Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this week's episode of the Conquer Your Weight podcast. We are talking about a topic that is near and dear to my heart, and this is weight loss before pregnancy, and we'll also talk about that in the context of IVF or in vitro fertilization because the reality is our health and our weight can have a really big impact both on our ability to get pregnant, to stay pregnant, and then when we look at pregnancy outcomes both for mom and for baby. And so with that, I want to make sure we take some time and talk about it. I realized I've had some episodes related to weight loss during pregnancy or how we should perceive our weight during pregnancy, but the reality are there are also special considerations that we need to be taking in order to think about getting pregnant, maybe medication concerns. Are we thinking about bariatric surgery, especially with all of these new medications on the market for the support of obesity, for the support of weight loss? Are those safe during pregnancy? Are those not safe during pregnancy? We're hearing lots of different stuff where our recommendations sit today as of 2025 because I do think this will be an evolving field. And then we'll transition a little bit more to talking about even the bariatric surgery space. And if you are trying to optimize your ability to get pregnant, have a healthy pregnancy outcome, what will make the most sense for you, your baby, your body, your family? So let's dive into it because we know that weight can have a really serious correlation with both our ability to get pregnant, but then also once we are pregnant, what those outcomes look like. And while there is no magic number at this weight or at this body mass index, you are more likely to get pregnant or have fertility issues versus not. There are certain thresholds and correlations that we see. So a lot of times my patients will come to me having been told that at a body mass index of greater than 35 or maybe that greater than 40, that they may be either at certain criteria that they're struggling with their pregnancy or they've been advised to get below those thresholds before pursuing pregnancy. Particularly with in vitro, we know that outcomes may be more likely at certain weights, so our weight can have a correlation with our fertility. Sometimes it can be related to conditions like PCOS, polycystic ovarian syndrome, which is a condition of insulin resistance by which our bodies do not ovulate regularly. There's other issues with PCOS as well, but the biggest one comes down to we do not have regular period cycles. For some women, they may actually not be ovulating much at all. They have cycles that we would describe as anovulatory cycles, meaning that no egg was released during that cycle. And you can imagine that if no egg is being released, then you would not be able to get pregnant because there's not that egg there for being able to conceive. And so women who have PCOS may have, sometimes they may have some cycles that are ovulatory, meaning some cycles they release an egg, other cycles they do not release an egg. But what they will note is that their bleeding patterns or their period is often irregular. And the reason for that is because our periods happen as a response to hormonal changes as a response to the lining of the uterus is sort of growing, growing, growing during the first half of the uterine lining is growing and then typically at about the midpoint of the cycle we are supposed to ovulate. And then if we do ovulate, then our body is continuing to elevate its hormone levels in order to support that fertilized egg potentially. And either we recognize, okay, an egg has fertilized here and the pregnancy continues, or an egg has not fertilized here and we have a period and shed all the lining of the uterus. Now what can happen in other conditions as well, but particularly with polycystic ovarian syndrome, if there is not that ovulation, the uterine lining can sort of grow and grow and grow. And there's a certain threshold at which the uterine lining can't really support itself to be any thicker. And so it sheds. So we bleed, we have what we perceive as a period because the uterine lining is shedding in order to sort of clear itself out, it can't support itself any longer. However, no egg was released during that cycle. So for the woman who has this happening, she still perceives that she's having periods and she is indeed having these bleeding episodes, but they may be really irregular, like if she were to track them on a calendar or in an app, what she would find is that the first day of her period may vary greatly. There may be long periods of time or long windows of time in between those periods. So maybe 40 days, 60 days would be, you wouldn't be able to say, oh yes, I ovulate every 28th day or 29th day or something like that. Now the window of a typical period cycle we usually think of as 28 days, but there can be some variation in that. There's women who have shorter cycles on the order of 21 days. There's women who can have longer cycles in the order of about 35 days. However, when we start pushing those extremes, we do want to make sure there's not other concerns going on, for example, like thyroid disease or something like that. And we won't go into a deep dive of fertility because that is not the goal of today's