The first time a doctor told Gina Balzano that she was too fat to have a baby was in 2013. She was 32, weighed 317 pounds and had been trying to get pregnant since soon after she and her husband, Nick, married in 2010. Balzano — whom I have known since high school — lives in Waltham, Mass., and works in special education. She’s the kind of person whom others often go to with their problems, but her own predicament, after three years of negative pregnancy tests, had left her feeling overwhelmed. “I’ve always had horrible, heavy, painful periods, so I thought something was wrong,” she says. “But I didn’t know enough to know what to worry about.” She told herself it was time to find out.
The couple braced themselves to hear some painful truths about fertility treatments. On average, a single cycle of in vitro fertilization costs between $10,000 and $15,000 — and that doesn’t include medications, follow-up visits or the expenses of prenatal care and childbirth. Just 10 states have a law requiring insurance companies to pay for I.V.F., and that coverage varies. The couple also knew that the experience of undergoing fertility treatments would be emotionally draining. And Balzano expected to hear about her size. She didn’t have any of the health conditions often associated with a high body weight; her blood pressure and cholesterol levels were normal, and she didn’t have diabetes or other chronic ailments. Nevertheless, it was the rare doctor who didn’t raise the subject. “When you’re fat, you get used to people assuming weight loss will fix everything wrong in your life,” Balzano says.
Conception requires four events to unfold perfectly: An ovary must release an egg; a sperm must reach and fertilize that egg; the fertilized egg must then travel through a woman’s fallopian tube and into her uterus; and finally, it must remain in the uterus, anchored in place, as it grows into a healthy fetus. Infertility results when something goes amiss during any of these steps. Reproductive endocrinologists — ob-gyns who have undergone training in the diagnosis and treatment of infertility — can facilitate the process by stimulating ovulation with drugs. If that doesn’t work, they can artificially inseminate patients or they can remove both sperm and egg, produce an embryo in a lab (the “in vitro” part of I.V.F.) and implant it back into a woman’s uterus.
During their first appointment at a large Boston fertility clinic, Balzano says, the reproductive endocrinologist was cold and unsmiling as she reviewed the couple’s medical history. Her first question was whether Balzano was ovulating. Irregular ovulation — when a woman’s ovaries fail to release eggs during the appropriate phase of the menstrual cycle — is one of the most common causes of infertility. Balzano wasn’t sure; it was difficult to track her erratic cycles at home. The specialist asked no follow-up questions. “It’s your weight,” she said.
The doctor, Balzano was convinced, had reduced her to a single characteristic. “I was like, ‘Wait, wait, wait, there might be something else wrong,’ ” she recalls. “My mom isn’t morbidly obese, but she only had one pregnancy, and she was never on birth control. Couldn’t there be something else going on here?” Nick was furious. “I know plenty of larger women who have been pregnant without any problems,” he says. “This didn’t make any sense.” But they both say the doctor, who declined my interview request on the basis of patient confidentiality, was adamant. “I would never give you I.V.F.,” they recall her saying. “You’re too fat. Have more sex and lose the weight.”
Although Balzano didn’t know it when she made the appointment, the clinic that would have performed the procedure had a policy against providing I.V.F. to patients with a body mass index above 45; Gina’s was 51.2. In that decision, it followed much of the fertility industry, including half of the 20 largest clinics in the United States, according to FertilityIQ, an online clearinghouse of information on fertility providers nationwide. At some clinics, the cutoff for treatment is a B.M.I. of 50, often classified as “extreme” or “severe” obesity (roughly 300 pounds for a 5-foot-5 woman). At others, it’s much lower. Chelsea Ritchie, now the mother of twins in Ham Lake, Minn., got a call from a nurse the day before her initial appointment with a fertility doctor in 2011. “She said, ‘The doctor only sees patients with a B.M.I. under 30, so you’ll need to lose 22 pounds,’ ” Ritchie recalls. (The doctor told me that his cutoff for seeing patients is actually a B.M.I. of 35, though he won’t do I.V.F. unless they’re under 30. Ritchie subsequently conceived her twins after going to a different clinic.) B.M.I. doesn’t factor in gender, age or muscle mass, all of which influence body composition and health. But the World Health Organization adopted the B.M.I. scale as an official classification in 1995, and it has since become medicine’s standard metric for categorizing patients by weight. A B.M.I. of 30 or above is classified as “obese,” the word still used by doctors, researchers and the media, although surveys of larger patients show that most consider it derogatory; many now reclaim the once-offensive “fat.”
