Dr. Gail Altschuler MD

Hi. Vyvance is a good choice as it has effect for both ADHD and can help with binge eating. One issue might be cost, as there is no generic available. The specific dose would be worked out with your provider. If you decide to try it, go to Vyvance.com to get starter and discount coupons. Another option might be phentermine, if you have a doc who is familiar with using it. Less expensive, less addictive, good appetite control and many people with ADHD also enjoy improvement in their symptoms. Let me know if you have more questions as you go along. All the Best. Dr. Gail

Hi. Sounds like a great decision. The band is one of many tools available to help you manage your weight. If you are comfortable and satisfied, then there's no need to adjust at this time. If you feel your appetite increasing, are less satisfied between meals, and your weight loss slows down, you can reconsider a fill at any time. Wishing you all the best.

Hi. Sounds like a great decision. The band is one of many tools available to help you manage your weight. If you are comfortable and satisfied, then there's no need to adjust at this time. If you feel your appetite increasing, are less satisfied between meals, and your weight loss slows down, you can reconsider a fill at any time. Wishing you all the best.

It's not typical to have diarrhea after a fill. Stick with warm liquids for a day or 2 (whatever your doc suggested) and avoid dairy until it clears. Let him know if the diarrhea persists. Enjoy the changes that are coming. Best. Dr. Gail

Hi Journey2befit. It's unlikely that you've done any harm. It takes practice and commitment to make life changes, not perfection. Share your experience and concerns with your doctor when you see him tomorrow. I"m sure your doctor will be pleased to see you doing well and hopefully you'll leave feeling reassured. Best of luck and let us know how it goes.

So many great responses, especially those reminding you that it may take a bit to find the best approach for you and for your body to kick into weight loss gear. A couple of suggestions. 1. Try planning your meals primarily solid Protein and vegetables. Eat slowly and chew your food really well. Enjoy Water a half hour before and an hour after meals, but eat your meals pretty dry. The sleeve is a restrictive surgery and liquids may not be giving you the sensation of fullness you're looking for to feel satisfied. 2. Aim for 1000 calories of carefully planned meals, protein and vegetables, only small amounts of complex carbs or fruit to start. Avoid liquid calories unless you can only manage a shake in a hurry. 3. Physical activity is really healthy and almost essential for maintenance, but it has a limited effect for weight loss. The focus should be on the food you eat. It's not necessary to exercise 3 hours a day or push yourself to the limit. If you do that to the extreme, you're body may think you're starving and go into high gear to hold on to your weight. 4. Trust your body and the process. You'll learn what works for you. Sometimes it just takes a bit longer to figure it out. Take care. Dr. Gail

It can take one or more fills to have good restriction. You might feel restriction right away, you may not notice much change. Each band has a recommended range of Fluid that you can add for the first and subsequent fills. It also depends on how you feel. It's not an exact science so you have to work with your surgeon or whoever is doing the fills to find the right amount. Be patient, ask questions, follow your post op instructions. It's an exciting time. Best of luck. Dr. Gail

Hi. I'm assuming that the swelling is not red, hot, tender and/or getting larger. If it is, you should call your surgeon in the morning and get seen. If the swelling is in the upper center, it might be a hernia of the abdominal wall. Again, if you have nausea or increased pain, call your surgeon in the morning. If the swelling is stable and not too uncomfortable, then hopefully you'll get a good explanation and a plan when you're seen on Thursday. Best of luck.

So nice to hear of your success. Stay committed and keep having fun.

The band is an incredible weight management tool. It is restrictive, meaning that the benefit largely comes from it's ability to restrict the amount of food needed to feel satisfied. When properly adjusted, you will typically feel full with a smaller volume of food and then not be hungry between meals. To get the best result, it works to follow the eating guidelines, eating Protein first and chewing your food really well, then vegetables, drinking Water 30 minutes before and an hour after and eating your meals pretty dry. Avoid liquids that have calories. If your meals are getting larger and your hungry between meals, your weight loss will probably slow down. This is the time to get an adjustment. Good luck. It's a great tool.