topic in terms of what are all of the other causes of it. But thinking about if you're having irregular cycles, that is likely a sign that you may struggle with fertility. And so having a conversation, especially if you desire pregnancy or honestly even if you don't desire pregnancy and you want to be most effective at preventing that if you desire pregnancy, having a conversation with your OB/GYN, with your primary care physician, with your reproductive endocrinologist and infertility specialist, your doctor who may be supporting you in vitro fertilization so that they can help assess are there other things that are contributing to fertility issues for you. Because as I mentioned briefly, things like thyroid can absolutely contribute to fertility and need to be diagnosed and treated in order to achieve the best likelihood of pregnancy. But if you are having very irregular cycles, if your doctor has evaluated you and said, yes, there is concern here for polycystic ovarian syndrome, then one of the best ways we support that for a woman who is not trying to conceive is actually by doing birth control pills. And the reason is that a oral contraceptive pill is going to support regular shedding of that uterine lining, which can be protective against uterine cancer. However, that sort of manages the condition, but it doesn't necessarily treat the condition. And you can also imagine then for a woman who is trying to conceive that, of course we can't have her on birth control pills because that is not going to help in the conception process. And so thinking about weight loss can be a very supportive way in order to support the improvement of PCOS. And the reason being, I mentioned that PCOS polycystic ovarian syndrome is this condition of insulin resistance and weight can also be a insulin resistant issue and PCOS and weight or obesity can often be the sort of chicken and the egg thing whereby the hormonal imbalances of PCOS can make it more likely that you gain weight, yet gaining weight can make your PCOS worse. And so it can be really hard to break that cycle. And so while there are certain dietary measures, for example, making sure that we are limiting processed carbohydrates, particularly flour and sugars and things like sugary or sweetened beverages, those things can be really supportive in polycystic ovarian syndrome, but they may not be enough in order to fully reverse the underlying cause. Similarly, things like exercise, particularly when we look at resistance training and building up our muscle mass, when we look at regular cardiovascular fitness and honestly even just walking for example, can be really supportive of reducing insulin resistance. There's really phenomenal studies about walking after meals and how that can help to reduce insulin resistance. We think about things like making sure someone is getting adequate sleep, that in the events of their life and the stress of their life that they're managing those. All of these things are still important and we may want support medically for helping to treat someone's underlying insulin resistance. We'll talk a little bit about the role of medications in that situation, but as we think about this in trying to get pregnant, there's often if someone is having very regular and predictable cycles off of birth control, so if you're taking a birth control pill and you're having regular cycles, this could be true, but we just don't necessarily know that birth control pill will be what's happening underneath. But if you are not taking any sort of birth control pill and you are having regular and predictable cycles that does not guarantee fertility, but is certainly a reassuring sign when it comes to things like polycystic ovarian syndrome for example. So having those regular cycles is certainly a good sign. Although if you are having regular cycles, if you're trying to conceive with your partner and you are unable to after a period of certainly after 12 months, but if you are over 35 years old, even after a shorter window of time, like after six months, if you've been trying to conceive and you feel like, okay, I have my cycles regularly every month, I'm trying to conceive around the midpoint of every month, maybe you're even using things like ovulation prediction kits for example. And if you're doing that and still unable to conceive, certainly you want to speak with your gynecologist, speak with a fertility specialist so they can help to assess why that is happening and discuss if it makes sense to pursue things like in vitro fertilization or other things that we won't go into terribly much so with weight loss in the pre-pregnancy period, we may be thinking about medications, but we may also consider bariatric surgery in the right situation. We know that depending on our fertility issues, depending on our body weight, there are issues that can arise during pregnancy that can make it challenging when we live in larger bodies, so things like gestational diabetes, gestational hypertension, preeclampsia, there are correlations with these conditions and obesity. And so when we have struggled with our weight for a long period of time, and particularly people who have, I would say a body mass index greater than 40, but as we cross higher thresholds, it may make sense to even consider bariatric surgery depending on what your pregnancy timeline is. Now I will say