CreditElinor Carucci for The New York Times
The belief that a high body weight causes infertility, and its corollary — that weight loss is necessary to resolve infertility — underpin almost every interaction a heavy woman will have with the reproductive health care industry. Yet the specialty’s two governing organizations, the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology, have not established any guidelines on whether treatment should be declined on the basis of weight. And as the percentage of American women categorized as obese has grown to 41.1 percent in 2016 from 25.4 in 1994, some doctors are pushing back against the notion that weight loss should ever be, in effect, a prerequisite for motherhood. “I think we’ve been overexaggerating the benefits of preconception weight loss,” says Dr. Richard S. Legro, a professor of public health services and chair of obstetrics and gynecology at Penn State University. In fact, a fixation on weight may be leading health care astray. “Many providers see a larger woman and say things like, ‘Don’t eat cheeseburgers,’ even though she’s a vegetarian,” says Sharon Bernecki DeJoy, the director of public health at West Chester University who studies maternity care in the United States. “There’s a lack of recognition of evidence that shows you can be healthy and still have a, quote-unquote, unhealthy B.M.I.” And a lack of recognition that when a heavy person does get sick, it might not be because of weight.
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When I knew Balzano back in high school, she was a quirky, glitter-covered theater kid who wrote plays about fairy tales. We lost touch for years after graduation, until our early 30s, when we began to run into each other once a year at the New York State Sheep and Wool Festival. The first few times I saw her, she was heavy, just as she had been when we were kids. Then suddenly, in 2016, she was much less so. A few weeks later I learned why. “I cut off 70 percent of my stomach so I could have the chance to be treated for infertility,” she wrote in an email.
At the festival, Balzano stocked up on yarn to make tiny sweaters and hats for friends’ babies. During our interviews, we often veered off course while she sorted through my struggles with potty training or tantrum management. Even though I was already a mother and she wasn’t, Balzano had more experience in navigating such milestones through her work as a special-ed teacher. In so many ways, Balzano had been maternal as long as I’ve known her. But motherhood is both an emotional state and an embodied one, and a doctor had said Balzano’s body wasn’t right for the job. In this respect, B.M.I. cutoffs become more than tools to promote patient health. They also become a way in which doctors might be settling the question: Which women’s bodies are worthy of carrying a child?
In 1952, a pair of Boston physicians published a study in The New England Journal of Medicine titled “The Relation of Obesity to Menstrual Disturbances.” The authors surveyed 100 women between the ages of 16 and 40 who had been given diagnoses of menstrual disorders and compared their weights with a control group with no reproductive health issues. Forty-three percent of the patients with menstrual disorders weighed 20 percent or more than their “ideal weight,” compared with just 13 percent of the control subjects. Their findings, the authors concluded, gave “factual proof to the clinical impression of the association of obesity and menstrual disturbances.”
Ever since, the idea that a high body mass contributes to infertility has been an accepted premise. “There’s no question — it’s been validated in a number of studies,” says Alan Penzias, a former surgical director for Boston I.V.F., a national chain of fertility clinics, and an associate professor of reproductive biology at Harvard Medical School. In 2007, researchers combed through data collected on 7,327 pregnancies from 1959 to 1965 and found that it took heavier women a median of one to two months longer to conceive, compared with women with B.M.I.s in the “normal weight” range. A 2015 study of 1,602 Italian women undergoing I.V.F. found that the bigger women were just as likely to get pregnant, but were more likely to miscarry. All in all, the research shows a correlating decline in successful pregnancy rates as B.M.I. rises.
Penzias’s clinic employs a tiered cutoff system and begins counseling patients about the importance of weight loss when their B.M.I. is 30, though it will still treat women whose B.M.I.s are higher, up to 45. Doctors say prescribing diet and exercise seems to be a logical place to start before moving up the treatment ladder to expensive drugs, blood work, imaging tests and, if a patient’s case warrants I.V.F., at least one minor operation. And whatever stalls ovulation, losing weight often appears to restart it. This was documented by a 1995 study published in the journal Human Reproduction, in which 13 overweight women who were not ovulating were assigned to a weight-loss program. Six months later, they had lost an average of 13.8 pounds, and all but one of them had resumed ovulating. Eleven became pregnant.
To critics of B.M.I. exclusions, the potential benefits of weight loss are outstripped by how difficult it is for patients to sustain. Studies on dieting show that people lose, at best, 5 to 10 percent of their body weight, and most will regain that within five years. “If a patient starts with a B.M.I. of 50 and now she’s at 45, does that make much difference?” Legro asks. In the meanwhile, he points out, the patient has lost crucial time. In 2017, when Swedish researchers put 160 high-weight women on a liquid diet for 12 weeks before starting I.V.F., resulting in a median loss of 20 pounds, they were no more likely to conceive than a control group.
