The Role of Bariatric Surgery in Enhancing Fertility among Women with Significant Obesity

The Role of Bariatric Surgery in Enhancing Fertility among Women with Significant Obesity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of Bariatric Surgery in Enhancing Fertility among Women with Significant Obesity Eman Elgendy, Reem Abdulla Abduljalil, Sharefa Alansari, Bayan Alsharqi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7594128/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Nov, 2025 Read the published version in Middle East Fertility Society Journal → Version 1 posted 13 You are reading this latest preprint version Abstract Objectives Bariatric surgery is a long-term treatment for obesity that leads to significant weight loss that impacts reproductive health. This study explored how bariatric surgery affects pregnancy rates post-surgery. Methods This retrospective study was conducted at Bahrain Defense Force Hospital in 2019–2022 and included 310 women of reproductive age who had bariatric surgery before planning pregnancy. Data were analyzed using standard statistical tests, with p < 0.05 considered significant. Result Of 310 patients who underwent bariatric surgery, 35.8% (111 patients) achieved pregnancy. Those with successful pregnancies had higher pre-surgery weight and body mass index (BMI) and a greater BMI drop (35.3%) compared to non-pregnant patients (29.4%). Receiver operating characteristic (ROC) curve analysis indicated that a BMI-loss cutoff of 34.6% was associated with pregnancy (sensitivity 61%, specificity 64%). Logistic regression was performed according to this cutoff value to exclude any other contributing factors, including age ≤ 35 years, BMI ≤ 30, and use of artificial reproductive therapy (ART) to achieve pregnancy; the analysis results were insignificant for all of the factors. Simple linear regression showed no correlation between pre-surgery weight, total weight loss, percentage of BMI loss, and the time required to achieve pregnancy after bariatric surgery ( P = 0.95, P = 0.25, and P = 0.72). Conclusion Higher pre-surgery BMI and greater BMI loss were linked to higher pregnancy success after bariatric surgery. Bariatric surgery obesity pregnancy rates body mass index Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Obesity is a global public health issue, with worldwide rates having tripled in the last four decades and continuously escalating to pandemic proportions. 1 As of 2016, among adults aged 18 years and over, the global prevalence of overweight (body mass index (BMI) ≥ 25 kg/m 2 ) was 39%, and that of obesity (BMI ≥ 30 kg/m 2 ) was 13%. 2 The prevalence of overweight and obesity is reported to be higher among women than men across the globe in both developed and developing countries. 3 In 2023, 58.6% of women in the UK were obese. The prevalence of overweight and obesity is increasing more alarmingly in low- and middle-income countries, including the Middle East, where it has become one of the most significant health issues. 4 A cross-sectional study found that 30–47% of overweight or obese women had menstrual abnormalities. 5 The fat cells of obese women produce a high amount of leptin, which can alter the menstrual cycle by disrupting the hormonal balance. Furthermore, they alter the hypothalamic–pituitary–ovarian (HPO) axis, promote insulin resistance, and cause persistent low-grade inflammation. All of these effects result in compromised ovarian function and an altered follicular environment. 6 Inflammatory pathways are critical for reproductive events such as follicle rupture during ovulation and trophoblast invasion into the receptive endometrium. Therefore, the altered inflammatory environment of women who are obese is likely to affect these critical reproductive processes. 7 , 8 Medical therapy and lifestyle changes have had limited success in maintaining long-term weight loss. Nevertheless, weight loss may improve a woman's ability to conceive by mitigating the effects of polycystic ovary syndrome (PCOS) and endometriosis. 9 , 10 Despite recent advances in pharmacotherapy for the treatment of obesity, bariatric surgery remains a highly desired fertility-enhancing modality. 11 This type of surgery falls into one of two categories based on whether restriction or malabsorption is the primary mechanism causing weight reduction, although some procedures use a combination of both mechanisms. Restrictive bariatric surgeries reduce the gastric pouch size while leaving the rest of the gastrointestinal tract intact, which decreases the percentage of nutrients absorbed from a meal and leads to weight loss. Sleeve gastrectomy is one of the most popular types of restrictive bariatric surgery. It involves removing approximately 80% of the stomach, including the part responsible for producing the satiety-controlling hormone ghrelin. Thus, a tube-like stomach is formed, which minimizes total food intake. The surgery is technically simple for high-risk medical conditions and is effective for weight loss, but it is a non-reversible procedure that may worsen reflux and has less impact on metabolism. Adjustable gastric banding uses a restrictive mechanism involving an inflatable band that limits food intake. Apart from being minimally invasive, its advantages include adjustability, reversibility, gradual weight loss, and no dumping syndrome. On the other hand, the rate of weight loss is slow, its effectiveness is limited, periodic adjustments are needed, and diet restrictions are necessary. 12 Malabsorptive processes are characterized by bypassing the duodenum and jejunum to limit both energy intake and absorption. Food intake is reduced by creating a gastric pouch, and less intestine, gastric acid, bile, and pancreatic enzymes are available for absorption. Gastric bypass surgery is the oldest and most commonly performed bariatric surgery. This procedure reduces the size of the stomach and leads to the bypass or omission of a sizable part of the upper part of the small intestines, where nutrients such as fat, protein, and vitamins are absorbed. However, it is non-reversible, it may worsen reflux, and it has less impact on metabolism. 13 Roux-en-Y gastric bypass is a restrictive and malabsorptive procedure where a stomach pouch is created, and a section of duodenum is attached to it so that food bypasses the duodenum. This procedure is surgically complex and leads to more vitamin deficiencies and risk for complications, including ulcers and dumping syndrome. Recently, new intraluminal or endoscopic techniques with few clinical risks and economic costs have been introduced to clinical practice. 14 After bariatric surgery, females have reported normalization of menstrual cycles, regular ovulation, and higher rates of spontaneous conception. Westerman et al. analyzed metabolic changes after weight-loss surgery and observed a steep increase of sex hormone-binding globulin (SHBG) and declines in the levels of testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEA-S), which might help to overcome menstrual abnormalities and infertility. 15– 17 Al Qureshi et al. documented improvements in hormonal profiles and sexual function among women after bariatric surgery. 18 The present study was conducted to examine the beneficial effects of bariatric surgery (sleeve gastrectomy, gastric banding, and gastric bypass with Roux-en-Y gastroenterostomy) on obese women and their fertility rates, as well as the factors that increase the chances of achieving pregnancy after surgery. Methods This retrospective observational study examined 310 obese patients who were planning for pregnancy and underwent bariatric surgery between January 2019 and December 2022 at Bahrain Defense Force Hospital, West Riffa, Bahrain. All surgeries were performed in the surgical department. The digital files of all women who were of reproductive age and underwent any bariatric surgery were collected along with their fertility and obstetric files before and after the surgery in accordance with our data protection policy. Patients who were not planning for pregnancy or failed to attend follow-up visits were excluded. The intervention group included participants who underwent a Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding. The main outcome of the study was the rate of pregnancy among patients planning for pregnancy after bariatric surgery, as well as the possible factors that play a role in achieving pregnancy after the surgery, including the patient’s BMI, age, and mode of pregnancy (either spontaneous conception or in vitro fertilization (IVF)). The time from the surgery to achieving conception was defined as the period in months between the date of surgery and the first day of the last menstrual cycle. Regarding BMI, patients were considered obese if their BMI exceeded 30. The BMI (kg/m 2 ) was calculated using the weight (kg) divided by the measured