this is a very nuanced caveat. I'm not making this as any sort of blanket recommendation, and the reality is it's really important for you to sit down and have a conversation with your fertility specialist, maybe with an obesity medicine specialist depending on your exact situation and what's been going on. But sometimes it does make sense even to pursue bariatric surgery in the setting of getting ready for pregnancy. And the reason that that is the case is that bariatric surgery, while there are ongoing changes of course from it, there's this idea that it is a sort of one and done procedure. Now you do need to be thinking about ongoing dietary management, like making sure you're getting adequate protein, making sure that you're getting your nutrition repletion with vitamins for women who are trying to become pregnant, making sure that you are really keeping up with those vitamins and monitoring levels of things like iron will be really, really important for supporting a healthy pregnancy. And there also needs to be a really healthy window of time from when bariatric surgery happens until when pregnancy is attempted. And so usually the minimum recommendation would be 18 months, however, that's from the time of surgery until the time of conception. And so if someone is sitting down to have this conversation with their physician and thinking about what makes the most sense for me recognizing that pursuing bariatric surgery means one, you're meeting with a bariatric surgeon to understand what is the wait list at that institution, what will your insurance require? There is usually a requirement as part of making sure that you have met the goals of weight loss before bariatric surgery. So many insurance companies will require that people meet certain weight loss thresholds in order to pursue surgery that differs from an insurance to insurance, but a lot of times there may be expected to lose 10% of weight loss or 10% of excess weight loss. Again, I won't get too into those numbers because it was really individualized based on what your insurance requires, but there is typically the six month plus or minus medically supervised weight loss program before pursuing surgery. And so if you're thinking about surgery, you're adding up how much time does it take to get into the surgeon If I have that, let's say six month window of medically supervised weight loss before surgery and then I have surgery, it's 18 months from surgery to pregnancy. So realistically we're talking about two years, probably a little bit more from when you make that decision to when it would be recommended to start trying to conceive at that point. And so depending on your age and other factors that may or may not make sense, I've had a patient who was in her mid to late twenties, I think she was 25 when we started having this conversation, and then she was 27 when she conceived, but she had significant obesity. Her body mass index was about 50, and while medical weight loss may make sense, she knew that her older sister, her mother, other people in her family had really struggled with their fertility as a result of weight. And so she was interested in pursuing bariatric surgery as a first step in the direction of her fertility goals. And because she was 25 years old at this time this happened, we knew that she still likely had a good window from a fertility standpoint in order to be able to still conceive after that bariatric surgery after a healthy window. And it's not like she was sort of rushing up against any sort of biological clock and that, I even hate saying that, but it is a really important thing that we're thinking about. We want to make sure that as we're supporting you in your goals and both in your health goals and in your pregnancy and childbearing goals, are we actually taking away from your ability to have children? Because while having bariatric surgery in the pursuit of having children make sense in certain situations, we may not do it in someone who has limited ovarian reserve and someone that we're really concerned about may not be otherwise able to have a healthy pregnancy. So that, again, very individualized conversation, but I wanted to mention it because I think it's something that doesn't always get talked about as a consideration. And it can be really frustrating if someone is for a period of time pursuing medical weight loss. Let's say they pursue medical weight loss over a year and they're achieving their goals but not as much as they had hoped to, and then they're recommended to stop their medications before pregnancy and may see some weight regain during that period of time and then they are unable to get pregnant. That can be incredibly frustrating to go into that weight cycle. And at that point, if someone starts talking to them about bariatric surgery, it can be like, oh my gosh, what in the world? Why did someone not talk to me about this a full year ago? And so I want to mention that as an option that may make sense to think about and may make sense even just to bring up with your conversation with your ob gyn, with your fertility specialist, with your obesity specialist. If you're seeing one to say, Hey, would bariatric surgery make sense for me and my timeline? Now if that is not a consideration or doesn't make sense for whatever reason, let's talk about the role of medical weight loss before pregnancy because