Semin Reprod Med 2023; 41(03/04): 97-107
DOI: 10.1055/s-0043-1776915
Review Article

Reproductive Surgery in Females with Obesity: Reproductive Consequences of Obesity and Applications for Surgical Care

1   Department of Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
Stephanie J. Estes
1   Department of Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
2   Division of Reproductive Endocrinology and Infertility, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
› Author Affiliations


Obesity is the most common medical problem in women of reproductive age. The surgical applications for this population, many of who are interested in current or future fertility, are critical to safe and effective evaluation and management of issues that impact the reproductive system. As rates of obesity continue to rise worldwide, it is projected that one in two individuals will have obesity by 2030 leading to increasing numbers of individuals affected by a disease process that has implications for their gynecologic surgical care, fertility-related assessment, and infertility treatment. Offering patients with obesity access to safe reproductive surgery is a cornerstone of reproductive autonomy. This review will summarize current recommendations regarding surgical concepts for the operating room, office hysteroscopy, oocyte retrieval, and embryo transfer in female patients with obesity.

Publication History

Article published online:
15 November 2023

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  • References

  • 1 World Health Organization. World Health Statistics 2023: Monitoring Health for the SDGs, Sustainable Development Goals. World Health Organization; 2023
  • 2 Hales CM. Prevalence of Obesity and Severe Obesity Among Adults: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2020
  • 3 Maxwell CV, Shirley R, O'Higgins AC. et al; FIGO Committee on Impact of Pregnancy on Long-Term Health and the FIGO Division of Maternal and Newborn Health. Management of obesity across women's life course: FIGO Best Practice Advice. Int J Gynaecol Obstet 2023; 160 (Suppl 1, Suppl 1): 35-49
  • 4 National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. National Heart, Lung, and Blood Institute; 1998
  • 5 Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. J Health Econ 2012; 31 (01) 219-230
  • 6 Lake JK, Power C, Cole TJ. Women's reproductive health: the role of body mass index in early and adult life. Int J Obes Relat Metab Disord 1997; 21 (06) 432-438
  • 7 Polotsky AJ, Hailpern SM, Skurnick JH, Lo JC, Sternfeld B, Santoro N. Association of adolescent obesity and lifetime nulliparity – the Study of Women's Health Across the Nation (SWAN). Fertil Steril 2010; 93 (06) 2004-2011
  • 8 Douchi T, Kuwahata R, Yamamoto S, Oki T, Yamasaki H, Nagata Y. Relationship of upper body obesity to menstrual disorders. Acta Obstet Gynecol Scand 2002; 81 (02) 147-150
  • 9 Hartz AJ, Rupley DC, Rimm AA. The association of girth measurements with disease in 32,856 women. Am J Epidemiol 1984; 119 (01) 71-80
  • 10 Castillo-Martínez L, López-Alvarenga JC, Villa AR, González-Barranco J. Menstrual cycle length disorders in 18- to 40-y-old obese women. Nutrition 2003; 19 (04) 317-320
  • 11 Rich-Edwards JW, Goldman MB, Willett WC. et al. Adolescent body mass index and infertility caused by ovulatory disorder. Am J Obstet Gynecol 1994; 171 (01) 171-177
  • 12 Kuchenbecker WK, Groen H, Zijlstra TM. et al. The subcutaneous abdominal fat and not the intraabdominal fat compartment is associated with anovulation in women with obesity and infertility. J Clin Endocrinol Metab 2010; 95 (05) 2107-2112
