The primary reason for balloon intolerance is delayed (slowed) stomach emptying. We know that this is the primary mechanism that leads to weight loss with Orbera, but in some cases the slowing can be so severe that patients have persistent nausea and vomiting. This is called gastroparesis. This may necessitate early removal. We see intolerance occur at two time points. The most common is at month 2-3 after placement. At that time, stomach emptying may further slow, and patients will re-develop nausea and vomiting. This is very difficult to overcome with medications and we typically recommend balloon removal. Less commonly, intolerance may develop immediately after placement and continue for the first 1-2 weeks without improvement, requiring removal. In practice, this is much less frequent than the first scenario. Overall, the incidence of balloon intolerance and early removal ranges from 10-16% globally. Unfortunately, we cannot accurately predict who will be intolerant. The only identified predictor is use of SSRI anti-depressants. For patients on these medications, I counsel about the higher risk of intolerance. Otherwise, we try to screen for a history of frequent nausea, easy vomiting, or a "weak" stomach. This would be reasons to potentially avoid an intragastric balloon. There are ongoing studies evaluating other risk factors for early balloon removal, including the presence of baseline (pre-balloon) gastroparesis, which may be a factor. Unfortunately, when early balloon removal is needed, a refund is not typically provided.