I find that even this subject is often undertreated as well because there is this fear of, oh my goodness, what if women get pregnant on these weight loss medications? We certainly do not recommend continuing weight loss during a pregnancy, and a lot of these medications either we know are not safe or likely are not safe during pregnancy. And so women are often counseled to come off of them, sometimes I'll say inappropriately early. So let's talk about some of the medications, which ones are safe, which ones are not safe? What does the current data show and how can you make sure that as a woman you are really advocating for yourself, but then also in a situation where you can conceive, feel comfortable and safe about that knowing that you haven't put your future baby at any sort of harms risk because I know that that's always such an important consideration for women as we are trying to get pregnant. So one of the really general things I will say about medications in pregnancy is that our society often has this idea that anything put into the body, whether it's medications or foods or beverages or external exposures that anything put into the body during pregnancy is toxic and therefore you should just stop everything before pregnancy. I will say that is a very dangerous belief system. And while there are certain things we know you should not put into your body during pregnancy, you should not put alcohol into your body during pregnancy. You should not put cigarettes into your body during pregnancy. You should not do crazy wild things during pregnancy. But when we talk about many stable medical conditions that have been managed for years upon years with the medication, there may be safety data. There's likely safety data for certain medications and it may make sense to continue those during pregnancy. So if you are on any medication that if you have not been told specifically to stop upon getting pregnant, I want to make sure that you reach out to your physician and you talk with them about, Hey, I just found out I'm pregnant. I am taking X, Y, Z medication. Is it safe for me to continue? I want to make sure that you have that conversation because like I said, there are many medications that are safe to continue or are likely safe to continue. And the benefits of continuing the medication far outweigh any theoretical risk of these medications. When I say this, the medications that pop to the very top of my mind are SSRIs and other medications used for the treatment of conditions like anxiety and depression and other mental health concerns. And if you are taking a medication that you have been stable on for a very long period of time, your mental health has been stable and doing well, you should not discontinue that medication because you find out that you're pregnant. Now, if your doctor tells you that you should move forward and have a conversation with them, but if you've been told unless you've been specifically told this medication is unsafe during pregnancy, you need to stop it. If you find out that you're pregnant, then you should be continuing those medications. So this happens very often where women have been stable in their mental health and then they find out they're pregnant and they stop a medication that may otherwise be safe in pregnancy, and now they're really riding this hormonal rollercoaster that can happen during pregnancy, this psychological rollercoaster that can happen during pregnancy without the support of medication on which they had been stable for a long period of time. And that's really just not fair to a pregnant woman or to her growing baby. She is not going to be in the best condition to be able to take care of herself if she's not adequately treating her anxiety and depression. If you are automatically told to stop a medication and you think that that's wrong, there are even psychiatrists who specialize in the treatment of pregnant women. And so just know that there are resources out there because especially in this category of mental health, I find a lot of people are advised to stop their medication or stop the medication on their own and that may really not be the best advice. Now, if you were someone who had been, let's say, weaning off your medication over the last year with a plan to stop it and you're on this smallest dose of medication and you were planning to stop it a month from now anyway, fine. It may make sense to stop the medication, but again, this is where it makes sense to have an individualized conversation with your physician before stopping any medications during pregnancy. Now, in the weight loss journey, there are medications that we know are not safe during pregnancy and we would advise people to stop those prior to trying to conceive. Now, the thing that I will say is that the trying to conceive window sometimes can be a really significant period of time. And so you need to know which medications are like absolutely do not take this medication versus like it may actually be safe, but you should definitely stop that medication upon finding out that you're pregnant. So we look at all the medications for the treatment of weight. One of the things I will say is that the medication, Topamax or Topiramate, this is sometimes used on its own even in other health conditions, particularly seizure disorders or migraine prevention, that this medication is a