Dihydrolipamide dehydrogenase deficiency, or DLD, is a severe metabolic disorder that causes neurological and liver problems. The symptoms of DLD are seen after episodes of stress such as fever, infection, injury or other bodily stress. The onset of DLD is often in the neonatal period but can be seen in the second or third decade. Most affected individuals do not survive the first years of life. Those who survive past early childhood often have delayed development and growth, muscle stiffness, seizures, and inability to coordinate muscle movements. Many of those diagnosed later in life have only liver disease without neurological problems. These individuals are the minority of those affected by DLD.
There are several other names for dihydrolipoamide dehydrogenase deficiency and they are listed below.
Dihydrolipoyl dehydrogenase deficiency
DLD deficiency
E3 deficiency
Lactic acidosis due to LAD deficiency
Lactic acidosis due to lipoamide dehydrogenase deficiency
Lipoamide dehydrogenase deficiency
Maple syrup urine disease, type III
Dihydrolipoamide dehydrogenase deficiency is seen almost exclusively within the Ashkenazi Jewish population where it is seen in approximately 1 in 35,000 to 1 in 48,000 individuals. Approximately 1 in 102 Ashkenazi Jewish individuals are symptomless carriers for DLD. Outside of this population the prevalence of this disease is unknown and expected to be rare.
Dihydrolipoamide dehydrogeanse deficiency is commonly abbreviated to DLD.
Frequently Asked Questions About Dihydrolipoamide dehydrogenase deficiency
Will the number of acute metabolic episodes increase with age with dihydrolipoamide dehydrogenase deficiency?
The number of acute metabolic episodes actually goes down with age for a majority of patients with dihydrolipoamide dehydrogenase deficiency. To locate a biochemical geneticist to manage your or your child’s care, use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
Will I be discriminated against for health insurance if I have dihydrolipoamide dehydrogenase deficiency?
In the United States, there is a federal law, the Genetic Information Nondiscrimination Act (GINA), that prohibits discrimination for health insurance and employment on the basis of genetic disorders. Therefore, individuals with dihydrolipoamide dehydrogenase deficiency should not have to be concerned about this discrimination. There are exceptions under this law and they are employers with fewer than 15 employees, employment in the US military, health insurance through the TRICARE military health system, the Indian Health Service, the Veterans Health Administration, or the Federal Employees Health Benefits Program. GINA also does not cover long term care insurance, life insurance or disability insurance. For more information about GINA, visit http://ginahelp.org/
Will a particular diet help the signs and symptoms of dihydrolipoamide dehydrogenase deficiency?
Some studies have reported that high fat, low protein diets are effective in maintaining metabolic stability in patients with dihydrolipoamide dehydrogenase deficiency. On the contrary, other studies have reported a worsening of symptoms with a high fat diet. No diet should be undertaken without the consultation of a physician; ideally a biochemical geneticist. To locate a biochemical geneticist to manage your or your child’s care, use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
Why is dihydrolipoamide dehydrogenase deficiency caused by the DLD gene change?
Dihydrolipoamide dehydrogenase deficiency is caused by mutations to the DLD gene, because the DLD gene is responsible for making a part of three different enzymes made up of multiples parts called enzyme complexes. The enzyme complexes works to break down amino acids for our bodies to make energy. When mutations (gene changes) to DLD occur, the enzyme complex is unable to work, which causes those amino acids to build up within the body and cause damage. For more information about how DLD gene changes cause dihydrolipoamide dehydrogenase deficiency, visit the Genetics Home Reference.
Who else in my family should I test for dihydrolipoamide dehydrogenase deficiency?
Dihydrolipoamide dehydrogenase deficiency (DLD) is inherited in an autosomal recessive fashion. Therefore, once someone is diagnosed and found to have two genetic mutations in one of the DLD genes their parents are considered obligate carriers. This means that it is assumed that each parent has one mutation (gene change) in a DLD gene. Each child of those parents has a 25% chance of also having DLD, a 50% chance of being a carrier, and a 25% change of having no mutations. Therefore, testing for siblings is recommend as well as the parents to confirm their status. Aunts and uncles of the patient are at a 50% chance of being a carrier and may be interested in testing for purposes of family planning.
