Modern Metabolic Health with Dr. Lindsay Ogle, MD

Fertility, Weight, And Metabolic Health

• Lindsay Ogle, MD

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We walk through how underweight, excess weight, and insulin resistance can change ovulation, fertility, and pregnancy risk long before a test turns positive. We also unpack PCOS basics, why some clinics enforce BMI cutoffs, and what safer preconception weight management can look like with your doctor. 

• extremes of weight affecting ovulation and menstrual cycles 
• RED-S and why under-fueling can stop periods 
• PCOS prevalence and diagnostic criteria in plain language 
• insulin resistance driving higher insulin and higher androgens 
• why weight loss can be harder with high insulin 
• small weight changes improving fertility potential in PCOS 
• metformin and GLP-1 medications as medically supervised options before pregnancy 
• fertility clinic BMI cutoffs, success metrics, and weight bias 
• pregnancy complications linked with higher starting BMI, with risks possible at any size 
• bariatric surgery timing and why waiting a year can matter 
• anti-obesity medications not recommended in pregnancy or breastfeeding 
• topiramate birth defect risk and the need for effective birth control 

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Birth Control Option (YouTube)

Birth Control & GLP-1s (YouTube)


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Welcome And Medical Disclaimer

Dr. Lindsay Ogle, MD

Welcome to the Modern Metabolic Health Podcast with your host, Dr. Lindsay Olville, Ford Certified Family Medicine and Obesity Medicine Physician. Here we learn how we can treat and prevent modern metabolic conditions such as diabetes, PCOS, fatty liver disease, metabolic syndrome, sleep apnea, and more. We focus on optimizing lifestyle while utilizing safe and effective medical treatments. Please remember that while I am a physician, I am not your physician. Everything discussed here is provided as general medical knowledge and not direct medical advice. Please talk to your doctor about what is best for you.

Weight, Metabolic Health, And Pregnancy

Dr. Lindsay Ogle, MD

What is the relationship between weight, metabolic health, and pregnancy? Whether you are planning a pregnancy in the future, are currently pregnant, or have been pregnant in the past, or know somebody who fits in one of those categories, this information is vitally important because it may be able to save your life or that person who you

Underweight, RED-S, And Lost Periods

Dr. Lindsay Ogle, MD

care about. We'll start with pre-pregnancy. What does weight have to do with becoming pregnant? The truth is extremes of weight, whether that is underweight or overweight, can impact somebody's ability to become pregnant. If you are underweight, your body is trying to protect you and use all of its reserves, its energy, calories, nutrition to fuel your body. You do not have enough stores to healthfully carry a pregnancy. So in an effort to protect you, you tend to stop ovulating. Especially high-performance athletes who are not getting enough calories and nutrition in, they may notice that their periods are either less frequent or stop altogether. This is now called relative energy deficiency in sports or reds.

PCOS And Insulin Resistance Explained

Dr. Lindsay Ogle, MD

Conversely, if somebody has excess weight, it may also be more difficult to become pregnant. We most commonly see this in the very common condition of polycystic ovarian syndrome or PCOS. And the reason this is happening is related to insulin resistance. And how common is PCOS? Depending on what source you're looking at, it is estimated to affect anywhere from 5 to 20% of women of reproductive age. So anywhere from 1 in 20 to 1 in 5 women have this condition, and some may not know it. The signs and symptoms are irregular menstrual cycles or no menstrual cycles. If you had hormonal labs collected, you may see relatively high levels of testosterone, and there are a few other lab changes that may indicate polycystic ovarian syndrome. And then if you've had an ultrasound of your ovaries, they may see several, usually more than 20 cysts along a single ovary. You need two out of three of those criteria to have the diagnosis. So that's the irregular menstrual cycles, either evidence of elevated testosterone in those facial features, or the lab results of elevated testosterone, or the ultrasound results of morphists on the ovaries. Insulin resistance leads to elevated insulin levels in the body because the body is trying to overcome that resistance that cells have for insulin by producing more insulin to again overcome it and for the insulin to be effective. And higher levels of insulin trigger the ovaries to create more androgen hormones, those typically considered male hormones, the testosterone and similar hormones in that category. And so those are higher, which can affect ovulation. There are also insulin receptors in the pituitary gland, which also can affect the reproductive hormone regulation, disrupt it, and cause irregular menstrual cycles or the complete cessation of menstrual cycles. And because we are not having regular menstrual cycles, it is harder to predict when you're ovulating or you may not be ovulating at all, and that is what leads to the difficulty conceiving in peace seeing in PCOS. The reason weight is often linked to PCOS is because higher levels of insulin that we see in insulin resistance makes it harder to lose weight because insulin is a storage hormone and it tells your body to hold on to extra calories as fat cells, and so while those insulin levels are high, your body is holding on to the calories and it's very difficult to lose weight. But if somebody who has PCOS and they have excess weight and they're wanting to conceive and they are struggling, even a 2.5% weight loss can help improve reproductive function and ovulation. So we don't need to see a dramatic weight loss to see improvements in fertility potential. And oftentimes, medications like metformin, which improve insulin resistance, can lead to some of that weight loss and can improve fertility. Also, our newer medications like the GLP ones can also help along this path. But lifestyle changes can also be effective.