Bariatric surgery may not typically be considered when discussing planning pregnancy, but in severely obese women, bariatric surgery can greatly improve the odds of conceiving, either naturally or assisted. Weight loss can help restore a healthy hormonal balance in both overweight and obese men and women. It can create an environment where the odds of becoming pregnant naturally, as well as the success of infertility treatments, are optimized. Physicians understand the negative health consequences of being overweight, including a higher incidence of heart disease, diabetes, cancer and back pain, to name a few. Another consequence is the effect of weight on fertility, fertility treatment and pregnancy, as well as the ongoing health of mother and child. Infertility, for example, is significantly higher in women who are overweight, and it increases as their BMI rises.1,2 Attempts to become pregnant through escalating interventions become ever more physically, financially and emotionally costly. These costs become statistically significant, and they are more pronounced at higher BMIs, especially if there is central obesity.2 Obesity brings multiple physiologic changes that affect fertility and pregnancy, including changes in estrogen, testosterone and LH/FSH ratios. Leptin, insulin and multiple inflammatory cytokines are also affected. These contribute to abnormalities of ovulation; abnormal egg, embryo and endometrial development; unsuccessful implantation; and failure to maintain a viable pregnancy. Male fertility is also negatively affected by obesity. The prevalence of male infertility is increasing, as evidenced by decreasing sperm counts throughout the world. It has been estimated that sperm counts have fallen by as much as 1.5% each year in the United States, a finding also noted in other Western nations.3 Health, volume and motility of sperm are all affected. Although the cause is uncertain, proposed explanations include increasing obesity and exposure to environmental toxins. Women who are underweight (BMI <19) often have difficulty conceiving as well. After ruling out underlying illness or eating disorders, it is generally easier for this population to reach an ideal weight and improve their odds for conception. For all groups, an ideal body weight results in the best outcome for fertility and fertility therapy, as well as maternal and fetal health. Other potential complications that overweight and obese women face around pregnancy and birth include:4,5 Irregular periods Difficulty or inability to conceive More complicated IVF cycles Lower IVF success and greater complications of pregnancy for those who do conceive Higher frequency of early pregnancy loss Greater anesthesia and surgical complications if surgery is required Greater frequency of hypertension, gestational diabetes, preeclampsia, stillbirth and other complications of pregnancy. Rates of stillbirth are twice as high in obese patients as in normal weight patients. Increased risk of cesarean section delivery. The C-section rate is almost 50% in obese women, and the postoperative complications following C-section are significantly higher as well. Due to larger babies, greater delivery complication rate for women delivering vaginally. Lower prolactin leading to decreased nursing Higher risk of maternal diabetes Consequences for the newborn into adulthood include fetal macrosomia, pneumonia, lifelong risk of obesity and its consequences, behavioral problems, and risk of asthma.6 In the face of all these potential complications and adverse effects, reduction in BMI through weight loss has been demonstrated to improve fertility and fertility therapy success and to lower complications of therapy and pregnancy. Women often ask for help with weight loss when they are considering pregnancy. Many of them understand that pregnancy will be easier if they don’t carry extra weight. Recently I helped care for a patient who had tried unsuccessfully to become pregnant during the past year. I chose her as an example because she might not be considered a typical candidate for weight-loss therapy, yet the intervention in her case turned out to be simple and effective. She had already been to an infertility specialist and was told she had a fibroid uterus. She had a long history of irregular or missed periods and a diagnosis of polycystic ovary syndrome. Her initial BMI was only 26.5, but her waist circumference was 36 inches. (Central obesity is often characteristic of women with impaired fertility.) The patient also had a high-stress job, many hours of driving and little physical