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PRACTICAL GASTROENTEROLOGY • OCTOBER 2009
10
Celiac Disease and
Reproductive Health
INTRODUCTION
Celiac disease is a common (1% prevalence)
chronic immune-mediated, inflammatory disor-
der of the small intestine induced by a permanent
intolerance to dietary wheat, barley, and rye (1,2). The
gluten and glutenin proteins of these grains may be
contained in various food products, additives, or med-
icines. Celiac disease is a unique autoimmune disorder
in that the environmental precipitant is known. Until
2004, medical schools taught that celiac disease was a
rare disease of childhood. However, current estimates
state that nearly three million Americans suffer from
celiac disease, but 95% of them remain undiagnosed,
making celiac disease the most common, and one of
the most under diagnosed, hereditary autoimmune dis-
eases in the United States (3,4). Celiac disease (CD) is
a permanent intolerance to gluten, for which the only
treatment currently available is a lifelong adherence to
a Gluten-Free Diet (GFD). Once patients are diag-
nosed with celiac disease and begin the gluten-free diet
70% report symptom relief within two weeks (5).
When a patient with celiac disease consumes
gluten an inflammatory cascade occurs primarily in the
proximal part of small intestinal mucosa. Specifically,
this means that the adaptive immune pathway is
thought to provide the major immune response, but
recent evidence also indicates the involvement of the
innate immune system (6). Besides increased T lym-
phocytes, other cell types are also increased, including
B lymphocytes, NK cells, neutrophils, eosinophils,
macrophages and mast cells. In particular, a chronic
recruitment of activated neutrophils is present even in
complete remission of celiac disease (7,8).
When celiac disease patients consume gluten, the
inflammatory cascade is initiated within hours result-
ing in a compromise of barrier integrity, followed by
tissue degradation and eventual inhibition of nutrient
absorption. Celiac disease (CD) has a multifactorial
pathogenesis (9).
CELIAC DISEASE: A COMPREHENSIVE REVIEW AND UPDATE, SERIES #5
Alice Bast, President and Founder, National Founda-
tion for Celiac Awareness, Ambler, PA. Dr. Tom
O’Bryan, Adjunct Faculty, Institute for Functional Med-
icine, National University of Health Sciences,
Chicago, IL. Elizabeth Bast, Student, Harvard Univer-
sity, NFCA Intern, Boston, MA.
Muralidhar Jatla, M.D., Ritu Verma, M.D., Series Editors
by Alice Bast, Tom O’Bryan, Elizabeth Bast
Despite re-classification of celiac disease as a rare disease of childhood to a common dis-
ease affecting men, women and children at any age, most of the three million estimated
sufferers remain undiagnosed. Proper education concerning the various symptoms and
manifestations of the disease is necessary to increase prompt and accurate diagnosis.
Celiac disease’s potentially negative effect on reproductive health is among the most
pressing matters associated with advancing awareness. Men and women with unex-
plained infertility, women with recurrent abortions, intrauterine growth retardation,
low birth weight babies and menstrual disorders are rarely screened for celiac disease
despite scientific studies that indicate a correlation. In the following article, we will
examine the evidence for these occurrences in a literature review, examine potential the-
ories about their cause, and discuss the need for additional research and the addition of
a celiac testing to the differential diagnosis in women with reproductive health problems.
Common symptoms may include bulky stool, con-
stipation, anemia, delayed growth, failure to thrive and
infertility (10,11). Celiac disease used to be perceived
as presenting with gastrointestinal symptoms sugges-
tive of malabsorbtion, such as edema secondary to
hypoalbuminemia, hypocalcemia, vitamin deficiency
states and osteomalacia (12). This manner of presenta-
tion is now described as the “classic” or “typical”
form. Patients with celiac disease may have the
“silent” or “atypical” form with no gastrointestinal
symptoms and the condition may present outside the
intestines and can affect any organ system (13). The
ratio of extra-intestinal to classical symptomatology is
8:1 and, thus, the vast majority of patients have silent
celiac disease and the condition does not present with
overt GI symptoms (14). Patients with this disorder
suffer from generalized poor absorption. Celiac
patients can be eutrophic or have mild to severe mal-
nutrition depending on several factors such as site and
length of the intestine involved in the disease, grade of
malabsorption, and interval between the first symp-
toms and a correct diagnosis. Thus, they may present
selective or universal malabsorption of nutrients.
Functional hypopituitarism and atrophy of reproduc-
tive organs are associated with malnutrition (15).
