By Dr Tejal Lathia
Consultant Endocrinologist, Hiranandani
Hospital, Vashi, Mumbai, India
Diabetes mellitus affects more than 70 million people in India. Though traditionally we expect diabetes at older ages, in India the demographic of diabetes is rapidly changing. Every single day we see young patients between the ages of 30-40, both male and female recently diagnosed with diabetes. This is attributable not only to our genes (which confer insulin resistance) but to our sedentary lifestyles, poor eating habits and stressful lives. Approximately 10-15% of the population also suffers from prediabetes the incidence of infertility is on the rise.
According to the Indian Society of Assisted Reproduction, infertility affects 10-14% of the Indian population with higher rates in urban areas where 1 in 6 couples suffer from infertility. Nearly 27.5 million couples actively seeking fertility suffer from infertility. This gives rise to a complex problem. Young people desiring fertility are afflicted with diabetes mellitus and often have to now face two problems instead of one.
Diabetes has both direct and indirect impact not only on the ability to get pregnant (fertility), but on the outcome of pregnancy itself as well as having long term repercussions on the future child. Both women and men experience the negative impact of diabetes mellitus on their fertility.
Diabetes & Men
Diabetes can affect men in several ways and all these factors either alone or together can impair fertility in men:
- Hormonal disturbance where reduced testosterone (male hormone) levels lead to reduced sexual drive.
- Erectile dysfunction due to nerve damage in the penis or poor blood flow with inability to have effective sexual intercourse.
- Retrograde ejaculation because of nerve damage where during ejaculation, sperms go backwards into the urinary bladder instead of forward into the vagina.
- Poor sperm quality and volume leading to lower pregnancy rate and often abortion.
- Good diabetic control with proper medications and lifestyle modifications leads to an increase in testosterone levels, better libido, improvement in sperm quality and improvement in overall fertility rates.
- A moral issue here is also that a healthy father can take care of his future child and fulfil his responsibilities.
Diabetes & Women
Diabetes mellitus affects women too.
- In women, the commonest cause of infertility is polycystic ovarian disease (PCOD). There is a single common thread which runs through the entire spectrum – Insulin resistance.
- Insulin resistance causes weight gain, delayed release of egg and delayed menses, increased male hormone levels (causing pimples and excess hair on the body). This defines polycystic ovarian disease because ovaries have a bubbled (cystic) appearance on sonography. Insulin resistance is also the underlying cause for diabetes mellitus.
- So, patients with PCOS not only suffer from infertility but are at a greater risk of becoming diabetic before, during or after the pregnancy.
- As we marry late, the diabetes is more likely to manifest already by the time the patient seeks fertility. Obesity caused by PCOS may be independently associated with poorer egg quality and adverse egg environment leading to infertility. Obesity also worsens diabetes mellitus.
- Diabetes mellitus and obesity are both chronic (long standing) inflammatory conditions where body releases inflammatory cytokines (chemicals) which are toxic to the egg. Good glycemic control will help reduce the levels of these chemicals.
- Diabetes mellitus makes a woman more vulnerable to infection. Genital tuberculosis or sexually transmitted infections can cause fallopian tubes to be damaged and they cannot transport the eggs properly interfering with fertility.
- Women like men also suffer from inadequate sexual arousal and inadequate vaginal lubrication affecting almost 14-45% of diabetic women as compared to controls. Female sexual dysfunction may have a secondary effect on fertility by decreasing sexual desire and limiting sexual activity, especially around the time of ovulation.
- Good control of diabetes mellitus will lead to reduction in infections, better egg release and menstrual regularity and thus, greater chances of fertility. Weight loss will also improve diabetes as well as improve egg quality.
- Once the couple is pregnant however, if the wife was diabetic, the problems continue. Diabetic pregnant women face greater risk of abortion in the early months, increased blood pressure, and sudden death of baby in the later months, more early and complicated deliveries. Even after delivery, the baby may face low sugars, breathing difficulties and heart enlargement, Over and above this is the long term risk of obesity, diabetes that this baby may grow up to have.
Prevention is better than cure
Take active steps to lead a healthy lifestyle right from the word go. A healthy lifestyle should be a way of life not a punishment for disease. A healthy lifestyle is a habit you have to acquire. It is not inborn. In developed countries, exercising is like brushing your teeth. People are very aware of what they are eating, the calorie content and its impact on their body.
Most people feel that their parents got diabetes mellitus when they were well into their 50’s and 60’s, so they are safe. This is not true. Diabetes comes earlier in each succeeding generation, so the millennials may well get diabetes in their 20’s and 30’s.
To my mind, the prevention of diabetes starts in childhood. Regular playtime, limited junk food right from preadolescence can help in averting PCOS altogether. Even if PCOS does develop in adolescent and teenage girls, weight maintenance by diet and exercise reduces the impact. Weight once gained by insulin resistant children is almost impossible to lose. Once women enter their 20’s, taking appropriate medical therapy in consultation with an Endocrinologist helps reduce androgen levels, regularize the cycles and maintain weight until a time that the woman is ready to plan fertility.
The same applies for men. To preserve their fertility, they must ensure normal weight and fitness.
All interventions must begin prior to planning pregnancy. All couples must screen themselves for diabetes prior to planning pregnancy. How do we screen ourselves? Not by random blood sugars or fasting blood sugar but by glycosylated hemoglobin (HbA1c) which gives a 3 month average blood sugar. Intervention at this stage ensures best outcome of pregnancy and the future of the child.
Diabetes and infertility are both issues which loom large on India’s horizon. Diabetes impacts fertility negatively both for men and women in multiple ways. Steps to prevent diabetes must begin in early childhood in homes and schools well before the problem has a chance to firmly entrench itself in our lives. Younger generation needs to walk the talk by leading healthy lifestyles which will not only improve their diabetes and fertility but prevent these diseases in future generations. Both men and women have equal responsibility for fertility. A man can empower a woman to take care of her health and vice versa.