height (m 2 ). BMI and weight were collected before and after surgery. The percentage of BMI loss was calculated by dividing the BMI loss by the original BMI. Other clinical variables included age and the methods of conception. Statistical analysis was performed using Statdirect software (Version 3.3.5 22/03/2021). An initial assessment was performed on the differences between patients who achieved pregnancy and the group that did not conceive. Variables such as age, initial weight/BMI, total loss of weight/BMI, and the percentage of BMI loss were analyzed. Normally distributed continuous variables were analyzed using a two-sided t -test and expressed as the mean ± standard deviation. Non-normally distributed variables were analyzed using a two-sided Mann -Whitney U test and expressed as the median (range). The optimal percentage of BMI loss after bariatric surgery to achieve pregnancy was evaluated by receiver operating characteristic (ROC) curve analysis. Multiple logistic regression analyses were then conducted to assess the effect of the optimal percentage of BMI loss on achieving pregnancy after excluding other contributing factors such as age and artificial reproductive therapy (ART). The final models reported the adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was defined by P < 0.05. The Royal Bahrain Defense Force Hospital Ethical Committee approved this study. Results The total number of patients who underwent bariatric surgery and planned pregnancy was 310. The percentage of patients who achieved pregnancy was 35.8% (111 patients). The group that did not conceive were considered as a control group (199 patients). The study groups had similar ages (34.3 vs. 35.3 P = 0.08). The patients who achieved pregnancy were significantly heavier with a higher BMI before bariatric surgery (117.7 kg vs. 107.5 kg; BMI 45.7 vs. 42; p < 0.0001). More post-procedure weight loss was observed among patients who conceived (41.4 kg vs. 31.9 kg; BMI reduction 16.2 vs. 12.5; P < 0.0001). The percentage of BMI loss compared to original levels was also significantly greater among patients who achieved pregnancy (35.3% vs. 29.4%; P < 0.0001). Surprisingly, however, the post-surgery weight and BMI were similar between the groups (76.4 kg vs. 75.4 kg; BMI 29.5 vs. 29.5; P = 98) (Table 1 ). The optimal percentage of BMI loss to achieve pregnancy was evaluated by ROC analysis, which indicated that losses above a cutoff value of 34.6% were associated with pregnancy with a sensitivity of 61% and specificity of 64% (Fig. 1 ). A logistic regression was performed according to the observed cutoff value of 34.6% loss of the original BMI measurement to adjust for confounding variables. The variables analyzed were age ≤ 35 years, BMI ≤ 30, and the use of ART to achieve pregnancy. The analysis results were not significant for any of the analyzed factors (Table 2 ). For the patients who achieved pregnancy, further analysis was performed to check for factors related to the timing of conception. Simple linear regression showed no correlation between pre-surgery weight, total weight loss, percentage of BMI loss, and the time required to achieve pregnancy after bariatric surgery ( P = 0.95, P = 0.25, and P = 0.72). (Figs. 2 , 3 and 4 ). Discussion Weight loss is a well-established strategy for improving fertility in obese women, and bariatric surgery has emerged as one of the most effective treatments for achieving significant and sustained weight reduction. As such, understanding the impact of bariatric surgery on future reproductive potential is an important area of clinical interest. This study presents a retrospective review conducted at a single center, involving 310 obese women of reproductive age who underwent bariatric surgery with the intention of conceiving. Among them, 35.8% (111 patients) achieved pregnancy following the procedure. While this pregnancy rate is notable, it is lower than those reported in other studies. For instance, Jamal et al. and Musella et al. documented spontaneous pregnancy rates ranging from 62% to 100% in women with prior infertility following bariatric surgery. 19,20 Similarly, Makhsosi et al. reported a pooled post-surgical conception rate of 67%, reinforcing the positive association between bariatric surgery and the restoration of fertility. 21 It is important to note, however, that not all studies have demonstrated a clear benefit of bariatric surgery on fertility outcomes. Research by Legro et al., Neto et al., and Christofolini et al. found no significant improvements in fertility post-surgery. 22–24 Similarly, Goldman et al., and Laurino et al. also reported no notable increase in pregnancy rates. 25 , 26 These discrepancies across studies may be attributed to a range of contributing factors, such as differences in sample size, age distribution, pre- and post-operative BMI, duration of follow-up, prevalence of polycystic ovary syndrome (PCOS), baseline infertility diagnoses, metabolic profiles, endocrine function, and the degree of weight loss achieved postoperatively. In the current study, the groups had similar age (34.3 vs. 35.3 years; P = 0.08). However, it is well known that pregnancy rates may be affected by factors such as decreased ovarian reserve and reproductive potential. Younger individuals may have a higher probability of conceiving naturally after surgery. Therefore, age should be a key factor when counselling patients about reproductive outcomes after bariatric surgery. Although most guidelines define a waiting time of 12–18 months after surgery before attempting to conceive, a more personalized approach that balances nutritional risks of earlier conception against the risk of declining ovarian reserve due to age when delaying pregnancy has been suggested. 27 Musella et al. found that patients who became pregnant after surgery had a lower BMI (34.2 kg/m 2 ) than those who remained infertile (41.5 kg/m 2 ), indicating that achieving a BMI closer to the normal range may lead to greater reproductive benefits. 20 In contrast, our analysis found similar post-surgery BMI between the study groups. A considerable drop in BMI after bariatric surgery was more important. Given that both groups had similar post-procedure BMI, patients who had achieved a greater drop in BMI were considerably heavier pre-surgery. Solaiman et al. obtained the same results and found that initial BMI and weight were higher among mothers who conceived early following bariatric surgery. 28 The optimal percentage of BMI loss after bariatric surgery to achieve pregnancy was evaluated by ROC analysis. It was found that percentages of BMI loss above the cutoff value of 34.6% were associated with pregnancy with sensitivity of 61% and specificity of 64%. Although post-operative BMI reductions have varied between trials, most patients achieved a considerable drop in body weight and typically attained a BMI in the overweight or moderately obesity range (BMI 25–35 kg/m 2 ). Some studies, such as those by Legro et al. and Milone et al., performed thorough longitudinal tracking of BMI changes over time and found that fertility improvements were frequently associated with the degree of weight reduction. 22 , 29 In the present study, the mean pre-surgery BMIs were 42 and 45, and it may have been possible to lose more than 34% of the original BMI. In studies with much lower initial BMI, it would be very difficult to achieve such percentages of BMI loss. Logistic regression was performed according to the observed cutoff value of 34.6% loss of original BMI to exclude any other contributing factors. The analyzed variables were age ≤ 35 years, BMI ≤ 30, and the use of ART. The results were not significant for any of these factors to achieve pregnancy Our analysis did not take into consideration the preconception fertility issues but found no difference in IVF conception after the surgery between the groups. In support of our finding, Khazraei et al. found that the duration and magnitude of weight loss are two essential aspects of managing infertility that are achieved by undergoing bariatric surgery. 30 In contrast, Grzegorczyk-Martin et al. observed that women who underwent bariatric surgery had higher embryo yields and fertilization rates compared to BMI-matched obese controls. 31 However, this heterogeneity in the results of studies may be due to different surgical methods, which may have both metabolic and hormonal consequences that may affect reproductive results differently. Simple linear regression analysis has demonstrated no significant association between pre-surgical weight and the duration required to achieve pregnancy (P = 0.95). Likewise, neither total weight loss (P = 0.25) nor percentage of BMI reduction (P = 0.72) showed a statistically significant correlation with time to conception. The relationship between weight parameters and time to conception following bariatric surgery remains complex and somewhat inconsistent across the literature. Solaiman et al. found that women who conceived within six months of surgery had significantly higher baseline BMI and weight (P < 0.001), suggesting that pre-operative weight may influence early conception in some cases. 