Celiac disease and reproductive disorders: meta-analysis of epidemiologic associations and potential pathogenic mechanisms

Perinatal Outcome and Long-Term Gastrointestinal Morbidity of Offspring of Women with Celiac Disease

The aim of this study was to evaluate perinatal outcome and long-term offspring gastrointestinal morbidity of women with celiac disease. Perinatal outcomes, as well as long-term gastrointestinal morbidity of offspring of mothers with and without celiac disease were assessed. The study groups were followed until 18 years of age for gastrointestinal-related morbidity. For perinatal outcomes, generalized estimation equation (GEE) models were used. A Kaplan–Meier survival curve was used to compare cumulative incidence of long-term gastrointestinal morbidity, and Cox proportional hazards models were constructed to control for confounders. During the study period, 243,682 deliveries met the inclusion criteria, of which 212 (0.08%) were to mothers with celiac disease. Using GEE models, maternal celiac disease was noted as an independent risk factor for low birth weight and cesarean delivery. Offspring born to mothers with celiac disease had higher rates of gastrointestinal related morbidity (Kaplan–Meier log rank test p < 0.001). Using a Cox proportional hazards model, being born to a mother with celiac disease was found to be an independent risk factor for long-term gastrointestinal morbidity of the offspring. Pregnancy of women with celiac disease is independently associated with adverse perinatal outcome as well as higher risk for long-term gastrointestinal morbidity of offspring.

The impact of depression, self-esteem, and body image on sleep quality in patients with PCOS: a cross-sectional study

BACKGROUND

To date, some factors associated with quality of sleep in patients with PCOS have been identified. Previous studies have mainly focused on limited psychological variables related to sleep disorder without evaluating them in a comprehensive framework.

OBJECTIVE

The aim of the present study was to evaluate the impact of predictive factors on the sleep quality of PCOS patients using structural equation modeling (SEM).

MATERIAL AND METHODS

The present study is a case control that is done in an infertility clinic in Hormozgan, Iran. The case group (n = 201) consisted of women with PCOS and the control group (n = 199) was healthy women whose partners had male infertility. All the women recruited to the study completed the Hospital Anxiety and Depression Scale, the Body Image Concern Investigation, the Rosenberg Self-esteem Scale, and the Pittsburgh Sleep Quality Index on attendance at the Hormozgan Infertility Clinic. Direct and indirect relationship between clinical signs, psychological situation, self-esteem, and body image was studied as independent predictors of sleep quality using structural equation modeling.

RESULTS

Compared with the control group, there was a lower sleep quality in women with PCOS in all fields, especially subjective sleep quality (P < 0.05), daytime function (P = 0.001), and use of sleep medication (P = 0.003). The strongest effect from a psychological variable on sleep quality was body image which had negative impact on sleep quality of patients with PCOS.

CONCLUSION

Our study showed that body image plays an important role in the sleep quality of women with PCOS.

Diagnostic Accuracy of a Point-of-Care Test for Celiac Disease Antibody Screening among Infertile Patients

BACKGROUND

Screening for celiac disease among infertile patients has been suggested. Several rapid point-of-care (POC) tests aimed at detecting celiac disease antibodies have been developed. It has been suggested that these POC tests can be implemented as a replacement for standard laboratory tests.

OBJECTIVE

To evaluate the diagnostic accuracy of a POC test (Simtomax®) that detects celiac disease antibodies compared with standard laboratory tests when screening for celiac disease among patients referred for fertility treatment in 2 Danish fertility clinics.

METHODS

Serum samples were analyzed for IgA anti-tissue transglutaminase (TGA) as the reference standard test with a cutoff of ≥7 kU/L and by the index POC test based on IgA and IgG antibodies against deamidated gliadin peptides (DGP). In IgA deficiency, the reference standard test was IgG DGP with a cutoff of ≥7 kU/L. Participants answered a questionnaire on gluten intake, symptoms, and risk factors. Diagnostic confirmation was made by duodenal biopsies. IgA TGA/IgG DGP were used as the reference standard to calculate positive and negative predictive values.

RESULTS

A total of 622 men and women (51.6%) were enrolled during 2015. The reference standard IgA TGA/IgG DGP was positive in 7 participants (1.1% [95% CI 0.5-2.3]) and the POC test was positive in 84 participants (13.5% [95% CI 10.9-16.4]), 3 of whom also had positive reference standard tests. This yields a sensitivity of the index POC test of 42.9% (95% CI 9.9-81.6) and a specificity of 86.8% (95% CI 83.9-89.4). Positive and negative predictive values were 3.57% (95% CI 0.7-10.1) and 99.3% (95% CI 98.1-99.8).

CONCLUSION

The sensitivity of the POC test was low; however, the specificity was moderately good. The POC test had a high negative predictive value in this low prevalent population but missed 1 patient with biopsy-confirmed celiac disease. However, because of many false-positive tests, it cannot be recommended as replacement for standard laboratory tests but rather as a triage test to decide if the standard serology tests should be performed.

Prediction of pre-eclampsia: review of reviews

OBJECTIVE

Primary studies and systematic reviews provide estimates of varying accuracy for different factors in the prediction of pre-eclampsia. The aim of this study was to review published systematic reviews to collate evidence on the ability of available tests to predict pre-eclampsia, to identify high-value avenues for future research and to minimize future research waste in this field.

METHODS

MEDLINE, EMBASE and The Cochrane Library including DARE (Database of Abstracts of Reviews of Effects) databases, from database inception to March 2017, and bibliographies of relevant articles were searched, without language restrictions, for systematic reviews and meta-analyses on the prediction of pre-eclampsia. The quality of the included reviews was assessed using the AMSTAR tool and a modified version of the QUIPS tool. We evaluated the comprehensiveness of search, sample size, tests and outcomes evaluated, data synthesis methods, predictive ability estimates, risk of bias related to the population studied, measurement of predictors and outcomes, study attrition and adjustment for confounding.