A genetic counselor is a medical professional who specializes in genetic testing and can help explain the inheritance and risk to each family member as well as coordinate the appropriate testing. The National Society of Genetic Counselors has a tool on their website called "Find a Genetic Counselor" to assist in finding one of these professionals.
Where do I find other people with dihydrolipoamide dehydrogenase deficiency?
One may be able to find other individuals with dihyrolipoamide dehydrogenase deficiency through a support group at the medical center they are being treated at or through a support group like CLIMB. You can visit CLIMB at http://www.climb.org.uk/
What ways can I help prevent other complications from dihydrolipoamide dehydrogenase deficiency?
To help prevent other complications of dihydrolipoamide dehydrogenase deficiency, one should ensure that their development is being monitored by their primary care physician. Also receiving vaccines at the appropriate ages is recommended; this includes the flu vaccine. To find a primary care physician near you, visit your your health insurance carrier’s website.
What specialist doctors should I see with dihydrolipoamide dehydrogenase deficiency?
A biochemical geneticist is one specialist that should be involved in the care of someone with dihydrolipoamide dehydrogenase deficiency. Biochemical geneticists are physicians who provide comprehensive diagnostic, management, and genetic counseling services for patients with inborn errors of metabolism. To locate a biochemical geneticist use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
What other medical professionals would be useful for someone with dihydrolipoamide dehydrogenase deficiency to see?
A metabolic nutritionist can be very helpful with dietary management for individuals with dihydrolipoamide dehydrogenase deficiency. A genetic counselor can also help families and individuals with DLD understand the inheritance of the disorder as well as coordinate genetic testing. To find a genetic counselor, visit the National Society of Genetic Counselors’ website.
What is the most common sign or symptom of dihydrolipoamide dehydrogenase deficiency?
The most common sign for dihydrolipoamide dehydrogenase deficiency (DLD) is aminoaciduria, and it is seen in approximately 90% of patients. Aminoaciduria is the presence of amino acids in the urine, specifically abnormally high amounts of amino acids in the urine. Amino acids are the building blocks of protein. The amino acids most commonly seen for DLD are leucine, isoleucine, and valine. To learn more about aminoaciduria testing, visit Medline.
What is the expected lifespan for patients with dihydrolipoamide dehydrogenase deficiency?
The lifespan for patients with dihydrolipoamide dehydrogenase deficiency varies significantly. Many people with the early-onset do not live past several years old. However, there are also a few patients who have been reported to live into their 20s and 30s.
What is the carrier frequency for dihydrolipoamide dehydrogenase deficiency?
The carrier frequency for dihydrolipoamide dehydrogenase deficiency (DLD) within the Ashkenazi Jewish population is estimated to be between 1 in 94 and 1 in 110. This estimation is for the most common mutation, c.685G>T (G229C). For less common mutations, the carrier frequency is likely much less. To discuss your risks of being a carrier for DLD, speak to a genetic counselor. A genetic counselor near you can be found through the National Society of Genetic Counselor’s website.
What is dihydrolipoamide dehydrogenase deficiency?
Dihydrolipamide dehydrogenase deficiency, or DLD, is a severe metabolic disorder that causes neurological and liver problems. The symptoms of DLD are seen after episodes of stress such as fever, infection, injury or other bodily stress. The onset of DLD is often in the neonatal period but can be seen in the second or third decade. Most affected individuals do not survive the first years of life. Those who survive past early childhood often have delayed development and growth, muscle stiffness, seizures, and inability to coordinate muscle movements. Many of those diagnosed later in life have only liver disease without neurological problems. These individuals are the minority of those affected by DLD.
What gene change causes dihydrolipoamide dehydrogenase deficiency?
Changes or mutations to the DLD gene cause dihydrolipoamide dehydrogenase deficiency. The DLD gene is responsible for making an enzyme called dihydrolipoamide dehydrogenase. Dihydrolipoamide dehydrogenase enzyme is part of three enzyme complexes (enzymes made up of multiple parts) involved in breaking down amino acids commonly found in protein-rich foods. Mutations to these enzymes disrupt the process of breaking down the amino acids leading to a build-up in the body that causes damage. To learn more about the cause of DLD, visit the Genetics Home Reference.