28 Despite these findings, the evidence is mixed. Some studies have proposed that greater post-operative weight loss—both in absolute terms and as a percentage of BMI—may be linked to shorter times to conception, while others have reported no significant differences between those who became pregnant and those who did not. 32–33 As a precautionary measure, clinical guidelines generally advise women to postpone pregnancy for at least 12 months following bariatric surgery. In several European countries, including the United Kingdom, the recommended waiting period extends to two years after gastric banding and 12 months after other surgical procedures. 34 Limitation. The small sample size and inclusion of different bariatric procedures may have influenced the results. Additionally, factors like PCOS, endocrine dysfunction, and other infertility issues affecting pregnancy success after BS were not assessed. Conclusion This analysis highlights that those obese patients with higher BMI are more likely to achieve pregnancy post BS compared to obese patients with lower BMI. Recommendation. The findings of our study support the consideration of BS in infertility treatment regimens. Women should be counseled that significant weight loss following BS is associated with an increased chance of achieving pregnancy. Abbreviations Bariatric Surgery = BS Body mass index = BMI Polycystic ovaries syndrome = PCOs In vitro fertilization = IVF Declarations Ethics approval and consent to participate The Royal Bahrain Defense Force Hospital Ethical Committee approved this study (Approval No: RMS-BDF /P&PEC/ 2023). As this was a retrospective review of patient records, the requirement for informed consent was waived by the ethics committee. Availability of data and material The work is based on a retrospective review of patient records, and therefore no research data are available for sharing due to patient privacy and ethical restrictions, but anonymized data are available from the corresponding author on reasonable request and with permission from Bahrain Defense Force Hospital. Consent for publication Not applicable, as this study does not contain any individual person’s data in any form (including individual details, images, or videos). Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions 1-E E 2-R A 3-S A 4-F S 5-B A 6-N D 1 - designed the study, analyzed the data, and wrote the manuscript 2-3-4-5 contributed to data collection and interpretation. 1-2-3- assisted in proofreading and correcting typographical errors. 6 - Prepared figures and tables and revised the manuscript for important intellectuals. 1-2-3-4-5-6 read and approved the final manuscript. Acknowledgements The authors would like to express their sincere gratitude to the Royal Bahrain Defense Force Hospital and the Maternity Unit, Riffa, Bahrain, for their support of this work. They also wish to acknowledge the Surgical Department at the Bahrain Defense Force Hospital for their assistance in accessing and reviewing patient records. The authors are further grateful to The American Manuscript Editors for their English language editing and for their valuable suggestions. Authors declare that the article was not presented in any conferences /not published. Authors have no conflict of interest and our study was not supported by any fund. we would like to clarify that no artificial intelligence (AI) tools were utilized in any part of our manuscript. The article, including its writing, figures, data collection, and analysis, was prepared entirely by the authors without assistance from AI technologies. The authors take full responsibility for the accuracy and integrity of the manuscript. References 1.Blüher, M. Obesity: Global epidemiology and pathogenesis. Nat. Rev. Endocrinol. 2019, 15, 288–298. [CrossRef] World Health Organization. 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Surgery for obesity and related diseases: official journal of the American Society for Bariatric Surgery 2018;14: 1594–1599. [DOI] [PubMed] [Google Scholar] Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care. Jill Shawe, Dries Ceulemans, Zainab Akhter, Karl Neff, Kathryn Hart, Nicola Heslehurst, Iztok Štotl, Sanjay Agrawal, Regine Steegers-Theunissen, Shahrad Taheri First published: 16 August2019DOI: 10.1111/obr.12927Obesity Reviews. 2019; 20:1507–1522. wileyonlinelibrary.com/journal/obr 1507. Tables Table 1 difference in weight profile between the groups. Pregnant N = 111 Non pregnant N = 199 P value Age years ± SD 34.3 ± 4.8 35.3 ± 5.5 0.083 Weight before surgery kg ± SD 117.7 ± 21.8 107.5 ± 19.7 < 0.0001 Weight after surgery Kg ± SD 76.4 ± 18.6 75.4 ± 17.8 0.649 Total weight loss ± SD 41.4 ± 15.3 31.8 ± 15.9 < 0.0001 BMI before kg/m² ± SD 45.7 ± 8.1 42 ± 7 < 0.0001 BMI after kg/m² ± SD 29.5 ± 6.8 29.5 ± 6.6 0.98 Total BMI loss kg/m² ±SD 16.2 ± 5.9 12.5 ± 6 < 0.0001 Percentage of BMI loss median (range) 35.3 (12.5–60.1) 29.4 (0.6–58.3) < 0.0001 ART treatment 23 (20.7) 8 (4) < 0.0001 Median period to pregnancy months(range) 22 (1-124) Caesarean section rate 61 (55%) Foetal weight Kg mean ± SD 2.8 ± 0.52 Table 2 logistic regression analysis for prediction of pregnancy. Odd ratio 95% Conf Z value P value Intercept n/a 1.95 0.05 Age ≤ 35 2.47 0.79 to 7.79 1.55 0.12 percentage of BMI loss > 34.6 4.39 0.87 to 22.14 1.79 0.07 BMI ≤ 30 0.63 0.21 to 1.91 -0.81 0.42 Use of ART 6.73 0.79 to 56.7 1.75 0.07 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Nov, 2025 Read the published version in Middle East Fertility Society Journal → Version 1 posted Editorial decision: Revision requested 01 Oct, 2025 Reviews received at journal 30 Sep, 2025 Reviews received at journal 28 Sep, 2025 Reviews received at journal 21 Sep, 2025 Reviewers agreed at journal 19 Sep, 2025 Reviews received at journal 19 Sep, 2025 Reviewers agreed at journal 19 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers invited by journal 18 Sep, 2025 Editor assigned by journal 18 Sep, 2025 Submission checks completed at journal 15 Sep, 2025 First submitted to journal 11 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Elgendy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYJACZgaGAwwM8s8PPgAziNfCkJNsQKqWBDMJorTwix1+9rig5o48f8OBtGqemjty/AzMDx/dwKNFcnaaufGMY88MZxxsPHab59gzY8kGNmPjHDxaDG4nmEnzsB1mbDjMkHYbyEjccICHTRqfFvvb6d+kef4dtp9/jMGsGMggrMVAOsdMmrcNqPIMgxkzmEFIi8TtnDLpmX2Hkzfe4EmWnNt32FiymYBf+Genb5Mu+HbYdt4N9oMf3nw7LMfP3vzwMT4tKICJB0QyE6scBBh/kKJ6FIyCUTAKRgwAAKdmUgDHhupTAAAAAElFTkSuQmCC","orcid":"","institution":"Bahrain Defense Force Royal Medical Services","correspondingAuthor":true,"prefix":"","firstName":"Eman","middleName":"","lastName":"Elgendy","suffix":""},{"id":521735490,"identity":"e39000e3-b6f6-4f27-9dfc-7f6dabeb83ff","order_by":1,"name":"Reem Abdulla Abduljalil","email":"","orcid":"","institution":"Bahrain Defense Force Royal Medical Services","correspondingAuthor":false,"prefix":"","firstName":"Reem","middleName":"Abdulla","lastName":"Abduljalil","suffix":""},{"id":521735491,"identity":"5433afec-c90d-4a58-9d75-69445f51a4ab","order_by":2,"name":"Sharefa Alansari","email":"","orcid":"","institution":"Bahrain Defense Force Royal Medical Services","correspondingAuthor":false,"prefix":"","firstName":"Sharefa","middleName":"","lastName":"Alansari","suffix":""},{"id":521735492,"identity":"f436ee3c-0fa5-418b-af3a-12405fdef381","order_by":3,"name":"Bayan Alsharqi","email":"","orcid":"","institution":"Bahrain Defense Force Royal Medical Services","correspondingAuthor":false,"prefix":"","firstName":"Bayan","middleName":"","lastName":"Alsharqi","suffix":""},{"id":521735493,"identity":"750b863f-2586-4329-a294-f8f0f1b66038","order_by":4,"name":"Fatema Sharif","email":"","orcid":"","institution":"Bahrain Defense Force Royal Medical Services","correspondingAuthor":false,"prefix":"","firstName":"Fatema","middleName":"","lastName":"Sharif","suffix":""},{"id":521735494,"identity":"00a21608-4947-42b6-8c4a-c341f0fedd7f","order_by":5,"name":"Nawal Dayoub","email":"","orcid":"","institution":"ARGC","correspondingAuthor":false,"prefix":"","firstName":"Nawal","middleName":"","lastName":"Dayoub","suffix":""}],"badges":[],"createdAt":"2025-09-11 17:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7594128/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7594128/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43043-025-00266-1","type":"published","date":"2025-11-18T15:58:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92477588,"identity":"7360dbdd-e08a-4ceb-9bb0-1f116194e31b","added_by":"auto","created_at":"2025-09-30 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07:16:22","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":44761,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7594128/v1/52bf1354d6c5f4f153e4a906.png"},{"id":92477594,"identity":"246ebe6f-d9c3-4ccb-9af1-ef24e4b28cb9","added_by":"auto","created_at":"2025-09-30 07:24:22","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99554,"visible":true,"origin":"","legend":"","description":"","filename":"5afe18b1b26f4078ab6ddf9160514bff1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7594128/v1/57f7b9b050b3dfca1d8ffa47.xml"},{"id":92475337,"identity":"868d08cd-b275-4993-b636-cd8328e5ccfd","added_by":"auto","created_at":"2025-09-30 07:16:22","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111872,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7594128/v1/1bb1831ab2e1b444b82f7b5e.html"},{"id":92475320,"identity":"8765e96b-fdaa-4029-9f4c-57e67414eaf6","added_by":"auto","created_at":"2025-09-30 07:16:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35768,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC analysis of percentage of BMI loss and pregnancy.