Some aspects of fertility treatment can be more complicated for larger patients. Retrieving eggs for I.V.F. requires that a patient be sedated while a doctor uses an ultrasound probe to identify and extract eggs. “With an obese patient, I sometimes have to go in through her abdomen instead of her vagina, and I might not be able to retrieve as many eggs,” says Rachel Ashby, a reproductive endocrinologist at Brigham and Women’s Hospital in Boston. This lowers the patient’s odds of success.
But to Linda Bacon, an associate nutritionist at the University of California, Davis, and author of the book “Health at Every Size,” trying to assess the odds is beside the point, because doctors’ jobs are to treat the patient in front of them. “Even if it is causative (and it may be), people still deserve the right to good health care,” she emailed me to say. “Health care needs to take care of our lived bodies, regardless of size.”
Balzano believes she would have been annoyed, but far less devastated, if the doctor she saw had explained that their clinic wasn’t set up to handle her case. “That would have felt kinder and more ethical, but the implication was, ‘It’s irresponsible of you to want to have a baby at this size,’ ” she says. Jen McLellan, an activist and childbirth educator who writes a blog called Plus Size Birth, gets similar stories from her 172,000 Facebook followers: “I have heard from women of size who have been told to abort their babies.”
This is where the conversation about risk and responsibility turns. It’s no longer about what a woman is willing to inflict on herself — it’s about whether she might jeopardize her not-yet-conceived offspring. “We police women over their fitness to become a mother,” DeJoy says. “ ‘Are you drinking, are you smoking, do you have enough money and a partner?’ And if you’re a larger woman, it’s: ‘You don’t know how to eat and exercise. You’ll raise that kid to be fat.’ ”
So just how dangerous is it for a larger woman to have a baby? “The majority of the obstetricians we work with have said, ‘We support you standing up to this,’ ” says Dr. Bill Meyer, a founder of Carolina Conceptions, a fertility clinic in Raleigh, N.C. His clinic does not perform I.V.F. on patients with B.M.I.s above 37.5, and it does not prescribe fertility-stimulating medications to patients above 40. He points to how rates of prenatal conditions like gestational diabetes and pre-eclampsia, as well as miscarriages and stillbirths, all increase as a patient’s B.M.I. climbs. Larger patients are at greater risk for airway obstruction and more likely to require intubation. “This has nothing to do with the fertility side,” Penzias says. “If they developed a complication under anesthesia, we’d have to transport them to a hospital.” In total, large women undergoing in vitro fertilization are 10 percent less likely to carry a pregnancy to full-term than women with lower B.M.I.s, according to a 2012 analysis of 27 studies.
“You can try to explain as much as possible to patients,” Meyer says. “But sometimes you say, ‘This is the best I can do with informed consent, and I’m just going to have to put my foot down.’ ”
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“Informed consent” is a process doctors use to educate their patients about the potential risks and benefits of treatments so that patients can make reasoned decisions about their care. It’s supposed to foster a partnership between patient and doctor, though doctors are allowed to initiate treatment without informed consent in an emergency, according to the American Medical Association’s code of ethics. The code also states that the doctor’s obligation to respect patient autonomy “does not mean that patients should receive specific interventions simply because they (or their surrogates) request them.” The A.M.A. then lists situations where a doctor is allowed to decline treatment, including when the physician “lacks the resources to provide safe, competent or respectful care for the individual.” But the code also notes that physicians are not allowed to turn down patients “on the basis of race, gender, sexual orientation or gender identity, or other personal or social characteristics that are not clinically relevant to the individual’s care.”
“I wouldn’t go so far as to say we understand why maternal weight is associated with” negative outcomes, says Dr. Chloe Zera, a maternal fetal medicine specialist who cares for patients during high-risk pregnancies at Beth Israel Deaconess Medical Center in Boston. “Obesity can require special care, but a majority of women with B.M.I. over 30 don’t have a complicated pregnancy and do have healthy babies.” Even when the risk for complications increases, the frequency of such events remains low. When Stanford University researchers analyzed more than 1.1 million birth records in California, they found the overall prevalence of stillbirths to be five per 1,000 deliveries. Among women with a B.M.I. above 30, the rate ranged from seven to 10 stillbirths per 1,000 deliveries — as much as a twofold increase, but still a rare event. In comparison, a 2008 evidence review of the relationship between maternal age and stillbirth risk found that thinner women over 35 were also almost twice as likely to have a stillborn delivery compared with their younger counterparts. And the Stanford study could not establish a causal relationship. Stillbirths may correlate with B.M.I. because it may be harder for doctors to detect fetal complications in bigger bodies as a result of technological limitations. Larger women may also receive less careful prenatal care. When researchers analyzed audio recordings of prenatal appointments between 22 providers and 117 pregnant women, they found that providers treating patients with higher B.M.I.s asked them fewer questions about their lifestyle habits and shared less information, according to data published in 2017 in the journal Patient Education and Counseling.