  • 13 Clark AM, Thornley B, Tomlinson L, Galletley C, Norman RJ. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 1998; 13 (06) 1502-1505
  • 14 Fauser BC, Tarlatzis BC, Rebar RW. et al. Consensus on women's health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril 2012; 97 (01) 28-38.e25
  • 15 Agarwal SK, Vogel K, Weitsman SR, Magoffin DA. Leptin antagonizes the insulin-like growth factor-I augmentation of steroidogenesis in granulosa and theca cells of the human ovary. J Clin Endocrinol Metab 1999; 84 (03) 1072-1076
  • 16 Greisen S, Ledet T, Møller N. et al. Effects of leptin on basal and FSH stimulated steroidogenesis in human granulosa luteal cells. Acta Obstet Gynecol Scand 2000; 79 (11) 931-935
  • 17 Pasquali R, Casimirri F, Platè L, Capelli M. Characterization of obese women with reduced sex hormone-binding globulin concentrations. Horm Metab Res 1990; 22 (05) 303-306
  • 18 McCartney CR, Blank SK, Prendergast KA. et al. Obesity and sex steroid changes across puberty: evidence for marked hyperandrogenemia in pre- and early pubertal obese girls. J Clin Endocrinol Metab 2007; 92 (02) 430-436
  • 19 Jain A, Polotsky AJ, Rochester D. et al. Pulsatile luteinizing hormone amplitude and progesterone metabolite excretion are reduced in obese women. J Clin Endocrinol Metab 2007; 92 (07) 2468-2473
  • 20 Santoro N, Lasley B, McConnell D. et al. Body size and ethnicity are associated with menstrual cycle alterations in women in the early menopausal transition: The Study of Women's Health across the Nation (SWAN) Daily Hormone Study. J Clin Endocrinol Metab 2004; 89 (06) 2622-2631
  • 21 Marci R, Lisi F, Soave I. et al. Ovarian stimulation in women with high and normal body mass index: GnRH agonist versus GnRH antagonist. Gynecol Endocrinol 2012; 28 (10) 792-795
  • 22 Rittenberg V, Seshadri S, Sunkara SK, Sobaleva S, Oteng-Ntim E, El-Toukhy T. Effect of body mass index on IVF treatment outcome: an updated systematic review and meta-analysis. Reprod Biomed Online 2011; 23 (04) 421-439
  • 23 DeUgarte DA, DeUgarte CM, Sahakian V. Surrogate obesity negatively impacts pregnancy rates in third-party reproduction. Fertil Steril 2010; 93 (03) 1008-1010
  • 24 Kortelainen M-L, Porvari K. Extreme obesity and associated cardiovascular disease verified at autopsy: time trends over 3 decades. Am J Forensic Med Pathol 2011; 32 (04) 372-377
  • 25 Roberts WC, Won VS, Vasudevan A, Guileyardo JM. Causes of death and heart weights in adults at necropsy in a tertiary Texas hospital, 2013–2015. Am J Cardiol 2016; 118 (11) 1758-1768
  • 26 Kral JG. Morbidity of severe obesity. Surg Clin North Am 2001; 81 (05) 1039-1061
  • 27 Wang L-Y, Cerny FJ. Ventilatory response to exercise in simulated obesity by chest loading. Med Sci Sports Exerc 2004; 36 (05) 780-786
  • 28 Saliman JA, Benditt JO, Flum DR, Oelschlager BK, Dellinger EP, Goss CH. Pulmonary function in the morbidly obese. Surg Obes Relat Dis 2008; 4 (05) 632-639 , discussion 639
  • 29 Grieco DL, Anzellotti GM, Russo A. et al. Airway closure during surgical pneumoperitoneum in obese patients. Anesthesiology 2019; 131 (01) 58-73
  • 30 Tomescu DR, Popescu M, Dima SO, Bacalbașa N, Bubenek-Turconi Ș. Obesity is associated with decreased lung compliance and hypercapnia during robotic assisted surgery. J Clin Monit Comput 2017; 31 (01) 85-92
  • 31 Sugerman HJ. Effects of increased intra-abdominal pressure in severe obesity. Surg Clin North Am 2001; 81 (05) 1063-1075 , vi