RESULTS

From 2444 citations identified, 126 reviews were included, reporting on over 90 predictors and 52 prediction models for pre-eclampsia. Around a third (n = 37 (29.4%)) of all reviews investigated solely biochemical markers for predicting pre-eclampsia, 31 (24.6%) investigated genetic associations with pre-eclampsia, 46 (36.5%) reported on clinical characteristics, four (3.2%) evaluated only ultrasound markers and six (4.8%) studied a combination of tests; two (1.6%) additional reviews evaluated primary studies investigating any screening test for pre-eclampsia. Reviews included between two and 265 primary studies, including up to 25 356 688 women in the largest review. Only approximately half (n = 67 (53.2%)) of the reviews assessed the quality of the included studies. There was a high risk of bias in many of the included reviews, particularly in relation to population representativeness and study attrition. Over 80% (n = 106 (84.1%)) summarized the findings using meta-analysis. Thirty-two (25.4%) studies lacked a formal statement on funding. The predictors with the best test performance were body mass index (BMI) > 35 kg/m² , with a specificity of 92% (95% CI, 89-95%) and a sensitivity of 21% (95% CI, 12-31%); BMI > 25 kg/m² , with a specificity of 73% (95% CI, 64-83%) and a sensitivity of 47% (95% CI, 33-61%); first-trimester uterine artery pulsatility index or resistance index > 90^th centile (specificity 93% (95% CI, 90-96%) and sensitivity 26% (95% CI, 23-31%)); placental growth factor (specificity 89% (95% CI, 89-89%) and sensitivity 65% (95% CI, 63-67%)); and placental protein 13 (specificity 88% (95% CI, 87-89%) and sensitivity 37% (95% CI, 33-41%)). No single marker had a test performance suitable for routine clinical use. Models combining markers showed promise, but none had undergone external validation.

CONCLUSIONS

This review of reviews calls into question the need for further aggregate meta-analysis in this area given the large number of published reviews subject to the common limitations of primary predictive studies. Prospective, well-designed studies of predictive markers, preferably randomized intervention studies, and combined through individual-patient data meta-analysis are needed to develop and validate new prediction models to facilitate the prediction of pre-eclampsia and minimize further research waste in this field. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Reproductive complications in celiac disease patients in Slovenia

OBJECTIVE

Celiac disease is associated with higher risk of infertility, recurrent abortions, and adverse outcomes in pregnancy and in puerperium. The aim of the study was to analyse the association between celiac disease and reproductive disorders in the group of celiac patients and compare these to healthy controls.

METHODS

A retrospective case-control matched study. The association between celiac disease and menstrual cycle, gyneco-obstetrical complications was assessed with a questionnaire specifically developed for the study. 144 celiac women and 61 celiac men, members of Slovenian Celiac Society, together with 71 healthy women and 31 healthy men participated in the study.

RESULTS

A higher percentage of celiac women (27.1%) had difficulties in conception of the first child when compared to healthy controls (12.7%) (p = 0.042). In addition, celiac women experienced more complications than healthy controls during the pregnancy, such as abortions or intrauterine growth retardation (p < 0.005). In our study, the prevalence of reproductive problems was not the same in celiac males and females. Altogether 2 celiac men (3.3%) reported having fertility problems, however, the difference between male cases and controls was not statistically significant (p = 0.548).

CONCLUSION

Physicians should examine women with unexplained infertility, recurrent abortions or intrauterine growth retardation for undiagnosed celiac disease. Compared with healthy women, women with celiac disease have increased risk of spontaneous abortions, preterm delivery and fewer successful pregnancies.

Comparison of celiac disease markers in women with early recurrent pregnancy loss and normal controls

PROBLEM

Celiac disease (CD) is an autoimmune intestinal inflammatory disease triggered by gluten in the diet. Untreated CD has been associated with pregnancy loss and infertility. The purpose of this study was to screen unselected women with recurrent pregnancy loss (RPL) for markers of CD to determine whether a correlation exists between RPL and CD serum markers.

METHOD OF STUDY

Frequencies of three serum markers of CD [tissue transglutaminase (TTG) IgA, endomysial (EMA) IgA, and deaminated gliadin peptide (DGP) IgA] were determined by enzyme-linked immunoassay (ELISA). Seven hundred and eight women who had two or more failed clinical pregnancies (cases) and one hundred women with at least one live birth and no miscarriages (controls) were included in this study. All cases had a full workup for RPL based on the American Society for Reproductive Medicine 2013 guidelines. Antiphospholipid antibodies (aPL) were correlated with CD markers based on their potential prothrombotic role. Results The results show no significant difference in the prevalence of CD autoantibodies when comparing the RPL patients with the controls. Over half of the patients who tested positive for serum markers for CD also had positive aPL. Conclusion Screening unselected women with RPL who are asymptomatic for CD is not supported based on these data. Women who test positive for CD may be candidates for aPL testing based on the association of adverse pregnancy outcomes.

Coeliac disease and obstetric and gynaecological disorders: where are we now?

Coeliac disease (CD) is a chronic gluten-dependent enteropathy very common in the general population and characterized by an extremely heterogeneous clinical picture. Although its prevalence is growing worldwide, case-finding strategy remains the mainstay to diagnosis. Thus, correct identification of high-risk categories of patients who need to be tested for CD is an essential part of medical knowledge to a large number of specialists and primary care providers. In this regard, although CD might have a serious effect on women's reproductive health, a widespread consensus is lacking on which categories of obstetric and gynaecological disorders should be tested for CD. The aim of this review is to critically summarize the current literature relevant to CD and obstetric and gynaecological disorders and to provide practical proposals that may be helpful to clinicians involved in the management of these patients.

Celiac Disease: Clinical Features and Diagnosis

The presentation in celiac disease is shifting from the classical malabsorptive presentation to more nonclassical presentations, requiring clinicians to maintain a high level of suspicion for the disease and to be aware of the possible extraintestinal manifestations. The diagnosis of celiac disease is guided by initial screening with serology, followed by confirmation with an upper endoscopy and small intestinal biopsy. In some pediatric cases, biopsy may be avoided.

