Information & Treatment of Infertility in Vancouver Canada
Diabetes and InfertilityDefinition
What Can Happen Over Time
diabetes mellitus - (the most common form of the disease) is a disorder in which blood levels of glucose (a simple sugar created by the metabolism or the body’s process of breaking down of carbohydrates, i.e. fruits, vegetables, grains) are abnormally high because the body doesn't release or use insulin (a hormone produced by the pancreas) adequately. The oxidation or metabolism of these sugars from carbohydrates is the major source of energy for the human body.
Doctors often use the full name diabetes mellitus, rather than diabetes alone, to distinguish this disorder from diabetes insipidus, a relatively rare disease.
Blood sugar (glucose) levels vary throughout the day, rising after a meal and returning to normal within 2 hours. Blood sugar levels are normally between 70 and 110 milligrams per deciliter (mg/dL) of blood in the morning after an overnight fast. They are usually lower than 120 to 140 mg/dL 2 hours after eating foods or drinking liquids containing sugar or other carbohydrates. Normal levels tend to increase slightly but progressively after age 50, especially in people who are sedentary.
Insulin, a hormone released from the pancreas, is the primary substance responsible for maintaining appropriate blood sugar levels. Insulin allows glucose to be transported into cells so that they can produce energy or store the glucose until it's needed. The rise in blood sugar levels after eating or drinking stimulates the pancreas to produce insulin, preventing a greater rise in blood sugar levels and causing them to fall gradually. Because muscles use glucose for energy, blood sugar levels can also fall during physical activity.
Type 1 diabetes, no one knows what causes type 1 diabetes, but it is known that it occurs when the pancreas (a gland needed in the digestive process) no longer produces any or very little insulin. The body needs insulin to use sugar obtained from food for energy. Approximately 10 percent of people with diabetes have type 1 diabetes.
Type 2 diabetes occurs when the pancreas does not produce enough insulin or when the body does not use the insulin that is produced effectively. 90 percent of people with diabetes have type 2.
Gestational diabetes is a temporary condition that occurs during pregnancy. It affects two to four percent of all pregnancies with an increased risk of developing diabetes for both mother and child.
Diabetes is a leading cause of death by disease worldwide. If not recognized or improperly managed, the high levels of blood glucose (sugar) can slowly damage both the small and large blood vessels in the body, possibly resulting in many serious health complications such as heart disease, which is two to four times more common in people with diabetes than without, it is also a leading cause of adult blindness & kidney disease. At least 50% of all limb amputations not due to traumatic injury are due to diabetes, and diabetes is now considered to be a major cause of erectile dysfunction (male sexual organ problems).
excessive hunger (polyphagia)
frequent urination (polyuria)
unusual weight loss (emaciation)
extreme fatigue or lack of energy
frequent or recurring infections
cuts and bruises that are slow to heal
tingling &/or numbness in hands &/or feet.
*** It is also quite important to understand that many people with type 2 diabetes may or may not display signs or symptoms. It is recommended to have routine screening every three years for everyone age 45 or over and screening every year for individuals with other risk factors.
The first symptoms of diabetes are related to the direct effects of high blood sugar levels. When the blood sugar level rises above 160 to 180 mg/dL, glucose passes into the urine. When the level rises even higher, the kidneys excrete additional water to dilute the large amounts of glucose lost. Because the kidneys produce excessive urine, a person with diabetes urinates large volumes frequently (polyuria). The excessive urination creates abnormal thirst (polydipsia). Because excessive calories are lost in the urine, the person loses weight. To compensate, the person often feels excessively hungry (polyphagia). Other symptoms include blurred vision, drowsiness, nausea, and decreased endurance during exercise. In addition, people whose diabetes is poorly controlled are more susceptible to infections. Because of the severity of insulin deficiency, people with type I diabetes almost always lose weight before undergoing treatment. Most people with type II diabetes don't lose weight.
In people with type I diabetes, the symptoms begin abruptly and may progress rapidly to a condition called diabetic ketoacidosis. Despite high levels of sugar in the blood, most cells can't use sugar without insulin; thus, they turn to other sources of energy. Fat cells begin to break down, producing ketones, toxic chemical compounds that can make the blood acidic (ketoacidosis). The initial symptoms of diabetic ketoacidosis include excessive thirst and urination, weight loss, nausea, vomiting, fatigue, and--particularly in children--abdominal pain. Breathing tends to become deep and rapid as the body attempts to correct the blood's acidity. The person's breath smells like nail polish remover. Without treatment, diabetic ketoacidosis can progress to coma, sometimes within a few hours.