known tigen, meaning that this medication is linked to known risk of birth defects, particularly risk of birth defects linked to cleft palate for example. And so this medication is absolutely contraindicated during pregnancy. It is recommended certainly to stop this medication upon trying to conceive because that early window of organogenesis when a baby, when a fetus is starting to develop, that is the window where this medication can be especially dangerous and is often the window where women may not even yet recognize that they're pregnant in those first couple of weeks even before you've had a positive pregnancy test. So if you are taking Topiramate Topamax medication, absolutely that needs to be stopped if you are not using any sort of protection to reduce the risk of pregnancy. So absolutely that medication does need to be stopped. There are other medications, for example, so phentermine and Topamax are combined together in the qia medication. And so that one would also need to be stopped absolutely because it contains that Topamax Topiramate medication phentermine we know is not safe during pregnancy. It's recommended to stop if a woman is trying to conceive this is a medication, absolutely does need to be stopped during pregnancy but doesn't have any known tigen effects, so should be stopped during pregnancy, but doesn't have that same in the way that qia the combination of phentermine and top topiramate. It's like absolutely you need to stop this a couple of months before trying to conceive in order to reduce that to genic effective medication. Then there are medications like contrave. This is a combination of bupropion and Naltrexone. Now, it's certainly not recommended during pregnancy to take this medication, but those medications, especially the Bupropion component, are often continued during pregnancy for the sake of mental health, like for the treatment of depression, for example. And so while it may not make sense to continue that combination of medication during pregnancy, and it absolutely should be stopped upon a pregnancy being recognized, it may make sense if you were using that medication to also support mental health. For example, it may make sense that if appropriate medication, that depression component of medication may actually be continued. That is a one-on-one conversation and you should not use my words and my podcast as medical advice because that will be determined by you, your individual health situation and your physician. But know that BU appropriate is a medication that may be continued during pregnancy that's done often. There's also the medication, metformin. Now this is not officially a weight loss medication, but metformin is used in the treatment of insulin resistance. So it's very common that people certainly with diabetes or with pre-diabetes may use this medication. But metformin is also often prescribed in polycystic ovarian syndrome to help work to reduce that underlying insulin resistance, which can improve fertility. And metformin is generally thought to be a safe medication in pregnancy. So you should talk with your physician if you're taking metformin, if you're trying to conceive if you become pregnant, does it make sense for you to continue that medication? Now there are mixed conversations out there about are there any potential downsides of this medication, but we actually have a lot of data of women who've taken this medication throughout pregnancy either because of a diagnosis like type two diabetes for example, or for other conditions that are known to be associated with birth defects. We know that hyperglycemia elevated blood sugar levels also can be associated with birth defects. So managing and supporting those with medications like metformin, certainly like insulin. For other women that may make a lot of sense. It's often done in the treatment of both type two diabetes as well as then gestational diabetes, which can crop up later in pregnancy. And so metformin really may be a safe option, but again, you should have a one-on-one conversation with your own physician to talk about if that makes sense for you. Now I want to take a minute to talk about the GLP medications, the Ozempic that everybody is talking about because there's a lot of conversation around these. There's also been a lot of conversation around Ozempic babies is the headline I see in the news often because we know that when we treat someone's underlying insulin resistance, which these medications do do that, we may support them in their fertility goals. And so there are people for whom you can imagine if you'd been struggling to get pregnant for the longest years period of time, maybe not having periods or having very irregular cycles, and you start taking a medication like any of these GLPs or GLP-GIP combination medications, you may not really even be thinking about your fertility because you've been struggling with your fertility for such a long time that pregnancy prevention has not been top of radar or you've been trying to get pregnant. And so the idea of preventing a pregnancy feels really counterintuitive when you do desire to have a child. And so we found that there are a lot of people for whom have accidentally conceived on these medications. So I want to talk about both what are the official recommendations as of this time? So I'm recording this in January of 2025. It'll