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Fertility, Pregnancy and IBD

IBD occurs equally as often in males and females and is most commonly diagnosed for the first time between the ages of 15 and 35. This tends to coincide with the time in life when people are becoming sexually active or are thinking about starting a family. It’s only natural then for many questions and concerns to arise about the possible impact of IBD and its treatment—including medications and/or surgery—on one’s ability to become pregnant and deliver a healthy baby.

It is important to keep in mind that despite some unique challenges, most women with IBD are able to have children and raise a family just like everyone else in the general population. The single most important element to achieving a successful pregnancy and delivery is to have your IBD under control, ideally before you attempt to become pregnant, and also throughout the pregnancy.

Because each case of IBD is highly individual and the specific needs of someone with IBD could change during the course of the disease, it’s always a good idea to raise any questions or concerns you might have with your clinical team, including your gynaecologist. Medical and surgical treatment can be tailored to suit your own personal circumstances at any given time, including the times when you’re planning, starting, or adding to your family.

 

On this page:

Does IBD affect fertility?

Generally speaking, inflammatory bowel disease (IBD) has no direct effect on fertility in either men or women. There are a few instances however where the medications or surgery used to treat IBD, or where the impact of active IBD on a person’s general health, can cause a temporary—and usually reversible—reduction in fertility.

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Women with IBD

It is important to keep in mind that women who have IBD but feel well, have their condition well in control, and do not require surgery need not worry about fertility or pregnancy issues.

Women who are unwell need to seek support and treatment for their symptoms.

Women who are unwell and need surgery need to discuss fertility issues with their surgeon before any procedure or operation. They also need to consult a specialist colorectal surgeon who will have experience with IBD and can address their specific concerns.

Among women with ulcerative colitis, fertility is the same as it is for women of a similar age in the general population. Among those with Crohn’s disease, fertility is also similar to the general population when the disease is in remission but might be lower when the disease is active. Fertility usually returns to normal once active disease is brought under control. Fertility might also be reduced if the ovaries and fallopian tubes have been affected by inflammation in the intestines, or if previous surgery has led to the formation of pelvic adhesions or scar tissue. Adhesions might require further treatment to help restore a woman’s ability to conceive.

Active disease, a lack of adequate nutrition, or excessive weight loss can affect the menstrual cycle by interfering with the normal function of the sex hormones. This can result in erratic ovulation and irregular periods. When IBD is brought under control and health and nutrition are restored, ovulation and menstrual cycles usually return to normal. Treatment with corticosteroids can also cause temporary irregularities in the menstrual cycle as well as amenorrhoea (the complete absence of periods) sometimes for months at a time. Again, this returns to normal when corticosteroid dosages are reduced or discontinued.

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Men with IBD

Sulfasalazine, which is one of the aminosalicylate or 5-ASA-containing medications, is known to have a negative effect on sperm. Within two months of starting sulfasalazine treatment, sperm count decreases, the presence of abnormal spermatozoa increases, and sperm motility is decreased. All of these changes are dose-related and are reversible. This issue can be avoided by would-be fathers by switching medications at least three months before attempting to conceive, by which time their sperm will have returned to normal.

Methotrexate can also lower sperm count but this returns to normal after discontinuing the medication. Men are advised to discontinue methotrexate three months before attempting to conceive.

Severe active disease or a lack of adequate nutrition can also reduce sperm count, which usually returns to normal once the IBD is brought under control and health and nutrition are restored.

Surgical procedures that remove the rectum (for example, proctocolectomy with ileostomy or ileal pouch anal anastomosis surgery) can sometimes (but rarely) impair men’s ability to achieve an adequate erection or ejaculation. Newer surgical techniques, however, that remove the rectum have significantly reduced the risk of this complication.

Surgery can sometimes be postponed if a couple wishes to start or complete their family, but it is always important to strike a balance between the benefits and risks of postponing or proceeding with an operation. Each IBD case is unique, and treatments are highly specialised, so it is important to have any operation discussed with the IBD team and done by a specialist colorectal surgeon.

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What’s the best type of contraception to use?

Women with IBD can use any form of contraception to avoid pregnancy, including oral contraceptives or the pill. Some evidence from clinical studies suggest that taking oral contraceptives can make Crohn’s disease worse, but it is important to note that most of the women who experienced this problem were also smokers. It is now well established that smoking increases the risk of developing Crohn’s disease and worsens the course of the disease, i.e., it increases the need for surgery and medications.

It should be noted that the absorption of oral contraceptives through the small intestine could be impaired because of disease activity and/or interaction with other medications such as sulfasalazine or certain antibiotics. During active stages of IBD, it is not unusual for the menstrual cycle to become irregular, so it’s important to be aware of your menstrual patterns. Consult your clinical team if you’re concerned about the effectiveness of your contraception or if you require further information about available alternatives.

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Will IBD affect my ability to conceive?

