Diabetes - The Silent ‘Fertility’ Killer
Infertility, i.e. the inability to become pregnant, affects about 10% of the population. The field of reproductive medicine to hasn’t been able to insulate itself from the recent scourge of diabetes. In the past, most of the Type 2 diabetes patients were typically peri-menopausal, but with the changing dietary and lifestyle patterns, diabetic patients are frequently being seen during their reproductive years. The reproductive axis extends from the brain to the ovaries in a woman and the transmission of biological signals is affected by various hormones. Insulin, the main hormone involved in diabetes, acts as a co gonadotropin i.e. assists the main reproductive hormones in their functioning. Any abnormality in insulin thus directly affects the reproductive axis, leading to fertility compromise.
Type 1 diabetes is associated with low insulin levels leading to poor functioning of this axis (hypogonadism), whereas type 2 diabetes causes high levels of insulin which in turn leads to polycystic changes in the ovaries. Polycystic ovarian syndrome (PCOS) is the most common hormonal disorder among women of reproductive age and one of the most common causes of female infertility. A large proportion of these PCOS patients are obese. PCOS and obesity, both are associated with insulin resistance and ultimately diabetes. Diabetes itself, as mentioned, leads to PCOS like changes in the ovaries. There is thus an intricate link between diabetes, obesity, PCOS, and infertility.
Fertility Challenges for Women with Diabetes
Diabetes may cause delayed menarche (onset of menses for the first time) and this is compounded by the fact that high sugar causes rapid and premature ovarian aging as evidenced by an early menopause. Thus diabetes leads to shortening of a woman’s reproductive lifespan. During the reproductive years, diabetes has consistently been associated with menstrual abnormalities as well. The risk of oligomenorrhea, or delayed periods, is directly proportional to the levels of blood glucose. Uncontrolled diabetes may also negatively affect a growing egg’s microenvironment, thus compromising on ovarian hormone synthesis, ovulation, and the egg’s quality. Further, it may lead to repeated STDs and infections of pelvic organs like the ovaries and the fallopian tubes, compromising on a woman's fertility potential. Even ARTs (Assisted Reproductive Techniques) like IVF (test tube babies) are fraught with challenges when dealing with a diabetic patient with complications ranging from procedure site infections to poor quality of retrieved eggs. And even if a woman manages to get pregnant crossing the plethora of hurdles, diabetes often prevents the embryo from implanting securely in the uterus, causing a miscarriage-at time even before the woman realizes she had been pregnant. High glucose levels are reported to increase a woman’s chances of miscarriage by 30-60% and diabetic pregnancies are well known for their high-risk nature with threats to both the mother and the fetus.
Men Aren’t Safe Either!
Men too can experience infertility issues secondary to diabetes. They may suffer from erectile dysfunction (very common in uncontrolled diabetes) or retrograde ejaculation, where semen is pushed up into the urinary bladder, instead of the female organs.
What Should We Do?
• Diabetes management in a woman of reproductive age involves close cooperation between the infertility specialist and an endocrinologist.
• The key lies in consistency, blood sugar levels should be under control and stable for at least 3 months before attempting pregnancy.
• This, along with intensive education and regular drug therapy with the aim of achieving strict sugar control, prevents or at least modifies many of these complications.
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