Advertisement

American Society for Metabolic and Bariatric Surgery position statement on the impact of obesity and obesity treatment on fertility and fertility therapy Endorsed by the American College of Obstetricians and Gynecologists and the Obesity Society

  • Author Footnotes
    1 Primary authors from the American College of Obstetricians and Gynecologists.
    Michelle A. Kominiarek
    Footnotes
    1 Primary authors from the American College of Obstetricians and Gynecologists.
    Affiliations
    Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
    Search for articles by this author
  • Author Footnotes
    1 Primary authors from the American College of Obstetricians and Gynecologists.
    Emily S. Jungheim
    Footnotes
    1 Primary authors from the American College of Obstetricians and Gynecologists.
    Affiliations
    Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
    Search for articles by this author
  • Author Footnotes
    1 Primary authors from the American College of Obstetricians and Gynecologists.
    Kathleen M. Hoeger
    Footnotes
    1 Primary authors from the American College of Obstetricians and Gynecologists.
    Affiliations
    Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York
    Search for articles by this author
  • Author Footnotes
    2 Primary authors from the American Society for Metabolic and Bariatric Surgery.
    Ann M. Rogers
    Footnotes
    2 Primary authors from the American Society for Metabolic and Bariatric Surgery.
    Affiliations
    Penn State Hershey Surgical Weight Loss Program, Hershey, Pennsylvania
    Search for articles by this author
  • Author Footnotes
    3 Primary author from the Obesity Society.
    Scott Kahan
    Footnotes
    3 Primary author from the Obesity Society.
    Affiliations
    George Washington University; Washington D.C.

    Johns Hopkins Bloomberg School of Public Health; Baltimore, MD
    Search for articles by this author
  • Author Footnotes
    2 Primary authors from the American Society for Metabolic and Bariatric Surgery.
    Julie J. Kim
    Correspondence
    Correspondence: Julie J. Kim, M.D, Department of Surgery, Mount Auburn Hospital, 330 Mount Auburn Street, Cambridge, MA 02138.
    Footnotes
    2 Primary authors from the American Society for Metabolic and Bariatric Surgery.
    Affiliations
    Harvard Medical School, Mount Auburn Weight Management, Mount Auburn Hospital, Cambridge, Massachusetts
    Search for articles by this author
  • Author Footnotes
    1 Primary authors from the American College of Obstetricians and Gynecologists.
    2 Primary authors from the American Society for Metabolic and Bariatric Surgery.
    3 Primary author from the Obesity Society.
Published:February 12, 2017DOI:https://doi.org/10.1016/j.soard.2017.02.006
      The American Society for Metabolic and Bariatric Surgery issues the following position statement for the purpose of enhancing quality of care in metabolic and bariatric surgery. In this statement, suggestions for management are presented that are derived from available knowledge, peer-reviewed scientific literature, and expert opinion. This was accomplished by performing a review of currently available literature regarding obesity and obesity treatment and fertility and fertility therapy. The intent of issuing such a statement is to provide objective information regarding the impact of obesity and obesity treatment on fertility and fertility therapy. The statement may be revised in the future should additional evidence become available.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery for Obesity and Related Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Obesity: preventing and managing the global epidemic
        Report of a WHO consultation.
        World Health Organ Tech Rep Ser. 2000; 894: 1-253
        • Ogden C.L.
        • Carroll M.D.
        • Kit B.K.
        • Flegal K.M.
        Prevalence of childhood and adult obesity in the United States, 2011–2012.
        JAMA. 2014; 311: 806-814
        • Flegal K.M.
        • Carroll M.D.
        • Ogden C.L.
        • Curtin L.R.
        Prevalence and trends in obesity among US adults, 1999–2008.
        JAMA. 2010; 303: 235-241
        • ACOG Practice Bulletin No. 156
        Obesity in Pregnancy.
        Obstet Gynecol. 2015; 126: e112-e126
        • Gunatilake R.P.
        • Perlow J.H.
        Obesity and pregnancy: clinical management of the obese gravida.
        Am J Obstet Gynecol. 2011; 204: 106-119
        • Evers J.L.
        Female subfertility.