Management of celiac disease in daily clinical practice

Celiac disease (CD) is the most common autoimmune enteropathy worldwide. In CD, dietary gluten triggers a T cell driven small intestinal inflammation in a subset of genetically predisposed subjects, expressing the HLA DQ2 and/or DQ8 genes on their antigen presenting cells. HLA DQ2/DQ8 can bind gluten peptides after their prior modification by the CD autoantigen, tissue transglutaminase (TG2). This process leads to the activation of gluten reactive T cells, small bowel villous atrophy, crypt hyperplasia and intraepithelial lymphocytosis, the histological hallmarks of CD. The clinical picture of CD is extremely heterogeneous including intestinal (especially diarrhea, abdominal pain, bloating) and extraintestinal (especially associated autoimmune diseases, anemia, osteoporosis) manifestations. The prevalence of CD in most parts of the world is estimated at 1:100-1:150 and its diagnosis is based on the presence of circulating autoantibodies (anti-TG2) and the histological detection of villous atrophy. Treatment is a lifelong gluten free diet but adjunctive therapies are in development. Although CD is a well-characterized disease, it is grossly underdiagnosed, despite the severe consequences of long-term gluten ingestion in CD, such as enhanced autoimmunity, refractory CD and intestinal T cell lymphoma. The aim of the presented review is to provide a clinical guide and to summarize the most recent clinical progress in CD research.

Celiac disease is not more prevalent in patients undergoing in vitro fertilization and does not affect reproductive outcomes with or without treatment: a large prospective cohort study

OBJECTIVE

To study the prevalence of celiac disease in the infertile population undergoing in vitro fertilization (IVF) and assess outcomes.

DESIGN

Prospective cohort study.

SETTING

A single infertility center from January 2016 to March 2017.

PATIENT(S)

Women 18-45 years of age participating in IVF.

INTERVENTION(S)

Patients had serum tissue transglutaminase (tTG) and endomysial (EMA) IgA testing to screen for celiac disease and completed a 10-question "yes or no" survey to assess their medical history, previous testing, dietary habits, and pertinent symptoms.

MAIN OUTCOME MEASURE(S)

IVF cycle outcomes were compared between seronegative and seropositive patients.

RESULT(S)

Of 1,000 patients enrolled, 995 completed serologic screening and 968 underwent oocyte retrieval. Eighteen patients screened positive for both tTG and EMA (1.8%) and 10 additional patients (1.0%) screened positive for one of the two antibodies. The number of mature oocytes retrieved, fertilization rates, and blastulation rates were equivalent between seronegative and seropositive patients. There were 987 patients who completed the questionnaire (98.7%), and 84 reported being gluten free (8.5%). Those who reported being gluten free were no more likely to be antibody positive than the general population. Furthermore, a low-gluten diet was not associated with markers of ovarian reserve, oocytes retrieved, fertilization, blastulation, sustained implantation and pregnancy loss rates.

CONCLUSION(S)

The prevalence of seropositive celiac disease was consistent with that of the general population (2.8%). Patients who were seropositive for celiac disease-related antibodies had outcomes equivalent to seronegative patients, and patients with a gluten-free diet did not have improved outcomes.

The Impact of Autoantibodies on IVF Treatment and Outcome: A Systematic Review

The role of autoantibodies in in vitro fertilization (IVF) has been discussed for almost three decades. Nonetheless, studies are still scarce and widely controversial. The aim of this study is to provide a comprehensive systematic review on the possible complications associated to autoantibodies (AA) impeding the chances of a successful IVF cycle. An Embase, PubMed/Medline and Cochrane Central Database search was performed on 1 December 2018, from 2006 until that date. From the 598 articles yielded in the search only 44 relevant articles ultimately fulfilled the inclusion criteria and were qualitatively analyzed. Five subsets of results were identified, namely, thyroid related AA, anti-phospholipid antibodies, anti-nuclear antibodies, AA affecting the reproductive system and AA related to celiac disease. It may be implied that the majority of auto-antibodies exert a statistically significant effect on miscarriage rates, whereas the effects on clinical pregnancy and live birth rates differ according to the type of auto-antibodies. While significant research is performed in the field, the quality of evidence provided is still low. The conduction of well-designed prospective cohort studies is an absolute necessity in order to define the impact of the different types of autoantibodies on IVF outcome.

Endocrine complications of celiac disease: a case report and review of the literature

PURPOSE

The purpose of this article is to review recent literature regarding endocrine disorders related to celiac disease (CD).

METHODS

We describe a case report and review existing literature on the endocrine manifestations of CD.

RESULTS

CD is an autoimmune disorder characterized by intestinal inflammation in response to gluten. CD can cause a wide range of extra-intestinal complications, including endocrine manifestations. Metabolic bone disease including osteoporosis and osteopenia, vitamin D deficiency, secondary hyperparathyroidism and less frequently osteomalacia can be seen. In CD, fracture risk is increased by 30-40%, while risk for hip fracture is approximately doubled. The risk for other endocrine disorders, particularly autoimmune endocrinopathies, is also increased in those with CD compared to the general population. Epidemiologic data indicate the risk for hypothyroidism is 3-4 times higher among those with CD, while risk of type 1 diabetes is greater than double. Risk for primary adrenal insufficiency is a striking 11-fold higher in those with versus without CD, though the absolute risk is low. Fertility is reduced in women with CD before diagnosis by 37% while male fertility in the absence of hypogonadism does not appear to be affected. Other endocrine conditions including hyperthyroidism, ovarian failure, androgen insensitivity, impaired growth and growth hormone deficiency and autoimmune polyendocrine syndromes have also been associated with CD.

CONCLUSIONS

CD is associated with a wide range of endocrine manifestations.

Gluten-Induced Extra-Intestinal Manifestations in Potential Celiac Disease-Celiac Trait

Celiac disease patients may suffer from a number of extra-intestinal diseases related to long-term gluten ingestion. The diagnosis of celiac disease is based on the presence of a manifest small intestinal mucosal lesion. Individuals with a normal biopsy but an increased risk of developing celiac disease are referred to as potential celiac disease patients. However, these patients are not treated. This review highlights that patients with normal biopsies may suffer from the same extra-intestinal gluten-induced complications before the disease manifests at the intestinal level. We discuss diagnostic markers revealing true potential celiac disease. The evidence-based medical literature shows that these potential patients, who are “excluded” for celiac disease would in fact benefit from gluten-free diets. The question is why wait for an end-stage disease to occur when it can be prevented? We utilize research on dermatitis herpetiformis, which is a model disease in which a gluten-induced entity erupts in the skin irrespective of the state of the small intestinal mucosal morphology. Furthermore, gluten ataxia can be categorized as its own entity. The other extra-intestinal manifestations occurring in celiac disease are also found at the latent disease stage. Consequently, patients with celiac traits should be identified and treated.