  • 32 Jaffin BW, Knoepflmacher P, Greenstein R. High prevalence of asymptomatic esophageal motility disorders among morbidly obese patients. Obes Surg 1999; 9 (04) 390-395
  • 33 Warner MA, Meyerhoff KL, Warner ME, Posner KL, Stephens L, Domino KB. Pulmonary aspiration of gastric contents: a closed claims analysis. Anesthesiology 2021; 135 (02) 284-291
  • 34 Jones PM, Hobai IA, Murphy PM. Anesthesia and glucagon-like peptide-1 receptor agonists: proceed with caution!. Canadian J Anesth 2023; 70 (08) 1281-1286
  • 35 Joshi GP, Abdelmalak BB, Weigel WA. et al. American Society of Anesthesiologists Consensus-Based Guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists. American Society of Anesthesiologists Task Force on Preoperative Fasting. Available at: Accessed August 27, 2023
  • 36 Poch AM, Dougherty M, Roman RA, Gavrilova-Jordan L. Perplexing findings during laparoscopic evaluation for tubal factor infertility resulting from a gastric leak after bariatric surgery: a case report. Case Rep Womens Health 2022; 36: e00460
  • 37 Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg 2009; 250 (01) 166-172
  • 38 Eisenhauer EL, Wypych KA, Mehrara BJ. et al. Comparing surgical outcomes in obese women undergoing laparotomy, laparoscopy, or laparotomy with panniculectomy for the staging of uterine malignancy. Ann Surg Oncol 2007; 14 (08) 2384-2391
  • 39 Donohoe CL, Feeney C, Carey MF, Reynolds JV. Perioperative evaluation of the obese patient. J Clin Anesth 2011; 23 (07) 575-586
  • 40 Menderes G, Gysler SM, Vadivelu N, Silasi D-A. Challenges of robotic gynecologic surgery in morbidly obese patients and how to optimize success. Curr Pain Headache Rep 2019; 23 (07) 51
  • 41 Scheib SA, Tanner III E, Green IC, Fader AN. Laparoscopy in the morbidly obese: physiologic considerations and surgical techniques to optimize success. J Minim Invasive Gynecol 2014; 21 (02) 182-195
  • 42 Khurana RN, Baudendistel TE, Morgan EF, Rabkin RA, Elkin RB, Aalami OO. Postoperative rhabdomyolysis following laparoscopic gastric bypass in the morbidly obese. Arch Surg 2004; 139 (01) 73-76
  • 43 Massey EW, Pleet AB. Compression injury of the sciatic nerve during a prolonged surgical procedure in a diabetic patient. J Am Geriatr Soc 1980; 28 (04) 188-189
  • 44 Opoku AA, Onifade RA, Odukoya OA. Challenges of morbid obesity in gynecological practice. Best Pract Res Clin Obstet Gynaecol 2023; 90: 102379
  • 45 American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 619: gynecologic surgery in the obese woman obstetrics and gynecology. Obstet Gynecol 2020; 125: 274-278
  • 46 American College of Obstetricians and Gynecologists. . ACOG practice bulletin no. 195: prevention of infection after gynecologic procedures. Obstet Gynecol 2018; 131 (06) e172-e189
  • 47 Pasic R, Levine RL, Wolf Jr WM. Laparoscopy in morbidly obese patients. J Am Assoc Gynecol Laparosc 1999; 6 (03) 307-312
  • 48 Inotsume-Kojima Y, Uchida T, Abe M, Doi T, Kanayama N. A combination of subcuticular sutures and a drain for skin closure reduces wound complications in obese women undergoing surgery using vertical incisions. J Hosp Infect 2011; 77 (02) 162-165
  • 49 Alexander CI, Liston WA. Operating on the obese woman – a review. BJOG 2006; 113 (10) 1167-1172
  • 50 Berek JS, Hacker NF. Berek and Hacker's Gynecologic Oncology. Lippincott Williams & Wilkins; 2010
  • 51 Brolin RE. Prospective, randomized evaluation of midline fascial closure in gastric bariatric operations. Am J Surg 1996; 172 (04) 328-331
  • 52 Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg 2017; 152 (03) 292-298
