A version of this article originally appeared on VICE Belgium.
Years ago, I was at my gynaecologist’s for a checkup. That’s when she told me – totally out of the blue – that I would never get pregnant in my current state. That was the word she used: my “state,” uttered with chilling bluntness. This conversation confused me, mainly because I was very young and we hadn’t been discussing the topic at all; she hadn’t even performed any actual tests to discern my fertility levels.
The state she was talking about was the size of my body, which is usually referred to with a “plus” prefix. My experience at the doctor’s is far from uncommon among fat people, as confirmed by the countless messages I received from the followers of my fat activist Instagram account.
“My gynaecologist forbade me from getting pregnant. She said it would be – and I’m quoting her here – ‘irresponsible’ to do so,” Céline said over DMs. Like everyone I spoke to, she preferred not to share her last name for privacy reasons. Another follower, Gaëlle, was told she was infertile without so much as an exam. “It really destroyed me… And after all that, it turned out to be bullshit anyway. I got pregnant on my first try,” she wrote.
Gaëlle’s experience points to an unfortunate truth: As a fat person, it can be difficult to trust your doctor to give you helpful medical advice. Research shows that, on average, doctors spend less time with fat patients, build less rapport with them and perceive them more negatively. These biases often result in doctors looking at fat patients only through the lens of group averages rather than at their individual health markers and needs.
British fat-positive fertility coach Nicola Salmon knows this all too well. At 16, she too was told she wouldn’t be able to get pregnant due to Polycystic Ovarian Syndrome (PCOS), a disorder that makes your period irregular and is often linked with weight gain and hormonal imbalances. “I was told that weight loss would help to cure it; that was the only treatment I was given,” she says. “So I spent my teens and 20s trying to lose the weight, regaining it, going through that whole cycle.”
Despite her diagnosis, Salmon said she had no problem conceiving. “I was in my biggest body and I had 100-plus-day [menstrual] cycles. It really planted the seed in me of, ‘Oh well, if conceiving worked for me, why are we told this, and what's the evidence behind it?’” That’s why she got into the field: to help people “who are navigating fertility spaces in bigger bodies get access to health care,” she explains.
Salmon believes most of the medical research used by healthcare professionals to make decisions for their fat patients “is based on the underlying assumption that being fat is unhealthy and that fatness is something that we want to move away from,” she says. “When you look at the evidence from a weight-neutral perspective, from this idea that being fat is just body diversity, then you have to start unpicking a lot of the puzzle pieces.”
So what do we know scientifically about fertility in fat people? On average, studies have shown that fertility decreases as Body Mass Index (BMI) increases, particularly with BMIs above 30. Higher BMIs are also connected to an increased chance of miscarriage and pregnancy complications, and with a lower effectiveness of IVF. However, these statements are often misconstrued to mean that all people with higher BMIs will have problems conceiving and birthing healthy babies, when in reality it all comes down to the individual.
BMI is an imperfect way of examining someone’s health. It doesn’t take into consideration muscle mass, nor does it make a distinction between metabolically unhealthy and metabolically healthy fat people, who do not experience health issues typically associated with being fat. On top of that, “decreased fertility doesn’t mean no fertility at all”, Salmon notes. Age, for instance, is also a complicating factor for couples trying to conceive naturally, but alternative treatments like assisted fertilisation can help.
Science hasn’t found a causal link between fatness and infertility. We don’t know if excess fat cells in someone’s body make them infertile, or if both symptoms are the result of another cause. This is particularly important, because, even though fat loss is routinely prescribed as a treatment for fertility, we have little evidence that it actually helps fat people conceive.
A 2017 meta-analysis of 40 studies found that weight loss seemed to help fat people conceive naturally, but made no difference during IVF treatment and did not improve their chances of birthing healthy babies. Besides, “none of the studies separated the effects of dieting for weight loss from those generated by health-promoting behaviours such as eating well or exercising”, Salmon adds.
Another study published in 2022 looked at 379 infertile women with a BMI above 30. They divided them in two groups: one on a restrictive diet and exercise regime aimed at weight loss, the other focusing on increased physical activity without weight loss goals. All participants were given fertility treatments after the lifestyle interventions. The study found no improvement in the women’s fertility, which could mean their issues were not connected to their body weight.