People with type I diabetes can develop ketoacidosis even after starting insulin treatment if they miss an insulin injection or become stressed by an infection, an accident, or a serious medical condition.
People with type II diabetes may not have any symptoms for years or decades. When insulin deficiency progresses, symptoms may develop. Increased urination and thirst are mild at first and gradually worsen over weeks or months. Ketoacidosis is rare. If the blood sugar level becomes very high (often exceeding 1,000 mg/dL)--usually as the result of some superimposed stress such as an infection or drugs--the person may develop severe dehydration, which may lead to mental confusion, drowsiness, seizures, and a condition called nonketotic hyperglycemic-hyperosmolar coma.
Symptoms of low blood glucose (sugar) levels
A low blood glucose level can occur when your blood glucose drops below a certain level (usually less than 4 mmol/L).
This may be caused by:
Not eating enough food
Missing or delaying a meal
Exercising without taking the necessary precautions
Taking too much insulin
*** Low blood glucose can happen quickly, so it is important to take care of it right away.
The warning signs of a low blood glucose level
Note the symptoms you are experiencing, this will help you to identify low blood sugar in the future.
You may feel:
Sudden severe hunger
Shaky or light-headed
Nervous or irritable
Your heart beats at a faster rate
A numbness or tingling in your tongue or lips.
mood changes or swings
& even unconsciousness or coma or seizures in extreme cases (Make sure you always wear MedicAlert® identification)
*** IMPORTANT NOTE: Some people do not have early warning signs of hypoglycemia. People like this must check their blood sugar levels more often to avoid this condition. It is of utmost importance for all persons with diabetes to check their blood sugar levels before driving a motor vehicle.
How to treat low blood glucose (As recommended by the Canadian Diabetes Association)
Check your blood glucose. If you do not have your meter with you treat the symptoms anyway. It is better to be safe. Eat or drink a form of sugar such as:
3 B-D Glucose Tablets™ or 5 Dextrose Tablets™
6 Life Savers TM
3/4 cup (175mL) of juice or regular pop
1 tablespoon (15mL) of honey.
Wait 10 to 15 minutes, then test your blood glucose again.
Scientists believe that an environmental factor--possibly a viral infection or a nutritional factor in childhood or early adulthood--causes the immune system to destroy the insulin-producing cells in the pancreas. Some genetic predisposition is most likely needed for this to happen. Whatever the cause, in type I diabetes more than 90 percent of the insulin-producing cells (beta cells) of the pancreas are permanently destroyed. The resulting insulin deficiency is severe, and to survive, a person with type I diabetes must regularly inject insulin.
In type II diabetes mellitus (non-insulin-dependent diabetes), the pancreas continues to manufacture insulin, sometimes even at higher than normal levels. However, the body develops resistance to its effects, resulting in a relative insulin deficiency. Type II diabetes may occur in children and adolescents but usually begins after age 30 and becomes progressively more common with age: About 15 percent of people over age 70 have type II diabetes. Obesity is a risk factor for type II diabetes; 80 to 90 percent of the people with this disease are obese. Certain racial and cultural groups are at increased risk: Blacks and Hispanics have a twofold to threefold increased risk of developing type II diabetes. Type II diabetes also tends to run in families.
Other less common causes of diabetes are abnormally high levels of corticosteroids, pregnancy (gestational diabetes), drugs, and poisons that interfere with the production or effects of insulin, resulting in high blood sugar levels.
To measure the blood sugar level, a blood sample is usually taken after the person has fasted for about 8 hours, but it may be taken after eating. Some elevation of blood sugar levels after eating is normal, but even then the levels shouldn't be very high. In people over 65 years old, the test is best performed after fasting because older people have a greater increase in blood sugar levels after eating.
Another kind of blood test, an oral glucose tolerance test, may be performed in certain situations, such as when a doctor suspects that a pregnant woman has gestational diabetes. In this test, a person fasts, has a blood sample taken for the fasting blood sugar level, and then drinks a special solution containing a standard amount of glucose. More blood samples are then obtained over the next 2 to 3 hours.
Learn about your condition: Diabetes education is an important first step. All people with diabetes need to learn about their condition in order to make healthy lifestyle choices and manage their diabetes.
The importance of nutrition & diet: What, when and how much you eat play an important role in regulating how well your body manages blood sugar levels.
Eat three meals and a bedtime snack each day.
Include a food from each of the food groups at each meal.
If you are thirsty drink water or diet pop.
If you are overweight, eat smaller portions. Reduce your intake of fat.
