Pittsburgh School of Medicine and Magee-Womens Hospital, says the findings are “concerning,” since recent research suggests that bariatric surgery increases the risk for small-for-gestational-age newborns, preterm deliveries, and neonatal intensive care unit admissions in the first 18 months after surgery.5

“Our findings highlight a public health issue that merits additional scrutiny regarding contraceptive counseling before and after surgery, and provision of contraceptive services for all reproductive-age women undergoing bariatric surgery,” Menke said in a press statement.

Review the Results

To perform the study, University of Pittsburgh researchers examined post-surgery contraceptive practices and conception rates by gathering information from the Longitudinal Assessment, which includes adults seeking first-time bariatric surgery at 10 U.S. hospitals. Women ages 18-44 with no history of menopause, hysterectomy, or estrogen and progesterone therapy were enrolled between 2005 and 2009. Participants completed preoperative and annual postsurgical assessments for up to seven years until January 2015. Primary outcomes included self-reported contraceptive practices, overall conception rate, and early (less than 18 months) postsurgical conception.1

Among all women in the study, first-year prevalence of intrauterine contraception was 9%, researchers report. Oral contraceptives were used by 11%. Despite a Category 3 (risks outweigh benefits) ranking by the U.S. Medical Eligibility Criteria for Contraceptive Use, 21% of those with a Roux-en-Y gastric bypass reported use of pills. Within the first 18 months after bariatric surgery, the conception rate was 4.2 per 100 woman-years.1

Counsel Before and After Surgery

Contraceptive counseling both before and after bariatric surgery are critical pieces of the multidisciplinary needs of the bariatric patient, noted Anita Courcoulas, MD, MPH, FACS, director of minimally invasive bariatric and general surgery at Magee-Womens Hospital.

“This study clearly shows that early conception rates and contraceptive practices after bariatric surgery are not ideal,” said study co-author Courcoulas in a press statement. “The findings highlight the need for more frequent referral to counseling for contraception guidance throughout the bariatric surgery process.”

The two approaches to bariatric surgery are restrictive and restrictive/malabsorptive surgeries. The most common restrictive procedure is adjustable gastric banding. The Roux-en-Y gastric bypass is the most common restrictive/malabsorptive procedure. For women who have undergone restrictive bariatric surgery, the U.S. Medical Eligibility Criteria for Contraceptive Use, 2016, rates all methods (combined hormonal ring, patch, and pills; contraceptive injection; the Copper-T and levonorgestrel intrauterine devices; progestin-only pills and progestin implant) as Category 1: “a condition for which there is no restriction for the use of the contraceptive method.”6

However, after malabsorptive bariatric surgery, for use of combined hormonal pills or progestin-only pills, the guidance issues a Category 3 rating: “a condition for which the theoretical or proven risks usually outweigh the advantages of using the method.”6 The reason for the Category 3 rating is that research suggests malabsorption of oral contraceptive hormones, as well as uncertainty about whether such malabsorption translates to decreased efficacy.7

REFERENCES

  1. Menke MN, King WC, White GE, et al. Contraception and conception after bariatric surgery. Obstet Gynecol 2017;130:979-987.
  2. National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD; 2014.
  3. ASMBS Clinical Issues Committee. Bariatric surgery in class I obesity (body mass index 30-35 kg/m²). Surg Obes Relat Dis 2013;9:e1-10.
  4. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient — 2013 update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery. Surg Obes Relat Dis 2013;9:159-191.
  5. Chevrot A, Kayem G, Coupaye M, et al. Impact of bariatric surgery on fetal growth restriction: Experience of a perinatal and bariatric surgery center. Am J Obstet Gynecol 2016;214:655.e1-7.
  6. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-103.
  7. Burke A. The effect of obesity on contraceptive efficacy: What we now know. Presented at the 2013 Contraceptive Technology Quest for Excellence conference. Atlanta; November 2013.