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData set: percentage of BMI loss (+ve), percentage of BMI loss (-ve)\u003c/p\u003e\n\u003cp\u003eArea under ROC curve by extended trapezoidal rule = 0.637761\u003c/p\u003e\n\u003cp\u003eWilcoxon estimate of area under ROC curve = 0.637761\u003c/p\u003e\n\u003cp\u003eDeLong standard error = 0.032115: 95% CI = 0.574816 to 0.700706\u003c/p\u003e\n\u003cp\u003eOptimum cut-off point selected = 34.6\u003c/p\u003e\n\u003cp\u003esensitivity (95% CI) = 0.612613 (0.515468 to 0.703591)\u003c/p\u003e\n\u003cp\u003especificity (95% CI) = 0.638191 (0.567246 to 0.704951)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7594128/v1/4da5fd2415a6c32f828ca861.png"},{"id":92475322,"identity":"fc5344bd-93f9-4a14-a192-835440df6987","added_by":"auto","created_at":"2025-09-30 07:16:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27611,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation between pre surgery weight and length of time to achieve pregnancy\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7594128/v1/ead920d709caa2d08b25def1.png"},{"id":92475321,"identity":"78cc6abc-d579-4a8d-8124-a4e3745ac0bd","added_by":"auto","created_at":"2025-09-30 07:16:21","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":27074,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ethe correlation between total weight loss and the length of time to achieve pregnancy\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7594128/v1/de327b72688a9c2363d579dc.png"},{"id":92475324,"identity":"810e2959-e20c-4926-b3df-5abbd5cacc51","added_by":"auto","created_at":"2025-09-30 07:16:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":35388,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ethe correlation between percentage of BMI loss and the length of time to achieve pregnancy\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7594128/v1/990530f4fa95814f343baa37.png"},{"id":96650221,"identity":"fe4a5f86-7d08-4918-88a4-68114cd273d4","added_by":"auto","created_at":"2025-11-24 16:09:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":840556,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7594128/v1/4754bb17-e418-4ca6-9916-2130375aa502.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Role of Bariatric Surgery in Enhancing Fertility among Women with Significant Obesity\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObesity is a global public health issue, with worldwide rates having tripled in the last four decades and continuously escalating to pandemic proportions.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e As of 2016, among adults aged 18 years and over, the global prevalence of overweight (body mass index (BMI)\u0026thinsp;\u0026ge;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e) was 39%, and that of obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e) was 13%.\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e The prevalence of overweight and obesity is reported to be higher among women than men across the globe in both developed and developing countries.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e In 2023, 58.6% of women in the UK were obese. The prevalence of overweight and obesity is increasing more alarmingly in low- and middle-income countries, including the Middle East, where it has become one of the most significant health issues.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA cross-sectional study found that 30\u0026ndash;47% of overweight or obese women had menstrual abnormalities.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e The fat cells of obese women produce a high amount of leptin, which can alter the menstrual cycle by disrupting the hormonal balance. Furthermore, they alter the hypothalamic\u0026ndash;pituitary\u0026ndash;ovarian (HPO) axis, promote insulin resistance, and cause persistent low-grade inflammation. All of these effects result in compromised ovarian function and an altered follicular environment.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e Inflammatory pathways are critical for reproductive events such as follicle rupture during ovulation and trophoblast invasion into the receptive endometrium. Therefore, the altered inflammatory environment of women who are obese is likely to affect these critical reproductive processes.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMedical therapy and lifestyle changes have had limited success in maintaining long-term weight loss. Nevertheless, weight loss may improve a woman's ability to conceive by mitigating the effects of polycystic ovary syndrome (PCOS) and endometriosis.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e Despite recent advances in pharmacotherapy for the treatment of obesity, bariatric surgery remains a highly desired fertility-enhancing modality.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e This type of surgery falls into one of two categories based on whether restriction or malabsorption is the primary mechanism causing weight reduction, although some procedures use a combination of both mechanisms.\u003c/p\u003e\u003cp\u003eRestrictive bariatric surgeries reduce the gastric pouch size while leaving the rest of the gastrointestinal tract intact, which decreases the percentage of nutrients absorbed from a meal and leads to weight loss. Sleeve gastrectomy is one of the most popular types of restrictive bariatric surgery. It involves removing approximately 80% of the stomach, including the part responsible for producing the satiety-controlling hormone ghrelin. Thus, a tube-like stomach is formed, which minimizes total food intake. The surgery is technically simple for high-risk medical conditions and is effective for weight loss, but it is a non-reversible procedure that may worsen reflux and has less impact on metabolism.\u003c/p\u003e\u003cp\u003eAdjustable gastric banding uses a restrictive mechanism involving an inflatable band that limits food intake. Apart from being minimally invasive, its advantages include adjustability, reversibility, gradual weight loss, and no dumping syndrome. On the other hand, the rate of weight loss is slow, its effectiveness is limited, periodic adjustments are needed, and diet restrictions are necessary.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMalabsorptive processes are characterized by bypassing the duodenum and jejunum to limit both energy intake and absorption. Food intake is reduced by creating a gastric pouch, and less intestine, gastric acid, bile, and pancreatic enzymes are available for absorption. Gastric bypass surgery is the oldest and most commonly performed bariatric surgery. This procedure reduces the size of the stomach and leads to the bypass or omission of a sizable part of the upper part of the small intestines, where nutrients such as fat, protein, and vitamins are absorbed. However, it is non-reversible, it may worsen reflux, and it has less impact on metabolism.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eRoux-en-Y gastric bypass is a restrictive and malabsorptive procedure where a stomach pouch is created, and a section of duodenum is attached to it so that food bypasses the duodenum. This procedure is surgically complex and leads to more vitamin deficiencies and risk for complications, including ulcers and dumping syndrome. Recently, new intraluminal or endoscopic techniques with few clinical risks and economic costs have been introduced to clinical practice.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAfter bariatric surgery, females have reported normalization of menstrual cycles, regular ovulation, and higher rates of spontaneous conception. Westerman et al. analyzed metabolic changes after weight-loss surgery and observed a steep increase of sex hormone-binding globulin (SHBG) and declines in the levels of testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEA-S), which might help to overcome menstrual abnormalities and infertility.