The Impact of Bariatric Surgery on Obesity-Related Infertility and Pregnancy Outcomes

Project description
I have about 1800 words of a document which I will upload as an attachment. The document is a medical review article. I need to expand what I currently have to a total of 3500 words. The style of what I need is VERY SPECIFIC. MOST IMPORTANTLY I need you to upload PDF files of each reference added for me to have and nothing can be plagarized. I will be doing my own plagiarism report upon receipt and will check to ensure that each reference matches the source from the PDF. The sites that can possibly used for research are Pubmed for example. I need everything in AMA citation as I have done in the document uploaded. For now in my paper I used letters so I could keep my references in order. You can change it all to numbers for the final version. You may edit/remove parts of my paper if you dont feel they fit. New headings can be added to expand on the topic. More data can be added. The intro/conclusion can be improved/expanded and tailored to the paper as a whole. No new information should be added and cited in the conclusion.

Here are specific guildelines on this assignment:

These articles offer either a concise critical assessment of the current state of knowledge about a disease or condition encountered by physicians or a how-to approach to diagnosing and/or managing a specific problem. A Surgical Techniques might focus on a particular type of surgery, a medical problem in surgical patients (for example, atrial fibrillation in patients undergoing heart surgery), and/or practical applications of recent primary research or new guidelines. The author should avoid writing a standard academic literature review, which is systematic, comprehensive, and heavily referenced, in favor of a selective review and update that emphasizes what is practical, current, and evidence-based. Do not simply summarize and describe what the literature shows; instead, explain how what the literature reveals can be practically applied. References should be recent and should, for the most part, be drawn from peer-reviewed journals. No review articles can be used as sources. Textbook references and generic medical Web sites should be largely avoided. These articles are intended above all to be useful. Once PAs read the article, they should be able to put the information it provides immediately into practice.
-Must reference all statistics of numerical data. All medications use generic name in lowercase.
Cite recent sources. If you are citing a paper that was published more than 5 years ago, the paper should be either one of a kind (a seminal study) or the only source for the data you are citing. If neither of these is the case, you probably either do not need to cite a source at all, or you need to find a more recent one.
Epidemiologic data should be absolutely current. Please look for the most recent information available.
Cite primary sources whenever possible since these carry the most weight. The primary source is the place where the information was first published. For example, the study where the data on the effectiveness of a certain treatment were first reported is the primary source; a review article that cites this study is a secondary source and is less desirable. Check the paper you are citing carefully to make sure that the authors have not in fact taken their information from another source. If they have, that other source is probably primary.
Cite peer-reviewed journals. Peer-reviewed primary source information appears in such journals, giving them more credibility than textbooks and medical Web sites that provide generic reviews (eMedicine, Up-To-Date, etc).
All direct quotes—including those from government sources, online publications, and publications that are in the public domain—must be presented as such, with quotation marks and appropriate citations. Treating direct quotes otherwise will be considered plagiarism. In addition, manuscripts that contain plagiarism or have extensive poor paraphrasing may be rejected, even after acceptance.
Multiple references are not required in most cases. Usually, you can cite the most recent reference, the most respected reference, or the primary reference and let it go at that. (If you can’t decide which reference is most respected, there probably isn’t one. Sometimes this is obvious, however. For instance, if you are citing epidemiology figures for sexually transmitted diseases, probably the best source is MMWR from the CDC.)
Do not reference statements that most clinicians would consider common knowledge. Many citations from textbooks fall into this category.
Do reference all statements that cite data or studies. If your sentence has numbers, the source of the numbers must be referenced.
Do reference statements that your readers may find controversial.
Do reference anything that is someone else’s thoughts, data, or conclusions