What determines the severity of dihydrolipoamide dehydrogenase deficiency?
It is difficult to predict the severity of dihydrolipoamide dehydrogenase deficiency. It does not seem to be linked to any particular factor. Some suggest that the age of onset does determine severity to some effect; the earlier the onset the more severe but this is not always the case. Individuals with dihydrolipoamide dehydrogenase deficiency with the hepatic (liver) presentation with no neurological symptoms have been found to have the DLD gene change c.685G>T (p.Gly229Cys).
What are the main symptoms of dihydrolipoamide dehydrogenase deficiency?
The symptoms of dihydrolipoamide dehydrogenase deficiency can vary from person to person. The most common features are lactic acidosis, neurological problems, and liver dysfunction. Lactic acidosis is a result of a buildup of lactic acid within the body. Signs of lactic acidosis include nausea, vomiting, severe breathing problems, and abnormal heartbeat.
Some of the neurological problems are decreased muscle tone (hypotonia), lethargy, developmental delay, and seizures. Liver dysfunction ranges from hepatomegaly or enlarged liver to liver failure. Liver disease can sometimes be the first symptom and onset can range from infancy to adulthood. Signs of the liver disease are vomiting and abdominal pain. If you have questions about the symptoms associated with dihydrolipoamide dehydrogenase deficiency, please speak to your doctor.
What are the first steps after an initial diagnosis of dihydrolipoamide dehydrogenase deficiency?
Once the diagnosis of dihydrolipoamide dehydrogenase deficiency is made there are several evaluations that should occur. Metabolic tests to check amino acid levels, liver function tests, check of liver size through physical exam or ultrasound, echocardiogram for heart size, assessment of growth and developmental milestones, eye exam if there is concern for vision loss, brain MRI if concern for brain damage and a medical genetics consultation. All of these tests can help physicians to know what problems need to be addressed. A biochemical geneticist should oversee your child’s care. To locate a biochemical geneticist use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
What are other health problems to watch for with dihydrolipoamide dehydrogenase deficiency?
Cardiac dysfunction and vision impairment can both occur with dihydrolipoamide dehydrogenase deficiency and should be monitored for by managing physicians. Individuals with dihydrolipoamide dehydrogenase deficiency may also experience muscle stiffness and difficulty coordinating movements (ataxia). If you have additional questions about symptoms that you or your child are experiencing, please contact your doctor.
Is there newborn testing for dihydrolipoamide dehydrogenase deficiency?
Dihydrolipoamide dehydrogenase deficiency is not currently on the recommended list of diseases by the American College of Medical Genetics and Genomics. However, two infants were found to have DLD because of a higher than normal amount of citrulline discovered through their newborn screening dried blood spot tests. Newborn screening has not identified any individuals who are not experiencing symptoms using either citrulline or leucine as screening markers. To find out more about newborn screening in your state, visit Baby’s First Test.
Is there more than one test for dihydrolipoamide dehydrogenase deficiency?
There are different tests that can be done to help diagnose dihydrolipoamide dehydrogenase deficiency. Evaluation for metabolic acidosis includes looking for the following metabolites: plasma lactate, urine alpha-ketogluatarate, urine branched-chain keto-acids, plasma leucine, plasma isoleucine, plasma valine, and plasma allo-isoleucine.
Molecular genetic testing will evaluate for the genetic mutations in the DLD gene. Ninety-eight percent of mutations are found through sequence analysis of the DLD gene. Sequencing analyzes the sequence of the DNA for any changes. For more information, discuss testing with your child’s doctor or find a biochemical geneticist through the American College of Medical Genetics’ website.
Is there clinical research happening on dihydrolipoamide dehydrogenase deficiency?
As of June 14, 2016, there are currently no ongoing research trials for dihydrolipoamide dehydrogenase deficiency.
Is there a treatment for dihydrolipoamide dehydrogenase deficiency?
There are no agreed upon recommendations for the management of dihydrolipoamide dehydrogenase deficiency (DLD). There is also no real treatment because DLD presents a unique challenge in that if affects several different metabolic pathways. Each metabolic pathway that is affected has a different treatment when it is the only affected pathway. Attempts have been made to treat DLD through dietary restriction of certain amino acids but with only questionable results. Discuss possible treatments with your child’s biochemical geneticist. To find a biochemical geneticist, use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
Is there a gender difference with dihydrolipoamide dehydrogenase deficiency?