Unrecognised coeliac disease among men and women undergoing fertility treatment: A screening study

BACKGROUND

Coeliac disease is an autoimmune disease triggered by dietary gluten and has been associated with several conditions influencing female and male reproduction. Due to unspecific symptoms, coeliac disease can be unrecognised for years.

OBJECTIVE

To estimate the prevalence of unrecognised coeliac disease among couples referred to fertility treatment.

METHODS

Cross-sectional screening for coeliac disease in men and women referred to fertility treatment using IgA tissue transglutaminase antibodies as a marker of coeliac disease and small-bowel biopsies to confirm the diagnosis. Participants answered a questionnaire on gluten intake, gastrointestinal symptoms and reproductive history.

RESULTS

A total of 893 participants (51% women) were screened and eight were coeliac disease antibody positive. Small-bowel biopsies were obtained from seven antibody positive participants and unrecognised coeliac disease was confirmed in one woman and three men, corresponding to a prevalence of 0.45% (95% confidence interval 0.12-1.14). The total prevalence, combining already diagnosed and unrecognised CD cases, was 0.63% (95% confidence interval 0.29-1.12).

CONCLUSION

The prevalence of unrecognised coeliac disease in a group of infertile patients was equivalent to that of the Danish general population and low compared with that observed in the majority of other screening studies of infertile patients. Surprisingly, it should be noted that more men than women had coeliac disease. This result does not support a need for routine screening among infertile patients.

Onset of menarche is not delayed in Slovenian patients with celiac disease

Objective

Celiac disease (CD) is an autoimmune disorder associated with numerous health problems, including reproductive disorders. This study was performed to analyze the association between CD and the menstrual cycle in a group of patients with CD and compare these patients’ characteristics with those of healthy women.

Methods

The study included 145 patients with CD (age, 15–51 years) and 162 healthy women (age, 18–55 years). Age at menarche and characteristics of the menstrual cycle were obtained by an anonymous questionnaire developed for the study.

Results

The age at onset of menarche was 12 to 14 years in 72.9% of the patients with CD and 77.3% of the healthy controls. For most patients (74.2%), the length of the menstrual cycle was around 27 to 28 days with 4 to 5 days of bleeding. Furthermore, 8.4% of patients versus 5.9% of controls experienced bleeding between cycles.

Conclusions

Our results suggest that in Slovenia, the age at menarche in patients with CD is 12.7 years, which is comparable with that in healthy women. We conclude that CD (treated or untreated) may not be associated with late menarche.

Extraintestinal Manifestations of Celiac Disease: Early Detection for Better Long-Term Outcomes

Population-based screening studies have shown celiac disease to be one of the most common chronic gastrointestinal diseases. Nevertheless, because of the diverse clinical presentation, the great majority of patients remain unrecognized. Particularly difficult to identify are the multifaceted extraintestinal symptoms that may appear at variable ages. Although the pathogenesis and long-term outcome of these manifestations are still poorly established, there is some evidence that unrecognized celiac disease predisposes to severe complications if not diagnosed and prevented with an early-initiated gluten-free diet. Therefore, it is of utmost importance that physicians of different disciplines learn to recognize celiac disease in individuals with non-gastrointestinal symptoms. In the future, more studies are needed to clarify the factors affecting development and prognosis of the extraintestinal manifestations.

Recurrent pregnancy loss is associated to leaky gut: a novel pathogenic model of endometrium inflammation?

BACKGROUND

Recurrent pregnancy loss (RPL) occurs in 3-5% in about 30% of cases no cause can be found. Women with RPL show higher prevalence of undiagnosed gut disorders. Furthermore, in endometrial tissues of RPL women, higher expression of pro-inflammatory cytokines and Nalp-3 inflammasome has been observed. Aim of this study was to investigate whether an abnormal gut permeability might occur in RPL women and allow passage into systemic circulation of pro-inflammatory molecules able to induce endometrial inflammation.

METHODS

70 women with idiopathic RPL and 30 healthy women were recruited at the Recurrent Pregnancy Loss Outpatient Unit of the Gemelli Hospital of Rome from March 2013 to February 2017. Enrolled women underwent ⁵¹Cr-ethylene-diamine-tetraacetic acid absorption test to evaluate intestinal permeability. Sera obtained from enrolled women were analysed for lipopolysaccharide (LPS) by ELISA. Anxiety and depression state were evaluated by administering STAI-Y and Zung-SDS tests, respectively. Of all recruited individuals, 35 women with idiopathic RPL and 20 healthy controls accepted to undergo diagnostic hysteroscopy and endometrial biopsy. Endometrial lysates were investigated for inflammasome Nalp-3 by Western blot analysis, and caspase-1, IL-1β and IL-18 by ELISA, respectively.

RESULTS

Higher prevalence of abnormal intestinal permeability (P < 0.0001), increased circulating levels of LPS (P < 0.05), anxiety (P < 0.05) and depression (P < 0.05) were observed in RLP women compared to controls. Endometrial expression of Nalp-3, caspase-1 and IL-1β was significantly increased in RPL group (P < 0.0001; P < 0.05 and P < 0.001, respectively). IL-18 endometrial levels were not found to be higher in RPL cases. Statistically significant association between higher intestinal permeability and abnormally increased expression of endometrial Nalp-3, was observed in RPL (P < 0.01). Furthermore, higher LPS serum levels, a bacterial-derived activator of Nalp-3 complex, was shown to be statistically associated to abnormal endometrial expression of Nalp-3 inflammasome (P < 0.01) in RPL women.

CONCLUSIONS

In women with RLP, leaky gut might occur and allow passage into circulation of immune triggers, potentially able to elicit endometrial innate immune response and, thus, to contribute to miscarriage pathogenesis. Diagnosis and treatment of intestinal disorders underlying leaky gut might improve endometrial environment and pregnancy outcome.

Ovarian Reserve Assessment in Celiac Patients of Reproductive Age

Background

This study aimed to investigate ovarian reserve in patients of reproductive age with Celiac disease (CD) using anti-Müllerian hormone (AMH) levels, antral follicle counts (AFCs), and ovarian volume.