When I ask what other reasons could be behind increased infertility in people with bigger bodies, Salmon says multiple things could be at play. “One factor that is never really taken into account in research is weight stigma,” she explains. “When we are under any kind of stress, we have increased levels of the stress hormone [cortisol], which we know impacts our hormone levels and how we function, our physiology.”
Weight cycling – which is more prevalent in people with higher BMIs – is also associated with health risks, including higher levels of inflammation and hormonal fluctuations, which could upset the delicate balance necessary for conception. And yet, when a fat person has trouble getting pregnant, many doctors will refuse to send them to get additional tests or to take their individual situation into consideration. The NHS, for instance, does not provide IVF treatment to those with a BMI above 25, and anti-fat discrimination is not illegal in the UK and in the EU.
For a follower named Melody, assisted fertilisation was the only path to conception. Her partner has a condition called cystic fibrosis, which makes 98 percent of male patients infertile. “I ran into fatphobia so quickly – I was told, ‘We won’t start you until you lose at least 45 kilos,’” Melody recalled. Running out of time and with her partner’s sperm quality declining, Melody finally decided to undergo gastric sleeve surgery, a procedure that removed two-thirds of her stomach. “I don’t regret anything I did, but obviously, I’m sad I had to do it,” she said. “That decision came with so many consequences. But I wanted my baby more than anything.”
And conceiving is just the beginning of the story, as discrimination and humiliation follows fat people throughout their pregnancy. “Don’t forget, when you’re pregnant, no need to eat for two!” a gynaecologist told Céline, adding she was astounded Céline’s fiancé wanted to marry her at all. Sonia, another follower of mine, told her obstetrician he was hurting her during a visit, only for him to reply, “I can’t see anything with all that fat of yours.”
“Pregnancy was painful. People talked to me a lot about my weight – much more than they talked about my baby,” Annaelle wrote in a DM. “Hearing people talk about me as if I was only a body, it was so dehumanising.”
The same thing happened to Diane, whose story I found particularly hard to read. “My whole pregnancy, people bugged me about my weight,” she said. “They said I’d get gestational diabetes – I didn’t. They said my child would be born fat – he wasn’t. They told me I was going to have complications – I didn’t. Then they forced me to induce early, so that the baby wouldn’t be born ‘too fat’ full-term. Since the baby wasn’t ready, they ended up having to do an emergency C-section. I haemorrhaged, the baby had respiratory problems – their fatphobia almost killed us.”
Anna, currently pregnant, was also told by doctors she would develop gestational diabetes. “When I took a test, the midwife asked me for the results,” she said. “I told her I was negative, and she said ‘Are you sure? I don’t believe you! Show me.’ And I really was negative. I still can’t bring myself to tell her how humiliated she makes me feel every time I go to see her.”
It’s not news that fat people are treated worse than others, but it still blows my mind that the medical profession is so hostile to us. Even if fat people are generally less fertile, they still deserve help and respect. But society judges fatness to be morally unacceptable; we are sympathetic to the plight of infertility in a thin person while we tell fat people that it serves them right to be infertile – all they had to do was not be fat in the first place.
“It's so upsetting because it’s not that our bodies are wrong, it’s the system around us that's wrong,” says Salmon. Having helped dozens of clients throughout their fertility journeys, she finds that people will usually just need a slightly more tailored approach to their treatment. “I have fat clients with PCOS who might just need ovulation induction as the only piece of the puzzle to go on and grow their family, but they just can’t get that healthcare access,” she adds.
Many contact Salmon because they are getting rebuffed by medical staff at IVF centres, who cite studies showing that the treatment has lower success rates in fat patients. “But actually when you look at the research, they usually give all patients the exact same medication at the exact same time, without taking into account that a fat person might need a higher dose of the medicine or a different protocol,” she says. “We know that children, as they get older, will need higher doses of medicine, but we never take that into account when we're looking at fat people's biology.”
As for me, I hope this article will give you hope and help you start a conversation with your doctors. Most of all, I hope it will give you strength to demand the dignity and kindness you deserve. No caregiver has the right to mistreat you.