7 Ways to Live Whole Lives as Fertile Fat Folks
(Content Notes: this piece will discuss anti-fat bias in the medical industrial complex, including commonly heard claims by providers that might be activating. There are brief mentions of eating disorders and intentional weight loss. Many linked sources include gendered and anti-fat language.
I use “fat” throughout this piece as a neutral signifier, just as I would with hair color, eye color, clothing style, etc. “Fat” is not a bad word. You should use the words you would like to use about your own body, and others should use the language you would like them to use when referring to you and your body.)
I am fat. My weight has fluctuated over the years as I’ve yo-yo dieted (cycles of dieting to lose weight and the body inevitably returning to its equilibrium) and engaged in a decade-long eating disorder, but on average, I’ve always been viewed as fat.
From my earliest memories of my first pediatrician, I’ve dreaded going to the doctor. They would look at my little, chunky, five-year old body, pull out their BMI chart, and tell my mom I needed to lose weight.
The Doctor’s Office Struggle
I’ve avoided the doctor throughout my life, sometimes to the detriment of my health. This has also inhibited my process of learning about and knowing my own body. I’ve let the flu and yearly well-patient visits go unchecked. When I noticed that I had the symptoms of a genetic disorder that runs in my family, I took years to get the care I needed. When I thought I might be pregnant in 2019, I took well over a month to go to the doctor.
If you are fat, chances are you relate to this feeling. It is very common for fat folks to avoid going to the doctor due to overt and covert anti-fat bias we encounter there, as well as the ever-frustrating and unhelpful experience of having providers blame all of our symptoms on our weight, regardless of whether there is a logical link. This form of anti-fat bias has caused delayed diagnoses, untreated illnesses, suffering, and even death to people in larger bodies.
When we (fat folks) start looking into getting pregnant, we are bombarded with study after study and doctor after doctor telling us we need to lose weight before we can get pregnant. They say we are “infertile” at our current weights, that our weight is “unsafe for the baby,” or that they won’t work with fertility patients our size. While this experience is very common for fat folks, it is even more pressing for super-fat and infini-fat folks, who may have a near impossible time of finding fertility care.
These messages from our providers can be devastating, disappointing, frustrating, and confusing. The more I’ve looked into these messages, the more I’ve learned that they are flawed.
Fundamental Flaws in the Evidence
While there are hundreds of articles linking higher BMI to infertility and poor fertility outcomes, we are finally starting to reckon with the flaws at the core of weight research that taints these studies.
BMI is not a measure of health, and, unfortunately, it is treated as such in a great deal of fertility research. There are studies, for example, that put people into two groups: “overweight or healthy”. Fertility is a multi-faceted piece of our health story, and there are dozens of confounding factors that might be interfering with our fertility other than weight. I have yet to find a study linking BMI to fertility that controls for the majority of the primary factors that complicate fertility, including ovulation disorders, abnormalities of the uterus, cervix, or fallopian tubes, endometriosis, pelvic adhesions, early menopause, cancer, and sperm-related issues. While some control for social locations, they often don’t consider the impact of stress or access to spaces for movement or nutritious foods. Additionally, most of these studies report intermediate outcomes like ovulation episodes or fertility drug experiences, and do not include pregnancy and live birth data.
BMI was never meant to be a measure of individual health, and was, in fact, created to be a population-level marker of body size.This means that it was meant to be used to create statistical averages across large groups, not to be applied to an individual to affect their treatment and care. On top of that, once we factor in the egregiously racist and sexist grounds upon which the BMI was built, it is obvious that this is not a reasonable measure to use as a barrier to individual fertility care.
Challenging the Refusal to Treat
Many clinics and providers won’t work with fat people, claiming that it is too costly or too hopeless to work with us, or that pregnancy complications are too risky. Consequently, we could be seeing a correlation between weight and infertility due to the common practice of barring fat folks from fertility treatment.
There is a wealth of studies that show that neither of these claims are based in evidence, so let’s get into it. One of the rare studies that includes people with a BMI over 40 concluded that there is no difference in pregnancy or live birth rates when comparing all four BMI groups. This was a large, retrospective study including 1,293 participants undergoing IVF and is an important contribution to the field. Another large study, a systemic review of available evidence on the effects of weight on assisted reproductive technologies, shows that there is no link between BMI and live births. A third large study focused on live births in North America shows that live birth rates were only slightly lower for fat folks than for people who weren’t fat. It is far from hopeless for fat folks to conceive and carry a baby through to birth.