All that can be said with any confidence, according to Legro, at Penn State, is that “there is no B.M.I. cut-point above which it is absolutely unsafe to have a pregnancy.” And weight loss does not ensure a safer pregnancy. When Scandinavian researchers linked data on bariatric surgery patients with infant health outcomes, they found that women who went through such procedures were more likely to have preterm deliveries and babies who were small for their gestational age than mothers of any weight who had not undergone the surgery. “Patients are told to lose weight to have a healthy baby,” Legro says. “But it’s possible that by doing so, you may be at higher risk for complications than you were before.”
One day when Balzano was 19, she walked out of a gas station and a man in a passing car yelled, “Fat bastard!” “That was the moment when I realized my body was this problem for the entire world,” she recalls. Studies dating back to the 1960s have shown that when children are presented with pictures of other kids with various body types, they rate the fat body as the one they like the least. In 2013, Yale University researchers asked 74 study participants to read a published news article about Canadian physicians who wanted to deny fertility treatments to women with obese B.M.I.s. One-third of the study subjects read the article alongside an image of a large couple eating junk food; the rest saw the same couple sitting on a bench holding hands or no accompanying image. When researchers surveyed the readers, those who had seen the junk food were more likely than the rest to support the doctors’ decision to deny fertility treatment to such patients.
Good health is often equated with being a disciplined person, a responsible citizen, a worthier mother. And stereotypes — like the assumption that all fat people are gluttonous and willfully large — can shape our understanding of a person’s health and morality. “We all have cultural biases, and health care providers are people, too,” DeJoy says. Studies have indicated that doctors across all specialties are more likely to consider an overweight patient uncooperative, less compliant and even less intelligent than a thinner counterpart. An Australian study on prenatal health care found that doctors expressed less sympathy and approval for their larger pregnant patients. “Until I found my doula and midwife, I had never had a medical professional touch my body with compassion,” says McLellan, who identifies as a fat woman and had a healthy pregnancy. “That feels normal to a person of size.”
Weight-science researchers are aware of how that lack of compassion can have health consequences. The kind of stigma that women like McLellan and Balzano encounter throughout their lives puts fat people at higher risk for depression, anxiety and suicidal thoughts. They also have higher blood pressure and higher levels of stress hormones. And many researchers documenting these risks control for B.M.I. when they collect their data. “This tells us that it’s stigma, rather than one’s weight per se, that contributes to these adverse health outcomes,” says Rebecca Puhl, an author of the 2013 Yale study and the deputy director for the Rudd Center for Food Policy and Obesity at the University of Connecticut. “This evidence also challenges the notion that stigma will motivate people to lose weight.”
Balzano’s husband, Nick, was eager to get a second opinion right away, but it was two years before she could bring herself to see another doctor. “I couldn’t take another conversation like that,” she says. “I felt like this waste of a person.” In private, she sobbed whenever friends announced a pregnancy. Then one friend, who was also heavy, told Balzano that she’d had a good experience at Boston I.V.F. So they made an appointment. When they arrived, a concierge greeted the couple as soon as they walked in. Balzano responded by starting to cry. The place felt too slick and fancy. She was sure she would once again be deemed unfit.
The doctor listened to Balzano’s story and said she understood how emotional the situation was. But she did want Balzano to lose weight. In the meantime, she was willing to prescribe letrozole, a medication used to promote ovulation, or, if that failed, a course of intrauterine insemination. I.U.I. is a low-risk procedure done without sedation in the doctor’s office; sperm is placed inside the patient’s uterus during ovulation in order to facilitate fertilization. “But it didn’t seem like she was all that interested in that,” Nick says. “The impression I got was that nobody thinks anything besides I.V.F. will work, and they wouldn’t give Gina I.V.F.” The doctor told me she recalls that she was “certainly willing to go ahead with medication and insemination,” but says she counseled Balzano to see a maternal fetal medicine specialist to discuss the potential impact of her weight on a pregnancy. Balzano declined the letrozole: “Essentially, she was saying the same thing as the first doctor — that nothing would change until I fixed my weight.”