activity. She started on a 1,200 calorie low-fat diet, avoiding refined carbohydrates (the whites: white sugar, white flour, white rice, and white potatoes because of all the toppings). I advised her to eat small, frequent servings of protein throughout the day. She also began phentermine at one-half of a 37.5 mg tab daily. She delayed pregnancy for several months during the active weight-loss phase. She resumed regular physical activity and started yoga. She was seen every two to four weeks for monitoring, and I adjusted her program as needed. At her six-month follow-up exam, she had lost 12 pounds, her menses had returned to normal, and she was feeling better than she had in a long time. Her husband also lost 25 pounds. (When women take better care of themselves, it is common for the entire family to benefit.) Medications were stopped, and she continued to lose weight following a program of reduced calories, optimal protein, regular physical activity, and yoga for stress management. Six months later she happily reported she was eight weeks pregnant. After five months of pregnancy, she was 10 pounds lighter than at her initial visit. This case illustrates the tremendous opportunity physicians have to influence weight loss in women before and during pregnancy. The U.S. Preventive Services Task Force recommends making height and weight measurements part of vital signs.7 They also recommend recording waist circumference for people with a BMI over 25. These actions go a long way toward letting patients know the importance of achieving and maintaining a healthy weight; they also alert patients to potential risks. People are often surprised to learn what weights are medically considered overweight, obese and extremely obese. Beginning weight counseling early, long before pregnancy is contemplated, makes a big difference. It’s easier to lose 10 to 30 pounds when a patient is younger, and changes made at this time of life can have a positive effect far into the future. Eating more protein, much less sugar and avoiding refined carbohydrates can result in significant weight loss. Even weight loss of 5–10 pounds can improve health and metabolic parameters. Anti-obesity medications can be a helpful tool when used with a comprehensive program. Patients who have a significant amount of weight to lose often do better with medications. All weight-loss medications are contraindicated during pregnancy, but they can offer a significant advantage when used selectively and carefully monitored with patients who are considering a pregnancy that might otherwise be impossible. Several weight-loss medications have recently been approved by the FDA, making it easier for primary care physicians and OB-GYNs to prescribe them. The medications include phentermine-topiramate (Qsymia), lorcaserin (Belviq), wellbutrin-naltrexone (Contrave) and liraglutide (Victoza). Each offers a different approach to a complex problem. Some older medications, such as phentermine, diethylpropion and phendimetrazine, have a long history of safety and effectiveness. Patients must use appropriate contraception during this active weight-loss phase. For pregnancy itself, clomiphene has long been considered first-line therapy to induce ovulation. Metformin plays a role in managing infertility caused by polycystic ovary syndrome (PCOS), an endocrine abnormality that, through numerous proposed mechanisms, leads to anovulation.8 Although the comparative results of clomiphene vs. metformin have differed, a 2009 meta-analysis showed no difference between the two treatments in terms of ovulation rate, pregnancy rate, or live birth rate.9 When clomiphene plus metformin was compared with monotherapy with each agent, combination therapy was no more successful than monotherapy. Patients who are candidates for metformin therapy must be made aware that it induces ovulation indirectly, taking up to six months to improve ovulation.9 Clomiphene, in contrast, acts directly by producing a surge of luteinizing hormone and could cause ovulation within days.9 Bariatric surgery may not typically be considered when discussing planning pregnancy, but in the severely obese woman, bariatric surgery can greatly improve her odds of conceiving, either naturally or assisted. A positive outcome of pregnancy is also directly linked to the degree of weight loss. A small cohort study reported at the 2011 meeting of the American Society of Metabolic and Bariatric Surgery showed that PCOS symptoms improved significantly after bariatric surgery, and previously infertile women successfully conceived. Almost all the