The argument that it costs more to support fat folks through fertility treatment is also baseless, as shown by a landmark study directly comparing the costs of the four BMI groups and finding that there were no significant differences. Rebecca Brown, a weight & fertility researcher shared, “Claims that the evidence is of sufficient clarity to make decisive cost-effectiveness cutoffs appropriate is disingenuous…[they] mask other influences, such as negative attitudes towards obese people that render them easy targets for cost-cutting commissioners.”
Many studies, including some of the ones linked above that showed no difference in pregnancy and birth rates, do show a link between fatness and pregnancy complications. These complications include hypertension, gestational diabetes, and Cesarean birth. When we consider these risks, we must take into account that the health outcomes we often see associated with BMI can be influenced highly by factors related to living in a fat body, but not due to the fat itself.
Hypertension? Heart concerns? Glucose levels? These are highly connected with both yo-yo dieting (cycles of dieting to lose weight and our bodies inevitably returning to their equilibrium) and the toxic weathering of experiencing fatphobia in our daily lives. Both experiences raise our blood pressure and put massive strains on our hearts. Furthermore, weight gain is often a symptom of a health issue, including fertility-altering endocrine issues such as PCOS, rather than the cause of the health issue. Additionally, poor care, late diagnoses, and imprecise treatment due to fatphobia makes us sicker. Perhaps these health experiences are more applicable to fertility than merely our body shape.
Intentional weight loss can in itself be dangerous and taxing on our bodies. More fertility researchers are starting to weigh that against potential pregnancy complications when considering the providers’ request for the patient to lose weight, as well as considering the impact of weight stigma and discrimination on overall health and fertility. This nuance matters!
At the end of the day, the request for you to lose weight to be able to engage in fertility treatment is lacking evidence, and pursuing weight loss is not in itself a healthy choice.
Living Whole Lives as Fertile Fat Folks
There are things we can do to support our health as we pursue fertility. For birth workers reading this, these are ideas and mindsets that you can practice and understand so that you can best show up for your fat clients.
Stop the yo-yo dieting. It is hard for our hearts, taxing for our bodies, and difficult for our mood. It does not lead to long-term weight loss.
Engage in activities that are nourishing to your body and self. Is there a type of movement that is joyful for you rather than punishing? Go for it! Invite friends and support folks in to do it with you if you’d like. Rest, journal, and practice affirmations of your body and your fertility.
Drink water! Most of us are under-hydrated, and most of us feel better and happier when we are drinking the water we need. While developing a habit of increased hydration, give yourself rewards along the way for drinking more. You can make a sticker chart, a water bottle covered in affirmations, or anything else to support you in staying hydrated.
Set your intentions for your nourishment. Focus on moving, hydrating, and eating foods that support your mood, ease, and well-being. Be mindful not to punish yourself or try to be “healthy enough.”
Find peer support with other fat folks trying to conceive. Peers can be an important part of feeling understood in your journey, having a community of people who see you, and getting positive support along your journey. Make sure you gather with others pursuing fat liberation and Health at Every Size rather than folks still in the diet-talk weeds. For example, consider the Fat and Fertile Alliance!
Fill your feeds, homes, and friendships with fat joy. This can go a long way in fostering our self-confidence, self-acceptance, and trust that our bodies are not the issue; the anti-fat medical industrial complex is. Move away from people who think that it is “glorifying obesity” to exist in your body and not center your life around weight loss. It is okay to just exist. It is okay to be joyful in your body.
Keep trying. Find Health at Every Size providers who will support you on the twists and turns of your fertility journey. Here is a great guide to finding fat-friendly providers to get you started.
Fat folks get pregnant. We really do! We have babies, families, sex, hobbies, and full lives. The fertility journey can be hard for us, but you are not alone. Birth workers should check out this great guide and article by fellow doula Amber Matteson about supporting fat birthing people.
If you are seeking fat-positive fertility or birth support, childbirth education, or sexual healing support, you can email amathedoula@gmail.com or visit embodiedcare.org.