\u003csup\u003e\u003cb\u003e15\u0026ndash; \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e Al Qureshi et al. documented improvements in hormonal profiles and sexual function among women after bariatric surgery.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe present study was conducted to examine the beneficial effects of bariatric surgery (sleeve gastrectomy, gastric banding, and gastric bypass with Roux-en-Y gastroenterostomy) on obese women and their fertility rates, as well as the factors that increase the chances of achieving pregnancy after surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective observational study examined 310 obese patients who were planning for pregnancy and underwent bariatric surgery between January 2019 and December 2022 at Bahrain Defense Force Hospital, West Riffa, Bahrain. All surgeries were performed in the surgical department. The digital files of all women who were of reproductive age and underwent any bariatric surgery were collected along with their fertility and obstetric files before and after the surgery in accordance with our data protection policy. Patients who were not planning for pregnancy or failed to attend follow-up visits were excluded. The intervention group included participants who underwent a Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding.\u003c/p\u003e\u003cp\u003eThe main outcome of the study was the rate of pregnancy among patients planning for pregnancy after bariatric surgery, as well as the possible factors that play a role in achieving pregnancy after the surgery, including the patient\u0026rsquo;s BMI, age, and mode of pregnancy (either spontaneous conception or in vitro fertilization (IVF)). The time from the surgery to achieving conception was defined as the period in months between the date of surgery and the first day of the last menstrual cycle. Regarding BMI, patients were considered obese if their BMI exceeded 30. The BMI (kg/m\u003csup\u003e2\u003c/sup\u003e) was calculated using the weight (kg) divided by the measured height (m\u003csup\u003e2\u003c/sup\u003e). BMI and weight were collected before and after surgery. The percentage of BMI loss was calculated by dividing the BMI loss by the original BMI. Other clinical variables included age and the methods of conception.\u003c/p\u003e\u003cp\u003eStatistical analysis was performed using Statdirect software (Version 3.3.5 22/03/2021). An initial assessment was performed on the differences between patients who achieved pregnancy and the group that did not conceive. Variables such as age, initial weight/BMI, total loss of weight/BMI, and the percentage of BMI loss were analyzed. Normally distributed continuous variables were analyzed using a two-sided \u003cem\u003et\u003c/em\u003e-test and expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Non-normally distributed variables were analyzed using a two-sided Mann -Whitney \u003cem\u003eU\u003c/em\u003e test and expressed as the median (range).\u003c/p\u003e\u003cp\u003eThe optimal percentage of BMI loss after bariatric surgery to achieve pregnancy was evaluated by receiver operating characteristic (ROC) curve analysis. Multiple logistic regression analyses were then conducted to assess the effect of the optimal percentage of BMI loss on achieving pregnancy after excluding other contributing factors such as age and artificial reproductive therapy (ART). The final models reported the adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was defined by \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The Royal Bahrain Defense Force Hospital Ethical Committee approved this study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe total number of patients who underwent bariatric surgery and planned pregnancy was 310. The percentage of patients who achieved pregnancy was 35.8% (111 patients). The group that did not conceive were considered as a control group (199 patients). The study groups had similar ages (34.3 vs. 35.3 \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.08). The patients who achieved pregnancy were significantly heavier with a higher BMI before bariatric surgery (117.7 kg vs. 107.5 kg; BMI 45.7 vs. 42; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). More post-procedure weight loss was observed among patients who conceived (41.4 kg vs. 31.9 kg; BMI reduction 16.2 vs. 12.5; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e\u003cp\u003eThe percentage of BMI loss compared to original levels was also significantly greater among patients who achieved pregnancy (35.3% vs. 29.4%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Surprisingly, however, the post-surgery weight and BMI were similar between the groups (76.4 kg vs. 75.4 kg; BMI 29.5 vs. 29.5; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;98) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The optimal percentage of BMI loss to achieve pregnancy was evaluated by ROC analysis, which indicated that losses above a cutoff value of 34.6% were associated with pregnancy with a sensitivity of 61% and specificity of 64% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA logistic regression was performed according to the observed cutoff value of 34.6% loss of the original BMI measurement to adjust for confounding variables. The variables analyzed were age\u0026thinsp;\u0026le;\u0026thinsp;35 years, BMI\u0026thinsp;\u0026le;\u0026thinsp;30, and the use of ART to achieve pregnancy. The analysis results were not significant for any of the analyzed factors (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor the patients who achieved pregnancy, further analysis was performed to check for factors related to the timing of conception. Simple linear regression showed no correlation between pre-surgery weight, total weight loss, percentage of BMI loss, and the time required to achieve pregnancy after bariatric surgery (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.95, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.25, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.72). (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWeight loss is a well-established strategy for improving fertility in obese women, and bariatric surgery has emerged as one of the most effective treatments for achieving significant and sustained weight reduction. As such, understanding the impact of bariatric surgery on future reproductive potential is an important area of clinical interest. This study presents a retrospective review conducted at a single center, involving 310 obese women of reproductive age who underwent bariatric surgery with the intention of conceiving. Among them, 35.8% (111 patients) achieved pregnancy following the procedure.\u003c/p\u003e\u003cp\u003eWhile this pregnancy rate is notable, it is lower than those reported in other studies. For instance, Jamal et al. and Musella et al. documented spontaneous pregnancy rates ranging from 62% to 100% in women with prior infertility following bariatric surgery. \u003csup\u003e\u003cb\u003e19,20\u003c/b\u003e\u003c/sup\u003e Similarly, Makhsosi et al. reported a pooled post-surgical conception rate of 67%, reinforcing the positive association between bariatric surgery and the restoration of fertility. \u003csup\u003e\u003cb\u003e21\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIt is important to note, however, that not all studies have demonstrated a clear benefit of bariatric surgery on fertility outcomes. Research by Legro et al., Neto et al., and Christofolini et al. found no significant improvements in fertility post-surgery. \u003csup\u003e\u003cb\u003e22\u0026ndash;24\u003c/b\u003e\u003c/sup\u003e Similarly, Goldman et al., and Laurino et al. also reported no notable increase in pregnancy rates.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e These discrepancies across studies may be attributed to a range of contributing factors, such as differences in sample size, age distribution, pre- and post-operative BMI, duration of follow-up, prevalence of polycystic ovary syndrome (PCOS), baseline infertility diagnoses, metabolic profiles, endocrine function, and the degree of weight loss achieved postoperatively.\u003c/p\u003e\u003cp\u003eIn the current study, the groups had similar age (34.3 vs. 35.3 years; \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.08). However, it is well known that pregnancy rates may be affected by factors such as decreased ovarian reserve and reproductive potential. Younger individuals may have a higher probability of conceiving naturally after surgery. Therefore, age should be a key factor when counselling patients about reproductive outcomes after bariatric surgery. Although most guidelines define a waiting time of 12\u0026ndash;18 months after surgery before attempting to conceive, a more personalized approach that balances nutritional risks of earlier conception against the risk of declining ovarian reserve due to age when delaying pregnancy has been suggested.