        Lancet. 2002; 360: 151-159
        • Practice Committee of American Society for Reproductive Medicine
        Definitions of infertility and recurrent pregnancy loss: a committee opinion.
        Fertil Steril. 2013; 99: 63
        • Hassan M.A.
        • Killick S.R.
        Negative lifestyle is associated with a significant reduction in fecundity.
        Fertil Steril. 2004; 81: 384-392
        • Chavarro J.E.
        • Rich-Edwards J.W.
        • Rosner B.A.
        • Willett W.C.
        Diet and lifestyle in the prevention of ovulatory disorder infertility.
        Obstet Gynecol. 2007; 110: 1050-1058
        • Practice Committee of the American Society for Reproductive Medicine
        Smoking and infertility: a committee opinion.
        Fertil Steril. 2012; 98: 1400-1406
        • Sharma R.
        • Biedenharn K.R.
        • Fedor J.M.
        • Agarwal A.
        Lifestyle factors and reproductive health: taking control of your fertility.
        Reprod Biol Endocrinol. 2013; 11: 66
        • Tolstrup J.S.
        • Kjaer S.K.
        • Holst C.
        • et al.
        Alcohol use as predictor for infertility in a representative population of Danish women.
        Acta Obstet Gynecol Scand. 2003; 82: 744-749
        • Eggert J.
        • Theobald H.
        • Engfeldt P.
        Effects of alcohol consumption on female fertility during an 18-year period.
        Fertil Steril. 2004; 81: 379-383
        • Bolúmar F.
        • Olsen J.
        • Rebagliato M.
        • Bisanti L.
        Caffeine intake and delayed conception: a European multicenter study on infertility and subfecundity. European Study Group on Infertility Subfecundity.
        Am J Epidemiol. 1997; 145: 324-334
        • Kauffman R.P.
        • Baker T.E.
        • Baker V.M.
        • DiMarino P.
        • Castracane V.D.
        Endocrine and metabolic differences among phenotypic expressions of polycystic ovary syndrome according to the 2003 Rotterdam consensus criteria.
        Am J Obstet Gynecol. 2008; 198 (e1–7): 670
        • Moran L.J.
        • Pasquali R.
        • Teede H.J.
        • Hoeger K.M.
        • Norman R.J.
        Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society.
        Fertil Steril. 2009; 92: 1966-1982
        • Rosenzweig J.L.
        • Ferrannini E.
        • Grundy S.M.
        • et al.
        • Endocrine Society
        Primary prevention of cardiovascular disease and type 2 diabetes in patients at metabolic risk: an endocrine society clinical practice guideline.
        J Clin Endocrinol Metab. 2008; 93: 3671-3689
        • Hartz A.J.
        • Rupley D.C.
        • Rimm A.A.
        The association of girth measurements with disease in 32,856 women.
        Am J Epidemiol. 1984; 119: 71-80
        • Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group
        Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome.
        Fertil Steril. 2004; 81: 19-25
        • Lim S.S.
        • Davies M.J.
        • Norman R.J.
        • Moran L.J.
        Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis.
        Hum Reprod Update. 2012; 18: 618-637
        • Carmina E.
        Genetic and environmental aspects of polycystic ovary syndrome.
        J Endocrinol Invest. 2003; 26: 1151-1159
        • Teede H.J.
        • Joham A.E.
        • Paul E.
        • et al.
        Longitudinal weight gain in women identified with polycystic ovary syndrome: results of an observational study in young women.
        Obesity (Silver Spring). 2013; 21: 1526-1532
        • Yildiz B.O.
        • Knochenhauer E.S.
        • Azziz R.
        Impact of obesity on the risk for polycystic ovary syndrome.
        J Clin Endocrinol Metab. 2008; 93: 162-168
        • Rexrode K.M.
        • Carey V.J.
        • Hennekens C.H.
        • et al.
        Abdominal adiposity and coronary heart disease in women.
        JAMA. 1998; 280: 1843-1848
        • Virtue S.
        • Vidal-Puig A.
        Adipose tissue expandability, lipotoxicity and the metabolic syndrome: an allostatic perspective.
        Biochim Biophys Acta. 2010; 1801: 338-349
        • Diamanti-Kandarakis E.
        • Dunaif A.
        Insulin resistance and the polycystic ovary syndrome revisited: an update on mechanisms and implications.