There has been a significant increase in prevalence of obesity in the United States. More than one-third of women in the United States are obese and fall under the category of having a body mass index (BMI) of thirty or more.A Obesity is very difficult to manage. Diet, exercise and behavioral modifications are ideal but weight regain is common. In 1991 the NIH conference on gastrointestinal surgery for obesity recommended bariatric surgery as the only effective treatment for those with BMI >40 as well as those over 35 with significant comorbidities.B Women of reproductive age account for 49% of patients undergoing bariatric surgery. Obese women are more likely to face infertility than women with a normal BMI. Although it has been shown that bariatric surgery is a good treatment for obesity, the effect on fertility and pregnancy outcomes has been questioned. Evidence is beginning to mount that some there are improvements in these areas after weight loss induced by bariatric surgery.
Many women are not at an ideal weight and nutritional status before attempting to conceive. Women need a certain minimal amount of body fat to be able to reproduce, but fat in excess has been linked to oligoannovulation, annovulation, polycystic ovarian syndrome (PCOS), infertility and poor response to assisted fertility treatments.C Many obese women are hyperinsulemic and have endocrine reports characteristic of PCOS, one of the leading causes of female infertility.D Insulin and luteinizing hormones are increased, the follicle-stimulating hormone and luteinizing hormone ratio is abnormal and the midluteal progesterone is low. These hormone profiles demonstrate annovulation.
Annovulation is a major problem in obese women but it has been shown that even obese women with regular cycles have an increased time to achieve pregnancy than women of normal weight.E Obese women exhibit abnormal LH pulsatility, which may affect ovarian follicular steroid development.F This may lead to poor oocyte quality and a change in endometrial development by affecting the function of the corpus luteum in the luteal phase. It has also been shown that a high-fat diet is associated with lipid accumulation in oocytes, which leads to poorer oocyte quality.G
Obesity increases morbidity for both the mother and fetus and is linked to a variety of adverse pregnancy outcomes. Women that are obese and pregnant are at increased risk of pregnancy induced hypertension, gestational diabetes, labor induction, cesarean delivery, postpartum hemorrhage, post-operative infections and thromboembolic events.H-M Obesity also increases the rate of spontaneous abortions.N Miscarriages in obese women can be caused by impaired progesterone release due to low insulin resistance and this can inhibit normal corpus luteum function. An obese mother places the fetus at risk of stillbirth, macrosomia, birth trauma, and birth defects and childhood obesity.M
There are several different types of bariatric surgery performed worldwide in open procedures and laparoscopically. The most common restrictive procedure is adjustable gastric banding, and the most common restrictive and malabsorptive procedure is the Roux-en-Y gastric bypass (RYGB). In restrictive procedures weight loss is predominantly due to the restriction of nutrient intake. Restrictive and malabsorptive procedures restrict nutrient intake as well but also create a physiological condition of malabsorption.
A laproscopic adjustable gastric band, commonly called a Lap-Band is an adjustable silicone device that is placed around the top of the stomach. The band squeezes to form a pouch and after banding the stomach can hold approximately one ounce of food. A silicone tube attaches the band to a device under the skin and by injecting saline the band can be adjusted to control weight loss. Gastric banding is considered the least invasive and the only reversible weight loss surgery. The band adjustability is an appealing aspect that allows room for adaptation to the nutritional requirements necessary for a healthy pregnancy. Average weight loss at two years is 50% of excess body weight or 25% of BMI. Gastric banding is generally a very safe operative procedure but the revision rates due to a band that has moved or broken is considerable. Long-term complications of the gastric band include vomiting, gastric prolapse, stomal obstruction, esophageal and gastric pouch dilatation, gastric erosion and necrosis, and access port problems.O
RYGB combines food restriction with a degree of malabsorption by decreasing the length of the intestinal tract. The procedure starts with the creation of a gastric pouch that is separated from the remaining stomach. The pouch empties directly into the distal jejunum through a gastrojejunostomy. Bypassing the remaining stomach, the duodenum and a portion of the proximal jejunum reduces the absorptive area. This procedure can be performed laparoscopically or by an open technique. Weight loss averages at 65-70% of excess body weight or 35% BMI one to two years after the surgery. RYGB can be complicated due to stomal steosis, marginal ulcers, staple lie disruption, internal hernias and nutrient deficiencies including folate, calcium and vitamin B12.P Dumping syndrome is also a major concern. It occurs when food high in simple sugars can cause a sudden fluid shift that can lead to watery diarrhea, abdominal pain and cramping, and hypotensive symptoms. At 24 weeks when women are screened for diabetes with the 50 gram glucose test, an alternative screening method should be used such as a glycosylated hemoglobin level or a fasting and 2-hour postprandial blood sugar.
Following bariatric surgery there is often resolution of conditions that leads to improved fertility. Weight loss after bariatric surgery improves the hormonal changes related to polycystic ovary syndrome (PCOS) reducing anovulation and increasing fertility.Q In a study of 142 women with infertility related to their weight, 69 became pregnant after having one of these procedures in the following 2.5 years and all of the pregnancies proceeded without complications and ended in live births.R There was no significant difference in the pregnancy rate among patients that had gastric lap bands or RYGB. The patients that lost more than 5 BMI were more successful in getting pregnant.
Study results have shown that pregnancy after bariatric surgery is safe and that the overall outcomes are similar to women that are not obeseS. The rates of morbidities including macrosomia, pregnancy-induced hypertension, preeclampsia, and gestational diabetes are lower in patients who have undergone bariatric surgery than those of obese women and are similar to those of nonobese women in the general population.T Studies have also shown improvements in neonatal outcomes. Obese women are more likely to experience intrauterine demise and early neonatal death.M Bariatric surgery has been shown to lead to lower birthweightM. While this results in a lower risk for large for gestational age infants it also puts the infant at a higher risk of small for gestational age infants. However, it has been demonstrated that these numbers are similar to the general population levels.
A conventional weight loss program including diet modification, exercise, and therapy should have been attempted. When the conventional attempts fail then bariatric surgery is the most successful method of weight loss. Bariatric surgery provides lasting and significant reductions in body weight (>60% long-term excess weight loss), correction of many comorbidities, and improved survival.U It increases fertility, reduces maternal and neonatal complications compared to that of obese women. Evidence has demonstrated that women are able to tolerate pregnancy and have minimal complications after bariatric surgery procedures.
Although bariatric surgery decreases many adverse obstetric outcomes it is important that the patient and provider be educated about possible complications. An informed patient is able to minimize risks and improve outcomes. A two-year interval is recommended before attempting to get pregnant.V Contraception is important during this period because this is the period when maternal nutritional status is not optimal and there is a period of very rapid weight loss. Pregnancy during this interval will also affect the amount of weight a person can lose from the surgery. By the time the rapid weight loss has passed and the patient is stabilized on supplementation the pregnancy and delivery is less risky to the mother and fetus.
The patient’s nutritional status should be closely monitored following the procedure. In particular RYGB patients are at risk of nutritional deficiencies because of the malabsorptive mechanism. Anemia and changes in hemoglobin levels are complications of bariatric surgery. Iron is absorbed in the duodenum that is bypassed in RYGB procedures. Iron deficiency is most likely to be of clinical significance in menstruating women. Vitamin B12 absorption requires stomach acid to dissociate it from foods, and R and intrinsic factors secreted by the gastric mucosa to permit its absorption in the distal ileum. This can be disrupted by gastric bypass surgery resulting in B12 deficiency. There may also be deficiencies of folic acid and calcium. It is recommended that women post-bariatric surgery be prescribed lifetime replacement therapy that includes ferrous sulfate, 500 to 1000 mg B12 daily, and 1200 mg of oral calcium citrate daily. All reproductive-age women should receive at least 400 mg of folic acid daily but it is unclear whether gastric bypass patients require greater folic acid doses to achieve the same protective effects as the general population. With folic acid supplementation it appears that post-op women are not at a high risk for fetuses with neural tube defects.W It is important for all pregnant women that have had a weight loss surgery to be screened through second trimester maternal serum alpha-fetoprotein and ultrasound. Protein needs will go up to about 60 grams per day. A nutritionist in post-op clinics can monitor most post-bariatric surgery patients. Close evaluation by the bariatric surgeon to diagnose nutritional deficiencies or wound complications plays an important role in achieving positive outcomes during pregnancy. If deficiencies are present they should be corrected preconceptionally.

