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Diabetes and Fertility

Posted on October 22, 2018 | No Comments on Diabetes and Fertility

Are you a sweet couple? Unfortunately, diabetes may adversely affect fertility. Diabetes affects other hormones and bodily functions in such a way that can make it more difficult for a couple to conceive.

Infertility is the inability of a couple to get pregnant after 1 year of regular, unprotected sexual intercourse. About a third of infertility problems are due to female infertility, and another third are due to male infertility. In the remaining cases, infertility affects both partners or the cause is unclear.

In women
Polycystic ovarian syndrome (PCOS) is the most common cause of female infertility. It is related to diabetes because of the strong feature of insulin resistance in this subset of women. Many patients with PCOS have diabetes.

PCOS is characterized by irregular or absent menstrual periods, problems with ovulation, increased levels of androgens such as testosterone, and ovaries with multiple cysts. The rationale for this complex syndrome is associated with insulin resistance (inefficient insulin).

Insulin is said to bind with low affinity to the luteinizing hormone receptor in the theca cells of the ovaries. The hyperinsulinemia or high insulin levels present in obesity, metabolic syndrome, diabetes, or insulin resistance in general, may stimulate ovarian theca cells and, thus, increase the production of hormones, including androgens. This, in turn, may inhibit normal ovulation because of the hampered development of ovarian follicles.

A woman’s ovaries have follicles, which are tiny, fluid-filled sacs that hold the eggs. When an egg is mature, the follicle releases the egg so it can travel to the uterus for fertilization. In women with PCOS, immature follicles bunch together to form large clumps. The eggs may mature within the bunched follicles, but the follicles don’t break open to release them. Thus, women with PCOS often don’t have regular menstrual periods. And because the eggs are not released, most women with PCOS have difficulty getting pregnant.

Here are the most common signs and symptoms of PCOS in teens or adult women:

  • Abnormal menstrual cycles, no periods, or irregular periods
  • Heavy or prolonged bleeding
  • Painful periods
  • Acne
  • Facial hair
  • Waist measurement greater than 35 inches, or waist bigger than hips (apple shape)
  • Acanthosis nigricans: darker patches of skin in neck folds, armpits, folds in waistline, or groin

Diagnosing PCOS
Diagnosing PCOS involves several steps. The doctor will take a detailed medical history about a woman’s menstrual cycle and reproductive history. During a pelvic exam, the doctor may check for swelling of cysts in the ovary. The doctor may perform a vaginal ultrasound to examine any ovarian cyst or cysts and to evaluate the endometrium (lining of the uterus). If the doctor suspects PCOS, he or she may recommend blood tests to measure hormone levels. Women with PCOS can have high levels of hormones such as testosterone. A glucose tolerance test and/or insulin level may likewise be ordered to look for diabetes or insulin resistance, since many women with PCOS have these conditions. Liver function and lipid profile may also be checked, since these are often abnormal in women with PCOS.

PCOS can negatively affect fertility since it can prevent ovulation. Some women with PCOS have menstrual periods, but do not ovulate. A woman with PCOS may take fertility drugs, such as clomid, or inject fertility medications to induce ovulation. Women can also take insulin-sensitizing medications, such as metformin, to help ovulation take place.

There appears to be a higher rate of miscarriage in women with PCOS. Increased levels of luteinizing hormone, which aids in secretion of progesterone, may play a role. Increased levels of insulin and glucose may cause problems with development of the embryo. Insulin resistance and late ovulation (after day 16 of the menstrual cycle) also may reduce egg quality, which can lead to miscarriage. The best way to prevent miscarriage in women with PCOS is to normalize hormone levels to improve ovulation, and normalize blood glucose and androgen levels. Recently, more doctors are prescribing the drug metformin to help with this.

Eating a balanced diet low in carbohydrates and maintaininga healthy weight can help lessen the symptoms of PCOS. Regular exercise helps weight loss and also aids the body in reducing blood glucose levels and in using insulin more efficiently.