patients had resolution of menstrual dysfunction, and fewer reported hirsutism. Every infertile woman in the study who wanted to conceive did so postoperatively, either naturally or by assisted reproduction. On the other hand, a 2009 practice bulletin from ACOG concluded that, “Bariatric surgery should not be considered a treatment for infertility.”10 I, personally, disagree with this statement. There is still significant prejudice against overweight people. Surgical options should be presented, as part of the spectrum of comprehensive care, to anyone whose weight is keeping them from a healthy, successful pregnancy. For women who have been unable to become pregnant, weight loss may be all that’s needed. The closer women get to their ideal weight, the better their chance of success. There are many reasons for infertility, however, and weight loss and lifestyle changes will not address all of them. Nonetheless, weight loss is one of the most powerful and effective interventions. In my experience, just reducing insulin resistance with proper diet and physical activity can make the difference. Weight loss can help restore a healthy hormonal balance in both overweight and obese men and women. It can create an environment where the odds of becoming pregnant naturally, as well as the success of infertility treatments, are optimized. Here are some suggestions for making weight management part of a busy practice: Ask permission to discuss weight. A few nonjudgmental questions can initiate a powerful partnership. “Would it be all right if we discussed your weight?” or “I’m concerned about your weight because I think it might cause health (or pregnancy) problems down the line” are a good place to start. Preferred words and phrases, such as unhealthy weight or excess weight, are better accepted by patients than words and phrases like obese, fat or large size. Make your office welcoming to overweight patients. Use scales that read higher weights, large-size gowns, and chairs that are comfortable and fitting. Respect their privacy and remain sensitive to how you speak about their weight as it impacts their health. Make weight, BMI and waist circumference part of routine vital signs as appropriate. Begin counseling early. Begin educating and counseling on the benefits of achieving and maintaining a healthy weight long before pregnancy is desired. Provide monthly follow-up. Patients who are actively in a weight-loss phase need regular follow-up extending through maintenance. Refer if necessary. Patients with complex weight-loss needs may need referral to a specialist. When seeing an overweight or obese woman choosing to become pregnant, offer counseling and recommendations for appropriate calorie and nutritional intake, plus physical activity. Handouts work well at this stage. Patients who are in an active weight-loss process should be seen every two to four weeks for support and guidance. Often these visits can be done by a nurse or medical assistant; minimal extra training is required. If these efforts are unsuccessful or the patient has significant weight to lose, refer them to a dietitian, community weight-loss program or specialist. In my experience, a physician’s interest in a patient’s weight loss frequently results in a positive response. :: Dr. Altschuler, a family and bariatric physician, is medical director of the Altschuler Center for Weight Loss & Wellness in Greenbrae and Novato. Email: drgail@marinweightloss.com Phone: (415) 897-9800 References 1. Rich-Edwards JW, et al, “Adolescent body mass index and infertility caused by ovulatory disorder,” Am J Ob Gyn, 171:171–177 (1994). 2. Zaadstra BM, et al, “Fat and female fecundity,” BMJ, 306:484–487 (1993). 3. Ahmad HO, et al, “Obesity and male infertility,” Semin Reprod Med, 30:486-495 (2012). 4. Robinson, et al, “Maternal outcomes in pregnancies complicated by obesity,” Ob Gyn, 106:1357-64 (2005). 5. ACOG, “Obesity in pregnancy,” Committee opinion 549 (2013). 6. O’Reilly JR, Reynolds RM, “Risk of maternal obesity to the long-term health of the offspring,” Clin Endocrinol, 78:9-16 (2013). 7. USPSTF, “Obesity in adults: screening and management,” www.uspreventiveservicestaskforce.org (2014). 8. Morin-Papunen L, et al, “Metformin improves pregnancy and live-birth rates in women with PCOS,” J Clin Endocrin Metab, 97:1492-1500 (2012). 9. Palomba S, et al, “Clomiphene citrate, metformin or both as first-step approach in treating anovulatory infertility in patients with PCOS,” Clin Endocrin, 70:311-321 (2009). 10. ACOG, “Bariatric surgery and pregnancy,” Obstet Gynecol 113:1405-13 (2009).