Even when they do receive fertility treatment, women in larger bodies may encounter stigma in how a reproductive endocrinologist approaches their care. Stephanie Robben, 44, and the mother of twin boys in St. Louis, says her doctor didn’t mention her weight — then 247 pounds — until the first I.V.F. cycle failed. Then he outlined a daily plan for her: Drink a gallon of water, eat fewer than 900 calories and exercise for an hour. If Robben followed these directions correctly, the doctor expected her to lose 50 pounds in a month, much more than the monthly rate of four to eight pounds considered safe by major health organizations. Such extreme dieting can lead to dangerous electrolyte imbalances, dehydration — and irregular menstruation. “Rapid weight loss achieved by crash diets or excessive exercise is detrimental to reproductive outcomes during fertility treatments,” British researchers concluded in a 2010 issue of the Journal of Human Reproductive Sciences.
“By the end of the second day, I couldn’t even formulate a sentence,” Robben says. “All I could think about was a piece of chicken breast in my fridge.” By the end of the month, she had lost 20 pounds. The next round of I.V.F. failed as well. (Her doctor declined to comment for this article.) Robben later conceived her twins after seeing a different doctor, and without losing additional weight.
Meyer, of Carolina Conceptions, objects to the idea that weight stigma, not health concern, motivates clinics to require weight loss. “There are tears in these conversations,” he acknowledges. “But most of the time, I feel pretty good after sitting down with these patients. I think we almost overcompensate so we’re not judged as being biased toward weight.” When Meyer’s clinic turns away a patient based on B.M.I., it offers a referral to a local weight-loss program. He estimates that around 60 percent of those women follow through. “The patients who then come back to us [for treatment] are very thankful that they’ve made those changes,” he says. “Or their husband will say, ‘Thank you for talking to her about that.’ ”
Meyer admits that he doesn’t know what happens to the patients who don’t return. But those are the patients whom Rachel Ashby, at Boston’s Brigham and Women’s Hospital, worries about most. “There probably is a subset of women out there who stop seeking treatment because they are aware that they may feel marginalized in the doctor’s office,” she says. “They feel this sense of ‘I can’t pursue this anymore,’ and just live quietly with infertility.’ ”
Balzano didn’t want to live quietly anymore. After the appointment, she says, “I reconciled myself to having weight-loss surgery pretty much that moment.” Bariatric surgery patients can lose 25 to 35 percent of their original weight, and keep it off longer than dieters do — making it the most enduring form of weight loss available. But many patients develop vitamin deficiencies because of their limited diets. And female patients are told it’s not safe to become pregnant for at least one year. The operation would cause Balzano to lose yet more time.
To Balzano’s doctors, this decision was a rational attempt to take control of her health and fertility. The couple see it as her required sacrifice. “We couldn’t achieve this goal because people didn’t like the way she looked,” says Nick, who was anxious about the surgery’s risks. Balzano recalls: “I was at the point where I would cut off a limb to have a baby. So fine, why not my stomach?” Balzano had her operation in December 2015. When we talked a year later, she told me how she had survived the first months consuming only liquids, and then, tiny portions of fat-free refried beans. Her B.M.I. was down to 32.1. Balzano got Ashby’s name from her bariatric surgeon and made an appointment for January 2017.
Balzano was now 37. However many high-quality eggs she’d had when she began trying to conceive at 30, there were thousands fewer now. “We have to get started,” Ashby told Balzano. “In fact, I would have begun treatment when you were at your highest weight.” Nick’s eyes bulged. “So we spent a ton of money and a ton of pain and we could have done this five years ago?” he asked. When we spoke the next day, Balzano was trying to remain calm about the revelation. “Look, it’s done; I’m in a good place,” she said of her surgery. “But I can understand why someone in my position might be incandescent with rage right now.”
Ashby told me that she would have treated Balzano at 340 pounds because she was in good health then. She doesn’t think weight was the primary cause of Balzano’s infertility, because the couple remained unable to conceive even after her surgical weight loss. “Patients often ask me, ‘If I were a normal B.M.I., would I be fertile?’ Often, that answer is no,” Ashby says. “And absent some grave risk to a patient, it’s paternalistic to say to a 35-year-old woman, ‘Go lose a hundred pounds.’ ”
Massachusetts health care law requires couples to try three rounds of intrauterine insemination before insurance will cover the cost of I.V.F. The first attempt failed, as everyone expected, but in November 2017, I heard from Balzano: “Just got a positive pregnancy test.” The second round of I.U.I. had worked. Logan Anthony was born on June 5, 2018, five weeks early but healthy. “I’m enjoying all the little moments daily, even the diapers,” Balzano told me, shortly after Logan turned 6 months old. “It’s still sinking in that I’m someone’s mom.”