Material/Methods

We included into this study 46 CD female patients and 40 healthy female subjects of reproductive age, ages 18–45 years. Venous blood samples were taken from both groups on days 2–4 of the menstrual cycle, and follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E₂), prolactin (PRL), and AMH levels were measured. On the same day, AFCs and ovarian volumes were determined. Data on body mass index (BMI), gravidity/parity/abortions/alive counts, disease duration, and Marsh histological classification were recorded.

Results

There were no statistically significant differences between CD and control groups in terms of mean age, BMI, or median gravidity/parity/abortions/alive counts (p>0.05). Also, there were no statistically significant differences between the 2 groups in terms of mean FSH, LH, E₂, PRL levels, right and left ovarian volumes, and median right and left ovarian AFCs (p>0.05). However, AMH level was significantly lower in the CD group (p=0.032). No statistically significant correlation was found between AMH levels and age, BMI, FSH, LH, E₂, PRL levels, right and left ovarian volumes, right and left ovarian AFCs, or Marsh histological classification using the Spearman correlation test (p>0.05). However, an inverse correlation was detected showing that AMH levels decrease with increasing CD duration (r=−0.054, p=0.001).

Conclusions

We found that AMH level and ovarian reserve was decreased in CD patients of reproductive age compared to healthy controls, and that AMH level and ovarian reserve decreased with increasing disease duration in CD patients.

Immunological Tolerance, Pregnancy, and Preeclampsia: The Roles of Semen Microbes and the Father

Although it is widely considered, in many cases, to involve two separable stages (poor placentation followed by oxidative stress/inflammation), the precise originating causes of preeclampsia (PE) remain elusive. We have previously brought together some of the considerable evidence that a (dormant) microbial component is commonly a significant part of its etiology. However, apart from recognizing, consistent with this view, that the many inflammatory markers of PE are also increased in infection, we had little to say about immunity, whether innate or adaptive. In addition, we focused on the gut, oral and female urinary tract microbiomes as the main sources of the infection. We here marshall further evidence for an infectious component in PE, focusing on the immunological tolerance characteristic of pregnancy, and the well-established fact that increased exposure to the father's semen assists this immunological tolerance. As well as these benefits, however, semen is not sterile, microbial tolerance mechanisms may exist, and we also review the evidence that semen may be responsible for inoculating the developing conceptus (and maybe the placenta) with microbes, not all of which are benign. It is suggested that when they are not, this may be a significant cause of PE. A variety of epidemiological and other evidence is entirely consistent with this, not least correlations between semen infection, infertility and PE. Our view also leads to a series of other, testable predictions. Overall, we argue for a significant paternal role in the development of PE through microbial infection of the mother via insemination.

Prevalence, incidence, and autoimmune comorbidities of celiac disease: a nation-wide, population-based study in Denmark from 1977 to 2016

AIM

The aim of this study was to describe and identify potential trends with respect to prevalence, incidence, age, sex, and autoimmune comorbidity of celiac disease (CD).

PATIENTS AND METHODS

A Danish nationwide cohort study of CD using data from The National Patient Register. Patients with a primary or secondary diagnosis code of CD during the period 1977 to 2016 were identified. Information on sex, date of birth, death, or immigration was obtained from the Danish Civil Registration System, and autoimmune comorbidities were identified in the Danish National Patient Register. The CD cohort was compared with the general Danish population using a control cohort and aggregated data obtained from Statistics Denmark.

RESULTS

The CD cohort consisted of 11 802 (65% women) patients. The median age at diagnosis of CD varied between 30 years in 1980-1984 and 45 years in 1995-1999 and 27 years in 2015-2016. The prevalence of CD in 1986 and 2016 was 14 and 180 per 100 000 persons, respectively, with a female/male ratio changing from 1.3 to 2.0. Incidence rates (per 100 000 person-years) changed from 1.6 in 1980-1984 to 15.2 in 2015-2016, with the largest increase among females aged 0-9 years. In 2016, prevalence of autoimmune comorbidities was 16.4% among the CD patients compared with 5.3% in the general population.

CONCLUSION

The prevalence of diagnosed CD has doubled every decade in Denmark from 1986 to 2016, and in the same period the female/male ratio has increased and the median age at diagnosis has decreased. The prevalence of autoimmune comorbidity in 2016 was three times higher among CD patients compared with the general Danish population.

Maternal autoimmune disease and birth defects in the National Birth Defects Prevention Study

BACKGROUND

Little is known about the association between maternal autoimmune disease or its treatment and the risk of birth defects. We examined these associations using data from the National Birth Defects Prevention Study, a multi-site, population-based, case-control study.

METHODS

Analyses included 25,116 case and 9897 unaffected control infants with estimated delivery dates between 1997 and 2009. Information on autoimmune disease, medication use, and other pregnancy exposures was collected by means of telephone interview. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for birth defects with five or more exposed cases; crude ORs and exact 95% CIs were estimated for birth defects with three to four exposed cases.

RESULTS

Autoimmune disease was reported by 373 mothers (279 case and 94 control mothers). The majority of birth defects evaluated were not associated with autoimmune disease; however, a statistically significant association between maternal autoimmune disease and encephalocele was observed (OR, 4.64; 95% CI, 1.95-11.04). Eighty-two mothers with autoimmune disease used an immune modifying/suppressing medication during pregnancy; this was associated with encephalocele (OR, 7.26; 95% CI, 1.37-24.61) and atrial septal defects (OR, 3.01; 95% CI, 1.16-7.80).

CONCLUSION

Our findings suggest maternal autoimmune disease and treatment are not associated with the majority of birth defects, but may be associated with some defects, particularly encephalocele. Given the low prevalence of individual autoimmune diseases and the rare use of specific medications, we were unable to examine associations of specific autoimmune diseases and medications with birth defects. Other studies are needed to confirm these findings. Birth Defects Research (Part A) 106:950-962, 2016. © 2016 Wiley Periodicals, Inc.

Prevalence of positive coeliac disease serology and HLA risk genotypes in a multiethnic population of adults in Canada: a cross-sectional study

OBJECTIVES

Coeliac disease (CD) is a complex autoimmune disorder with known genetic risk factors. Approximately 1% of individuals of European ancestry have CD, but the prevalence among different ethnicities living in Canada remains unknown. The objective of the present study was to determine the prevalence of positive CD serology in a population of Canadian adults living in Toronto, and to determine whether the prevalence of CD seropositivity and predisposing human leucocyte antigen (HLA)-DQ2/DQ8 risk genotypes differ between major ethnocultural groups.

