Coeliac disease is an autoimmune condition affecting about 2% of females and males who are planning a pregnancy and can be a factor to consider in the world of unexplained infertility (Glimberg et al., 2021). The World Health Organization (WHO) classes Celiac disease as a chronic illness that occurs in people who are genetically predisposed to it. Between 1 and 2% of the general population have Celiac disease and it is mostly present in women who are of a fertile age.
What is gluten and how does coeliac disease damage fertility-related health?
What is gluten? Gluten is a mixture of proteins found in certain grains like wheat, barley, rye, triticale, and spelt. It gives dough its elasticity, allowing it to rise and keep its shape. Coeliac disease affects the small intestine specifically the villi or finger-like projections which are responsible for extracting some key nutrients from your food. Due to the autoimmune and inflammatory reaction in people with Coeliac Disease after eating a gluten-containing food (even the tiniest amount) over time this can lead to blunting of the villi, leading to nutrient malabsorption specifically iron, calcium and sometimes vitamin D, inflammation, and has been linked to impacts on male and female fertility when left unmanaged and/or undiagnosed.
Evidence linking untreated coeliac disease to infertility and pregnancy complications
Research suggests that women with untreated Coeliac Disease have a higher risk of infertility and recurrent miscarriages (Butler et al., 2011). Furthermore, untreated Celiac disease increases the risk of spontaneous pregnancy loss, premature birth and deterioration of foetal growth leading to babies that are born with a very low weight and delayed intrauterine growth14. Therefore, early detection and an appropriate diet is essential for improving these symptoms and ensuring a safe pregnancy.
The researchers found that women with coeliac disease, either before or after diagnosis, were no more likely to report fertility problems than women in the general population. The only exception were women diagnosed with coeliac disease aged between 25 and 29 years old. Women with coeliac disease may be fertile for a shorter period of time because they may start their periods later and have an earlier menopause.
Male fertility and coeliac disease
However, it can also affect men and can cause abnormalities in sperm quality that can be reversed when sufferers follow an appropriate gluten-free diet 3. Therefore, men with Celiac disease also need to be careful with their diet in order to guarantee optimum semen quality when they are trying for a child.
How nutrient malabsorption affects reproductive health
If you have coeliac disease and are not following a gluten free diet, you are more likely to be deficient in folic acid, iron, zinc and selenium. This is because you are not absorbing these nutrients from food because of the damage to the lining of your gut. These nutrients are all essential for a healthy reproductive life. If you have Celiac disease and are pregnant, you must ensure that you follow a balanced diet that takes the special circumstance of your pregnancy into account.
In fact, wholegrains have been shown to support the uterine lining thickness for implantation (Gaskins et al., 2016). Unnecessarily limiting gluten-containing food has been found to be linked to a reduction in key areas such as dietary fibre, due to the reduction in whole grains. And interestingly, those following a gluten-free diet have also been shown to have a harder time reaching their nutrient goals of zinc, iodine, and folate.
Diagnosis, population data and clinical relevance
For the study, the research team pulled data on 9,368 women with celiac disease from the TriNetX database, which includes health records from 80 healthcare organizations in the United States. On why this study is important, lead researcher Dr. Rama Nanah said in an interview with Healio, “By raising awareness of these higher rates of women’s health disorders in women with celiac disease, we hope this will provide a call to gastroenterologists to think of this association and evaluate patients accordingly, including referral to and partnership with our OB/GYN colleagues to care for these women.
If Coeliac Disease has been ruled out through sufficient testing with your medical team, current research suggests that there is no specific benefit to avoiding gluten for the average person who is trying to conceive. So, following a strict gluten-free diet can be highly restrictive and may limit the variety of foods in your diet, potentially impacting your overall nutritional status.
When a gluten-free diet may help: endometriosis and Hashimoto’s thyroiditis
Some People with Endometriosis: A small study of 200 participants with Endometriosis, who went gluten-free for 12 months showed 75% of participants had an improvement in symptom profile. The study did not measure fertility or inflammation. The other 25% of participants did not show any worsening or improvement of symptom profile (Marziali et al., 2012). So, while more studies are required there is some evidence that some individuals with endometriosis may experience symptom relief by adopting a gluten-free diet.
Those with Hashimoto’s Thyroiditis: Hashimoto’s thyroiditis is an autoimmune disorder that affects the thyroid gland. It can lead to an underactive thyroid (hypothyroidism), which may impact fertility. In these cases, a trial of a gluten-free diet may help in managing some of the thyroid autoantibodies. We must exclude Coeliac Disease first because the level of strict gluten exclusion for Coeliacs is much higher than those aiming to be gluten-free or significantly reducing gluten in the diet.
Whilst being gluten-free will not directly impact your fertility for those with Hashimoto’s, it may help with your thyroid autoantibody management and subsequently may assist with menstrual cycle regularity and ovulation, which naturally increases the chances of conception.