DIAGNOSIS
The diagnosis of early developing celiac disease
should be based on a combination of clinical features,
histology, serology, and genetics. Conventional histol-
ogy is no longer a gold standard in the diagnosis of the
various stages of this disease (16). Numerous authori-
ties have identified that the majority of celiac patients
visit five or more doctors prior to diagnosis, with a
median time for diagnosis of five-to-11 years after ini-
tial presentation (10,16,17). Historically, diagnosis
was suggested by positive serology and confirmed
with endoscopy. Serum immunoglobulin IgA-class
endomysial (EmA) and transglutaminase 2 (TG2) anti-
bodies are powerful tools in diagnosing celiac disease
with overt villous atrophy (18). However, with an
overwhelming majority of patients presenting silent
celiac disease (ratio of 8:1), knowledge of the limita-
tions of serology is important (19). Recent literature
shows that serology (not only EmA, but also TG2)
seems to be ineffective in detecting most patients
affected by subclinical or silent disease (20). An eval-
uation of endomysial antibodies showed that the sensi-
tivity of this marker was 100% in patients with total
villous atrophy, but the value plummeted to 31% in
patients with celiac disease who had partial villous
atrophy. Antibodies to tissue transglutaminase like-
wise correlate with the degree of villous atrophy (21).
The diagnosis of celiac disease requires the pres-
ence of small intestinal mucosal villous atrophy and
crypt hyperplasia, (Marsh III). However, evidence sug-
gests that small bowel mucosal damage in celiac dis-
ease develops gradually from mucosal inflammation to
crypt hyperplasia and, finally, to partial and subtotal
villous atrophy. Mucosal intraepithelial lymphocytosis
evincing normal villous architecture (Marsh I) precedes
this lesion. From the pathologist’s point of view, an
increased number of intraepithelial lymphocytes in an
architecturally normal duodenal mucosa always sug-
gests potential celiac disease (18,22,23). The 2004 NIH
Consensus Development Conference Statement con-
firms that genetic markers HLA-DQ2 and HLA-DQ8
are present in those with celiac disease (90% and 10%
respectively). Gluten interacts with HLA molecules
activating an abnormal mucosal immune response and
inducing tissue damage.
AUTOIMMUNITY
While many individual autoimmune diseases are rare,
collectively they are thought to affect approximately
8% of the United States population (24). Celiac dis-
ease patients contract other autoimmune disorders 10
times more commonly than the general population
(12). Impaired hypothalamic-pituitary regulation of
gonadal function is a well-recognized complication of
celiac disease. These changes occur independently of
the general nutritional status and an auto-immune
mechanism has been theorized (15,25).
Autoimmune polyendocrine syndromes (APS)
were initially defined as multiple endocrine gland
insufficiencies associated with an autoimmune disease
in a patient. Thyroid autoimmune diseases are the most
frequent autoimmune diseases in the population with a
prevalence rate of 7%–8% of the general population,
(approximately 24 million people) in the U.S.(26). A
PRACTICAL GASTROENTEROLOGY • OCTOBER 2009 11
CELIAC DISEASE: A COMPREHENSIVE REVIEW AND UPDATE, SERIES #5
Celiac Disease and Reproductive Health
PRACTICAL GASTROENTEROLOGY • OCTOBER 2009
12
CELIAC DISEASE: A COMPREHENSIVE REVIEW AND UPDATE, SERIES #5
Celiac Disease and Reproductive Health
classification of APS has identified APS-3 as autoim-
mune thyroid diseases associated with other autoim-
mune diseases, including celiac disease. Fifty-two
percent of patients with autoimmune thyroid disease
can be considered affected by APS-3. During the first
trimester, pregnant women with an increase in thyroid
autoimmunity (TAI) carry a significantly increased
risk for a miscarriage compared to women without
TAI, even when euthyroidism was present before preg-
nancy (27). Autoimmune thyroid disease is the second
most prevalent autoimmune disorder associated with
celiac disease after Type 1 diabetes (28). Patients with
celiac disease are at risk for developing thyroid disease
with an overall three-fold higher frequency than in
controls. Between 30% and 43% of celiac disease
patients will present with thyroid disorders. The preva-
lence of thyroid antibody positivity in euthyroid sub-
jects was four-fold higher in celiac disease patients
than in controls (29,30).