  • 53 Thorell A, MacCormick AD, Awad S. et al. Guidelines for perioperative care in bariatric surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg 2016; 40 (09) 2065-2083
  • 54 Stone R, Carey E, Fader AN. et al. Enhanced recovery and surgical optimization protocol for minimally invasive gynecologic surgery: an AAGL white paper. J Minim Invasive Gynecol 2021; 28 (02) 179-203
  • 55 Moss EL, Sarhanis P, Ind T, Smith M, Davies Q, Zecca M. Impact of obesity on surgeon ergonomics in robotic and straight-stick laparoscopic surgery. J Minim Invasive Gynecol 2020; 27 (05) 1063-1069
  • 56 Estes SJ, Waldman I, Gargiulo AR. Robotics and reproductive surgery. Semin Reprod Med 2017; 35 (04) 364-377
  • 57 Woodburn KL, Kho RM. Vaginal surgery: don't get bent out of shape. Am J Obstet Gynecol 2020; 223 (05) 762-763
  • 58 Rosengart TK, Doherty G, Higgins R, Kibbe MR, Mosenthal AC. Transition planning for the senior surgeon: guidance and recommendations from the Society of Surgical Chairs. JAMA Surg 2019; 154 (07) 647-653
  • 59 Onalan R, Onalan G, Tonguc E, Ozdener T, Dogan M, Mollamahmutoglu L. Body mass index is an independent risk factor for the development of endometrial polyps in patients undergoing in vitro fertilization. Fertil Steril 2009; 91 (04) 1056-1060
  • 60 Cenksoy P, Ficicioglu C, Yıldırım G, Yesiladali M. Hysteroscopic findings in women with recurrent IVF failures and the effect of correction of hysteroscopic findings on subsequent pregnancy rates. Arch Gynecol Obstet 2013; 287 (02) 357-360
  • 61 Serhat E, Cogendez E, Selcuk S, Asoglu MR, Arioglu PF, Eren S. Is there a relationship between endometrial polyps and obesity, diabetes mellitus, hypertension?. Arch Gynecol Obstet 2014; 290 (05) 937-941
  • 62 McGuigan RD, Wilkinson JM. Obesity and healthcare avoidance: a systematic review. AIMS Public Health 2015; 2 (01) 56-63
  • 63 Paulo AAS, Solheiro MHR, Paulo COS. Is pain better tolerated with mini-hysteroscopy than with conventional device? A systematic review and meta-analysis : hysteroscopy scope size and pain. Arch Gynecol Obstet 2015; 292 (05) 987-994
  • 64 Rodriguez S, Moore J, Marbin S, Carugno J. 7536 Can body mass index be a predictor of pain during office hysteroscopy? Findings from a single-center study. J Minim Invasive Gynecol 2022; 29 (11) S94
  • 65 Romanski PA, Farland LV, Tsen LC, Ginsburg ES, Lewis EI. Effect of class III and class IV obesity on oocyte retrieval complications and outcomes. Fertil Steril 2019; 111 (02) 294-301.e1
  • 66 Wikland M, Enk L, Hamberger L. Transvesical and transvaginal approaches for the aspiration of follicles by use of ultrasound. Ann N Y Acad Sci 1985; 442 (01) 182-194
  • 67 Kwan I, Wang R, Pearce E, Bhattacharya S. Pain relief for women undergoing oocyte retrieval for assisted reproduction. Cochrane Database Syst Rev 2018; 5 (05) CD004829
  • 68 Roman-Rodriguez CF, Weissbrot E, Hsu C-D, Wong A, Siefert C, Sung L. Comparing transabdominal and transvaginal ultrasound-guided follicular aspiration: a risk assessment formula. Taiwan J Obstet Gynecol 2015; 54 (06) 693-699
  • 69 Rosenberg JC, Guzman ER, Vintzileos AM, Knuppel RA. Transumbilical placement of the vaginal probe in obese pregnant women. Obstet Gynecol 1995; 85 (01) 132-134
  • 70 Barton SE, Politch JA, Benson CB, Ginsburg ES, Gargiulo AR. Transabdominal follicular aspiration for oocyte retrieval in patients with ovaries inaccessible by transvaginal ultrasound. Fertil Steril 2011; 95 (05) 1773-1776