DESIGN

Cross-sectional screening study of participants from the Toronto Nutrigenomics and Health and the Toronto Healthy Diet studies.

SETTING

University campus and households across Toronto, Canada.

PARTICIPANTS FREE-LIVING

Adults (n=2832) of diverse ethnocultural backgrounds.

MAIN OUTCOME MEASURES

Prevalence of positive CD serology was determined by screening for antitissue transglutaminase antibodies in individuals with predisposing HLA-DQ2/DQ8 genotypes. HLA genotypes were determined using six single nucleotide polymorphisms in the HLA gene region.

RESULTS

Of the 2832 individuals screened, a total of 25 (0.88%; 95% CI 0.57% to 1.30%) were determined to have positive CD serology. The majority of seropositive CD cases were undiagnosed (87%). Prevalence was highest among Caucasians (1.48%; 95% CI 0.93% to 2.23%), and similar in those of 'Other' (0.74%; 95% CI 0.09% to 2.63%) or 'Unknown' (0.43; 95% CI 0.01% to 2.36%) ethnicity. No cases of positive CD serology were identified among East Asian or South Asian individuals. East Asians had a lower prevalence of HLA risk genotypes than Caucasians and South Asians (p<0.005).

CONCLUSIONS

The prevalence of positive CD serology among Canadian adults living in Toronto is likely ~1%, with 87% of cases being undiagnosed. These findings suggest the need for better screening in high genetic risk groups.

TRIAL REGISTRATION NUMBER

NCT00516620; Post-results.

Meat and Nicotinamide: A Causal Role in Human Evolution, History, and Demographics

Hunting for meat was a critical step in all animal and human evolution. A key brain-trophic element in meat is vitamin B3 / nicotinamide. The supply of meat and nicotinamide steadily increased from the Cambrian origin of animal predators ratcheting ever larger brains. This culminated in the 3-million-year evolution of Homo sapiens and our overall demographic success. We view human evolution, recent history, and agricultural and demographic transitions in the light of meat and nicotinamide intake. A biochemical and immunological switch is highlighted that affects fertility in the 'de novo' tryptophan-to-kynurenine-nicotinamide 'immune tolerance' pathway. Longevity relates to nicotinamide adenine dinucleotide consumer pathways. High meat intake correlates with moderate fertility, high intelligence, good health, and longevity with consequent population stability, whereas low meat/high cereal intake (short of starvation) correlates with high fertility, disease, and population booms and busts. Too high a meat intake and fertility falls below replacement levels. Reducing variances in meat consumption might help stabilise population growth and improve human capital.

Self-compassion directly and indirectly predicts dietary adherence and quality of life among adults with celiac disease

Strict adherence to a gluten-free diet (GFD) is the only treatment for preventing both short- and long-term consequences of celiac disease. Given that following a strict GFD can be difficult, evidence-based strategies are needed to improve the psychological experience of living with celiac disease and following the GFD. Self-compassion appears to be an important component of effectively self-regulating one's behavior to cope with a chronic disease. The main goal of this study was to examine the relationships between self-compassion and management of celiac disease as assessed by (a) adherence to a strict GFD and (b) celiac-specific quality of life (CQoL). The secondary goal of this study was to explore self-regulatory efficacy (i.e., confidence in one's ability to self-manage behavior to follow a strict GFD) and concurrent self-regulatory efficacy (i.e., one's confidence to self-manage other valued life goals while following a strict GFD) as mediators of the relationship between self-compassion and the primary outcomes (adherence and CQoL). In this prospective study, 200 North American adults diagnosed with celiac disease completed online questionnaires at two time points (baseline and 1 month later). Self-compassion at baseline directly predicted stricter adherence (at Time 2; b = -0.63, p = 0.006) and enhanced CQoL (at Time 2; b = -0.50, p = 0.001). Further, self-compassion (at Time 1) also indirectly predicted stricter Time 2 adherence through self-regulatory efficacy (at Time 1; b = -0.26, 95% CI [-0.58, -0.04], R² = 0.29) and enhanced Time 2 CQoL through concurrent self-regulatory efficacy (at Time 1; b = -0.07, 95% CI [-0.14, -0.03], R² = 0.33). This was the first study to assess the effects of self-compassion in relation to the psychological experience of coping with celiac disease and following a GFD. The findings indicate that self-compassion, self-regulatory efficacy and concurrent self-regulatory efficacy are important cognitions in understanding adherence to a GFD and CQoL among adults with celiac disease.

Coeliac disease: a unique model for investigating broken tolerance in autoimmunity

Coeliac disease, a prevalent immune-mediated enteropathy driven by dietary gluten, provides an exceptional human model to dissect the genetic, environmental and immunologic factors operating in autoimmunity. Despite the causative antigen being an exogenous food protein, coeliac disease has many features in common with autoimmune disease including a strong HLA class II association and the presence of pathogenic CD4⁺ T cells and autoantibodies. CD8⁺ intraepithelial lymphocytes specifically target and destroy intestinal epithelium in response to stress signals and not a specific antigen. A unique feature of coeliac disease is the ability to remove gluten to induce disease remission and reintroduce it to trigger a memory response. This provides an unparalleled opportunity to study disease-relevant CD4⁺ T cells that have been expanded in vivo. As a result, the causative peptides have been characterised at a level unprecedented for any autoimmune disease. Despite the complexity of the gluten proteome, resistance to gastrointestinal proteolysis and susceptibility to post-translational modification by transglutaminase help shape a restricted repertoire of immunogenic gluten peptides that have high affinity for disease-associated HLA. The critical steps in coeliac disease pathogenesis have been broadly elucidated and provide the basis for experimental therapies in pre-clinical or clinical development. However, little is known about how and why tolerance to gluten sometimes breaks or fails to develop. Understanding the interactions between genes, the environment, gluten immunity and the microbiome may provide novel approaches for the prevention and treatment of disease.