go live in February of 2025. So what are the official recommendations at this time? And then what are some of the data that's coming out from studies? Again, we certainly do not recommend continuing these medications during pregnancy for the sake of weight loss goals, but it is important to know what are those recommendations? And if, oh my gosh, I found out I was pregnant while taking these medications, have I caused huge harm to my baby? Let's talk about that. So the Wegovy, Ozempic products, the semaglutide products are recommended to stop eight weeks before pregnancy before trying to conceive. Interestingly, Zepbound, Mounjaro tirzepatide products are actually only recommended to stop when a pregnancy is recognized. There is advice in the labeling guideline about four weeks after initiating or titrating a dose that women on oral birth control pills should use some sort of backup method because that can impact fertility. However, making sure that a woman that certainly if someone is trying to get pregnant, usually people will also follow that eight week guideline that will go via Ozempic. Semaglutide products recommend you can have a conversation one-on-one with your physician if something different may make sense. Now, the other piece of this is this idea of, oh my gosh, we've gathered a lot of data from women who have gotten pregnant on these medications. And last year in 2024, there was a study that looked at about 168 women who had either GLP exposure. So Ozempic Wegovy Zepbound Mounjaro in the first trimester, women who had diabetes or women who had obesity. They were sort of compared what were the difference in major birth defects in life births and losses? What did that look like? And what's really interesting is across the board now recognizing this is a pretty low sample size, there was a similar rate of live births. There was no difference in major birth defects. Interestingly, there was actually a lower rate of losses, but I will say a much higher rate of pregnancy terminations for women who were using GLP medications. And what that may signal is that women recognizing they were pregnant, maybe had not intended to become pregnant, were concerned about any risk of birth defects or concerned that they had not intended to become pregnant. At that time, the percentage of terminations was quite a bit higher, two to three times higher compared to either the diabetes group or the overweight or obesity group. And so even the losses standpoint being lower, I think some of that may be because these pregnancies were terminated earlier in pregnancy. However, like I said, the live birth rate was actually very similar, which is reassuring. So I say that to say my recommendation for any of these medications is that they are absolutely stopped during pregnancy. That following the guidelines of stopping eight weeks before trying to conceive is absolutely the recommended. And what I will say is that if you have accidentally found out you are pregnant on these medications, have a very serious conversation with your provider, you should stop these medications right away if you find out that you're pregnant. But that doesn't mean anything in terms of has there been some sort of serious exposure to your baby and only you and your individual provider can decide what makes the most sense in moving forward. But that window is eight weeks. And so if your doctor has told you, Hey, you need to be off these medications for six months or some long period of time, which interestingly, we hear really often that people have been advised to stop all of their medications, that may not be the most accurate advice. The other thing is using these medications alongside lifestyle interventions. For example, making sure that you are improving diet to reduce the processed carbohydrates, really emphasizing proteins so that your body can be supported in maintaining its muscle mass is such an important thing in these medications. And so there may even be room for in discontinuing these medications intentionally with the goal of trying to conceive that maybe there's some sort of bridge with another medication like metformin for example. That's a conversation that makes sense again in a one-on-one situation. And so what I wanted to share is that if you are trying to conceive, if you are confused about taking medications or not taking medications or feeling like you are not getting adequate support, I want you to reach out and talk with either your ob gyn, he or she may have great advice for you. If you feel like you're not getting great advice there, talk to an REI, a reproductive endocrinologist and infertility specialist. These are the type of physicians who help support you. If you are moving forward with things like IVF for example, and even reaching out to have a conversation with an obesity medicine specialist, someone who is confident in prescribing these medications, can give you the most up-to-date guidelines about what makes sense for you, your body, your risk factors. That is absolutely the most important thing. So my biggest advice as always is to advocate for yourself, be willing to have that conversation. If you are living in Illinois, Virginia, or Tennessee where I am licensed to practice medicine, I would love to support you in your weight loss goals. Thank you for joining me today. We'll see you all next week. Bye-bye.