The Intersection of Fatphobia, PCOS and Fertility Care Systems

Written by Emily Opthof, RD (she/her) and Sarah O’Hara, RD (she/her)

TW: Use of words ov*rw*ight and ob*sity in references, discussion of WL recommendations and infertility.

Language note: We use the term “fat” in this article as a neutral body size descriptor, and as allies of the fat acceptance movement. 

Becoming a parent is a wonderful, messy and sometimes incredibly complicated journey. For some, it is an easy process full of joy. For others, it is not so simple. And for parents-to-be impacted by PCOS, the journey is riddled with fatphobia and racial discrimination (1,2). 

From pre-conception, through the process of becoming pregnant, to prenatal visits, labour & delivery, and even into parenthood, weight stigma is causing significant harm to the physical and mental well-being of many folks with PCOS. This post will examine just a handful of the ways in which weight discrimination in fertility care systems impacts those in higher weight bodies with PCOS. 

Ovulation: The Waiting Game

Due to the nature of PCOS, becoming pregnant can become a waiting game. Many folks are diagnosed with PCOS in the months/years after they decide the timing is right to start a family, and realize that their cycles aren’t regular. Ultimately, the chances of having a successful pregnancy with PCOS are very good, but it may take more waiting than expected. Waiting for ovulation, waiting for a period, waiting for a doctor’s appointment, waiting for test results, waiting for treatment to work, waiting for those two pink lines….

Delayed and irregular ovulation can be a hallmark presentation of PCOS when attempting pregnancy, and weight loss is often recommended (even “advocated” for) prior to the offering of ovulation induction medications (3). However, a growing body of evidence seems to be in contradiction to this recommendation. A recent study has shown body weight doesn’t influence the outcome of ovulation induction aside from a needed dose adjustment in medication use (4), and it has been long-established that crash dieting for rapid weight loss has negative impacts on fertility.

IVF Access

Fat folks are routinely recommended to lose weight (or even required to do so) prior to accessing IVF, despite evidence showing no change in pregnancy success when compared to those who don’t attempt weight loss. In fact, a recent study actually showed that, when compared to folks engaging in dietary changes and exercise for the purposes of weight loss, those who don’t lose weight and live in larger bodies have just as much success in pregnancy outcomes, and have no significant increase in pregnancy complications (5). Data showing that IVF is less successful for those in larger bodies has been challenged by evidence showing that standard IVF medication doses are simply less effective for fat folks, and that this can be adjusted for by individualizing the dose based on size. Some insurance companies may even “require” an individual to attempt weight loss in order to access coverage for fertility treatments, which are already less accessible to those with a low income or living far away from fertility centres (6).

Inappropriate Medication Dosing Guidance

Similar to how IVF medications may need to be adjusted to optimize success for those at higher weights, Plan B in its standard dose is less effective for fat folks. Yet we don’t have alternatives widely available and providers are not educated in how to recommend modifications for emergency contraception (7). A fat person may require a double or more dose of Plan B in order to prevent unintentional pregnancy, but you probably won’t hear this from a general practitioner. The various medications used in the treatment of PCOS may potentially interact with Plan B or birth control medications, but with so much emphasis on weight loss and dieting alone these may not be appropriately reviewed with an individual.

Pregnancy Weight Gain

Pregnant fat folks are often recommended to limit weight gain or (in some severely inappropriate cases) lose weight during pregnancy for the fear of gestational diabetes, which can affect any pregnant body particularly those with a strong genetic history (8). Large organizations are as guilty as the providers who recommend weight loss – The American College of Obstetricians and Gynecologists is one of many who strongly encourage limiting weight gain and losing weight quickly after delivery; trigger warning in reading the referenced article for discriminatory language regarding weight status (9). This recommendation fails to recognize the higher risks of gestational diabetes that folks with PCOS already have, and places even more shame and blame on them unnecessarily. Having gestational diabetes does not mean that you’ve failed as a pregnant person or that you are unable to care for yourself. Health is not a moral obligation, nor is it accessible to everyone. 

Labour and Delivery

Pregnant fat folks are also more likely to be told they will require a C-section delivery regardless of their birth plan, which can be disheartening and traumatizing when done without informed consent or support (10). Fat bodies are just as capable of delivering vaginally as thin bodies. Unfortunately, medical providers are trained in a weight-centric system that has been shown to provide subpar care for those in larger bodies, and this is also true in the perinatal medical community (11). Adding further risk of poor care and birth outcomes is racial discrimination in healthcare settings (12). Seeking out fat-positive birthing support can be incredibly empowering if it is accessible to you/available in your area. Many midwives and doulas offer a higher level of support for expectant parents in larger bodies, and can help to advocate for the birth plan that is right for you. 

Weight Stigma in Postpartum and Parenthood

Social stigma is also prevalent around existing in a fat body as a parent, as if this has any indication about your ability to raise tiny humans (13). Being a parent is like any other job – your body shape and size has no bearing on how well you can do it. And the idea of “bouncing back” to a pre-pregnancy body (or a “normal” BMI) is rooted in white supremacy and capitalist patriarchy; the urgency to “do something” and promotion of products for the approval of others and social standing are hallmark indicators.

Evidence also shows that experiencing weight stigma during pregnancy and postpartum may increase risk for postpartum depression; trigger warning in referenced article for discriminatory language regarding weight status (14). It is so critical that healthcare providers begin to do the work to examine personal and procedural weight bias in healthcare, and advocate for changes that will improve equity in access to person-centered, unbiased care for all folks in the fertility care space.