Your responses confirm how important it is for everyone to have access to the care they need to build a family when they are ready. The good news is that for many people, fertility can be restored with even moderate weight loss. Work with your doc to find the best time for you.

Physicians understand the negative health consequences of being overweight, including a higher incidence of heart disease, diabetes, cancer and back pain, to name a few. Another consequence is the effect of weight on fertility, fertility treatment and pregnancy, as well as the ongoing health of mother and child. Infertility, for example, is significantly higher in women who are overweight, and it increases as their BMI rises.1,2 Attempts to become pregnant through escalating interventions become ever more physically, financially and emotionally costly. These costs become statistically significant, and they are more pronounced at higher BMIs, especially if there is central obesity.2 Obesity brings multiple physiologic changes that affect fertility and pregnancy, including changes in estrogen, testosterone and LH/FSH ratios. Leptin, insulin and multiple inflammatory cytokines are also affected. These contribute to abnormalities of ovulation; abnormal egg, embryo and endometrial development; unsuccessful implantation; and failure to maintain a viable pregnancy. Male fertility is also negatively affected by obesity. The prevalence of male infertility is increasing, as evidenced by decreasing sperm counts throughout the world. It has been estimated that sperm counts have fallen by as much as 1.5% each year in the United States, a finding also noted in other Western nations.3 Health, volume and motility of sperm are all affected. Although the cause is uncertain, proposed explanations include increasing obesity and exposure to environmental toxins. Women who are underweight (BMI <19) often have difficulty conceiving as well. After ruling out underlying illness or eating disorders, it is generally easier for this population to reach an ideal weight and improve their odds for conception. For all groups, an ideal body weight results in the best outcome for fertility and fertility therapy, as well as maternal and fetal health. Other potential complications that overweight and obese women face around pregnancy and birth include:4,5 Irregular periods Difficulty or inability to conceive More complicated IVF cycles Lower IVF success and greater complications of pregnancy for those who do conceive Higher frequency of early pregnancy loss Greater anesthesia and surgical complications if surgery is required Greater frequency of hypertension, gestational diabetes, preeclampsia, stillbirth and other complications of pregnancy. Rates of stillbirth are twice as high in obese patients as in normal weight patients. Increased risk of cesarean section delivery. The C-section rate is almost 50% in obese women, and the postoperative complications following C-section are significantly higher as well. Due to larger babies, greater delivery complication rate for women delivering vaginally. Lower prolactin leading to decreased nursing Higher risk of maternal diabetes Consequences for the newborn into adulthood include fetal macrosomia, pneumonia, lifelong risk of obesity and its consequences, behavioral problems, and risk of asthma.6 In the face of all these potential complications and adverse effects, reduction in BMI through weight loss has been demonstrated to improve fertility and fertility therapy success and to lower complications of therapy and pregnancy. Women often ask for help with weight loss when they are considering pregnancy. Many of them understand that pregnancy will be easier if they don’t carry extra weight. Recently I helped care for a patient who had tried unsuccessfully to become pregnant during the past year. I chose her as an example because she might not be considered a typical candidate for weight-loss therapy, yet the intervention in her case turned out to be simple and effective. She had already been to an infertility specialist and was told she had a fibroid uterus. She had a long history of irregular or missed periods and a diagnosis of polycystic ovary syndrome. Her initial BMI was only 26.5, but her waist circumference was 36 inches. (Central obesity is often characteristic of women with impaired fertility.) The patient also had a high-stress job, many hours of driving and little physical activity. She started on a 1,200 calorie low-fat diet, avoiding refined carbohydrates (the whites: white sugar, white flour, white rice, and white potatoes because of all the toppings). I advised her to eat small, frequent servings of protein throughout the day. She also began phentermine at one-half of a 37.5 mg tab daily. She delayed pregnancy for several months during the active weight-loss phase. She resumed regular physical activity and started yoga. She was seen every two to four weeks for monitoring, and I adjusted her program as needed. At her six-month follow-up exam, she had lost 12 pounds, her menses had returned to normal, and she was feeling better than she had in a long time. Her husband also lost 25 pounds. (When women take better care of themselves, it is common for the entire family to benefit.) Medications were stopped, and she continued to lose weight following a program of reduced calories, optimal protein, regular physical activity, and yoga for stress management. Six months later she happily reported she was eight weeks pregnant. After five months of pregnancy, she was 10 pounds lighter than at her initial visit. This case illustrates the tremendous opportunity physicians have to influence weight loss in women before and during pregnancy. The U.S. Preventive Services Task Force recommends making height and weight measurements part of vital signs.7 They also recommend recording waist circumference for people with a BMI over 25. These actions go a long way toward letting patients know the importance of achieving and maintaining a healthy weight; they also alert patients to potential risks. People are often surprised to learn what weights are medically considered overweight, obese and extremely obese. Beginning weight counseling early, long before pregnancy is contemplated, makes a big difference. It’s easier to lose 10 to 30 pounds when a patient is younger, and changes made at this time of life can have a positive effect far into the future. Eating more protein, much less sugar and avoiding refined carbohydrates can result in significant weight loss. Even weight loss of 5–10 pounds can improve health and metabolic parameters. Anti-obesity medications can be a helpful tool when used with a comprehensive program. Patients who have a significant amount of weight to lose often do better with medications. All weight-loss medications