Weight matters
Obesity independent of PCOS is associated with anovulation, and weight loss is an effective therapy for ovulation. Consequently, lifestyle changes that encourage weight loss, including diet, exercise, and folic acid supplementation, all should be instituted in advance of ovulation-induction therapy. Women who have a body mass index above 35 should lose weight before conception, and this should be an integral part of any fertility program’s management of all overweight and obese patients. Weight loss of 5-10 percent of total body weight can achieve a 30 percent reduction of visceral adiposity, an improvement in insulin sensitivity, and may help with restoration of ovulation. More often than not, pharmacotherapy for fertility is needed in addition to all these lifestyle changes; thus, the expert management of a fertility specialist is pivotal.

In women with type 2 diabetes, there has been found to be higher incidence of secondary hypogonadotropic amenorrhea (low sex hormones leading to absence of periods), more so if body mass index is low and glycosylated hemoglobin (HbA1c) is higher than normal. In women with diabetes mellitus desiring pregnancy, prepregnancy counseling is essential and adequate sugar control before conception is critical to diminish the risk of spontaneous abortion, fetal abnormalities, macrosomia (abnormally big baby), and other pregnancy complications. Thus, diabetic women should aimfor an HbA1c of below 6 percent, or below 7 percent if the risk of hypoglycemic episodes is too high, before getting pregnant.

For women with type 1 diabetes, a Swedish study published in 2007 associated type 1 diabetes with reduced fertility. This, however, is reduced if the diabetes is found to be uncomplicated and if the onset of type 1 diabetes is 20 years or less. The study suggested that strict metabolic control, especially exercised in the preceding 20 years, may help prevent subfertility. However, although the risk of congenital malformations has decreased for these mothers with type 1 diabetes, it is still higher than that for the general population.

In men
Men with diabetes mellitus can experience infertility for many reasons. Men with longstanding diabetes mellitus might have retrograde ejaculation due to autonomic neuropathy.

Erectile dysfunction is also highly prevalent in men who have had diabetes for more than 10 years. Men with type 2 diabetes mellitus have a higher prevalence of low testosterone levels than age-matched controls.

In numerous cross-sectional studies, levels of testosterone in men have been inversely associated with several recognized risk factors for the development of type 2 diabetes, such as obesity, central adiposity (belly fat), and an elevated fasting plasma concentration of insulin and glucose. Several prospective studies found that low levels of testosterone and sex hormone–binding globulin predict the subsequent development of type 2 diabetes among aging men. Low plasma testosterone concentration is associated with other correlates of diabetes, such as cardiovascular disease and hypertension.

Majority of patients with type 2 diabetes are overweight or obese. The relationship between obesity and erectile dysfunction can be explained by decreased testosterone levels and elevated pro-inflammatory cytokines (substances produced in the cell), which induce dysfunction in the blood vessel wall through the so-called nitric oxide pathway. Increased testicular temperature also adversely affects sperm production.

Obesity often is associated with decreased physical activity and increased fat deposition in the abdomen and scrotum, which may increase local testicular temperature. Weight loss is the cornerstone of the treatment of obesity-associated infertility.

Diagnosing male infertility
Diagnosis of male infertility includes a thorough physical exam, semen analysis, ultrasound, and hormonal tests if warranted. Treatment for infertility should first address any underlying medical condition that may be contributing to fertility problems. Control of diabetes and its complications is clearly important. Drug therapy may be used to treat hypogonadism and other hormonally related conditions. Surgery is used to repair varicoceles and correct any obstructions in the reproductive tract.

If fertility issues remain unresolved, intrauterine insemination (also called artificial insemination) and assisted reproductive technologies, such as in vitro fertilization, may be considered.

Other lifestyle changes or tips for helping fertility include the following:

  • Avoid cigarettes and any drugs that may affect sperm count or may reduce sexual function.
  • Overweight men should try to reduce their weight as obesity may be associated with infertility.
  • Get sufficient rest, and exercise moderately but regularly. (Excessive exercise can impair fertility.)
  • Stress may contribute to reduced sperm quality. Although it is not proven that stress reduction can improve fertility, this may help couples go through the difficult processes involved in fertility treatments.
  • Although no studies indicate that tight underwear and pants contribute to male infertility, there is no harm in wearing looser clothing.
  • To prevent overheating of the testes, men should avoid hot baths, showers, and steam rooms.
  • Avoid use of sexual lubricants (e.g., KY-jelly) as they may affect sperm motility.

If all else fails, despite all human intervention, it may well be comforting to accept that everything does happen “in God’s time!”

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