Inclusive Fertility Care 101

Weight stigma remains rampant at every stage of perinatal care, and the responsibility for changing this lies with healthcare providers and the institutions that guide professional practice. Informed consent is the ONLY way to provide fertility care, and you CAN decline weight loss recommendations. 

You deserve access to providers who see you as a person and not as a number on a scale or BMI chart. 

You can request that your weight not be taken in prenatal care appointments, or request that they be taken without you seeing them (15). 

There are only a few cases where your weight absolutely is necessary to direct your care (such as personalizing medication dosing!), and you can ask a provider for more information about this in appointments. 

Regardless of clinical guidelines in pregnancy, weight loss recommendations are actively harmful to most, particularly in anyone with a history of disordered eating and eating disorders – in fact, the incidence of clinical eating disorders in folks with PCOS is 21% compared to 4% in folks without PCOS (16). We also don’t have any long-term data demonstrating the ability of most bodies to maintain intentional weight loss either. 

Body guilt, shame, and fear of experiencing stigmatization from healthcare providers prevents people from accessing timely and routine medical care. Weight stigma leads to avoidance of health care settings, stress, inflammation, metabolic issues, depression, disordered dating, and reduced health-promoting behaviours (17).

Lastly, and most importantly, it’s CRITICAL to learn from fat folks with lived experience about navigating the fertility world and PCOS – here are some of our favourites at InclusivePCOS.ca:

Let us know in the comments if you have any personal favourite resources on this topic!

If you enjoyed this post, please share!

References:

1. Aquino L. 2019. “How racism and fatphobia prevent us from getting a PCOS diagnosis”. Hello Giggles. Article available at: https://hellogiggles.com/lifestyle/health-fitness/racism-fatphobia-pcos-diagnosis/. Link accessed April 11 2022.

2. Lindsley H. 2021. “Fatphobia and discrimination in medicine”. Planned Parenthood. Article available at: https://www.plannedparenthoodaction.org/planned-parenthood-votes-nevada/blog/fatphobia-and-discrimination-in-medicine. Link accessed April 11 2022.

3. Yildize BO, Chang W, Azziz R. 2003. Polycystic ovary syndrome and ovulation induction. Minerva Ginecol; 55(5): 425-39. PMID: 14581885.

4. Balen AH et al. 2006. The influence of body weight on response to ovulation induction with gonadotropins in 335 women with World Health Organization group II anovulatory infertility. BJOG: An International Journal of Obstetrics & Gynaecology; 113(10):1195-202. DOI: 10.1111/j.1471-0528.2006.01034.x

5. Legro RS et al. 2022. Effects of preconception lifestyle intervention in women with obesity: The FIT-PLESE randomized control trial. PLOS Medicine; 19(1). DOI: 1003883.

6. Brown H. 2021. Modern Stories on A Modern Fertility Blog. Article available at: https://modernfertility.com/blog/weight-stigma-fertility-haley-brown/. Link accessed April 11 2022.

7. Villines Z, 2021. “Is there a Plan B weight limit?”. Medical News Today. Article available at: https://www.medicalnewstoday.com/articles/plan-b-weight-limit. Link accessed April 11 2022.

8. Shah A et al. 2011. The association between Body Mass Index and gestational diabetes mellitus varies by race/ethnicity. Am J Perinatol; 28(7): 515-520. DOI: 10.1055/s-0031-1272968.

9. Seitz J. 2022. “You can have a happy and healthy plus-size pregnancy”. Sanford Health. Article available at: https://news.sanfordhealth.org/womens/can-happy-healthy-plus-size-pregnancy/. Link accessed April 11 2022.

10. Lee J. 2020. “‘You will face discrimination’: Fatness, motherhood, and the medical profession. Fat Studies; 9(1): 1-16. DOI: 10.1080/21604851.2019.1595289.

11. Incollingo Rodriguez AC et al. 2020. Pregnant and postpartum women’s experiences of weight stigma in healthcare. BMC Pregnancy and Childbirth; 20:499. DOI: 10.1186/s12884-020-03202-5.

12. Alhusen JL et al. 2016. Racial discrimination and adverse birth outcomes: An integrative review. J Midwifery Womens Health; 61(6): 707–720. DOI: 10.1111/jmwh.12490.

13. Friedman M. 2014. Reproducing fat-phobia: Reproductive technologies and fat women’s right to mother. Journal of the Motherhood Initiative. Article available at: https://jarm.journals.yorku.ca/index.php/jarm/article/download/39755/35989/48832. Link accessed April 11 2022.

14. Incollingo Rodriguez et al, 2019. Association of Weight Discrimination During Pregnancy and Postpartum With Maternal Postpartum Health. American Psychological Association 38(3): 226-237. https://escholarship.org/content/qt8ns2m564/qt8ns2m564_noSplash_3df81dfab9077c33d76b5293d4a901d7.pdf

15. Stone C, 2022. “‘Don’t Weigh Me’ cards help empower patients at the doctor’s office”. Motherly. Article available at: https://www.mother.ly/news/news-viral-trending/dont-weigh-me-cards/. Link accessed April 11 2022.

16. Cesta CE et al. 2016. Polycystic ovary syndrome and psychiatric disorders: Co-morbidity and heritability in a nationwide Swedish cohort. Psychoneuroendocrinology; 73:196-203. DOI: 10.1016/j.psyneuen.2016.08.005.

17. Tylka T, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014; 2014: 983495. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132299/

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