Physiological Aspects of Female Fertility: Role of the Environment, Modern Lifestyle, and Genetics

Across the Western World there is an increasing trend to postpone childbearing. Consequently, the negative influence of age on oocyte quality may lead to a difficulty in conceiving for many couples. Furthermore, lifestyle factors may exacerbate a couple's difficulty in conceiving due mainly to the metabolic influence of obesity; however, the negative impacts of low peripheral body fat, excessive exercise, the increasing prevalence of sexually transmitted diseases, and smoking all have significant negative effects on fertility. Other factors that impede conception are the perceived increasing prevalence of the polycystic ovary syndrome, which is further exacerbated by obesity, and the presence of uterine fibroids and endometriosis (a progressive pelvic inflammatory disorder) which are more prevalent in older women. A tendency for an earlier sexual debut and to have more sexual partners has led to an increase in sexually transmitted diseases. In addition, there are several genetic influences that may limit the number of oocytes within the ovary; consequently, by postponing attempts at childbearing, a limitation of oocyte number may become evident, whereas in previous generations with earlier conception this potentially reduced reproductive life span did not manifest in infertility. Environmental influences on reproduction are under increasing scrutiny. Although firm evidence is lacking however, dioxin exposure may be linked to endometriosis, phthalate exposure may influence ovarian reserve, and bisphenol A may interfere with oocyte development and maturation. However, chemotherapy or radiotherapy is recognized to lead to ovarian damage and predispose the woman to ovarian failure.

Extraintestinal manifestations of celiac disease: 33-mer gliadin binding to glutamate receptor GRINA as a new explanation

We propose a biochemical mechanism for celiac disease and non-celiac gluten sensitivity that may rationalize many of the extradigestive disorders not explained by the current immunogenetic model. Our hypothesis is based on the homology between the 33-mer gliadin peptide and a component of the NMDA glutamate receptor ion channel - the human GRINA protein - using BLASTP software. Based on this homology the 33-mer may act as a natural antagonist interfering with the normal interactions of GRINA and its partners. The theory is supported by numerous independent data from the literature, and provides a mechanistic link with otherwise unrelated disorders, such as cleft lip and palate, thyroid dysfunction, restless legs syndrome, depression, ataxia, hearing loss, fibromyalgia, dermatitis herpetiformis, schizophrenia, toxoplasmosis, anemia, osteopenia, Fabry disease, Barret's adenocarcinoma, neuroblastoma, urinary incontinence, recurrent miscarriage, cardiac anomalies, reduced risk of breast cancer, stiff person syndrome, etc. The hypothesis also anticipates better animal models, and has the potential to open new avenues of research.

Celiac disease and obstetric complications: a systematic review and metaanalysis

The aim of this metaanalysis was to evaluate the risk of the development of obstetric complications in women with celiac disease. We searched electronic databases from their inception until February 2015. We included all cohort studies that reported the incidence of obstetric complications in women with celiac disease compared with women without celiac disease (ie, control group). Studies without a control group and case-control studies were excluded. The primary outcome was defined a priori and was the incidence of a composite of obstetric complications that included intrauterine growth restriction, small for gestational age, low birthweight, preeclampsia and preterm birth. Secondary outcomes included the incidence of preterm birth, intrauterine growth restriction, stillbirth, preeclampsia, small for gestational age, and low birthweight. The review was registered with PROSPERO (CRD42015017263) before data extraction. All authors were contacted to obtain the original databases and perform individual participant data metaanalysis. Primary and secondary outcomes were assessed in the aggregate data analysis and in the individual participant data metaanalysis. We included 10 cohort studies (4,844,555 women) in this metaanalysis. Four authors provided the entire databases for the individual participant data analysis. Because none of the included studies stratified data for the primary outcome (ie, composite outcome), the assessment of this outcome for the aggregate analysis was not feasible. Aggregate data analysis showed that, compared with women in the control group, women with celiac disease (both treated and untreated) had a significantly higher risk of the development of preterm birth (adjusted odds ratio, 1.35; 95% confidence interval, 1.09-1.66), intrauterine growth restriction (odds ratio, 2.48; 95% confidence interval, 1.32-4.67), stillbirth (odds ratio, 4.84; 95% confidence interval, 1.08-21.75), low birthweight (odds ratio, 1.63; 95% confidence interval, 1.06-2.51), and small for gestational age (odds ratio, 4.52; 95% confidence interval, 1.02-20.08); no statistically significant difference was found in the incidence of preeclampsia (odds ratio, 2.45; 95% confidence interval, 0.90-6.70). The risk of preterm birth was still significantly higher both in the subgroup analysis of only women with diagnosed and treated celiac disease (odds ratio, 1.26; 95% confidence interval, 1.06-1.48) and in the subgroup analysis of only women with undiagnosed and untreated celiac disease (odds ratio, 2.50; 95% confidence interval; 1.06-5.87). Women with diagnosed and treated celiac disease had a significantly lower risk of the development of preterm birth, compared with undiagnosed and untreated celiac disease (odds ratio, 0.80; 95% confidence interval, 0.64-0.99). The individual participant data metaanalysis showed that women with celiac disease had a significantly higher risk of composite obstetric complications compared with control subjects (odds ratio, 1.51; 95% confidence interval, 1.17-1.94). Our individual participant data concurs with the aggregate analysis for all the secondary outcomes. In summary, women with celiac disease had a significantly higher risk of the development of obstetric complications that included preterm birth, intrauterine growth restriction, stillbirth, low birthweight, and small for gestational age. Since the treatment with gluten-free diet leads to a significant decrease of preterm delivery, physicians should warn these women about the importance of a strict diet to improve obstetric outcomes. Future studies calculating cost-effectiveness of screening for celiac disease during pregnancy, which could be easily performed, economically and noninvasively, are needed. In addition, further studies are required to determine whether women with adverse pregnancy outcomes should be screened for celiac disease, particularly in countries where the prevalence is high.

Celiac Disease in Women With Infertility: A Meta-Analysis

BACKGROUND

Celiac disease (CeD) is a systemic disease with manifestations not limited to small intestine. The data on association between CeD and infertility is contradictory. There are no recommendations for the screening of female patients with infertility for CeD.

AIM

We conducted a meta-analysis to find out whether women with infertility are at higher risk of CeD.