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMusella et al. found that patients who became pregnant after surgery had a lower BMI (34.2 kg/m\u003csup\u003e2\u003c/sup\u003e) than those who remained infertile (41.5 kg/m\u003csup\u003e2\u003c/sup\u003e), indicating that achieving a BMI closer to the normal range may lead to greater reproductive benefits.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e In contrast, our analysis found similar post-surgery BMI between the study groups. A considerable drop in BMI after bariatric surgery was more important. Given that both groups had similar post-procedure BMI, patients who had achieved a greater drop in BMI were considerably heavier pre-surgery. Solaiman et al. obtained the same results and found that initial BMI and weight were higher among mothers who conceived early following bariatric surgery.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe optimal percentage of BMI loss after bariatric surgery to achieve pregnancy was evaluated by ROC analysis. It was found that percentages of BMI loss above the cutoff value of 34.6% were associated with pregnancy with sensitivity of 61% and specificity of 64%. Although post-operative BMI reductions have varied between trials, most patients achieved a considerable drop in body weight and typically attained a BMI in the overweight or moderately obesity range (BMI 25\u0026ndash;35 kg/m\u003csup\u003e2\u003c/sup\u003e).\u003c/p\u003e\u003cp\u003eSome studies, such as those by Legro et al. and Milone et al., performed thorough longitudinal tracking of BMI changes over time and found that fertility improvements were frequently associated with the degree of weight reduction.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e In the present study, the mean pre-surgery BMIs were 42 and 45, and it may have been possible to lose more than 34% of the original BMI. In studies with much lower initial BMI, it would be very difficult to achieve such percentages of BMI loss.\u003c/p\u003e\u003cp\u003eLogistic regression was performed according to the observed cutoff value of 34.6% loss of original BMI to exclude any other contributing factors. The analyzed variables were age\u0026thinsp;\u0026le;\u0026thinsp;35 years, BMI\u0026thinsp;\u0026le;\u0026thinsp;30, and the use of ART. The results were not significant for any of these factors to achieve pregnancy Our analysis did not take into consideration the preconception fertility issues but found no difference in IVF conception after the surgery between the groups.\u003c/p\u003e\u003cp\u003eIn support of our finding, Khazraei et al. found that the duration and magnitude of weight loss are two essential aspects of managing infertility that are achieved by undergoing bariatric surgery.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e In contrast, Grzegorczyk-Martin et al. observed that women who underwent bariatric surgery had higher embryo yields and fertilization rates compared to BMI-matched obese controls.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e However, this heterogeneity in the results of studies may be due to different surgical methods, which may have both metabolic and hormonal consequences that may affect reproductive results differently.\u003c/p\u003e\u003cp\u003eSimple linear regression analysis has demonstrated no significant association between pre-surgical weight and the duration required to achieve pregnancy (P\u0026thinsp;=\u0026thinsp;0.95). Likewise, neither total weight loss (P\u0026thinsp;=\u0026thinsp;0.25) nor percentage of BMI reduction (P\u0026thinsp;=\u0026thinsp;0.72) showed a statistically significant correlation with time to conception. The relationship between weight parameters and time to conception following bariatric surgery remains complex and somewhat inconsistent across the literature.\u003c/p\u003e\u003cp\u003eSolaiman et al. found that women who conceived within six months of surgery had significantly higher baseline BMI and weight (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), suggesting that pre-operative weight may influence early conception in some cases. \u003csup\u003e\u003cb\u003e28\u003c/b\u003e\u003c/sup\u003e Despite these findings, the evidence is mixed. Some studies have proposed that greater post-operative weight loss\u0026mdash;both in absolute terms and as a percentage of BMI\u0026mdash;may be linked to shorter times to conception, while others have reported no significant differences between those who became pregnant and those who did not. \u003csup\u003e\u003cb\u003e32\u0026ndash;33\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAs a precautionary measure, clinical guidelines generally advise women to postpone pregnancy for at least 12 months following bariatric surgery. In several European countries, including the United Kingdom, the recommended waiting period extends to two years after gastric banding and 12 months after other surgical procedures.\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitation.\u003c/b\u003e The small sample size and inclusion of different bariatric procedures may have influenced the results. Additionally, factors like PCOS, endocrine dysfunction, and other infertility issues affecting pregnancy success after BS were not assessed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis analysis highlights that those obese patients with higher BMI are more likely to achieve pregnancy post BS compared to obese patients with lower BMI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendation.\u003c/strong\u003e The findings of our study support the consideration of BS in infertility treatment regimens. Women should be counseled that significant weight loss following BS is associated with an increased chance of achieving pregnancy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBariatric Surgery = BS\u003c/p\u003e\n\u003cp\u003eBody mass index = BMI\u003c/p\u003e\n\u003cp\u003ePolycystic ovaries syndrome = PCOs \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn vitro fertilization = IVF\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Royal Bahrain Defense Force Hospital Ethical Committee approved this study (Approval No: \u0026nbsp; RMS-BDF /P\u0026amp;PEC/ 2023). As this was a retrospective review of patient records, the requirement for informed consent was waived by the ethics committee.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe work is based on a retrospective review of patient records, and therefore no research data are available for sharing due to patient privacy and ethical restrictions, but anonymized data are available from the corresponding author on reasonable request and with permission from Bahrain Defense Force Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, as this study does not contain any individual person\u0026rsquo;s data in any form (including individual details, images, or videos).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1-E E\u003c/p\u003e\n\u003cp\u003e2-R A\u003c/p\u003e\n\u003cp\u003e3-S A\u003c/p\u003e\n\u003cp\u003e4-F S\u003c/p\u003e\n\u003cp\u003e5-B A\u003c/p\u003e\n\u003cp\u003e6-N D\u003c/p\u003e\n\u003cp\u003e1 - designed the study, analyzed the data, and wrote the manuscript\u003c/p\u003e\n\u003cp\u003e2-3-4-5 contributed to data collection and interpretation.\u003c/p\u003e\n\u003cp\u003e1-2-3- assisted in proofreading and correcting typographical errors.\u003c/p\u003e\n\u003cp\u003e6 - Prepared figures and tables and revised the manuscript for important intellectuals.\u003c/p\u003e\n\u003cp\u003e1-2-3-4-5-6 read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to the Royal Bahrain Defense Force Hospital and the Maternity Unit, Riffa, Bahrain, for their support of this work. They also wish to acknowledge the Surgical Department at the Bahrain Defense Force Hospital for their assistance in accessing and reviewing patient records. The authors are further grateful to The American Manuscript Editors for their English language editing and for their valuable suggestions.\u003c/p\u003e\n\u003cp\u003eAuthors declare that the article was not presented in any conferences /not published.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eAuthors have no conflict of interest and our study was not supported by any fund. \u0026nbsp;we would like to clarify that no artificial intelligence (AI) tools were utilized in any part of our manuscript. The article, including its writing, figures, data collection, and analysis, was prepared entirely by the authors without assistance from AI technologies. The authors take full responsibility for the accuracy and integrity of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cspan dir=\"RTL\"\u003e1.Bl\u0026uuml;her, M. Obesity: Global epidemiology and pathogenesis. Nat. Rev. Endocrinol. 