        Endocr Rev. 2012; 33: 981-1030
        • Toulis K.A.
        • Goulis D.G.
        • Farmakiotis D.
        • et al.
        Adiponectin levels in women with polycystic ovary syndrome: a systematic review and a meta-analysis.
        Hum Reprod Update. 2009; 15: 297-307
        • Naderpoor N.
        • Shorakae S.
        • de Courten B.
        • Misso M.L.
        • Moran L.J.
        • Teede H.J.
        Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis.
        Hum Reprod Update. 2015; 21: 560-574
        • Mannerås L.
        • Cajander S.
        • Lönn M.
        • Stener-Victorin E.
        Acupuncture and exercise restore adipose tissue expression of sympathetic markers and improve ovarian morphology in rats with dihydrotestosterone-induced PCOS.
        Am J Physiol Regul Integr Comp Physiol. 2009; 296: R1124-R1131
        • Chen X.
        • Jia X.
        • Qiao J.
        • Guan Y.
        • Kang J.
        Adipokines in reproductive function: a link between obesity and polycystic ovary syndrome.
        J Mol Endocrinol. 2013; 50: R21-R37
        • Löffler S.
        • Aust G.
        • Köhler U.
        • Spanel-Borowski K.
        Evidence of leptin expression in normal and polycystic human ovaries.
        Mol Hum Reprod. 2001; 7: 1143-1149
        • Escobar-Morreale H.F.
        • San Millán J.L.
        Abdominal adiposity and the polycystic ovary syndrome.
        Trends Endocrinol Metab. 2007; 18: 266-272
        • Luke B.
        • Brown M.B.
        • Stern J.E.
        • Missmer S.A.
        • Fujimoto V.Y.
        • Leach R.
        • SART Writing Group
        Female obesity adversely affects assisted reproductive technology (ART) pregnancy and live birth rates.
        Hum Reprod. 2011; 26: 245-252
        • Shah D.K.
        • Missmer S.A.
        • Berry K.F.
        • Racowsky C.
        • Ginsburg E.S.
        Effect of obesity on oocyte and embryo quality in women undergoing in vitro fertilization.
        Obstet Gynecol. 2011; 118: 63-70
        • Cardozo E.R.
        • Karmon A.E.
        • Gold J.
        • Petrozza J.C.
        • Styer A.K.
        Reproductive outcomes in oocyte donation cycles are associated with donor BMI.
        Hum Reprod. 2016; 31: 385-392
        • Provost M.P.
        • Acharya K.S.
        • Acharya C.R.
        • et al.
        Pregnancy outcomes decline with increasing recipient body mass index: an analysis of 22,317 fresh donor/recipient cycles from the 2008–2010 Society for Assisted Reproductive Technology Clinic Outcome Reporting System registry.
        Fertil Steril. 2016; 105: 364-368
        • Pasquali R.
        • Antenucci D.
        • Casimirri F.
        • et al.
        Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss.
        J Clin Endocrinol Metab. 1989; 68: 173-179
        • Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group
        Consensus on infertility treatment related to polycystic ovary syndrome.
        Hum Reprod. 2008; 23: 462-477
        • Traub M.L.
        Assessing and treating insulin resistance in women with polycystic ovarian syndrome.
        World J Diabetes. 2011; 2: 33-40
        • Moos M.K.
        • Dunlop A.L.
        • Jack B.W.
        • et al.
        Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age.
        Am J Obstet Gynecol. 2008; 199: S280-S289
        • Practice Committee of the American Society for Reproductive Medicine
        Obesity and reproduction: a committee opinion.
        Fertil Steril. 2015; 104: 1116-1126
        • Metwally M.
        • Amer S.
        • Li T.C.
        • Ledger W.L.
        An RCT of metformin versus orlistat for the management of obese anovulatory women.
        Hum Reprod. 2009; 24: 966-975
        • Becker G.F.
        • Passos E.P.
        • Moulin C.C.
        Short-term effects of a hypocaloric diet with low glycemic index and low glycemic load on body adiposity, metabolic variables, ghrelin, leptin, and pregnancy rate in overweight and obese infertile women: a randomized controlled trial.
        Am J Clin Nutr. 2015; 102: 1365-1372
        • Jayagopal V.
