Gut Health and Fertility: An Often Overlooked Link
A case study by Tara Valencius
Hippocrates stated that all disease begins in the gut. This case demonstrates how an undiagnosed gastrointestinal condition can impact on fertility.
Initial Consultation
A 29 year old female presented with fertility concerns. Her and her partner had been attempting to conceive for over 12 months. During this time, she had fallen pregnant twice, however she suffered early pregnancy loss both times. Her GP had referred her for standard bloods, serum sex hormone testing, and a pelvic ultrasound. No abnormalities had been detected aside from low iron. Her partner’s sperm count and morphology were also normal. Her GP recommended continuing to try, with a referral to a specialist fertility clinic for further investigation if she experienced another miscarriage or failed to conceive again within six months. The patient was understandably very distressed about her pregnancy losses and wanted to do everything possible to improve her chances of a successful pregnancy. Her cycle was regular, she was ovulating each month (as confirmed by basal body temperature charting and ovulation test kits), and she had no major menstrual symptoms aside from mild premenstrual syndrome (PMS). This PMS was worsened by the emotional stress of hoping to conceive and being terrified of another miscarriage each month. She had no diagnosed health conditions. She did suffer from constant bloating, abdominal discomfort, and diarrhoea on and off for the past two years. She also experienced frequent mouth ulcers, migraines every two to three months, and was somewhat underweight with a body mass index (BMI) of 18. She was taking an over-the-counter multivitamin, plus folic acid and iodine.
Prescription
Recommended to cease trying to conceive for at least three months, to conduct further investigations and implement preconception care (use of barrier contraception, to avoid impacting hormones)
Recommended a fertility support diet, rich in healthy fats and antioxidants
Referred for further tests, including comprehensive stool analysis, coeliac antibodies, antiphospholipid antibodies, extensive thyroid panel, serum vitamin D, folate, vitamin B12, homocysteine, methylenetetrahydrofolate reductase (MTHFR) gene testing, and anti-mullerian hormone (AMH)
Prenatal + Pregnancy Multivitamin Tablets, 1 tablet daily; containing metabolically active B vitamins. Cease over-the-counter vitamins
Multi-Strain Probiotic Powder, 1.5 g twice daily; providing 30 billion CFU per serve
Herbal Iron Tonic liquid, 15 mL daily; containing iron plus supportive herbs and nutrients
Liquid herbal blend, 5 mL three times daily; containing Chaste tree (Vitex agnus-castus) 1:2 20 mL, Shatavari (Asparagus racemosus) 1:2 30 mL, Dong Quai (Angelica polymorpha) 30 mL, Chamomile (Matricaria chamomilla) 1:2 20 mL
Follow Up- Three Weeks
Test results showed positive coeliac antibodies, and low vitamin D. All other results were normal. Untreated coeliac disease is associated with reduced conception rates, increased risk of repeated miscarriage, and adverse pregnancy outcomes including stillbirth, premature birth, and low birth weight.1 This may be due to immunological dysfunction compromising placental development and function, or causing coagulation abnormalities which affects placental and foetal microvascular function. Nutrient deficiencies caused by coeliac-induced malabsorption may also play a role.1
Prescription
Referred back to GP for gastroenterologist referral and confirmation of coeliac disease via endoscopy
Continue previous prescription
The initiation of a gluten free diet and gut repair program was delayed so as not to impede an accurate diagnosis. A risk-benefit assessment of this approach was discussed in depth with the patient, who chose this path.
Follow Up- Eight Weeks
Further testing and endoscopy had confirmed the diagnosis of coeliac disease. The patient was feeling a little stressed about the diagnosis, but also hopeful that treating it would improve her chances of a healthy pregnancy. After discussion, she agreed to wait another three months before attempting to conceive again, to implement a gut healing program.
Prescription
Implement a strict gluten-free diet. Provided resources, dietary plan, and recipes to assist.
Add anti-inflammatory and gut repairing foods daily, including bone broth, turmeric, ginger, garlic, chamomile tea, and fermented foods such as kefir, kimchi, and sauerkraut. Avoid inflammatory foods such as alcohol, processed meats, trans fats, fried foods, excessive sugar, and artificial additives.
The patient had been very compliant with her diet, and had avoided all sources of gluten since her diagnosis. Her digestive symptoms had improved significantly, with normal bowel movements, no abdominal pain, and bloating only occasionally which was worse before her period. Her emotional regulation was better, and she was feeling positive about attempting to conceive again. Her iron and vitamin D levels had normalised.
The patient conceived within two months of ceasing contraception. She had no major complications during pregnancy aside from morning sickness, and iron deficiency anaemia which required an iron transfusion during her second trimester. She delivered a healthy baby girl at full term, and is absolutely besotted with her.
Clinical Reflections
When treating infertility, our first response is to treat the reproductive system and hormones. However, as this case demonstrates, chronic low-grade inflammation and micronutrient deficiencies can significantly impair the chances of successful conception and pregnancy outcomes. As our wise forefather taught us, the gut is the seat of health and should not be overlooked, even in seemingly unrelated conditions such as infertility.