In conclusion, evidence suggests pregnancy after bariatric surgery is safe and has good outcomes. Rates of many adverse fetal and maternal outcomes are decreased in women who become pregnant after having had bariatric surgery compared with pregnant women who are obese. Efforts should be made to educate and counsel pregnant women about weight gain and healthy lifestyle during pregnancy. Both non-surgical and surgical weight loss can improve fertility and outcomes. Lifestyle modifications might be a better approach for an overweight individual. However for an obese patient that has attempted lifestyle modifications in the past or for a patient older than thirty-five it may not be the best option. Preconception interventions may offer more potential for an impact on subsequent reproductive and pregnancy outcomes.
Bariatric surgery provides lasting and significant reductions in body weight, correction of many comorbidities, and improved survival.
Bariatric surgery improves obesity-related PCOS, annovulation and irregular menses.
Rates of negative outcomes are believed to be lower in women who become pregnant after bariatric surgery compared with pregnant women who are obese.
It is recommended that a woman wait 2 years post bariatric surgery before attempting to get pregnant to maximize weight loss and minimize negative outcomes.

REFERENCES (Note-My references are in order but they are alphabetized for now because it will help me organize my paper later. You approved this)
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B: Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(2 Suppl):615S-619S.
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D: Eid GM, Cottam DR, Velcu LM, et al. Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2005;1(2):77-80.
E: Wise LA, Rothman KJ, Mikkelsen EM, Sørensen HT, Riis A, Hatch EE. An internet-based prospective study of body size and time-to-pregnancy. Hum Reprod. 2010;25(1):253-64.
F: Jain A, Polotsky AJ, Rochester D, et al. Pulsatile luteinizing hormone amplitude and progesterone metabolite excretion are reduced in obese women. J Clin Endocrinol Metab. 2007;92(7):2468-73.
G: Jungheim ES, Macones GA, Odem RR, et al. Associations between free fatty acids, cumulus oocyte complex morphology and ovarian function during in vitro fertilization. Fertil Steril. 2011;95(6):1970-4.
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