        • Kilpatrick E.S.
        • Holding S.
        • Jennings P.E.
        • Atkin S.L.
        Orlistat is as beneficial as metformin in the treatment of polycystic ovarian syndrome.
        J Clin Endocrinol Metab. 2005; 90: 729-733
        • Panidis D.
        • Farmakiotis D.
        • Rousso D.
        • Kourtis A.
        • Katsikis I.
        • Krassas G.
        Obesity, weight loss, and the polycystic ovary syndrome: effect of treatment with diet and orlistat for 24 weeks on insulin resistance and androgen levels.
        Fertil Steril. 2008; 89: 899-906
        • Cho L.W.
        • Kilpatrick E.S.
        • Keevil B.G.
        • Coady A.M.
        • Atkin S.L.
        Effect of metformin, orlistat and pioglitazone treatment on mean insulin resistance and its biological variability in polycystic ovary syndrome.
        Clin Endocrinol (Oxf). 2009; 70: 233-237
        • Tang T.
        • Glanville J.
        • Hayden C.J.
        • White D.
        • Barth J.H.
        • Balen A.H.
        Combined lifestyle modification and metformin in obese patients with polycystic ovary syndrome: a randomized, placebo-controlled, double-blind multicentre study.
        Hum Reprod. 2006; 21: 80-89
        • Cnattingius S.
        • Villamor E.
        Weight change between successive pregnancies and risks of stillbirth and infant mortality: a nationwide cohort study.
        Lancet. 2016; 387: 558-565
        • Callegari L.S.
        • Sterling L.A.
        • Zelek S.T.
        • Hawes S.E.
        • Reed S.D.
        Interpregnancy body mass index change and success of term vaginal birth after cesarean delivery.
        Am J Obstet Gynecol. 2014; 210 (e1–7): 330
        • Getahun D.
        • Kaminsky L.M.
        • Elsasser D.A.
        • Kirby R.S.
        • Ananth C.V.
        • Vintzileos A.M.
        Changes in prepregnancy body mass index between pregnancies and risk of primary cesarean delivery.
        Am J Obstet Gynecol. 2007; 197 (e1–7): 376
        • Getahun D.
        • Ananth C.V.
        • Peltier M.R.
        • Salihu H.M.
        • Scorza W.E.
        Changes in prepregnancy body mass index between the first and second pregnancies and risk of large-for-gestational-age birth.
        Am J Obstet Gynecol. 2007; 196 (e1–8): 530
        • Guelinckx I.
        • Devlieger R.
        • Vansant G.
        Reproductive outcome after bariatric surgery: a critical review.
        Hum Reprod Update. 2009; 15: 189-201
        • Maggard M.A.
        • Yermilov I.
        • Li Z.
        • et al.
        Pregnancy and fertility following bariatric surgery: a systematic review.
        JAMA. 2008; 300: 2286-2296
        • Curtis K.M.
        • Tepper N.K.
        • Jatlaoui T.C.
        • et al.
        U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.
        MMWR Recomm Rep. 2016; 65: 1-104
        • Mengesha B.
        • Griffin L.
        • Nagle A.
        • Kiley J.
        Assessment of contraceptive needs in women undergoing bariatric surgery.
        Contraception. 2016; 94: 74-77
        • Mody S.K.
        • Hacker M.R.
        • Dodge L.E.
        • Thornton K.
        • Schneider B.
        • Haider S.
        Contraceptive counseling for women who undergo bariatric surgery.
        J Womens Health (Larchmt). 2011; 20: 1785-1788
        • Ginstman C.
        • Frisk J.
        • Ottosson J.
        • Brynhildsen J.
        Contraceptive use before and after gastric bypass: a questionnaire study.
        Obes Surg. 2015; 25: 2066-2070
        • Chor J.
        • Chico P.
        • Ayloo S.
        • Roston A.
        • Kominiarek M.A.
        Reproductive health counseling and practices: a cross-sectional survey of bariatric surgeons.
        Surg Obes Relat Dis. 2015; 11: 187-192
        • Paulen M.E.
        • Zapata L.B.
        • Cansino C.
        • Curtis K.M.
        • Jamieson D.J.
