As mentioned above, this issue was the most common source of discussion during development of our policy. While many measures of well-being worsen even with mild and moderate obesity, it is also true that many obese women have very healthy pregnancies and long and active lives. Comorbidities that tend to track with obesity, such as hypertension and glucose intolerance, are more risky to certain pregnancy and delivery outcomes than the obesity itself, yet it is hard to predict whether a particular woman will manifest these comorbidities during a future pregnancy. It is also difficult to decide upon a level of increased risk, or decreased efficacy, which is compelling enough to warrant delay in a much desired treatment for infertility. Furthermore, there is little evidence in the literature looking at reproductive outcomes for women in the very highest BMI categories or reproductive outcomes specifically for obese women treated for infertility.

Our experience with a BMI limit of 40 kg/m² in our shared risk IVF program has generally been positive, with interested couples demonstrating motivation and success in meeting this criterion. The survey of infertility clinics in the United States noted above also suggests physicians feel that 40 kg/m² may be a reasonable limit for provision of IVF treatment [11]. Other countries with subsidized infertility care set limits that are significantly lower, such as 30 kg/m² in England (http://​www.​hfea.​gov.​uk/​fertility-treatment-cost-nhs.​html#1). For a woman who is 5 ft 4 in. tall, a BMI limit of 40 kg/m² or 30 kg/m² means she could weigh up to 230 lb or 175 lb, respectively, and still receive care. By way of comparison, the average adult woman in the United States is 5 ft 4 in. tall and weighs 166 lb [14]. Since we were very motivated by medical indications in development of this policy, we decided that the evidence was less equivocal regarding the reproductive risks of very severe obesity, and thus we chose 50 kg/m² as our limit to start. This means that a woman of average height can weigh up to 290 lb and still receive infertility care in our clinic, assuming that other medical untreated comorbidities do not exist. While this is our upper limit for now, we are certainly open to lowering this BMI limit as medical knowledge and policy efficacy dictate.

Since acute weight loss may be just as detrimental to a woman’s health and the efficacy of their infertility treatment, we encourage steady but moderate weight loss supervised by a primary care physician. Unfortunately, for women in their late 30s and early 40s and those with diminished ovarian reserve, time is of the essence in proceeding with infertility treatment. As described in our policy, we understand that not all patients have the time needed to make effective lifestyle changes leading to weight loss and improved glucose control, and thus there are exceptions to our BMI policy for situations such as these when BMI is between 40 and 49. Similarly, if oocyte freezing is sought for fertility preservation prior to cancer treatment, for example, exceptions to the policy can be made. As a practice, we reserve the right to discuss particular medical situations as a group and make rare exceptions to our policy, always keeping in mind the primacy of the health of our patients and their offspring.

The issue of time also arose in considering how improved obesity counseling and support from our physicians, nurses, and schedulers would likely increase the length of clinic visits and amount of clinical work. Efforts were made to have resources readily available to faculty and support staff to facilitate these efforts (see Box 13.1), but there is no question that effective obesity care takes additional time in clinic, and more clinic visits. Our expectation is that making obesity care a routine part of the whole team’s practice will result in improved efficiency and efficacy over time.

We initially considered developing a larger number of policy-related resources that would meet the needs of patients, support staff, nursing, and physicians. This quickly became confusing, however, and we decided instead to simplify our 2-page information sheet and policy description. This 2-page document became an informational resource for previsit patients, a worksheet for patient-provider interactions, and a reference for practice physicians and nurses and referring providers. In order to effectively meet all of these needs, the document had to be thorough but concise and relatively simple to read. We recognize that the final result may not be fully understandable by patients of every reading level; however, we plan to overcome this issue by working through the document in person with each patient so that the message is personalized.