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Obstetrical & Gynecological Survey:
CME Program: Category 1 CME Review Articles 3, 4, 5, and 6: CME Review Article

Subfertility and Gastrointestinal Disease: ‘Unexplained’ Is Often Undiagnosed

Bradley, Ryan J.* and; Rosen, Mitchell P. MD†

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Abstract

Subfertility can be more reliably explained and effectively treated with an improved understanding of the contribution of chronic medical disease to reproductive dysfunction. This review addresses several common gastrointestinal disorders which are increasingly implicated in infertility and early pregnancy loss: celiac disease, inflammatory bowel disease (ulcerative colitis and Crohn’s disease), and hemochromatosis. Appreciating the reproductive impact of these comorbidities and their treatments enables clinicians to accurately counsel patients and to modify medical and fertility treatments based on etiology. Because unexplained infertility can represent the initial presentation of undiagnosed medical disease, considering these often-subclinical gastrointestinal disorders in the differential diagnosis of subfertility provides an opportunity not only to increase the probability of conception and uncomplicated pregnancy, but also to improve overall maternal health.

Target Audience: Obstetricians & Gynecologists, Family Physicians

Learning Objectives: After completion of this article, the reader should be able to describe the impact of gastrointestinal disease on infertility and early pregnancy outcomes, and to outline the clinical presentations of celiac disease, ulcerative colitis, Crohn’s disease, and hemochromatosis.

The diagnosis of female reproductive dysfunction is primarily focused on disorders originating in the reproductive system; ovulatory dysfunction is responsible for fully 40% of female factor infertility, and tubal and pelvic pathology account for an additional 40%. When diagnostic efforts do not yield an etiologic explanation, physicians acknowledge “unexplained infertility” and often initiate nonspecific fertility treatment. However, with an improved understanding of the reproductive impact of common medical comorbidities (and their treatments), infertility can be more frequently explained and better treated.

This review addresses the impact of several gastrointestinal diseases on infertility and adverse early pregnancy outcomes. Celiac disease, inflammatory bowel disease (ulcerative colitis and Crohn’s disease), and hemochromatosis commonly affect women of reproductive age, have highly variable (often subclinical) presentations, and can be effectively treated if diagnosed. Discussed for each comorbid condition are disease pathophysiology, evidence for an association with subfertility and adverse pregnancy outcomes, proposed etiologies of reproductive dysfunction, risks and benefits of common treatments, and recommendations for optimizing fertility treatment. Although the data in these areas are often limited, awareness of the existing evidence is essential to providing the best possible care for patients desiring pregnancy.

© 2004 Lippincott Williams & Wilkins, Inc.

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