METHODS

Literature search was performed using the MeSH keywords "CeD," "gluten," and "infertility." Diagnosis of CeD was based on positive serology and biopsies showing villous atrophy. Data were extracted about CeD patients in 3 groups-women with infertility (including unexplained infertility), unexplained infertility, and controls. Pooled odds ratio (OR) and prevalence, with 95% confidence intervals (CI), were calculated.

RESULTS

Of 105 relevant studies, 5 studies were included for calculation of pooled OR. Four additional studies, where data on controls were not available, were also considered for calculation of pooled prevalence of CeD. Women with infertility had 3.5 times higher odds of having CeD in comparison with control population (OR=3.5; 95% CI, 1.3-9; P<0.01). Similarly, women with "unexplained infertility" had 6 times higher odds of having CeD than controls (OR=6; 95% CI, 2.4-14.6). Of 884 women with infertility, 20 had CeD indicating a pooled prevalence of 2.3% (95% CI, 1.4-3.5). Of 623 women with "unexplained infertility," 20 had CeD. The pooled prevalence of CeD in women with unexplained infertility was 3.2 (95% CI, 2-4.9).

CONCLUSIONS

CeD is more prevalent in women with "all-cause" infertility and "unexplained" infertility than that in general population.

Extraintestinal manifestations of coeliac disease

Coeliac disease is a common disorder that can arise at any age and typically presents with a broad spectrum of symptoms. The disease is thought to be underdiagnosed, in part owing to the fact that coeliac disease is often characterized by associated conditions and extraintestinal manifestations that can misdirect and impede diagnosis. Some of these manifestations are direct consequences of autoimmunity, such as dermatitis herpetiformis or gluten ataxia, whereas others are indirectly related to inflammation and/or malabsorption including anaemia, osteoporosis, short stature and delayed puberty. Any organ from the central nervous system to joints, liver or teeth can be affected. In some cases, extraintestinal symptoms are the only clinical manifestations of coeliac disease or occur in conjunction with diarrhoea and malabsorptive symptoms. An increased awareness among medical practitioners of the variety of extraintestinal manifestations of coeliac disease is essential to improve diagnosis and treatment.

Advances in diagnosis and management of celiac disease

Celiac disease is an autoimmune disorder that is induced by dietary gluten in genetically predisposed individuals. It has a prevalence of approximately 1% in many populations worldwide. New diagnoses have increased substantially, owing to increased awareness, better diagnostic tools, and probable real increases in incidence. The breadth of recognized clinical presentations continues to expand, making the disorder highly relevant to all physicians. Newer diagnostic tools, including serologic tests for antibodies against tissue transglutaminase and deamidated gliadin peptide, greatly facilitate diagnosis. Tests for celiac-permissive HLA-DQ2 and HLA-DQ8 molecules are useful in defined clinical situations. Celiac disease is diagnosed by histopathologic examination of duodenal biopsy specimens. However, according to recent controversial guidelines, a diagnosis can be made without a biopsy in certain circumstances, especially in children. Symptoms, mortality, and risk for malignancy each can be reduced by adherence to a gluten-free diet. This treatment is a challenge, however, because the diet is expensive, socially isolating, and not always effective in controlling symptoms or intestinal damage. Hence, there is increasing interest in developing nondietary therapies.

Extraintestinal manifestations of celiac disease

Case finding for celiac disease (CD) is becoming increasingly common practice and is conducted in a wide range of clinical situations ranging from the presence of gastrointestinal symptoms to failure to thrive in children, prolonged fatigue, unexpected weight loss and anemia. Case finding is also performed in associated conditions, such as autoimmune thyroid disease, dermatitis herpetiformis and type 1 diabetes, as well as in patients with irritable bowel syndrome, unexplained neuropsychiatric disorders and first-degree relatives of patients with diagnosed CD. This aggressive active case finding has dramatically changed the clinical characteristics of newly diagnosed patients. For instance, higher numbers of patients who present with extraintestinal symptoms are now being diagnosed with CD. Current recommendations state that due to a high risk for complications if the disease remains undiagnosed, patients with extraintestinal symptoms due to CD require appropriate diagnosis and treatment. Despite criticism regarding the cost-effectiveness of case finding in CD, such an aggressive approach has been considered cost-effective for high-risk patients. The diagnosis of CD among patients with extraintestinal symptoms requires a high degree of awareness of the clinical conditions that carry a high risk for underlying CD. Also, understanding the correct use of specific serology and duodenal histology is key for an appropriate diagnostic approach. Both procedures combined are able to confirm diagnosis in the vast majority of cases. However, in certain circumstances, serology and even duodenal histology cannot confirm or rule out CD. A common cause of negative IgA serology is IgA deficiency. For such eventuality, IgG-based serological tests can help confirm the diagnosis. Importantly, some histologically diagnosed cases still remain seronegative despite exclusion of IgA deficiency. On the other hand, duodenal histology may be normal despite the presence of CD-specific antibodies and active CD. This has been clearly demonstrated in some cases of untreated dermatitis herpetiformis, but may also be due to the patchy condition of CD or lesions that are not adequately recognized by nonexpert endoscopists and/or pathologists. The effectiveness of agluten-free diet depends on the clinical end point addressed. A good example is the outcome of bone loss. While risk for fracture normalizes after the first year of dietary treatment, bone parameters measured by densitometry may not be normalized in the long-term follow-up. Moreover, it is still unclear how far an early gluten-free diet will positively affect associated autoimmune diseases like type 1 diabetes and autoimmune thyroiditis.

Immune profiling in patients with recurrent miscarriage

The central role of the maternal immune system for successful and disturbed pregnancies such as recurrent miscarriage (RM) is apparent. Recent studies have increased understanding of the complex interaction of the different immunological players and the adaptation of the maternal immune system to the semi-allogeneic embryo. There is growing evidence for immunological abnormalities in RM patients, including autoimmune and allogeneic factors. However, the question remains unsolved whether these changes represent the cause or the consequence of RM. As in half of the RM patients the underlying mechanism remains unknown, further diagnostic methods are urgently needed. Within this review we summarize (recent) literature on the immunological diagnosis in RM patients to find out current trends and to identify potential targets of therapy. As the exact mechanisms of feto-maternal tolerance have not yet been determined we suggest that the immunological diagnosis should be implemented only in well-designed clinical trials in specialized centers to establish a standardized immunological work-up in RM patients.