Antiphospholipid syndrome is a syndrome of arte-
rial and venous thrombotic disease, thrombocytopenia,
and fetal wastage. Of the three most commonly asso-
ciated antibodies in antiphospholipid syndrome (lupus
anticoagulant, anticardiolipin and anti-b2-glycopro-
tein-1 antibodies), the anti-b2-glycoprotein-1 antibod-
ies were associated with an unusually high proportion
of pregnancy losses after the tenth week of gestation,
as high as 38.5% (31,32). Fourteen percent of
untreated celiac disease patients will have an elevation
of antiphospholipid antibodies, and, as a result, be at a
higher risk of pregnancy loss.
In a review of 57 patients diagnosed with
antiphospholipid syndrome and 171 healthy controls,
celiac disease-suggestive anti-endomysial antibody
(EMA) positive serology was found in 62.5%. All of
these EMA positive patients also presented with eleva-
tions of the primary pregnancy-risk antibody, anti-b2-
glycoprotein-1 antibodies, the primary pregnancy risk
antibody of antiphospholipid syndrome versus 47% of
EMA negative patients (33). A case study gives a stun-
ning example of the positive impact of celiac diagno-
sis and the implementation of a gluten-free diet. A 34
year old female with APS had suffered two sponta-
neous abortions at week 16. After six months on a
gluten-free diet, all previously elevated antibodies
were undetectable, including anti-b2Glycoprotein-1,
antiendomysial, transglutaminase, anti-thyroglobulin
antibodies and lupus anticoagulant (34).
INFERTILITY
Twelve percent of the reproductive age population in
the United States, about 7.3 million American couples,
suffers from infertility (35). Infertility is commonly
diagnosed when people are unable to conceive after
six-to-12 months without using birth control, depend-
ing on several factors, such as age. Women with recur-
rent spontaneous abortions are also considered infertile
(36). In an effort to have children, couples seek various
treatments, such as surgery or artificial insemination.
The average couple spends about $10,000 per attempt
on Assisted Reproductive Technology (ART). How-
ever, nearly one third of all pregnancy losses are the
result of undiagnosed, treatable diseases (37).
While infertility in 27 % of infertile couples is the
result of ovulation disorders and 25 % the result of
identified male disorders, 17% of couples remain
infertile for unexplained reasons (38). Researchers
have found the rate of celiac disease to be 2.5 to 3.5
times greater in women with unexplained infertility
than in women with normal fertility (39).
The suggested relationship between proper nutrition
in females and the ability to conceive is an additional
worthy note. It has been suggested that positive energy
balance, as well as increased fat storage in females as a
result of proper nutrition, creates an environment within
the reproductive system that enhances a female’s poten-
tial to conceive. A continuum of ovarian function has
been proposed, indicating that ovarian function and
associated fecundity may be subject to minor changes in
energetic environment, creating changes below the
“clinical horizon” of menstruation. For example, studies
have shown that rates of ovarian steroidogenesis in
women with positive energy balances are significantly
higher than in those in negative energy balance who are
subject to follicular suppression (40).
Malnutrition and its derived symptoms most com-
monly present in undiagnosed females with celiac dis-
ease. This symptom can directly compromise the
potential and ability to conceive due to a negative
(continued on page 15)
energy balance and the decreased ability to maintain fat
storage in afflicted females. Those with undiagnosed
celiac disease and who do not follow a gluten-free diet
may intensify unfavorable conditions for conception
within the body and, more specifically, within the repro-
ductive system. Men also suffer from infertility stem-
ming from undiagnosed celiac disease (25). Affected
males show a picture of tissue resistance to androgens.
The increases of follicle-stimulating hormone and pro-
lactin may indicate an imbalance at hypothalamus-pitu-
itary level (41). Hypogonadism is a known factor in
male infertility and has been found in 7% of celiac
males in one survey. Endocrine dysfunction unaccom-
panied by other features of hypogonadism was found
commonly and 19% of male celiacs were infertile.
Improvement in semen quality and successful
pregnancy in previously infertile women is associated
with gluten withdrawal by their male partners. The
most striking endocrine findings in a study of 41
recently diagnosed men with celiac disease was
increased plasma testosterone and free testosterone
index, reduced dihydrotestosterone (testosterone’s
potent peripheral metabolite), and raised serum lut-
enizing hormone, a pattern of abnormalities indicative
of androgen resistance. As jejunal morphology
improved, hormone levels returned to normal (42).
These higher rates of infertility among sufferers of
celiac disease, as well as improvement associated with
the gluten-free diet, indicate the value of celiac-related
antibody testing in couples, both the male and female
partners with unexplained infertility.