are contraindicated during pregnancy, but they can offer a significant advantage when used selectively and carefully monitored with patients who are considering a pregnancy that might otherwise be impossible. Several weight-loss medications have recently been approved by the FDA, making it easier for primary care physicians and OB-GYNs to prescribe them. The medications include phentermine-topiramate (Qsymia), lorcaserin (Belviq), wellbutrin-naltrexone (Contrave) and liraglutide (Victoza). Each offers a different approach to a complex problem. Some older medications, such as phentermine, diethylpropion and phendimetrazine, have a long history of safety and effectiveness. Patients must use appropriate contraception during this active weight-loss phase. For pregnancy itself, clomiphene has long been considered first-line therapy to induce ovulation. Metformin plays a role in managing infertility caused by polycystic ovary syndrome (PCOS), an endocrine abnormality that, through numerous proposed mechanisms, leads to anovulation.8 Although the comparative results of clomiphene vs. metformin have differed, a 2009 meta-analysis showed no difference between the two treatments in terms of ovulation rate, pregnancy rate, or live birth rate.9 When clomiphene plus metformin was compared with monotherapy with each agent, combination therapy was no more successful than monotherapy. Patients who are candidates for metformin therapy must be made aware that it induces ovulation indirectly, taking up to six months to improve ovulation.9 Clomiphene, in contrast, acts directly by producing a surge of luteinizing hormone and could cause ovulation within days.9 Bariatric surgery may not typically be considered when discussing planning pregnancy, but in the severely obese woman, bariatric surgery can greatly improve her odds of conceiving, either naturally or assisted. A positive outcome of pregnancy is also directly linked to the degree of weight loss. A small cohort study reported at the 2011 meeting of the American Society of Metabolic and Bariatric Surgery showed that PCOS symptoms improved significantly after bariatric surgery, and previously infertile women successfully conceived. Almost all the patients had resolution of menstrual dysfunction, and fewer reported hirsutism. Every infertile woman in the study who wanted to conceive did so postoperatively, either naturally or by assisted reproduction. On the other hand, a 2009 practice bulletin from ACOG concluded that, “Bariatric surgery should not be considered a treatment for infertility.”10 I, personally, disagree with this statement. There is still significant prejudice against overweight people. Surgical options should be presented, as part of the spectrum of comprehensive care, to anyone whose weight is keeping them from a healthy, successful pregnancy. For women who have been unable to become pregnant, weight loss may be all that’s needed. The closer women get to their ideal weight, the better their chance of success. There are many reasons for infertility, however, and weight loss and lifestyle changes will not address all of them. Nonetheless, weight loss is one of the most powerful and effective interventions. In my experience, just reducing insulin resistance with proper diet and physical activity can make the difference. Weight loss can help restore a healthy hormonal balance in both overweight and obese men and women. It can create an environment where the odds of becoming pregnant naturally, as well as the success of infertility treatments, are optimized. Here are some suggestions for making weight management part of a busy practice: Ask permission to discuss weight. A few nonjudgmental questions can initiate a powerful partnership. “Would it be all right if we discussed your weight?” or “I’m concerned about your weight because I think it might cause health (or pregnancy) problems down the line” are a good place to start. Preferred words and phrases, such as unhealthy weight or excess weight, are better accepted by patients than words and phrases like obese, fat or large size. Make your office welcoming to overweight patients. Use scales that read higher weights, large-size gowns, and chairs that are comfortable and fitting. Respect their privacy and remain sensitive to how you speak about their weight as it impacts their health. Make weight, BMI and waist circumference part of routine vital signs as appropriate. Begin counseling early. Begin educating and counseling on the benefits of achieving and maintaining a healthy weight long before pregnancy is desired. Provide monthly follow-up. Patients who are actively in a weight-loss phase need regular follow-up extending through maintenance. Refer if necessary. Patients with complex weight-loss needs may need referral to a specialist. When seeing an overweight or obese woman choosing to become pregnant, offer counseling and recommendations for appropriate calorie and nutritional intake, plus physical activity. Handouts work well at this stage. Patients who are in an active weight-loss process should be seen every two to four weeks for support and guidance. Often these visits can be done by a nurse or medical assistant; minimal extra training is required. If these efforts are unsuccessful or the patient has significant weight to lose, refer them to a dietitian, community weight-loss program or specialist. In my experience, a physician’s interest in a patient’s weight loss frequently results in a positive response. :: Dr. Altschuler, a family and bariatric physician, is medical director of the Altschuler Center for Weight Loss & Wellness in Greenbrae and Novato. Email: drgail@marinweightloss.com Phone: (415) 897-9800 References 1. Rich-Edwards JW, et al, “Adolescent body mass index and infertility caused by ovulatory disorder,” Am J Ob Gyn, 171:171–177 (1994). 2. Zaadstra BM, et al, “Fat and female fecundity,” BMJ, 306:484–487 (1993). 3. Ahmad HO, et al, “Obesity and male infertility,” Semin Reprod Med, 30:486-495 (2012). 4. Robinson, et al, “Maternal outcomes in pregnancies complicated by obesity,” Ob Gyn, 106:1357-64 (2005). 5. ACOG, “Obesity in pregnancy,” Committee opinion 549 (2013). 6. O’Reilly JR, Reynolds RM, “Risk of maternal obesity to the long-term health of the offspring,” Clin Endocrinol, 78:9-16 (2013). 7. USPSTF, “Obesity in adults: screening and management,” www.uspreventiveservicestaskforce.org (2014). 8. Morin-Papunen L, et al, “Metformin improves pregnancy and live-birth rates in women with PCOS,” J Clin Endocrin Metab, 97:1492-1500 (2012). 9. Palomba S, et al, “Clomiphene citrate, metformin or both as first-step approach in treating anovulatory infertility in patients with PCOS,” Clin Endocrin, 70:311-321 (2009). 10. ACOG, “Bariatric surgery and pregnancy,” Obstet Gynecol 113:1405-13 (2009).

