To the Editor:
We read with great interest the article by Gosman et al (1). The authors highlight that 13.1% of female patients undergoing bariatric surgery had already been diagnosed with PCOS by a health care provider. Data on the incidence of polycystic ovary syndrome (PCOS) in this population from outside the U.S. and the U.K. in particular are limited. Our group has recently prospectively measured the prevalence of PCOS in 149 consecutive women of child bearing age (18-45 years old) undergoing bariatric surgery using the same question as the one used by Gosman et al., i.e., ‘‘Have you ever been told by a health care provider that you have PCOS?” Twenty-three out 149 (15.4%) women replied yes. The mean age (±SD) was 32.1 (±6.6) and the mean body mass index (BMI) was 50.7 (±5.2). The prevalence of PCOS in our U.K. sample was higher than reported in the general population (2,3).
Of note was the fact that we also found that for 11 of 149 (7.4%) women of childbearing age, subfertility was the main reason for undergoing bariatric surgery. This most likely reflects the fact that obesity may be associated with poor outcomes following assisted reproduction techniques (4). This proportion of subfertile women is very similar to the 9% reported by Gosman. As awareness increases that bariatric surgery may lead to improved fertility outcomes by weight loss alone it is possible that subfertility may become an increasingly common reason for referral (5).
Our U.K. sample appeared to mirror PCOS prevalence in the U.S. study. The cost effectiveness of such an intervention for fertility-related reasons in the UK must be first evaluated and should also take into account maternal and neonatal morbidity before implementation.
Dimitrios Pournaras, MRCSa
aDepartment of Bariatric Surgery
bDepartment of Obstetrics and Gynaecology
Musgrove Park Hospital
Taunton, United Kingdom
1. Gosman GG, King WC, Schrope B, Steffen KJ, Strain GW, Courcoulas AP, Flum DR, Pender JR, Simhan HN. Reproductive health of women electing bariatric surgery. Fertil Steril 2009. In press.
2. Yildiz BO, Knochenhauer ES, Azziz R. Impact of obesity on the risk for polycystic ovary syndrome. J Clin Endocrinol Metab 2008; 93: 162-8.
3. Balen A, Michelmore K. What is polycystic ovary syndrome? Are national views important? Hum Reprod 2002; 17: 2219-27.
4. Maheshwari A, Stofberg L, Bhattacharya S. Effect of overweight and obesity on assisted reproductive technology–a systematic review. Hum Reprod Update 2007; 13: 433-44.
5. Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, Hilton L, Santry HP, Morton JM, Livingston EH, Shekelle PG. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA. 2008 Nov 19;300(19):2286-96.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2010.04.046
The Authors Respond:
We thank Drs. Pournaras, Manning, Bidgood, et al for their comment on our manuscript. We acknowledge the remarkable similarity of their findings to ours, despite the differences in both population demography and health care structure between the US and the UK.
We commend the authors for asking women about their reasons for undergoing surgery and determining that 7% of women underwent surgery to improve their fertility. This is likely consistent with our finding that, among women who had tried to conceive, 42% had experienced infertility and 8% never had a pregnancy.
We also found that 30% of women, who had the potential to get pregnant, considered postoperative pregnancy an important goal. Certainly the public health and policy implications of our collective findings ought to be weighed carefully before making decisions regarding the approach to bariatric surgery to improve reproductive fitness.
As that evidence builds, we hope that our data can serve as guidance to providers and women in making individual doctor-patient decisions.
Gabriella G. Gosman, M.D.a
Wendy C. King, Ph.D.b
Beth Schrope, M.D., Ph.D.c
Kristine J. Steffen, Pharm.D., Ph.D.d
Gladys W. Strain, Ph.D.e
Anita P. Courcoulas, M.D.a
David R. Flum, M.D., M.P.H.f
John R. Pender, M.D.g
Hyagriv N. Simhan, M.D., M.S.C.R.a
aUniversity of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania; bUniversity of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania; cColumbia University, College of Physicians and Surgeons, New York, New York; dNeuropsychiatric Research Institute, Fargo, North Dakota; eCornell University, Weill-Cornell School of Medicine, New York, New York; fUniversity of Washington, School of Medicine, Seattle, Washington; gEast Carolina University, Brody School of Medicine, Greenville, North Carolina
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2010.04.047