2019, 15, 288\u0026ndash;298. [CrossRef] \u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Obesity and Overweight; WHO: Geneva, Switzerland, 2020; Available online: https://www.who.int/ news-room/fact-sheets/detail/obesity-and-overweight (accessed on 13 October 2020).\u003c/li\u003e\n\u003cli\u003e\u003cspan dir=\"RTL\"\u003e3.NCD RiskFactor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet 2016, 387, 1377\u0026ndash;1396. [CrossRef]\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eWHO. Obesity: Preventing and managing the global epidemic. 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Update 25(4), 439\u0026ndash;451 (2019).\u003c/li\u003e\n\u003cli\u003eThe Impact of Overweight and Obesity on Pregnancy: A Narrative Review of Physiological Consequences, Risks and Challenges in Prenatal Care, and Early Intervention Strategies..Brunner K, Linder T, Klaritsch P, Tura A, Windsperger K, G\u0026ouml;bl C.Curr Diab Rep. 2025 Apr 21;25(1):30. doi: 10.1007/s11892-025-01585-3.PMID: 40257685 Free PMC article. Review.\u003c/li\u003e\n\u003cli\u003ePolycystic ovary syndrome and excessive body weight impact independently and synergically on fertility treatment outcomes.\u003cspan dir=\"RTL\"\u003e Vale-Fernandes E, Moreira MV, Bernardino RL, Sousa D, Brand\u0026atilde;o R, Leal C, Barreiro M, Monteiro MP. Reprod Biol Endocrinol. 2025 Jul 7;23(1):97. doi: 10.1186/s12958-025-01434-8.PMID: 40624700\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eImpact on Metabolism Generated by Surgical and Pharmacological Interventions for Weight Loss in Women with Infertility. Gete Palacios PC, Moscona-Nissan A, Saucedo R, Ferreira-Hermosillo A\u003cspan dir=\"RTL\"\u003e. \u003c/span\u003eMetabolites. 2025 Apr 10;15(4):260. doi: 10.3390/metabo15040260.PMID: 40278389 Free PMC article. Review.\u003c/li\u003e\n\u003cli\u003eFertility and Pregnancy after Bariatric Surgery: Challenges and Solutions AngelikiMina1 AmnaAsraiti2 Elamin Abdelgadir2 Department of Gynecology and Obstetrics and Medicine, Yas Clinic Khalifa City, Abu Dhabi, United Arab Emirates 2Department of Endocrinology, Dubai Hospital, Dubai, United Arab Emirates IbnosinaJMedBiomedSci2024;16:38\u0026ndash;48.\u003c/li\u003e\n\u003cli\u003eBusettoL, Dicker D,AzranC,etal. Obesity Management Taskforce of the European Association for the Study of Obesity Released \u0026ldquo;Practical Recommendations for the Post-Bariatric Surgery Medical Management\u0026rdquo;. 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Goulis, \u0026ldquo;e complex interaction between obesity, metabolic syndrome and reproductive axis: a narrative re view,\u0026rdquo; Metabolism, vol. 62, no. 4, pp. 457\u0026ndash;478, 2013.\u003c/li\u003e\n\u003cli\u003eWesterman, R.; Kuhnt, A.-K. Metabolic risk factors and fertility disorders: A narrative review of the female perspective. Reprod. Biomed. Soc. Online 2022, 14, 66\u0026ndash;74. [CrossRef] [PubMed]\u003c/li\u003e\n\u003cli\u003eAlQurashi, A.A.; Qadri, S.H.; Lund, S.; Ansari, U.S.; Arif, A.; Durdana, A.R.; Maryam, R.; Saadi, M.; Zohaib, M.; Khan, M.K.; et al. The effects of BS on male and female fertility: A systematic review and meta-analysis. Ann. Med. Surg. 2022, 80, 103881. [CrossRef] [PubMed] [PubMed Central\u003c/li\u003e\n\u003cli\u003eJamal M, Gunay Y, Capper A, Eid A, Heitshusen D, Samuel I. Roux-en-Y gastric bypass ameliorates polycystic ovary syndrome and dramatically im proves conception rates: a 9-year analysis. Surg Obes Relate Dis. 2012;8(4):440-4.\u003c/li\u003e\n\u003cli\u003eMusella M, Milone M, Bellini M, et al. Effect of BS on obesity-related infertility. Surg Obes Reltd Dis 2012; 8:445\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eMakhsosi, B.R.; Ghobadi, P.; Otaghi, M.; Tardeh, Z. Impact of BS on infertility in obese women: A systematic review and meta-analysis. Ann. Med. Surg. 2024, 86, 7042\u0026ndash;7048. [CrossRef] [PubMed] [PubMed Central\u003c/li\u003e\n\u003cli\u003eLegro RS, Dodson WC, Gnatuk CL, Estes SJ, Kunselman AR, Meadows JW, et al. Effects of gastric bypass surgery on female reproductive function. J Clin Endocrinol Metab. 2012;97(12): 4540-8. \u003c/li\u003e\n\u003cli\u003eNeto, R.M.L.; Herbella, F.A.M.; Tauil, R.M.; Silva, F.S.; De Lima, S.E. Comorbidities Remission After Roux-en-Y Gastric Bypass for Morbid Obesity is Sustained in a Long-Term Follow-up and Correlates with Weight Regain. Obese. Surg. 2012, 22, 1580\u0026ndash;1585. [CrossRef] [PubMed]\u003c/li\u003e\n\u003cli\u003eChristofolini, J.; Bianco, B.; Santos, G.; Adami, F.; Christofolini, D.; Barbosa, C.P. BS influences the number and quality of oocytes in patients submitted to assisted reproduction techniques. Obesity 2014, 22, 939\u0026ndash;942. [CrossRef] \u003c/li\u003e\n\u003cli\u003eGoldman RH, Missmer SA, Robinson MK, Farland LV, Ginsburg ES. Reproductive outcomes differ following roux-en-Y gastric bypass and adjustable gastric band compared with those of an obese non-surgical group. Obes Surg. 2016;26(11):2581-9.\u003c/li\u003e\n\u003cli\u003eLaurino Neto RM, Herbella FA, Tauil RM, Silva FS, de Lima SE Jr. Comorbidities remission after Roux-en-Y Gastric Bypass for morbid obesity is sustained in a long-term follow-up and correlates with weight regain. Obes Surg. 2012;22(10):1580-5.\u003c/li\u003e\n\u003cli\u003eChristinajoice, S.; Misra, S.; Bhattacharya, S.; Kumar, S.S.; Nandhini, B.D.; Palanivelu, C.; Raj, P.P. Impact of BS on female reproductive health and maternal outcomes. Obes. Surg. 2020, 30, 383\u0026ndash;390. [CrossRef] [PubMed].\u003c/li\u003e\n\u003cli\u003eMaternal and perinatal outcomes in women conceiving after bariatric surgery: A cohort study. Solaiman S, Al-Baghdadi OO, Thin Hla T, Abdulmajid Kapadia S, Elbiss HM. Medicine 2023; 102:24(e33913). \u003c/li\u003e\n\u003cli\u003eMilone, M.; Sosa Fernandez, L.M.; Sosa Fernandez, L.V.; Manigrasso, M.; Elmore, U.; De Palma, G.D.; Musella, M.; Milone, F. Does BS Improve Assisted Reproductive Technology Outcomes in Obese Infertile Women? Obes. Surg. 2017, 27, 2106\u0026ndash;2112. [CrossRef]\u003c/li\u003e\n\u003cli\u003eKhazraei, H.; Hosseini, S.V.; Amini, M.; Bananzadeh, A.; Najibpour, N.; Ganji, F.; Sadeghi, F.; Vafa, L. Effect of weight loss after laparoscopic sleeve gastrectomy on infertility of women in Shiraz. J. Gynecology. Surg. 2017, 33, 43\u0026ndash;46. [CrossRef]\u003c/li\u003e\n\u003cli\u003eGrzegorczyk-Martin, V.; Fr\u0026eacute;our, T.; De Bantel Finet, A.; Bonnet, E.; Merzouk, M.; Roset, J.; Roger, V.; C\u0026eacute;drin-Durnerin, I.; Wainer, R.; Avril, C.; et al. IVF outcomes in patients with a history of bariatric surgery: A multicenter retrospective cohort study. Hum. Reprod. 2020, 35, 2755\u0026ndash;2762. [CrossRef]\u003c/li\u003e\n\u003cli\u003eAlatishe A, Ammori BJ, Syed AA. Pregnancy after bariatric surgery does not affect weight loss. BMJ: British Medical Journal 2012;345: e6293. [DOI] [PubMed] [Google Scholar]\u003c/li\u003e\n\u003cli\u003eRottenstreich A, Shufanieh J, Kleinstern G, Goldenshluger A, Elchalal U, Elazary R. The long-term effect of pregnancy on weight loss after sleeve gastrectomy. Surgery for obesity and related diseases: official journal of the American Society for Bariatric Surgery 2018;14: 1594\u0026ndash;1599. [DOI] [PubMed] [Google Scholar]\u003c/li\u003e\n\u003cli\u003ePregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care. Jill Shawe, Dries Ceulemans, Zainab Akhter, Karl Neff, Kathryn Hart, Nicola Heslehurst, Iztok \u0026Scaron;totl, Sanjay Agrawal, Regine Steegers-Theunissen, Shahrad Taheri First published: 16 August2019DOI: 10.1111/obr.12927Obesity Reviews. 2019; 20:1507\u0026ndash;1522. wileyonlinelibrary.com/journal/obr 1507.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003edifference in weight profile between the groups.\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePregnant\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eN\u0026thinsp;=\u0026thinsp;111\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNon pregnant\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eN\u0026thinsp;=\u0026thinsp;199\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eP value\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAge years\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e34.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e35.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.083\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWeight before surgery kg\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e117.7\u0026thinsp;\u0026plusmn;\u0026thinsp;21.8\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e107.5\u0026thinsp;\u0026plusmn;\u0026thinsp;19.7\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.0001\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eWeight after surgery Kg\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e76.4\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e75.4\u0026thinsp;\u0026plusmn;\u0026thinsp;17.8\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e0.649\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTotal weight loss\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e41.