Celiac Disease and Reproductive Problems

When Alice Bast was pregnant with her second child, she felt well until the end of her second trimester. But then she was suddenly struck with unrelenting, severe diarrhea. Her obstetrician assured her there was nothing to worry about. Two weeks before her due date, she complained to her doctor that her diarrhea continued unabated and the baby was hardly moving. Again she was told not to worry so much, that the baby simply didn’t have much room to move around.

“Two days later, I told my husband, Will, that our baby was dead, that all movement had ceased,” said Bast. They drove to the hospital where she delivered a full-term, stillborn girl. They were devastated.

After the loss of her daughter, Bast suffered several early miscarriages before she succeeded in carrying another child without apparent complications until the sixth month. Then the diarrhea began again. A few weeks later, when she again felt very little fetal movement, her new, high-risk obstetrician performed an emergency caesarian section. Her premature, 3-pound baby—another girl—survived and eventually thrived.

Several years and many doctors later, Bast was diagnosed with celiac disease. Could the disease be responsible for her miscarriages and stillborn baby? According to what she learned during a lecture at the 9th International Symposium on Celiac Disease in 2000, the answer was yes. The discovery prompted Bast to form the National Foundation for Celiac Awareness (NFCA).

Supported by Research
Research suggests an association between untreated celiac disease and reproductive problems, including menstrual disorders, unexplained infertility, recurrent spontaneous abortion, intrauterine growth retardation, and low birth-weight babies.

In several studies, women with celiac disease who consumed a normal diet experienced a shortened reproductive span with delayed onset of menstruation and early menopause, along with more frequent secondary amenorrhea—the temporary or permanent cessation of menstruation in a woman who previously had normal periods. Researchers have found the rate of celiac disease to be 2.5 to 3.5 percent higher among women with unexplained infertility than among women with normal fertility.

Several studies report miscarriage rates to be substantially higher among women with untreated celiac disease than among healthy women, with one study finding the rate of spontaneous abortion to be nearly nine times higher. The incidence of low birth-weight babies is reportedly almost six times higher in women with untreated celiac disease. The risk of intrauterine growth retardation may be increased three-fold.
Women aren’t the only ones to suffer reproductive ills. A study of men with celiac disease found nearly half of them to have hypogonadism, sexual dysfunction, or poor semen quality, resulting in increased infertility.

Conflicting Evidence
Not all studies reach the same conclusions. Several have found little or no connection between celiac disease and infertility or poor pregnancy outcomes. One study reports higher rates of reproductive problems among women with obvious symptoms of celiac disease but not among asymptomatic women. Others conclude the risk of fertility and pregnancy problems exists regardless of disease severity and the presence or absence of symptoms.

“Most studies are small and observational” and don’t use consistent methodology, said Kay Stout, M.D., obstetrician/gynecologist at the Virginia Women’s Center in Kilmarnock, when asked about conflicting results. Although most studies suggest an association between celiac disease and infertility and early pregnancy loss, “it is safe to say more research is needed,” she said.

What’s the connection?
The reason celiac disease may contribute to reproductive problems is unclear. One proposed explanation for infertility and poor pregnancy outcomes is malabsorption of folic acid and other nutrients. However, several studies found no overt signs of malnutrition, with the exception of iron deficiency, in pregnant and infertile women with previously undiagnosed celiac disease.

Nutritional issues may not be a major factor in pregnancy loss or low birth-weight babies, suggests one small study of women with untreated celiac disease. Instead, disruption of normal immune system functioning—a hallmark of celiac disease—may be the culprit.

Although the underlying mechanism remains uncertain, reproductive problems associated with celiac disease have been effectively overcome with a gluten-free diet.

Screening for Celiac Disease
Stout has found undiagnosed celiac disease in patients who experience infertility, miscarriage, menstrual disorders, and pelvic pain. She notes that women diagnosed with irritable bowel syndrome are more likely to screen positive for celiac disease, yet reproductive problems alone justify screening.

Should all women with unexplained infertility be screened for celiac disease? “Absolutely,” said Stout. She noted the National Osteoporosis Foundation and similar organizations have started recommending routine screening for celiac disease when evaluating patients for secondary causes of osteoporosis. “The data is very strong for the association of celiac disease and osteoporosis, yet it still took time and awareness for…adoption of screening for celiac in these patients,” she said. “It is time for women’s health care providers to gain that same awareness.”

That’s what the NFCA and other celiac-related voluntary organizations are working toward. “Other women should not have to suffer the way I—and my husband—suffered, or lose babies the way I lost mine,” said Alice Bast. “All I needed to do was stop eating gluten.”

The following articles review recent studies of celiac disease and reproductive issues:
Pellicano R, Astegiano M, Bruno M, Fagoonee S, Rizzetto M. Women and celiac disease: association with unexplained infertility. Minerva Medica. 2007:98(3);217–219.
Goddard CJR, Gillett HR. Complications of celiac disease: are all patients at risk? Postgraduate Medical Journal. 2006:82;705–712.