Keep sweet and fatty foods to a minimum.
Stay active: Regular exercise helps your body lower blood sugars, promotes weight loss, reduces stress and enhances overall fitness.
Talk to your diabetes health care team to learn how to adjust your insulin and food to prevent low blood glucose levels while exercising.
Carry some form of sugar with you and extra food.
Carry your meter with you. Be prepared to stop and test during exercise if you feel any symptoms.
Wear a MedicAlert® identification.
Carry a record of the names and amounts of insulin you use and any other medications you use regularly.
Wear comfortable shoes and socks.
Test your blood glucose before exercising. If lower than __________ mmol/L, (have your doctor determine this value for you) you may need extra food before you start.
Stop exercising if you have pain or feel tired.
Watch your waistline: Maintaining a healthy weight is especially important in the control of type 2 diabetes.
Taking your medication: Type 1 diabetes always requires daily injections of insulin. Type 2 diabetes is controlled through exercise and meal planning and may require medications and/or insulin to assist the body in making or using insulin more effectively.
A chance for a new ‘healthy’ lifestyle: Learning to reduce stress levels in day-to-day life can help people with diabetes better manage their disease.
The main goal of diabetes treatment is to keep blood sugar levels within the normal range as much as possible. Completely normal levels are difficult to maintain, but the more closely they can be kept within the normal range, the less likely that temporary or long-term complications will develop. The main problem with trying to control blood sugar levels tightly is an increased chance of overshooting, resulting in low blood sugar levels (hypoglycemia).
The treatment of diabetes requires attention to weight control, exercise, and diet. Many obese people with type II diabetes would not need medication if they lost weight and exercised regularly. However, weight reduction and increased exercise are difficult for most people with diabetes. Therefore, either insulin replacement therapy or an oral hypoglycemic medication is often needed. Exercise directly lowers blood sugar levels, often reducing the amount of insulin needed.
Diet management is very important. In general, people with diabetes shouldn't eat too much sweet food and should eat their meals on a regular schedule. However, eating a snack at bedtime or in the late afternoon often helps prevent hypoglycemia in people who inject themselves in the morning or evening with an intermediate-acting insulin. Since people with diabetes also have a tendency toward high cholesterol levels, dietitians usually recommend limiting the amount of saturated fat in the diet. Yet, the best way to reduce cholesterol levels is to control blood sugar levels and body weight.
Most people with diabetes benefit greatly from learning about their disease and what they can do to help control it. This education is best provided by a nurse trained in diabetes education. All diabetics must understand how diet and exercise affect their blood sugar levels and be aware of how to avoid complications, such as checking their skin for ulcerations. They must also take special care to avoid foot infections and can often benefit from having their toenails cut by a podiatrist. Yearly eye examinations are essential to check for changes in the blood vessels that can lead to blindness (diabetic retinopathy).
In case of injury or high or low blood sugar levels, people with diabetes should always carry a card or wear a Medic Alert bracelet identifying the disease. In an emergency, alerting health care professionals to the presence of diabetes allows them to start proper lifesaving treatment quickly.
Insulin Replacement Therapy
In type I diabetes, the pancreas can't produce insulin, so insulin must be replaced. Replacement can be accomplished only by injection; because insulin is destroyed in the stomach, it can't be taken by mouth. New forms of insulin, such as a nasal spray, are being tested. To date, these new forms haven't worked well because variability in the rate of absorption leads to problems in determining dose.
Insulin is injected under the skin into the fat layer, usually in the arm, thigh, or abdominal wall. Small syringes with very thin needles make the injections nearly painless. An air pump device that blows the insulin under the skin can be used for people who can't tolerate needles.
An insulin pen, which contains a cartridge that holds the insulin and closes like a large pen, is a convenient way to carry insulin, especially for those who take several injections a day outside the home. Another device is an insulin pump, which pumps insulin continuously from a reservoir through a small needle left in the skin. Additional doses of insulin can be programmed or triggered so that the pump more closely mimics the way the body normally produces insulin. For some people, the pump offers an added degree of control, while others find wearing the pump annoying or develop sores at the needle site.