        Contraceptive use among women with a history of bariatric surgery: a systematic review.
        Contraception. 2010; 82: 86-94
        • Gerrits E.G.
        • Ceulemans R.
        • van Hee R.
        • Hendrickx L.
        • Totté E.
        Contraceptive treatment after biliopancreatic diversion needs consensus.
        Obes Surg. 2003; 13: 378-382
        • Ciangura C.
        • Corigliano N.
        • Basdevant A.
        • et al.
        Etonorgestrel concentrations in morbidly obese women following Roux-en-Y gastric bypass surgery: three case reports.
        Contraception. 2011; 84: 649-651
        • Murthy A.S.
        Obesity and contraception: emerging issues.
        Semin Reprod Med. 2010; 28: 156-163
        • Brewer C.J.
        • Balen A.H.
        The adverse effects of obesity on conception and implantation.
        Reproduction. 2010; 140: 347-364
        • Clark A.M.
        • Thornley B.
        • Tomlinson L.
        • Galletley C.
        • Norman R.J.
        Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment.
        Hum Reprod. 1998; 13: 1502-1505
        • Mutsaerts M.A.
        • van Oers A.M.
        • Groen H.
        • et al.
        Randomized trial of a lifestyle program in obese infertile women.
        N Engl J Med. 2016; 374: 1942-1953
        • Sim K.A.
        • Dezarnaulds G.M.
        • Denyer G.S.
        • Skilton M.R.
        • Caterson I.D.
        Weight loss improves reproductive outcomes in obese women undergoing fertility treatment: a randomized controlled trial.
        Clin Obes. 2014; 4: 61-68
        • Khaskheli M.N.
        • Baloch S.
        • Baloch A.S.
        Infertility and weight reduction: influence and outcome.
        J Coll Physicians Surg Pak. 2013; 23: 798-801
        • Palomba S.
        • Falbo A.
        • Giallauria F.
        • et al.
        Six weeks of structured exercise training and hypocaloric diet increases the probability of ovulation after clomiphene citrate in overweight and obese patients with polycystic ovary syndrome: a randomized controlled trial.
        Hum Reprod. 2010; 25: 2783-2791
        • Tsagareli V.
        • Noakes M.
        • Norman R.J.
        Effect of a very-low-calorie diet on in vitro fertilization outcomes.
        Fertil Steril. 2006; 86: 227-229
        • Conway G.
        • Dewailly D.
        • Diamanti-Kandarakis E.
        • et al.
        • ESE PCOS Special Interest Group
        The polycystic ovary syndrome: a position statement from the European Society of Endocrinology.
        Eur J Endocrinol. 2014; 171: P1-29
        • Skubleny D.
        • Switzer N.J.
        • Gill R.S.
        • et al.
        The impact of bariatric surgery on polycystic ovary syndrome: a systematic review and meta-analysis.
        Obes Surg. 2016; 26: 169-176
        • Tsur A.
        • Orvieto R.
        • Haas J.
        • Kedem A.
        • Machtinger R.
        Does bariatric surgery improve ovarian stimulation characteristics, oocyte yield, or embryo quality?.
        J Ovarian Res. 2014; 7: 116
        • Doblado M.A.
        • Lewkowksi B.M.
        • Odem R.R.
        • Jungheim E.S.
        In vitro fertilization after bariatric surgery.
        Fertil Steril. 2010; 94: 2812-2814
        • Kolotkin R.L.
        • Zunker C.
        • Østbye T.
        Sexual functioning and obesity: a review.
        Obesity (Silver Spring). 2012; 20: 2325-2333
        • Pasquali R.
        Obesity and androgens: facts and perspectives.
        Fertil Steril. 2006; 85: 1319-1340
        • Sermondade N.
        • Massin N.
        • Boitrelle F.
        • et al.
        Sperm parameters and male fertility after bariatric surgery: three case series.
        Reprod Biomed Online. 2012; 24: 206-210
        • Thomsen L.
        • Humaidan P.
        • Bungum L.
        • Bungum M.
        The impact of male overweight on semen quality and outcome of assisted reproduction.
        Asian J Androl. 2014; 16: 749-754
        • Eisenberg M.L.
        • Kim S.
        • Chen Z.
        • Sundaram R.
