Infertility and adverse outcomes of pregnancy

What is the relationship between coeliac disease and infertility?

The National Institute for Health and Clinical Excellence (NICENational Institute for Health and Clinical Excellence - an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. NICE had produced a clinical guideline on the recognition and assessment of coeliac disease.) guideline on the recognition and diagnosis of coeliac disease gives evidence of untreated coeliac disease and an increased prevalence in unexplained infertility (1).

One study found that menarche was significantly delayed in people with untreated coeliac disease (2). A further study confirmed this statement and also reported significantly earlier age of menopause (3).

What is the relationship between coeliac disease and pregnancy outcomes?

The NICE guideline also states, ’There is evidence that undiagnosed maternal coeliac disease has a negative effect on intrauterine growth and birth weight, and is associated with increased preterm birth and caesarean section rates.’(1)

Outcome for the baby

Maternal undiagnosed coeliac disease is associated with a poorer outcome for the baby (4). A Danish cohort study found that babies of people with untreated coeliac disease had significantly lower birth weights than babies of the control group. Such outcomes were not observed in newborns of treated patients. 

The data suggests that treatment with the gluten-freeWhen a food has less than 20 parts per million (ppm) of gluten so it is safe for people with coeliac disease to eat. diet is important in reducing the incidence of low birth weights (5). After a glutenA protein that is found in the cereals wheat, barley and rye. -free diet was prescribed to mothers with coeliac disease, the prevalence of low birth weight before and fell from 29% to 0% (4). 

Miscarriage

An increased incidence of miscarriage among women with untreated coeliac disease has also been reported (2, 6). Following a gluten-free diet, the miscarriage rate among women with untreated coeliac disease was similar to that of controls.  However, a further study found no difference in the incidence of coeliac disease among people with recurrent miscarriage screened for coeliac disease and among healthy controls (7).

Caesarean

In a cohort study, the proportion of births by Caesarean section was moderately higher for women with coeliac disease than for the women in the comparison group (8).

Other Pregnancy Outcomes

The cohort study also showed pregnancy experiences such as preeclampsia, postpartum haemorrhage, and still births to be similar between women with coeliac disease and those without (8). 

In addition, none of the women with coeliac disease had babies with neural tube defects, despite the concerns about folate deficiency in coeliac disease. These results indicate that the risks of adverse pregnancy-related outcomes for women with coeliac disease are not as high as previously reported (2,5).

Dietary implications in pregnancy for people with coeliac disease

There are no specific guidelines for pregnant women with coeliac disease. Standard nutritional advice during pregnancy is appropriate for women with coeliac disease. All women prior to conception and until the twelfth week of pregnancy should take a folic acid supplement (400ug a day) to protect against neural tube defects.

If an individual's folic acid levels are low before conception, they may need to take a higher dose of 5 milligrams a day. This should be discussed with their GPGeneral Practitioner, or local doctor.

It is important that people with coeliac disease are followed up regularly, particularly at times of stress, for example, pregnancy. Depending on individual assessment and diet, supplementation with calcium, iron, and vitamin B12 may be required.

References

1 NICE (2009) Coeliac Disease: Recognition and assessment of coeliac disease. www.nice.org.uk

2 Molteni N, Bardella MT & Bianchi PA (1990) Obstetric and gynaecological problems with untreated sprue.  Journal of Clinical Gastroenterology. 12: 37-39.

3 Sher KS & Mayberry JF (1994) Female fertility, obstetric and gynaecological history in coeliac disease.  Digestion. 55: 243-246.

4 Ciacci C, Cirillo M, Auriemma G, et al (1996) Coeliac disease and pregnancy outcome.  American Journal of Gastroenterology. 91: 718-722.

5 Norgard S, Fonager K, Sorensen HT et al (1996) Birth outcomes of women with celiac disease; A nationwide historical cohort study.  American Journal of Gastroenterology. 94: 2435-2440.

6 Sher KS & Mayberry JF (1994) Female fertility, obstetric and gynaecological history in coeliac disease. Digestion. 55: 243-246.

7 Kolho KL, Tiitinen A, Tulppala L, et al (1999) Screening for celiac disease in women with a history of recurrent miscarriage or infertility.  British Journal of Obstetrics and Gynaecology. 106:171-173.

8 Tata LJ, Card TR & Logan RFA (2005) Fertility and pregnancy-related events in women with celiac disease: A population-based cohort study.  Gastroenterology. 128: 849-855.

9 Office for National Statistics (2003) Population trends: spring 2003. No 111. Published with permission of the Controller of Her Majesty's Stationery Office.  Office for National Statistics, London, England.