Insulin is available in three basic forms, each with a different speed and duration of action. Rapid-acting insulin, such as regular insulin, is the fastest and shortest acting. This type of insulin often begins to lower blood sugar levels within 20 minutes, reaches maximum activity in 2 to 4 hours, and lasts for 6 to 8 hours. Rapid-acting insulin is often used by people who take several daily injections and is injected 15 to 20 minutes before meals. Intermediate-acting insulin, such as insulin zinc suspension or isophane insulin suspension, starts to work in 1 to 3 hours, reaches its maximum activity in 6 to 10 hours, and works for 18 to 26 hours. This type of insulin may be used in the morning to provide coverage for the first part of the day or in the evening to provide coverage during the night. Long-acting insulin, such as extended insulin zinc suspension, has very little effect for about 6 hours but provides coverage for 28 to 36 hours. Insulin preparations are stable at room temperature for months, allowing them to be carried, brought to work, or taken on a trip.
Choosing which insulin to use may be complex. The decision is based on how tightly a person wishes to control his diabetes, how willing he is to monitor his blood sugar and adjust his dosage, how varied his daily activity is, how adept he is in learning about and understanding his disease, and how stable his blood sugar levels are during the day and from day to day.
The easiest regimen to follow is a single daily injection of one intermediate-acting insulin. However, such a regimen provides the least control over the blood sugar levels. Tighter control may be achieved by combining two insulins--a rapid-acting and an intermediate-acting insulin--in one morning dose. This requires more skill but offers more opportunity to adjust the blood sugar levels. A second injection may be taken at dinner or bedtime. Tightest control is usually achieved by injecting some rapid-acting and intermediate-acting insulin in the morning and evening along with several additional injections of rapid-acting insulin during the day.
Some people, especially older people, take the same amount of insulin every day; others adjust the insulin dose daily depending on their diet, exercise, and blood sugar patterns. The need for insulin varies with changes in food intake and amount of exercise. Thus, people who vary their diet and exercise very little usually need to make little change to their insulin dose. However, over time, insulin needs may change if the person experiences weight changes, emotional stress, or illness, especially infection. People who vary their diet and exercise patterns need to adjust their insulin accordingly.
Some people develop resistance to insulin. Because the insulin is not exactly like the insulin the body manufactures, the body can produce antibodies to the insulin. These antibodies interfere with the insulin's activity, so a person with insulin resistance must take very large doses.
Insulin injections can affect the skin and underlying tissues at the injection site. An allergic reaction, which occurs rarely, produces pain and burning, followed by redness, itchiness, and swelling around the injection site for several hours. More commonly, the injections either cause fat deposits, making the skin look lumpy, or destroy fat, causing indentation of the skin. Changing the site of injection with each dose and switching the type of insulin generally prevent these complications. Insulin resistance and insulin allergy are uncommon with the use of synthetic human insulins, which are the insulins predominantly used today.
Oral Hypoglycemic Drugs
Oral hypoglycemic drugs are usually prescribed for people with type II diabetes if diet and exercise fail to lower blood sugar levels adequately. The drugs can sometimes be taken only once a day, in the morning, although some people need two or three doses. If oral hypoglycemic drugs can't control blood sugar well enough, insulin injections alone or in combination with the oral drugs may be needed.
How to test your blood glucose level
You can purchase a meter from your local pharmacy. Checking blood glucose requires obtaining a small drop of blood to place on a blood glucose strip. Talk to your diabetes educator or pharmacist about the various methods, and which one is right for you. When you decide, make sure you receive the proper training. Ask about the size of the drop of blood and the type of blood glucose strips to use, how to clean you meter, how to check if your meter is accurate, how to code your meter.
A drop of blood is obtained by pricking the tip of the finger with a small lancet. The lancet holds a tiny needle that can be jabbed into the finger or placed in a spring-loaded device that easily and quickly pierces the skin. Most diabetics find the pricking nearly painless. Then, a drop of blood is placed on a reagent strip. In response to sugar, the reagent strip changes color or undergoes some other chemical change. Some strips change color enough to read the blood sugar level when the color of the strip is compared to colors printed on a chart. A better and more accurate system is to use a machine that reads the changes in the test strip and reports the result on a digital display. Most of these machines time the reaction and read the result automatically. The machines are small, from the size of a pen to that of a pack of cigarettes.
People with diabetes should record their blood sugar levels and report them to their doctor or nurse for advice in adjusting the insulin or oral hypoglycemic drug dose. Some people can be taught to adjust the insulin dose on their own as necessary between visits to their doctor or nurse. Doctors use a blood test called glycosylated hemoglobin, also called hemoglobin A1C, to monitor treatment. When the blood sugar level is high, changes occur in hemoglobin, the chemical that carries oxygen in the blood. These changes are in direct proportion to the blood sugar level over an extended period. Thus, unlike the blood sugar measurement, which reveals the level at a particular moment, the glycosylated hemoglobin measurement demonstrates whether the blood sugar level has been controlled over the previous few weeks. The normal level for glycosylated hemoglobin is less than 7 percent. Diabetics rarely achieve such levels, but tight control aims to come close to it. Levels above 9 percent show poor control, and levels above 12 percent show very poor control. Most doctors who specialize in diabetes care recommend that glycosylated hemoglobin be measured every 3 to 6 months.