        • Schisterman E.F.
        • Buck Louis G.M.
        The relationship between male BMI and waist circumference on semen quality: data from the LIFE study.
        Hum Reprod. 2014; 29: 193-200
        • M Al-Ali B.
        • Gutschi T.
        • Pummer K.
        • et al.
        Body mass index has no impact on sperm quality but on reproductive hormones levels.
        Andrologia. 2014; 46: 106-111
        • Duits F.H.
        • van Wely M.
        • van der Veen F.
        • Gianotten J.
        Healthy overweight male partners of subfertile couples should not worry about their semen quality.
        Fertil Steril. 2010; 94: 1356-1359
        • Lotti F.
        • Corona G.
        • Colpi G.M.
        • et al.
        Elevated body mass index correlates with higher seminal plasma interleukin 8 levels and ultrasonographic abnormalities of the prostate in men attending an andrology clinic for infertility.
        J Endocrinol Invest. 2011; 34: e336-e342
        • MacDonald A.A.
        • Herbison G.P.
        • Showell M.
        • Farquhar C.M.
        The impact of body mass index on semen parameters and reproductive hormones in human males: a systematic review with meta-analysis.
        Hum Reprod Update. 2010; 16: 293-311
        • Povey A.C.
        • Clyma J.A.
        • McNamee R.
        • et al.
        • Participating Centres of Chaps-UK
        Modifiable and non-modifiable risk factors for poor semen quality: a case-referent study.
        Hum Reprod. 2012; 27: 2799-2806
        • Chavarro J.E.
        • Toth T.L.
        • Wright D.L.
        • Meeker J.D.
        • Hauser R.
        Body mass index in relation to semen quality, sperm DNA integrity, and serum reproductive hormone levels among men attending an infertility clinic.
        Fertil Steril. 2010 May 1; 93: 2222-2231
        • Dupont C.
        • Faure C.
        • Sermondade N.
        • et al.
        Obesity leads to higher risk of sperm DNA damage in infertile patients.
        Asian J Androl. 2013; 15: 622-625
        • Fariello R.M.
        • Pariz J.R.
        • Spaine D.M.
        • Cedenho A.P.
        • Bertolla R.P.
        • Fraietta R.
        Association between obesity and alteration of sperm DNA integrity and mitochondrial activity.
        BJU Int. 2012; 110: 863-867
        • La Vignera S.
        • Condorelli R.A.
        • Vicari E.
        • Calogero A.E.
        Negative effect of increased body weight on sperm conventional and nonconventional flow cytometric sperm parameters.
        J Androl. 2012; 33: 53-58
        • Rybar R.
        • Kopecka V.
        • Prinosilova P.
        • Markova P.
        • Rubes J.
        Male obesity and age in relationship to semen parameters and sperm chromatin integrity.
        Andrologia. 2011; 43: 286-291
        • Tunc O.
        • Bakos H.W.
        • Tremellen K.
        Impact of body mass index on seminal oxidative stress.
        Andrologia. 2011; 43: 121-128
        • Bakos H.W.
        • Henshaw R.C.
        • Mitchell M.
        • Lane M.
        Paternal body mass index is associated with decreased blastocyst development and reduced live birth rates following assisted reproductive technology.
        Fertil Steril. 2011; 95: 1700-1704
        • Colaci D.S.
        • Afeiche M.
        • Gaskins A.J.
        • et al.
        Men׳s body mass index in relation to embryo quality and clinical outcomes in couples undergoing in vitro fertilization.
        Fertil Steril. 2012; 98 (e1): 1193-1199
        • Corona G.
        • Rastrelli G.
        • Monami M.
        • et al.
        Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: a systematic review and meta-analysis.
        Eur J Endocrinol. 2013; 168: 829-843
        • di Frega A.S.
        • Dale B.
        • Di Matteo L.
        • Wilding M.
        Secondary male factor infertility after Roux-en-Y gastric bypass for morbid obesity: case report.
        Hum Reprod. 2005; 20: 997-998
        • Lazaros L.
        • Hatzi E.
        • Markoula S.
        • et al.
        Dramatic reduction in sperm parameters following bariatric surgery: report of two cases.
        Andrologia. 2012; 44: 428-432