EARLY INDICATION: MENARCHE,
MENOPAUSE AND AMENORRHEA
Although few reproductive health organizations cur-
rently have an official stance on celiac disease’s impact
on fertility, multiple studies concerning celiac disease
sufferers and their ages at menarche and menopause
indicate a potential link between celiac disease and fer-
tility. Women with untreated celiac disease who did not
maintain a gluten-free diet were found to have their
first menstrual periods up to 1.5 years later than women
on gluten-free diets. This delay was increased with
increased malnutrition (43). Those with untreated
celiac disease were also found to enter menopause four
or five years before those who were avoiding gluten.
Periods of secondary amenorrhea, when menstrual
periods cease for at least three months, were found in
39% of those with untreated celiac disease, but only 9%
of those on gluten-free diets (44).
In a study examining 59 mother-daughter pairs, 10
of whom had untreated or late onset celiac disease and
49 who were treating their celiac disease with gluten-
free diets, researchers found a significant difference
between ages of menarche. Daughters with untreated
or late onset celiac disease showed a mean age at
menarche of 16.16 years and their mothers showed
15.49 years. This contrasted greatly with the treated
celiac patients who had significantly earlier onsets,
which respectively showed a mean age of 12.33 and
13.82 years in the countryside, 13.08 and 13.49 in a
small town and 12.90 and 12.33 in an urban area.
Overall, this finding demonstrates a strong correlation
between celiac disease, maintaining a gluten-free diet
and a beneficial effect on the reproductive system (45).
In a British study, in which 68 patient-control pairs
were matched to examine celiac disease’s impact on
reproductive health, researchers found similar results.
The mean age at menarche was older in patients with
celiac disease than in controls at 13.6 years and 12.7
years, respectively (46). In summary, a delay in menar-
che could be an early symptom of undiagnosed celiac
disease and may warrant testing for celiac disease.
MISCARRIAGES AND STILLBIRTHS
Studies have shown an increase in miscarriages and
stillbirths in women with celiac disease who are not on
a gluten-free diet, illustrating the need for a proper
diagnosis and the education of obstetrics, gynecolo-
gists and fertility specialists. An Italian study demon-
strated in 2000 that testing for celiac disease can
prevent unfavorable outcome of pregnancy. Since up
to 50% of female celiac pregnancies result in unfavor-
able outcomes or miscarriages, researchers screened
845 pregnant women for celiac disease and found 12.
Of these 12 pregnancies, seven outcomes were unfa-
vorable. There were three deaths, five premature births
and three children born with low birth weights. How-
ever, after six months on a gluten-free diet, these 12
women with celiac disease had six successful pregnan-
PRACTICAL GASTROENTEROLOGY • OCTOBER 2009 15
CELIAC DISEASE: A COMPREHENSIVE REVIEW AND UPDATE, SERIES #5
Celiac Disease and Reproductive Health
(continued from page 12)
PRACTICAL GASTROENTEROLOGY • OCTOBER 2009
16
CELIAC DISEASE: A COMPREHENSIVE REVIEW AND UPDATE, SERIES #5
Celiac Disease and Reproductive Health
cies (47). In a case-control study, comparison of 94
untreated and 31 treated celiac women indicated that
the relative risk of spontaneous abortion was 8.9 times
higher, the relative risk of low birth weight baby was
5.84 times higher and duration of breast feeding was
2.54 times shorter in untreated mothers. None of these
markers related to the severity of celiac disease in the
untreated women. The high incidence of spontaneous
abortion, low birth weight babies and shortened dura-
tion of breastfeeding was effectively corrected with a
gluten-free diet (48).
In a study of female fertility, obstetric and gyneco-
logical history in celiac disease patient-control pairs
illustrated a higher incidence of miscarriages in
patients with untreated celiac disease. Fifteen percent
of pregnancies among women with untreated celiac
disease ended in miscarriage, in contrast to the 6% in
controls. Mothers with untreated celiac disease pro-
duced 120 live babies and seven stillbirths, as opposed
to 161 live babies and one stillbirth found in controls
(49). A study using patients with previously failed
pregnancies, those who began gluten-free diets
showed a 35.6% drop in pregnancy loss and 39.4%
drop in producing babies with low birth weights (44).
Cumulatively, these studies provide evidence that
there is a strong correlation between incidences of mis-
carriage, stillbirth and undiagnosed celiac disease,
while also indicating that maintenance of the gluten-
free diet is imperative to maintaining reproductive
health in celiac disease patients.