Why you should test your blood glucose level?
It is a quick measurement of your blood glucose level at any point in time.
It shows how your blood glucose levels are affected by your food intake, insulin, stress levels, illness and physical activity.
It is a quick method to identify high and low blood glucose levels to avoid potential emergencies.
It helps you, and your diabetes health care team, to make the necessary changes in insulin, meal planning, lifestyle, or exercise to achieve good blood glucose control.
Hypoglycemia must be treated quickly because within minutes it can become severe, leading to increasing confusion, coma, and rarely permanent brain injury. At the first sign of hypoglycemia, the person should eat some form of sugar. Therefore, people with diabetes should always carry candy, lumps of sugar, or glucose tablets to treat episodes of hypoglycemia. Other options are to drink a glass of milk (which contains lactose, a type of sugar), sugar water, or fruit juice or to eat a piece of cake, some fruit, or other sweet food. People with type I diabetes should always carry or have available glucagon (a hormone that raises blood sugar levels), which can be injected in case they aren't able to take any food containing sugar.
Diabetic ketoacidosis is a medical emergency. Without prompt and excellent treatment, diabetic ketoacidosis can cause a coma and death. Hospitalization, usually in an intensive care unit, is necessary. Large amounts of intravenous fluids are given along with electrolytes, such as sodium, potassium, chloride, and phosphate, to replace those lost through excessive urination. Insulin is generally given intravenously so that it works quickly and the dose can be adjusted frequently. Blood levels of glucose, ketones, and electrolytes are measured every few hours so that doctors can adjust the treatment. Doctors also take samples of arterial blood to measure its acidity. Sometimes additional treatments are needed to correct the acidity, although controlling blood sugar levels and replacing electrolytes usually allow the body to restore the normal acid-base balance.
The treatment of nonketotic hyperglycemichyperosmolar coma is similar to that of diabetic ketoacidosis. Fluid and electrolytes must be replaced. Blood sugar levels must be restored gradually to avoid sudden shifts of fluid into the brain. Blood sugar levels tend to be more easily controlled than in diabetic ketoacidosis, and blood acidity problems are not severe.
Most of the long-term complications of diabetes are progressive unless the blood sugar level is tightly controlled. Diabetic retinopathy, however, can be directly treated. Laser surgery can seal the leaking eye blood vessels to prevent permanent damage to the retina. Early laser treatment can help prevent or substantially slow the loss of vision.
For all of these reasons, people with diabetes may experience many serious long-term complications. Heart attacks and strokes are more common. Damage to the blood vessels of the eye can cause loss of vision (diabetic retinopathy). The kidneys can malfunction, resulting in kidney failure that requires dialysis. Damage to nerves can manifest in several ways. If a single nerve malfunctions (mononeuropathy), an arm or leg may suddenly become weak. If the nerves to the hands, legs, and feet become damaged (diabetic polyneuropathy), sensation may become abnormal and tingling or burning pain and weakness in the arms and legs may develop. Damage to the nerves of the skin makes repeated injuries more likely because the person can't sense changes in pressure or temperature. Poor blood supply to the skin can also lead to ulcers, and all wounds heal slowly. Foot ulcers may become so deep and infected and heal so poorly that part of the leg may need to be amputated. Recent evidence has shown that complications of diabetes can be prevented, delayed, or slowed by controlling blood sugar levels. Other unknown factors, including genetic ones, also determine the subsequent course of events.
Two conditions may result in a diabetic emergency:
1. Not enough insulin, causing a high level of sugar or hyperglycemia. This could lead to diabetic coma. This may be caused by:
a) not taking enough insulin
b) eating too much food
c) doing less exercise than usual
2. Too much insulin, causing a low level of sugar or hypoglycemia. This may lead to insulin shock. This may be caused by:
a) taking too much insulin
b) not eating enough food or vomiting
c) doing more exercise than usual
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Dr. Spence Pentland is a provincially licenced Doctor with the College of Traditional Chinese Medicine practitioners and Acupuncturists of BC,
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2. The IVF Acupuncture Group - a team of doctors specializing in providing quality, evidence-based acupuncture services for patients undergoing IVF in Greater Vancouver
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