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e31.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.0001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eBMI before kg/m\u0026sup2; \u0026plusmn; SD\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e45.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e42\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.0001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eBMI after kg/m\u0026sup2; \u0026plusmn; SD\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e0.98\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTotal BMI loss kg/m\u0026sup2; \u0026plusmn;SD\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e16.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.0001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003ePercentage of BMI loss median (range)\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e35.3 (12.5\u0026ndash;60.1)\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e29.4 (0.6\u0026ndash;58.3)\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.0001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eART treatment\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e23 (20.7)\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e8 (4)\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.0001\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eMedian period to pregnancy months(range)\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e22 (1-124)\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eCaesarean section rate\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e61 (55%)\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eFoetal weight Kg mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003elogistic regression analysis for prediction of pregnancy.\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOdd ratio\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e95% Conf\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eZ value\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eP value\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIntercept\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003en/a\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.95\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.05\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAge\u0026thinsp;\u0026le;\u0026thinsp;35\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.47\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.79 to 7.79\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.55\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.12\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003epercentage of BMI loss\u0026thinsp;\u0026gt;\u0026thinsp;34.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4.39\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.87 to 22.14\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.79\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.07\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBMI\u0026thinsp;\u0026le;\u0026thinsp;30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.63\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.21 to 1.91\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.81\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.42\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUse of ART\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6.73\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.79 to 56.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.75\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.07\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"middle-east-fertility-society-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mefj","sideBox":"Learn more about [High Temperature Corrosion of Materials](https://www.springer.com/journal/43043)","snPcode":"43043","submissionUrl":"https://submission.nature.com/new-submission/43043/3","title":"Middle East Fertility Society Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bariatric surgery, obesity, pregnancy rates, body mass index","lastPublishedDoi":"10.21203/rs.3.rs-7594128/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7594128/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eBariatric surgery is a long-term treatment for obesity that leads to significant weight loss that impacts reproductive health. This study explored how bariatric surgery affects pregnancy rates post-surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective study was conducted at Bahrain Defense Force Hospital in 2019\u0026ndash;2022 and included 310 women of reproductive age who had bariatric surgery before planning pregnancy. Data were analyzed using standard statistical tests, with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eOf 310 patients who underwent bariatric surgery, 35.8% (111 patients) achieved pregnancy. Those with successful pregnancies had higher pre-surgery weight and body mass index (BMI) and a greater BMI drop (35.3%) compared to non-pregnant patients (29.4%). Receiver operating characteristic (ROC) curve analysis indicated that a BMI-loss cutoff of 34.6% was associated with pregnancy (sensitivity 61%, specificity 64%). Logistic regression was performed according to this cutoff value to exclude any other contributing factors, including age\u0026thinsp;\u0026le;\u0026thinsp;35 years, BMI\u0026thinsp;\u0026le;\u0026thinsp;30, and use of artificial reproductive therapy (ART) to achieve pregnancy; the analysis results were insignificant for all of the factors. Simple linear regression showed no correlation between pre-surgery weight, total weight loss, percentage of BMI loss, and the time required to achieve pregnancy after bariatric surgery (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.95, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.25, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.72).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eHigher pre-surgery BMI and greater BMI loss were linked to higher pregnancy success after bariatric surgery.\u003c/p\u003e","manuscriptTitle":"The Role of Bariatric Surgery in Enhancing Fertility among Women with Significant Obesity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 07:16:17","doi":"10.21203/rs.3.rs-7594128/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-01T14:10:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-30T22:04:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T10:53:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-21T15:43:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19459779442260603953036223304395757043","date":"2025-09-19T18:11:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T17:58:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4669319825694866585478163277592000511","date":"2025-09-19T17:50:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315370419164294819743057339225610399035","date":"2025-09-18T18:30:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175223644362563184473060894882475095610","date":"2025-09-18T07:57:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-18T07:52:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-18T07:47:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-15T09:23:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"Middle East Fertility Society Journal","date":"2025-09-11T17:28:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"middle-east-fertility-society-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mefj","sideBox":"Learn more about [High Temperature Corrosion of Materials](https://www.springer.com/journal/43043)","snPcode":"43043","submissionUrl":"https://submission.nature.com/new-submission/43043/3","title":"Middle East Fertility Society Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aaee4330-532b-4230-aca9-38329506391a","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:04:38+00:00","versionOfRecord":{"articleIdentity":"rs-7594128","link":"https://doi.org/10.1186/s43043-025-00266-1","journal":{"identity":"middle-east-fertility-society-journal","isVorOnly":false,"title":"Middle East Fertility Society Journal"},"publishedOn":"2025-11-18 15:58:52","publishedOnDateReadable":"November 18th, 2025"},"versionCreatedAt":"2025-09-30 07:16:17","video":"","vorDoi":"10.1186/s43043-025-00266-1","vorDoiUrl":"https://doi.org/10.1186/s43043-025-00266-1","workflowStages":[]},"version":"v1","identity":"rs-7594128","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7594128","identity":"rs-7594128","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}