INTRAUTERINE GROWTH RETARDATION
An important mechanism of low fertility in untreated
celiac patients may be due to intrauterine growth retar-
dation (IUGR). Also called intrauterine growth restric-
tion or fetal growth restriction, IUGR is defined as a
poorly growing fetus whose weight is less than the tenth
percentile for its gestational age based on a standard
curve for the general population (50). In addition to
common causes such as smoking and alcohol abuse,
numerous studies have linked celiac disease and IUGR.
In a retrospective study of 48 patients with known celiac
disease and 143,663 controls, rates for IUGR were sig-
nificantly higher in celiac patients, 6.3% versus 2.1%,
respectively. The same study also showed a higher rate
of labor induction at 29.2% and 11.9% (51). The authors
concluded that perinatal outcomes of celiac disease
patients are generally favorable; however, higher rates
of IUGR exist in celiac patients. According to the
authors, these results indicate the need for careful sur-
veillance for detection of IUGR and the advise that
prospective studies should focus on screening for celiac
disease among patients presenting with IUGR without a
known cause (48). In a 1999 Danish study of 211 infants
and 127 mothers with celiac disease and 1,260 control
deliveries, Norgard found a 3.4-fold increased risk of
IUGR in infants whose mothers had untreated celiac
disease. In contrast, mothers on gluten-free diets had no
increased risk of bearing children with fetal growth
restriction. This study also found that women with
celiac disease gave birth to infants with a mean birth
weight that was 238 g lower than observed in the con-
trol deliveries. However, the women with celiac disease
who were on gluten-free diets gave birth to babies 67 g
heavier than the controls (52).
Investigating the correlation from a reverse per-
spective, Gasbarrini showed that patients with both
repeated spontaneous abortions (RSA) and IUGR
showed a statistically significant higher frequency of
celiac disease when tested serologically than did the
controls (with no RSA or IUGR). Specifically, 8 %
(3/40) RSA patients and 15% (6/39) IUGR patients
were positive for celiac antibodies, whereas all con-
trols were negative (53). Similarly, Kumar placed 45
patients in two test groups, one comprised of patients
positive for IUGR and one with patients undergoing a
normal trimester. Two patients in the IUGR group
tested positive for celiac antibodies whereas none of
the controls did (54). Greco, et al in Italy demonstrated
that one in every 70 pregnant women admitted to a
major city hospital suffered from untreated celiac dis-
ease; 70% had a poor outcome of pregnancy, and 8/9
women had a second healthy baby after one year on a
gluten free diet (55). In a follow up study, Grecco’s
group demonstrated that the increased risk of sponta-
neous abortions and IUGR achieved statistical signifi-
cance in symptomatic celiac disease pregnant women
(55). An unfavourable neonatal outcome was not only
associated with maternal celiac disease but also with
paternal celiac disease. Infants of celiac mothers
weighed 222 g less than the population average, and
infants of celiac fathers weighed 266 g less than the
population average. The risk of a low birth weight
baby to celiac fathers was five times higher than that in
the general population (11% versus 2.5%) (56).
FERTILITY, NUTRITION AND CELIAC DISEASE
In 2007, Chavarro showed that many cases of infertil-
ity due to ovulatory disorder could be prevented
through changes in diet and lifestyle (57). These
results indicate a niche for celiac disease. Protein from
food is efficiently and almost completely absorbed by
the proximal part of the small intestine. As celiac dis-
ease mainly affects precisely this area of the small
intestine, absorption of proteins can be compromised
and decreased quantities are detected in the plasma.
Fat malabsorption is a common consequence of
celiac disease due to the inflammatory cascade,
impaired meal-induced release of gut hormones (i.e.
