Undiagnosed coeliac disease is one of the leading causes of unexplained infertility. CARA BOATSWAIN explores the link between fertility and coeliac disease with leading researcher DR ALESSIO FASANO.
Susan, 33, and her husband Mark, 34, were despondent. They’d spent three years trying to conceive and by definition the couple was infertile. “It was certainly taking its toll,” says Susan. “All around us we were watching our friends start families and we were always wondering when it would be our turn.”
The couple was considering IVF fertility treatment. A costly and emotionally draining process that has a success rate of less than 50 percent. Before commencing treatment, Susan went to see a new GP. “My old doctor had retired,” she explains. “So I made an appointment to see a new one. She then told me about the link between coeliac disease and infertility and suggested I get tested.”
Susan, now a mum to two young boys, is forever thankful to her GP. “I still can’t believe the heartache we went through for something that could have been diagnosed much sooner. To think we were considering IVF is incredible.”
Gluten and Infertility
It’s a situation that’s all too common for people with silent coeliac disease. At gluten-free expos across Australia, I’ve spoke with numerous women who, like Susan, tell me that the best thing about their coeliac disease diagnosis has been their ability to start a family.
“Coeliac disease can affect any organ or system of the body; the reproductive system is not immune from its negative effects,” explains Dr Alessio Fasano, founder of the Centre for Celiac Research in the United States and author of Gluten Freedom. “In women, this can manifest in delayed menarche, increased miscarriages and difficulty in conceiving.”
Men too can experience fertility issues as a result of untreated coeliac disease. “Although it has been thought that coeliac disease affects fertility mainly in women, a recent study has shown a possible link between coeliac disease and sperm motility and androgen levels,” explains Fasano. He does note however that the research was conducted with a small sample size (68 couples), so further research is necessary to understand the full link.
As symptoms of coeliac disease can present differently in patients, it is a condition that is often misdiagnosed. While for those suffering from silent coeliac disease (where no gastrointestinal symptoms are present), infertility can be the first sign that something is amiss. According to the Gastroenterological Society of Australia (GESA) roughly 75 percent of people with coeliac disease are undiagnosed. They estimate around 160,000 Australians have the condition but do not know it.
While undiagnosed coeliac disease, might be an underlying cause of unexplained infertility, those already diagnosed with coeliac disease need not be concerned. A study published in Gastroenterology,
the official journal of the American Gastroenterological Association, in 2014, showed that women medically diagnosed with coeliac disease were no more likely than women without the condition to experience fertility problems.
The large population-based cohort study analysed more than 2 million women of childbearing age in the United Kingdom to compare rates of newly recorded fertility problems in women with and without coeliac disease. “Coeliac patients should rest assured,” says Dr Nafeesa N. Dhalwani, lead author of the study. “Our findings indicate that women with coeliac disease do not report fertility problems more often than women without coeliac disease.”
I WASN’T A COELIAC BEFORE MY PREGNANCY
The onset of coeliac disease can occur at any time. According to the Centre for Digestive Disease in Sydney, surgery, pregnancy, childbirth, viral infection and severe emotional stress can sometimes cause the conditions onset. “Pregnancy can be a trigger for coeliac disease in genetically susceptible women,” explains Fasano. “It’s possible that the change in the gut microbiota from hormonal changes that occur during pregnancy might be involved in the development of coeliac disease.”
While the link between coeliac disease and fertility is becoming better understood, there is still much we don’t know. “Although we know the cause for systemic damage is malabsorption of nutrients from immune-mediated mechanisms, we do need to do a lot more research into how coeliac disease affects the endocrine and reproductive systems of women and men,” says Fasano.
Nutrition is Key
Once diagnosed with coeliac disease, it is crucial patients follow a strict gluten-free diet and nutrient levels should be observed. “It is vital to have nutrient levels checked and monitored closely for women diagnosed with coeliac disease during pregnancy,” says Fasano. “A deficit in folic acid is of most concern for the proper development of the fetus.”
Folate is especially important before conception and during the first trimester. It is necessary for healthy growth and development and for the prevention of neural tube defects such as spina bifida. While many naturally gluten-free foods are high in folate (like asparagus and avocado) speak with you doctor about supplementation and always make sure that the vitamins you take are gluten-free.”It’s important to work closely with a dietitian and a gastroenterologist knowledgeable in coeliac disease to maintain a safe and healthy gluten-free diet to protect the mother and the fetus,” says Fasano.
WHAT IF I’VE BEEN “GLUTENED”?
One of the biggest challenges facing all newly diagnosed coeliac patients is the strict adherence to the gluten-free diet. Gluten can lurk in many unexpected products and issues with cross-contamination remain, particularly when dining out.
While all it takes is a crumb of gluten to cause damage to the small intestine of a person with coeliac disease, fortunately it shouldn’t affect a pregnancy. “A single incident of gluten ingestion is unlikely to adversely affect a pregnancy,” says Fasano. Continued gluten ingestion however, is another story.
“If gluten is present for a long time, and the mother-to-be- has elevated tTG antibody levels, she might feel fatigued and experience gastrointestinal symptoms,” he says. “The worst case scenario of continuous exposure can harm the fetus with possible consequences from abortion (miscarriage) to malformations (spina bifida).”
WHAT ABOUT THE BIRTH?
The debate surrounding health outcomes of children born by caesarean section (c-section) as opposed to a vaginal birth is nothing new. While there’s a lot of new research, many questions remain unanswered.
“As the infant travels through the birth canal, he or she is ‘coated’ with the beneficial microbes from his or her mother,” explains Fasano. “There is a robust, and growing, body of research that shows that babies born via caesarean section have a higher risk of developing coeliac disease and other autoimmune disorders.”
Dr Fasano believes that research into the role of the microbiome is crucial to better understanding the role our method of birth plays in our overall health and likelihood of developing coeliac disease. “As we learn more about the role of the microbiome in health and disease, we will become better equipped to answer this question,” he says. “We are only just at the beginning of understanding the enormous importance of the gut microbiome and the role that it plays in health and disease.”
IS BREAST BEST?
It’s understandable that new mothers have questions about how to best feed their child, especially when the child may have a genetic predisposition to coeliac disease. And for now, it does appear that for those who are able, breastfeeding is preferred.
“Breastfeeding is the best nutrition for children no matter what the manner of delivery,” says Fasano. “Mothers of children born via c-section should make an effort to breastfeed for the first six months.” Dr Fasano also notes that the early use of antibiotics should be controlled and monitored.
It was previously thought that breastfeeding might protect against the development of coeliac disease or delay its onset. However, several studies now indicate that this is not the case.
SHOULD I FEED MY CHILD GLUTEN?
Unsure when you should introduce gluten into the diet of our child? You shouldn’t be, is the resounding response from Dr Fasano. He co-authored a study with Italian pediatrician Dr Carlo Catassi that over five years examined 700 infants who were considered a risk of developing coeliac disease. “A recent study in the New England Journal of Medicine that we published in collaboration with our Italian colleagues shows that the delayed introduction of gluten does not have an effect on preventing coeliac disease,” he explains.
For Susan, her focus is now on her boys. “I was lucky as I was diagnosed at a time when I was still able to conceive,” she says. “We’re now keeping a close eye on the boys for any symptoms and this year we plan for them to undergo the coeliac gene test. I’d prefer them not to need the blood test, but this is important.”
This article first appeared in Issue 9 of Australian Gluten-Free Life magazine.
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