A 28-year-old IT professional named Sara who came to me for a consultation on her gynaecologist’s advice, whom she consulted to plan her pregnancy. She was overweight, had been diagnosed with Polycystic Ovarian Disease (PCOD/ PCOS), resulting in irregular periods with excessive facial hair.
She worked long hours, had little or no time to exercise, and consumed quite a bit of junk food. Her mother had a history of diabetes, which was diagnosed at 40 years of age.
As her age was only 28 years, she did not consider the possibility of diabetes in herself. Her gynaecologist screened her for diabetes with a test called HbA1C, which gives an indication of blood sugar levels for the past 3 months. She was shocked to find out that she was diabetic, and had probably been one for quite some time, as evidenced by an elevated HbA1C.
What is the link between diabetes and fertility?
Diabetes mellitus is linked with fertility across multiple junctures in a woman’s life. It starts right from the time a baby girl is in her mother’s womb, till the time she becomes an adult.
A woman who suffers from diabetes during her pregnancy alters the genetic make-up of her daughter by increasing her risk for insulin resistance. Insulin resistance is the inability of the body to use insulin appropriately, leading to high levels of insulin in the body; this can result in obesity, PCOD and type 2 diabetes mellitus (in adolescence for this child).
When this young girl grows up and gets married, her PCOS can cause infertility, increasing her need for assisted reproduction (medications to get pregnant). Once a woman is reported to be diabetic, and if she enters pregnancy in an unplanned manner, it can have grievous consequences. The baby can have major defects in the development of the Brain, Heart and Spine.
Even when some women are not reported to be diabetic prior to pregnancy, they develop diabetes at approximately 7-8 months of pregnancy. The consequences of diabetes during pregnancy are abnormal/ excessive growth of the baby (macrosomia), excess fluids around the baby (polyhydramnios), etc. At delivery, the baby may have low blood sugars, low Calcium, Jaundice and may experience difficulty in breathing.
The long term consequences? Probably the most serious consequence of diabetes during pregnancy, is the risk of the mother becoming permanently diabetic in the next 5-10yrs after delivery. This is a grave consequence, as this young mother will need to juggle her own health with the myriad responsibilities of a growing child.
PCOS and diabetes also increase the long term risk of Cardiovascular Disease and Endometrial Cancer. So, diabetes in mother begets diabetes in daughter. Of course, a history of diabetes in the father or other family members further heightens the risk of developing diabetes.
What is the solution to this complex problem?
The intervention should start right at the time of adolescence. Preventing weight gain in adolescence with healthy diet and plenty of physical activity can delay and dilute the impact of PCOS.
Counselling which entails explanation of why need for weight maintenance, helps the adolescent to adjust to curbing junk food intake when others around her are consuming it.
How to manage this issue?
If PCOS develops, appropriate evaluation and treatment by an Endocrinologist is very important. Once a woman with insulin resistance or with pcos gets married, planning pregnancy after ruling out diabetes is of great importance.
She must be counselled to use effective contraception until a time she is ready to conceive; then she can be screened for diabetes prior to discontinuing her contraception. Prevention is the key in absence of a cure for insulin resistance, PCOS or diabetes mellitus.
What happened to Sara?
I counselled Sara to start an exercise program with at least 150mins of moderate intensity aerobic exercise each week. This could include brisk walking, jogging, swimming or cycling. I also asked her to avoid all bakery products, fried foods and sweets in her diet.
I emphasised the need to include more salads, whole grains and fruits to increase fibre, minerals and vitamin intake. I started her on medication to reduce insulin resistance and to control her blood sugars.
I will reassess the HBA1C after 3mnths and once she achieves a value as close to normal as possible (<= 6.5%), I will advise her to go back to her gynaecologist to plan her pregnancy. I emphasised that she needs to use contraception (to avoid pregnancy) till we achieve a good blood sugar value, when safe pregnancy can be planned.
What should women like Sara look out for?
When planning a pregnancy, women must get themselves screened for diabetes; this screening should be done irrespective of age, due to the high prevalence of undiagnosed diabetic Indians at earlier age.
One should look out for the usual markers of PCOS – irregular periods, excessive facial hair, acne or hair loss (on the scalp) coupled with excessive weight gain. Insulin resistance can be diagnosed by looking for a dark skin around the neck (called Acnathosis Nigricans), or by measuring levels of Insulin in the blood.
The author is a Consultant Endocrinologist Hiranandani Hospital, Vashi- A Fortis Network Hospital