Non-coeliac gluten sensitivity, fructan intolerance and symptom improvement
If you have ruled out coeliac disease but notice you do actually feel better with fewer gluten-containing foods in your diet, there may be a number of reasons. Another possible explanation is fructan intolerance, a digestive disorder characterised by difficulty in digesting and absorbing fructans, which are a type of carbohydrate found in certain foods. Fructans are a type of oligosaccharide, a chain of sugar molecules, and they are present in various fruits, vegetables, and grains…. including, you guessed it wheat!
The symptoms of fructan intolerance can vary, but they often include things like bloating, tummy aches, gas, diarrhea, constipation, and just an overall uncomfortable feeling in your digestive system. If Coeliac Disease has been ruled out through sufficient testing with your medical team, current research suggests that there is no specific benefit to avoiding gluten for the average person who is trying to conceive.
Dietary guidance for people with coeliac disease planning pregnancy
For those with Coeliac Disease, adhering strictly to a gluten-free diet is paramount for general health and fertility. According to the Spanish Federation of Associations of Celiac Disease Sufferers, the future mother must follow a diet that is rich in nutrients and free from gluten. It must be carefully monitored by a nutritionist. Pregnant women with Celiac disease can eat a wide range of cereals that do not contain gluten. For example, rice, corn, buckwheat, pseudocereals such as quinoa and, of course, legumes.
Therefore, unless there are specific gluten-related sensitivities or medical conditions, it is generally unnecessary and may restrict food choices for those trying to conceive. Commonly this leads to more stress and worry about eating, especially eating out and can impact social life but can also have physical impacts on the diversity of the gut microbiome due to a restriction in certain grains from the diet as well as some nutrients may be at risk, particularly dietary fibre.
Practical points for clinicians and patients
- Exclude Coeliac Disease with sufficient testing before recommending a gluten-free diet to improve fertility.
- Refer and partner across specialties: gastroenterology, OB/GYN and fertility dietitians to optimise care for women with coeliac disease (Dr. Rama Nanah).
- Monitor and correct nutrient deficiencies common in untreated coeliac disease: folic acid, iron, zinc, selenium, calcium and vitamin D.
- Consider a trial of a gluten-free diet under supervision for selected patients with endometriosis or Hashimoto’s after excluding coeliac disease.
- Advise balanced gluten-free alternatives that preserve fibre and micronutrient intake: rice, corn, buckwheat, quinoa and legumes.
Evidence summary and resources
Research suggests that women with untreated Coeliac Disease have a higher risk of infertility and recurrent miscarriages (Butler et al., 2011). Some studies show symptom improvement in endometriosis with gluten exclusion (Marziali et al., 2012) while other large data analyses did not find an overall higher likelihood of fertility problems among women with coeliac disease except for specific age groups. In Vitro Fertilization (IVF) and fertility treatment outcomes are reported across cohorts, and further high-quality prospective studies would help clarify when dietary changes impact conception success.
Who should consider seeing a specialist?
- Anyone with unexplained infertility should discuss screening for coeliac disease with their GP or fertility specialist.
- People with diagnosed coeliac disease planning pregnancy should consult a fertility dietitian and their OB/GYN for preconception planning.
- Men with coeliac disease concerned about semen quality should ensure diagnosis and adherence to a gluten-free diet and seek urological or fertility advice if needed.
Can Celiac Disease Effect On Fertility || Fertility Tips || Dr C Suvarchalaa || ZIVA Fertilityy
As fertility dietitians, we often come across a myth that is …gluten is universally bad for fertility. Here at The Dietologist, we are passionate about helping individuals understand how their dietary choices can impact their ability to conceive. Remember, every individual is unique, and it’s important to consult with a healthcare professional, such as a fertility dietitian to tailor a dietary plan that suits your specific needs. By making informed choices, you can empower yourself on your fertility journey.
| Condition | Evidence | Dietary recommendation |
|---|---|---|
| Coeliac disease | Higher risk of infertility, miscarriage, preterm birth; nutrient malabsorption | Strict gluten-free diet, nutrient monitoring and supplementation as needed |
| Endometriosis | Small study: 75% symptom improvement on gluten-free diet (no fertility data) | Consider supervised trial of gluten-free diet for symptom relief |
| Hashimoto’s thyroiditis | Autoimmune thyroid disease can impact fertility; gluten-free trial may lower antibodies | Exclude coeliac disease first; consider supervised gluten reduction if indicated |
| Non-coeliac individuals | No evidence gluten avoidance improves conception | Do not adopt restrictive gluten-free diet without medical reason |
If you have any concerns about your fertility speak to your GP for further advice. Listen to more info about How Coeliac Disease Affects Fertility on our podcast episode with Sally Marchini APD here.