Both genders are affected equally with the dihydrolipoamide dehydrogenase deficiency. This is due to autosomal recessive pattern of inheritance. There is no sex specificity for disorders inherited in an autosomal recessive fashion. To learn more about autosomal recessive inheritance, visit Medline .
Is dihydrolipoamide dehydrogenase deficiency seen in other ethnic groups aside from Ashkenazi Jewish?
There have been case reports of individuals with dihydrolipoamide dehydrogenase deficiency who are not of Ashkenazi Jewish ancestry. However, due to the limited number of reports the frequency with which it is seen outside of the Ashkenazi Jewish population is unknown.
How is the hepatic onset of dihydrolipoamide dehydrogenase deficiency treated?
The hepatic onset form of dihydrolipoamide dehydrogenase deficiency is treated mostly with supportive therapy if there is liver trauma or failure. This therapy includes nutritional supplementation, sugar monitoring, medications to treat metabolic acidosis, and avoiding liver-toxic medications. To learn more about maintaining you or your child’s heath, speak to a biochemical geneticist. To locate a biochemical geneticist use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
How is dihydrolipoamide dehydrogenase deficiency inherited?
Dihydrolipoamide dehydrogenase is inherited in an autosomal recessive fashion. Autosomal recessive inheritance is when a mutation or gene change occurs in both copies of a gene, the one inherited from the mother and the one inherited from the father. The mutations do not have be same type or even in the same place. Both parents have only one copy of the gene with a mutation and do not have any related medical problems. Due to this lack of symptoms within the parents, autosomal recessive disorders can seem to appear out of nowhere within a family. To learn more about autosomal recessive inheritance, visit Medline.
How is an acute episode of dihydrolipoamide dehydrogenase deficiency managed?
When an acute episode occurs with dihydrolipoamide dehydrogenase deficiency the goal is to correct the metabolic acidosis. This is best done by treating with sodium bicarbonate, maintaining the glucose or sugar level at normal, and withholding protein until metabolic state is returned. Other treatments may be tried if needed and should always be done under the direction of a physician, typically a biochemical geneticist. To locate a biochemical geneticist use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
How do you distinguish between hepatic presentation and early-onset presentation of dihydrolipoamide dehydrogenase deficiency?
The easiest way to determine the different type of onsets of dihydrolipoamide dehydrogenase deficiency (DLD) is to look for the presence or absence of low muscle tone, brain dysfunction causing seizures and lethargy, and liver symptoms. Absence of low muscle tone and brain dysfunction with the presence of liver symptoms is likely the hepatic onset. Whereas presence of low muscle tone and brain dysfunction with absence of liver symptoms is likely the early-onset presentation of DLD. Your doctor may look for these differences to help determine which presentation of dihydrolipoamide dehydrogenase deficiency you or your child may have.
How do I get tested for dihydrolipoamide dehydrogenase deficiency?
A biochemical geneticist should evaluate individuals for dihydrolipamide dehydrogenase deficiency. Metabolic or genetic testing can be ordered by that physician to confirm a suspected diagnosis. To discuss testing options, speak to a genetic counselor. You can find a genetic counselor near you on the NSGC website.
How do I find clinical research on dihydrolipoamide dehydrogenase deficiency?
In order to find up-to-date information on clinical trials and research, visit clinicaltrials.gov and search "dihydrolipoamide dehydrogenase deficiency."
How do I find a center of excellence in dihydrolipoamide dehydrogenase deficiency?
It is not likely that one will find a center of excellence specifically in dihydrolipoamide dehydrogenase deficiency. However, there are several centers of excellence for metabolic disorders like DLD. Oregon Health and Science University has put together a list of United States Metabolic Clinics and some in Canada. There is at least one listed in every state with their contact information. To find a metabolic clinic near you, visit metabolic clinics.
How do I donate money to dihydrolipoamide dehydrogenase deficiency research?
There are several groups that one could donate money to that may be involved in dihydrolipoamide dehydrogenase research. The National Organization for Rare Disorders (NORD) and the Genetic Disease Foundation (GDF) both work in research on rare genetic disorders, which dihydrolipoamide dehydrogenase deficiency is one of.
