One of the paramount goals of infertility workups is discovering the cause of the childlessness. As a first-line of treatment, practitioners need to assess the reasons behind this woman’s hormonal imbalances and anovulation (Item 147-8). A red flag in the scenario described is the woman’s inability to gain weight despite continuous eating. A full medical workup is indicated to determine whether there are any health conditions causing her symptoms. In particular, consider the possibility of celiac disease, which even when clinically silent, can raise the risk of infertility in women. A list of studies on the link between infertility and celiac disease can be found at the National Foundation for Celiac Awareness website (accessed February 15, 2011). — STACEY M. CARROLL, PhD, ANP-BC, Holden, Mass.

Dr. Carroll is correct in that celiac disease could be considered when evaluating this patient for infertility. Serologic testing, followed by small-intestine biopsy, could provide valuable information to the clinician. Given this patient’s history, however, the possibility of an eating disorder should also be explored. A weeklong dietary recall might shed some light on what “continuous eating” means in this case. Referral to specialists who work with individuals with eating disorders should be made if warranted. For more information, see Obstet Gynecol. 2009;114:1353-1367. For further discussion of the diagnosis and management of CD in adults, see our feature.—Robin Meize-Grochowski, RN, PhD, professor and PhD program director with the University of New Mexico College of Nursing in Albuquerque (149-19)