BMI Cutoffs, Bias, And Patient Choice

Dr. Lindsay Ogle, MD

Unfortunately, I have also seen that many fertility clinics have weight cutoffs or BMI cutoffs that they use to determine if they will move forward with treatment for patients. This is something that I was not aware of until I was seeing patients in my previous primary care clinic, and I had women come to me to help with their weight management in hopes that they will be able to undergo fertility treatments because they were unable to conceive over a year of trying. This is extremely emotionally devastating. These women already feel like their body is not working properly, and now they're being told that because they carry excess weight, they can't move forward with treatment that may allow them to carry a baby. This was really upsetting when I heard it the first time. But I think there are reasons, um, both legitimate and maybe not so legitimate, that this is the case. And of course, I'm speaking for my perspective and not those fertility clinics and their perspective. I don't know exactly what went into making these decisions, but I do think that part of it is to try to protect these women and improve their health outcomes.

Higher BMI And Pregnancy Complications

Dr. Lindsay Ogle, MD

Because we do know that if somebody is starting at a higher BMI prior to becoming pregnant, then they are at higher risk for several pregnancy complications. And that can range from gestational diabetes, gestational hypertension, high blood pressure during pregnancy, pre-eclampsia, that can lead to eclampsia, which is seizures during pregnancy. There can be help syndrome, which is liver dysfunction during pregnancy. Babies may be large for their gestational age or big babies, and that can lead to difficulty during delivery, which may lead to need for C-section or other assisted deliveries. It can increase the risk of postpartum hemorrhage or excessive bleeding after delivery, as well as increased risks of infections. Other unfortunate complications may be increased risk of blood clots, miscarriages, or stillbursts. But truly, any of these terrible complications can happen at any body weight. It is my belief that women should have a choice to become pregnant if and when they want to. And if they want to move forward with fertility treatments at a higher BMI, they should have that opportunity. I also wonder if one of the reasons that it is not offered is that it may be less likely to be successful. And these treatments are very expensive, and oftentimes insurance does not cover fertility treatments. So it's possible that these physicians and clinics are trying to protect the financial interests of the patient, especially if they are able to move forward with medical supervised weight loss that could prepare them for a better chance at achieving fertility and a healthy pregnancy. But again, I think that should really be the patient's choice. One of the maybe not so legitimate reasons is again that statistical outcome. Many of these clinics are judged based on their success rate, and it may be that they want to choose the patients who are most likely to become pregnant with their treatment options, which is unfair to other patients who may not meet that criteria. And of course, weight bias is almost ubiquitously present and is likely contributing to some of these cutoffs.

Options Before Pregnancy And Timing

Dr. Lindsay Ogle, MD

However, if you are looking for medical supervised weight loss to prepare for a pregnancy in the future, you have options and you can use medications up until pregnancy to help achieve those goals. Surgery is also an option, and I've had patients go down this path. If you do choose to have metabolic and bariatric surgery, then you want to plan for at least a year after the surgery before becoming pregnant. And that allows your body to regulate itself and allow you to be able to take in enough calories and nutrients when you are pregnant, so then you can have that healthy pregnancy.

Medication Safety And Birth Control

Dr. Lindsay Ogle, MD

I also want to highlight that any of the anti-obesity medications, none of them are recommended to be used during pregnancy or breastfeeding. And most of that is related to that making sure that baby gets the nutrition, baby and mom get the nutrition that they need. But specifically, keusemia or topiramate is associated with birth defects, and so that one is really important to make sure that you have effective birth control prior to starting and while on treatment. I have a full video about birth control options if you are curious about what might be a great option for you, which I will include a tab here for so you can easily access that. Because when women are able to choose the timing of their pregnancies, they have better health outcomes for themselves and baby. This was a lot that we covered, and we really focused on the preconception and infertility aspect. I'm gonna stop here and then make a part two that talks about metabolic health weight management after pregnancy. Thank you for listening and leaving how you can improve your metabolic health in this modern

Part Two Tease And How To Help

Dr. Lindsay Ogle, MD

world. If you found this information helpful, please share with a friend, family member, or colleague. We need to do all we can to combat the dangerous misinformation that is out there. Please subscribe and write a review. This will help others find the podcast so they may also improve their metabolic health. I look forward to our conversation next week.