  • 71 Bodri D, Colodrón M, García D, Obradors A, Vernaeve V, Coll O. Transvaginal versus transabdominal ultrasound guidance for embryo transfer in donor oocyte recipients: a randomized clinical trial. Fertil Steril 2011; 95 (07) 2263-2268 , 2268.e1
  • 72 Mohamed Hassan S, Ramadan W, Elsharkawy M, Ali Bayoumi Y. The role of Transvaginal ultrasound guided embryo transfer to improve pregnancy rate in obese patients undergoing Intracytoplasmic sperm injection. Int J Womens Health 2021; 13: 861-867
  • 73 Anderson RE, Nugent NL, Gregg AT, Nunn SL, Behr BR. Transvaginal ultrasound-guided embryo transfer improves outcome in patients with previous failed in vitro fertilization cycles. Fertil Steril 2002; 77 (04) 769-775
  • 74 Moon TS, Joshi GP. Are morbidly obese patients suitable for ambulatory surgery?. Curr Opin Anaesthesiol 2016; 29 (01) 141-145
  • 75 Gillett WR, Peek JC, Herbison GP. Development of clinical priority access criteria for assisted reproduction and its evaluation on 1386 infertile couples in New Zealand. Hum Reprod 2012; 27 (01) 131-141
  • 76 Brown RCH. Irresponsibly infertile? Obesity, efficiency, and exclusion from treatment. Health Care Anal 2019; 27 (02) 61-76
  • 77 Turner-McGrievy GM, Grant BL. Prevalence of body mass index and body weight cut-off points for in vitro fertilization treatment at U.S. clinics and current clinic weight loss strategy recommendations. Hum Fertil (Camb) 2015; 18 (03) 215-219
  • 78 Kaye L, Sueldo C, Engmann L, Nulsen J, Benadiva C. Survey assessing obesity policies for assisted reproductive technology in the United States. Fertil Steril 2016; 105 (03) 703-706.e2
  • 79 American College of Obstetricians and Gynecologists. . Obesity in pregnancy: ACOG practice bulletin, number 230. Obstet Gynecol 2021; 137 (06) e128-e144
  • 80 American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 549: obesity in pregnancy. Obstet Gynecol 2013; 121 (01) 213-217
  • 81 Chu SY, Kim SY, Schmid CH. et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obes Rev 2007; 8 (05) 385-394
  • 82 Aune D, Saugstad OD, Henriksen T, Tonstad S. Maternal body mass index and the risk of fetal death, stillbirth, and infant death: a systematic review and meta-analysis. JAMA 2014; 311 (15) 1536-1546
  • 83 Alvarez R, Bonham AJ, Buda CM, Carlin AM, Ghaferi AA, Varban OA. Factors associated with long wait times for bariatric surgery. Ann Surg 2019; 270 (06) 1103-1109
  • 84 Beard JH, Bell RL, Duffy AJ. Reproductive considerations and pregnancy after bariatric surgery: current evidence and recommendations. Obes Surg 2008; 18 (08) 1023-1027
  • 85 Milone M, De Placido G, Musella M. et al. Incidence of successful pregnancy after weight loss interventions in infertile women: a systematic review and meta-analysis of the literature. Obes Surg 2016; 26 (02) 443-451
  • 86 Johansson K, Cnattingius S, Näslund I. et al. Outcomes of pregnancy after bariatric surgery. N Engl J Med 2015; 372 (09) 814-824
  • 87 Insogna IG, Ginsburg ES. Infertility, inequality, and how lack of insurance coverage compromises reproductive autonomy. AMA J Ethics 2018; 20 (12) E1152-E1159
  • 88 Schon S, Butts S. Obesity, reproductive outcomes, and access to infertility treatments: a clinical and ethical debate. Obes Fertil 2015
  • 89 Goldman RH, Farland LV, Thomas AM, Zera CA, Ginsburg ES. The combined impact of maternal age and body mass index on cumulative live birth following in vitro fertilization. Am J Obstet Gynecol 2019; 221 (06) 617.e1-617.e13
  • 90 Kelley AS, Badon SE, Lanham MSM, Fisseha S, Moravek MB. Body mass index restrictions in fertility treatment: a national survey of OB/GYN subspecialists. J Assist Reprod Genet 2019; 36 (06) 1117-1125