How common is dihydrolipoamide dehydrogenase deficiency?
Dihydrolipoamide dehydrogenase deficiency is seen almost exclusively within the Ashkenazi Jewish population where it is seen in approximately 1 in 35,000 to 1 in 48,000 individuals. Approximately 1 in 102 Ashkenazi Jewish individuals are symptomless carriers for DLD. Outside of this population the prevalence of this disease is unknown and expected to be rare.
How can I prevent having an acute episode with dihydrolipoamide dehydrogenase deficiency?
Thus far, no strategy has been proven to help prevent or reduce the acute metabolic acidosis episodes for dihydrolipoamide dehydrogenase deficiency. To locate a biochemical geneticist to manage your and your child’s care, use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
Does having dihydrolipoamide dehydrogenase deficiency make someone more susceptible to anything?
Individuals with dihydrolipoamide dehydrogenase deficiency are more susceptible to certain viruses that affect the liver such as Epstein-Barr and medications that have a significant impact on the liver like acetaminophen. This means that if they are infected with those viruses their symptoms are likely to be worse and that they are more likely to catch those viruses over someone who does not have DLD. People with DLD should avoid medications that impact the liver and other people who have contagious viruses that impact the liver.
Does an acute episode worsen intellect for patients with dihydrolipoamide dehydrogenase deficiency?
Patients with the hepatic presentation of dihydrolipoamide dehydrogenase deficiency may not have any loss of intellect or neurological problems following an acute episode. This has not been studied well in the early onset form.
Do people with dihydrolipoamide dehydrogenase deficiency always show symptoms?
Individuals with dihydrolipoamide dehydrogenase deficiency (DLD) do not always show symptoms of DLD. This is particularly true of patients who have the hepatic presentation. They often return to a normal state in between acute episodes of metabolic acidosis, especially if they avoid fasting and liver toxic medications. To learn more about maintaining you or your child’s heath, speak to a biochemical geneticist. To locate a biochemical geneticist use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
Do all patients with dihydrolipoamide dehydrogenase deficiency have intellectual disability?
Although a majority of patients with dihydrolipoamide dehydrogenase deficiency do have some brain function abnormalities and intellectual disability, this is not the case for all patients. Even some patients diagnosed with the early onset presentation can have normal intellect. Normal intelligence is seen more often in patients with the hepatic presentation.
Can someone with dihydrolipoamide dehydrogenase deficiency have children?
There are case reports of patients with dihydrolipoamide dehydrogenase deficiency having children. A review of several affected families found one patient with four healthy children. However, since this is only one case report and it was an affected male who did not have symptoms until age 20. Therefore, we cannot know whether having children is something that can happen for a majority of patients.
Can dihydrolipoamide dehydrogenase deficiency be diagnosed during pregnancy?
One study in the literature demonstrated the possibility of diagnosing dihydrolipoamide dehydrogenase deficiency (DLD) during pregnancy. The patient already had an affected child and was pregnant when they did chorionic villus sampling; sampling of some of the placental tissue. They analyzed different cells from the sample for the levels of the enzyme. Based on their results the fetus was not expected to have DLD This was confirmed with post-birth tests for the baby. As this is only one case, we cannot be certain that this technique would work for all pregnancies. For more information about prenatal testing for DLD, speak to a genetic counselor. You can locate a genetic counselor through the National Socie.ty of Genetic Counselors’ website.
Are there other names for dihydrolipoamide dehydrogenase deficiency?
There are several other names for dihydrolipoamide dehydrogenase deficiency and they are listed below.
Are there good support groups for dihydrolipoamide dehydrogenase deficiency?
The Children Living with Inherited Metabolic Diseases (CLIMB) is a good support group for individuals and families with dihydrolipoamide dehydrogenase deficiency as well as all other inherited metabolic diseases. You can visit them at http://www.climb.org.uk
Are there diseases that are similar to dihydrolipoamide dehydrogenase deficiency?
There are several diseases that are similar to dihydrolipoamide dehydrogenase deficiency. Pyruvate dehydrogenase complex (PDHC) deficiency present with low muscle tone, brain abnormalities, and lactic acidosis. The difference between PDHC and DLD is individuals with DLD also have other biochemical abnormalities in their lab results.