cholecystokinin) secondary to the loss of enterocyte
mass (villous atrophy) and increased somatostatin lev-
els (58). Within the discussion of reproductive system
imbalances, the fat-soluble nutrients Vitamins A, D, E
and K merit special attention. Vitamin A is fundamen-
tal for the maintenance of spermatogenesis (59) and
testosterone secretion (60). Retinols appear to act on
three main types of testicular cells (Sertoli cells, germ
cells and Leydig cells) of both adult and fetus (60). A
decrease in testosterone production leads to atrophy of
the accessory sex organs (61). Vitamin D controls Th1-
driven autoimmunity by down-regulating nuclear fac-
tor-kB (NF-kB) activity, increasing IL-10 production
and decreasing IL-6, IL-12, IFN-c, and TNF-a produc-
tion, leading to a cytokine profile which favors less
inflammation (62,63). Vitamin E supports the correct
differentiation and function of epidydimal epithelium,
spermatid maturation, and secretion of proteins by the
prostate (62). Vitamin K deficits in pregnant women
can harm the fetus, leading to chondrodysplasia
punctata with nasal hypoplasia and spinal cord abnor-
malities (64). Hypoprothrombinemia caused by malab-
sorption of vitamin K is a well-known complication of
celiac disease. Prolonged prothrombin time is reported
in 18.5% of adults and 25.6% of children with celiac
(65). Given the preponderance of studies showing a
correlation between undiagnosed celiac disease and
IUGR discussed previously, Rostami investigated the
correlation between celiac disease and reproductive
disorders proposing possible causal relationships. He
noted that 25% of celiac patients have hyperprolacti-
naemia, which may be one of the causes of impotence.
Furthermore, the most likely causes of reproductive
disorders resulting from malnutrition are zinc defi-
ciency, selenium deficiency and anemia (66).
Selenium deficiencies have been linked to fertility
problems (65,67), iron deficiency to fetal-maternal
morbidity (49,62,68), and folate deficiency to congen-
ital malformations, recurrent spontaneous miscarriage,
abruption placentae, and pre-eclapisa (11,35,50). Zinc
is an essential trace element key in numerous functions
including DNA synthesis, cell division, protein synthe-
sis and immune response (66,35,69). Zinc has also
been linked to fertility and zinc deficiency has been
associated with impaired synthesis/secretion of FSH
and LH, as well as abnormal ovarian development and
obstetrical disorders, including IUGR (32,33). Zinc
also has been proposed as a factor in male fertility
issues (34), specifically in spermatozoal function. Zinc
deficiency is associated with fertility problems, spon-
taneous abortions, congenital malformation, still birth
pre-eclampsia, and intrauterine growth retardation
(25,26,32,34). Intestinal biopsy correlated inversely
with plasma zinc concentration. Decreased concentra-
tions of zinc and other micronutrients may be attribut-
able to an acute phase response and reverses with
treatment with a gluten-free diet (70).
Women with celiac disease are often deficient in
iron, as well as other micronutrients, and have altered
reproductive function, including infertility. Chavarro
investigated the effect of iron intake on risk of ovula-
tory infertility among apparently healthy women. The
results showed an inverse relationship between iron
intake and risk. Chavarro concludes overall that iron is
important in ovulatory function, but may also be
important in other aspects of fertility as many celiacs
are shown to have low-iron and also show idiopathic
infertility (71).
FUTURE IMPLICATIONS
It is surprising that although clear reports were given
the pilot work (67,72) about 20 years ago, celiac dis-
PRACTICAL GASTROENTEROLOGY • OCTOBER 2009 17
CELIAC DISEASE: A COMPREHENSIVE REVIEW AND UPDATE, SERIES #5
Celiac Disease and Reproductive Health
PRACTICAL GASTROENTEROLOGY • OCTOBER 2009
18
ease has not yet gained adequate attention among
obstetricians. In the subsequent two decades, many
epidemiological studies clearly showed that it is a very
common disease, one of the most common life-long
disorders in both the U.S. and Europe (13), that it
affects women more than men, and that it has to be
considered in relation to reproductive function.
The bottom-line drawn from countless studies on
celiac disease and infertility over 25 years is the
importance of diagnosis, yet celiac disease is not com-
monly tested as part of preconception health require-
ments in those suffering from reproductive issues.
Despite the strong recommendation of many studies
prompting a strict dietary treatment to prevent neo-
plastic and systemic complications, decrease mortality
and reverse the risk to many complications of preg-
nancy, neither the American College of Obstetricians
and Gynecologists (ACOG) nor the March of Dimes
officially recommend testing for celiac disease. Both
groups are waiting for more studies in the United
States as their knowledge of celiac disease’s causal
effects on fertility is continually evolving. Despite this
argument, the cost-to-benefit ratio of testing for celiac
disease is clear. The only negative repercussion to test-
ing for celiac in unexplained infertility is the compar-
atively nominal cost of the test, whereas testing
positive may give potential parents the answer to the
problem without the use of costly and invasive proce-
dures. Above all, it is imperative that those with celiac
disease are diagnosed and begin their gluten free diet
as soon as possible in order to maintain their health in
all respects. n
Acknowledgment
A special thanks to Sydney Lupkin, undergraduate at
Boston University and NFCA Intern.
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