03 June 2021
IBD and pregnancy
The reality is that many people diagnosed with IBD are in their reproductive years, and there is a lot of misinformation around fertility and IBD. Your Crohn’s or Colitis can have significant effects on the outcome of pregnancy and your pregnancy can impact your disease control.
Fertility and IBD
Patients often assume that their Crohn’s or Colitis will cause infertility. But the biggest issues faced by patients are:
- Lack of libido
- Body image issues, especially after surgical resections
- Stomal issues
- Dyspareunia (painful intercourse)
- Depression or mental health disorders
- Erectile dysfunction
In IBD there is a higher rate of voluntary childlessness than in the general population (14-18% versus 6%). There may be many things that contribute to this, such as:
- Fears around outcomes of the pregnancy related to IBD
- Fears around pregnancy’s impact on IBD
- Infertility related to IBD
- Hereditability of IBD
- Perceived negative impact of medications on the course of pregnancy
The reality is that there is no difference in involuntary childlessness in IBD patients that have not had surgery. Patients whose IBD is under control have the same fertility rates for those not affected by the disease. It has also been shown that IBD medications do not decrease fertility in women.
Unfortunately, active disease can affect fertility in both men and women. The mechanism in women is unclear. However, for men, problems such as erectile dysfunction and retrograde ejaculation can be caused by active IBD.
Will my baby get IBD?
While genetic factors play a part in IBD, there is no one gene that is passed down from parents to child to cause IBD (in fact, current studies believe there is over 300 genes involved in developing IBD). The risk of a child developing IBD when one parent is affected is low, however this does increase if both parents have IBD.
Will my IBD affect my baby?
The good news is that the most recent data indicates that using modern IBD therapies birth outcomes are excellent and comparable to women without IBD. If you have active disease during pregnancy, however, there are increased risks of adverse outcomes, such as premature birth, congenital anomalies, low birth weight and miscarriage or stillbirth.
The biggest indicator of active disease during pregnancy is disease activity at conception
Will pregnancy affect my disease control?
Unlikely other autoimmune conditions, IBD does not necessarily get better during pregnancy. It has been found that the rate of Crohn’s Disease flares are no different to that of those who aren’t pregnant, however there is a higher risk of flares in Ulcerative Colitis in the final trimester and post-partum. Pouch function can also change in the third trimester.
There are some studies that suggest pregnancy has an improvement in Crohn’s Disease in the longer term.
It’s all about planning!
If it’s possible, discuss your plans with your gastroenterologist 6 months prior to conception. The aim is to keep your disease under control for 3 to 6 months. Your specialist will be able to reassess your disease activity and change therapy if medications are unsafe during pregnancy.
In the case of unplanned pregnancy, talk to your gastroenterologist or IBD team as soon as you find out you are pregnant.
It may also be worth engaging with an obstetrician and/or a high-risk pregnancy service, particularly in the event of active disease during pregnancy.
Are medications safe during pregnancy?
As with any medications during pregnancy, there are some that are safe, some that are probably safe, some that are unsafe, and some for which we don’t have enough data (especially the newer medications).
Are procedures and scans safe during pregnancy?
Whether your procedure or scan is safe will depend on what you need to have done. It will always be discussed with your specialist, and other treating doctors if necessary, to be discussed on a case-by-case basis to weigh up the benefits and risks.
Sedation in the first trimester is not recommended, as it can increase the risk of miscarriage. If it is imperative to perform the procedure, it could be done without sedation. During the third trimester both flexible sigmoidoscopy and colonoscopy are advised against as they an induce premature labour.
Unless they are absolutely necessary, it is recommended that surgery is avoided during pregnancy. However, if the surgery is urgent, treatment should not be delayed.
Ultrasound is a safe imaging method that can be used during pregnancy. There are limited studies to look at the use of MRI, but it seems that it is safe. However, certain contrasts are avoided. Generally CT scans are avoided due to radiation exposure to the baby.
Delivery and beyond
Delivery of the baby is generally approached from an obstetric need perspective, rather than an IBD perspective. However, a cesarean delivery is generally recommended for active perianal disease and those with an ileal-anal pouch. The good news is that delivery modality does not seem to impact IBD activity or inheritance in the baby.
Following delivery, if you plan to breastfeed it’s important to talk about your medications with your gastroenterologist. Most medications are safe, however methotrexate and tofacitinib should be avoided.
Vaccinating your child is ok when using non-live vaccinations. For live vaccinations (such as the rotavirus vaccine and Measles, Mumps and Rubella (MMR) vaccine), these should be delayed by at least 6 months where biologic therapy was administered (particularly in the last trimester), as placental transfer can occur from 18 weeks onwards.
There are plenty of credible resources available if you are looking for more information:
As always, talk to your gastroenterologist or IBD team if you ever have any questions or concerns.
Contributed by Dr Chris Hrycek