Maple syrup urine disease types 1 and 2 have very similar presenting symptoms but again have different biochemical lab results. Also, individuals with maple syrup urine disease have a strong odor of maple syrup to their urine which is not usually found in individuals with DLD. Some defects in lipoic acid metabolism present with the lactic acidosis like DLD, but also have elevated glycine in their bodily fluids unlike DLD. The best person to help figure out if someone is having symptoms of DLD or another health problem is a biochemical geneticist, a doctor specially trained to diagnose and treat metabolic disorders. Biochemical geneticists in an area can be found by talking to doctors about who they would recommend or using the “Find Genetic Services” function at the American College of Medical Genetics’ website.
Are there different types of dihydrolipoamide dehydrogenase deficiency?
Dihydrolipamide dehydrogenase deficiency is often classified based on their presentation (symptoms first seen). These presentations include early-onset neurologic presentation, hepatic presentation and myopathic presentation.
Early-onset neurologic presentation is the most common and symptoms begin in infancy. These infants often do not survive the first couple years of life. Those that do make it past that have growth delay, intellectual disability, inability to coordinate movements (ataxia), and seizures.
Hepatic presentation onset can be seen from neonatal to third decade of life. Liver dysfunction or failure is the first symptom and is associated with nausea and vomiting. Liver failure can lead to death.
The myopathic presentation has only been seen in one patient. They presented with ptosis or drooping eyelid, weakness and elevated levels of creatine kinase and lactate. As only one patient has been described with this presentation, it is uncertain as to how often this presentation occurs. For more information about the presentations of DLD, please visit the Genetics Home Reference.
Are there certain things to avoid with dihydrolipoamide dehydrogenase deficiency?
People with dihydrolipoamide dehydrogenase deficiency should avoid fasting, catabolic stressors such as surgery, and liver toxic medications like acetaminophen and ibuprofen. To locate a biochemical geneticist to manage your child or your care, use the “Find Genetic Services” function at the American College of Medical Genetics’ website.
Are there any professional groups that specialize in dihydrolipoamide dehydrogenase deficiency?
There are no groups that are specific to dihydrolipoamide dehydrogenase deficiency. There are several societies for hereditary metabolic disorders. The Society of Inherited Metabolic Disorders is a professional group that was started in 1978 to "increase knowledge of and promote research in inborn errors of metabolism in humans and to stimulate interactions between clinicians and investigators in inborn errors of metabolism." It also founded the North American Metabolic Academy, whose purpose is to provide medical genetic and biochemical genetic trainees a forum to develop knowledge of the diagnosis and management of inborn errors of metabolism. There is also the Society for the Study of Inborn Errors of Metabolism. This group was founded in 1963 and promotes interdisciplinary education about inborn errors of metabolism. You can visit the Society for Inherited Metabolic Disorders at http://www.simd.org/
Are there any common mutations for dihydrolipoamide dehydrogenase deficiency?
The most common mutation is c.685G>T (G229C) in dihydrolipoamide dehydrogenase deficiency. However, other mutations have also been reported and new (or novel) mutations are being noted within the literature.
Are there any abbreviations for dihydrolipoamide dehydrogenase deficiency?
Dihydrolipoamide dehydrogeanse deficiency is commonly abbreviated to DLD.
Are patients with dihydrolipoamide dehydrogenase deficiency able to walk?
Within the literature there is limited information in regards to developmental milestones for patients with dihydrolipoamide dehydrogenase deficiency (DLD). Based on case reports, there does not seem to be any proof that patients who live past infancy have any challenges with walking or are unable to walk. Given that many patients do not make it past infancy, it is a challenge to know the impact of DLD on developmental milestones. Speak to your child’s doctor about any concerns you have for their development,
Are miscarriages common for patients with dihydrolipoamide dehydrogenase deficiency?
There is very limited information on pregnancy and dihydrolipoamide dehydrogenase deficiency (DLD). Pregnancy seems to be possible for patients with DLD. Studies of families seem to show a higher reporting of miscarriages and early sibling death. It is not clear if it is due to DLD or other causes. Speak to your doctor before attempting a pregnancy.