Hi All. If you're looking for a fill in or near the Bay Area, CA, I'm available. We have a full spectrum of support for weight loss and would love to see you. Gail Altschuler, MD The Altschuler Center for Weight Loss & Wellness, Novato, CA. 415-897-9800

This is a great article, both informative and sensitive. Many people don't realize that even modest weight loss can make a healthy pregnancy possible.

Hi Sara. It sounds like you are a bit overfilled. I think that the best course is to have a bit of Fluid removed, especially if you'll be out of town all weekend. In my experience, this rarely gets better and often gets much worse. Check with your doc if you're not sure. He may be able to help you decide. Best of luck

I'm Dr. Gail Altschuler. We do lap band fills for people who've had there bands placed elsewhere. The cost is $349 for the first fill and $165 after that. I'm a weight loss specialist so I can help support the whole process of weight loss in addition to adjusting the band. I've got hundreds of band patients. I don't use fluoro, but rarely find it necessary. Give us a call at 415-897-9800. www.marinweightloss.com Looking forward to meeting you.

Fill Centers is closed and I am still available for all Lap-Band fills and aftercare. My office is in Novato, Marin, County CA. support@marinweightloss.com 415-897-9800

Hi. I've just signed on and I could use some quidance. I'm a Bariatric Physician and I've done over 500 fills through Fill Centers USA. They have closed and I will continue to provide lap band fills to anyone, regardless of where they had their band placed. Is there a way to register as a provider, rather than a patient? How can I add my picture to my signature? What does it mean to be "pinned"? Thanks. Looking forward to being a helpful member of the community. Dr. Gail

Fill Centers USA closed for financial reasons. All the doctors are still available to provide ongoing care and support. If you've seen someone in the past, call them directly to schedule a fill or with questions. The Fill Center will maintain a list of contact information on it's website. Give me a call if you have questions. Dr. Gail

Fill Centers USA closed for financial reasons. I and all the doctors who have provided fills through their service are still available. Just call the doctor that you've seen with any questions or concerns, or to schedule an appointment or. Let me know if you'd like more info. Dr. Gail

I have been providing lap band fills for the past 2 1/2 years through Fill Centers USA. I can help if you've had your band placed in another state or country. Fill Centers closed today and I would like you all to know that I'm available to provide lap band adjustments at a reasonable cost as well as a full range of weight loss support services. Gail Altschuler, MD 415-897-9800 www.marinweightloss.com.

I have been providing lap band fills for the past 2 1/2 years through Fill Centers USA. I can help if you've had your band placed in another state or country. Fill Centers closed today and I would like you all to know that I'm available to provide lap band adjustments at a reasonable cost as well as a full range of weight loss support services. Gail Altschuler, MD 415-897-9800 www.marinweightloss.com.

Hi. I have been providing lap band fills for the past 2 1/2 years through Fill Centers USA. Fill Centers closed today and I would like you all to know that I'm available to continue to provide lap band adjustments at a reasonable cost as well as a full range of weight loss support services. Give me a call when you're ready for your first fill. To your success. Gail Altschuler, MD 415-897-9800 www.marinweightloss.com.