Most women with IBD can conceive as easily as other women of the same age. If you’re contemplating becoming pregnant, however, you should consider your current state of health before conceiving. Generally speaking, the outcome of pregnancy among women with IBD is best when the disease is inactive at the time of conception. If pregnancy occurs during a period of active disease, the IBD is likely to remain active or to worsen, and there is a greater chance of miscarriage, premature delivery, or a lower-birthweight baby. It’s also important to be aware that if medical or surgical treatment becomes necessary because of disease flare-up, your IBD would need to be treated in the same way as it would if you were not pregnant.

Although relatively uncommon, women with Crohn’s disease can develop complications involving the genital tract that can have an impact on their ability to conceive. These complications can have a direct effect on specific genital organs, or an indirect effect by causing discomfort or intense pain during intercourse. The most common types of genital tract complications include:

  • Development of scar tissue, either through the natural healing process or after surgery, which adheres to the fallopian tubes or ovaries.
  • Formation of abnormal channels or fistulae between the intestine and other organs that seep faecal matter and bacteria into the connecting organ. Fistulae that develop between the intestine and uterus cause inflammation and infection of the endometrium, on-again-off-again pelvic pain, and possible low-grade fever. Fistulae from the intestine to the vagina can result in the passing of gas and/or stool from the vagina.
  • Formation of abscesses or boil-like sacs containing intestinal fluid, bacteria, and pus in and around the pelvic region.
  • Development of slit-like or knife-cut ulcers on the vulva or labia (the outer lips of the vagina) which can be extremely swollen and painful and might also drain fluid. These ulcers could be tiny fistulae coming from the inflamed intestine or could also occur as numerous sores or pimples on the labia.

These complications usually resolve once the inflammation of Crohn’s disease is brought under control by treatment with medications such as corticosteroids, immunomodulators, or antibiotics. Surgery might sometimes be needed to drain an abscess or to remove the part of the intestine causing the problem.

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Will I have a normal pregnancy?

Yes, this is the most likely outcome especially if you plan your pregnancy and are in remission at the start. But do remember that any woman can have a ‘problem’ pregnancy and having IBD doesn’t change that.

Most women with IBD have normal pregnancies and normal deliveries, in proportions similar to women in the general population. Problems during pregnancy are most likely to occur among women with active Crohn’s disease, who might experience a greater risk of spontaneous abortion (miscarriage), premature delivery, or stillbirth. If the symptoms of Crohn’s disease become severe enough to require surgery during pregnancy, the risk to the foetus could be even greater. It is important to remember, however, that these complications of pregnancy are rare—especially if you entered the pregnancy healthy and well—and that the majority of women with Crohn’s disease experience normal, healthy pregnancies.

 

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Can IBD begin during pregnancy?

Only by coincidence and this is extremely rare. It is possible that both ulcerative colitis and Crohn’s disease can begin during pregnancy, but there is no evidence to suggest that IBD is more likely to be diagnosed for the first time during pregnancy or in the post-partum period (the first few weeks immediately after delivery). Nor is IBD likely to be any more severe if it is diagnosed during pregnancy or during the post-partum period.

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Will the medications I’m taking harm my baby?

Every pregnant woman wants to give her baby the best possible chance of being born healthy. It is only natural therefore for women with IBD to be concerned about the possible effects the medications they’re taking could have on their developing foetus.

If you are planning to have a baby, it is important for you to discuss these issues with your IBD specialist before you try to conceive, and keep yourself well informed.

Every pregnant woman with IBD needs to know if her disease is in remission, whether or not she can stop medication during her pregnancy, and what the risks are to both herself and her baby if she stops medication and experiences a flare-up during pregnancy. It might be necessary for some pregnant women to continue with their medication to control inflammation or maintain remission.

First and foremost, it is important to know that the greatest threat to conception, normal foetal development, and a successful pregnancy is the presence of active disease, not the use of medications. The outcome of pregnancy in women with IBD whose condition is well managed is similar to that of the general population, without any increase in the number of congenital abnormalities or premature births. As always, you and your clinical team should jointly weigh up the risks and benefits of your taking versus your not taking medications while pregnant or breastfeeding, according to your own individual circumstances.

Aminosalicylates

Numerous studies investigating the use of aminosalicylates or 5-ASA-containing medications have not shown any increase in adverse outcomes during pregnancy. These medications are therefore considered safe to take during pregnancy and breastfeeding. Sulfasalazine, however, is known to interfere with the metabolism of folic acid, which is essential to normal foetal development. All women who are pregnant or who are trying to become pregnant should take supplemental folic acid to reduce the risk of neural tube defects (e.g., spina bifida) in their unborn child, and this is especially true for women taking sulfasalazine.

Corticosteroids

Long-term use of corticosteroids is not generally recommended by health professionals. Having said that, many decades of use of corticosteroids in the treatment of conditions such as asthma, rheumatoid arthritis, and IBD during pregnancy have not shown any increase in the risk of complications such as stillbirths, premature delivery, and spontaneous abortion, even among those who are corticosteroid-dependent. Given that the risk to the foetus is far less from use of corticosteroids than it is from acute disease flare-up, corticosteroids can be used to control flare-ups during pregnancy and breastfeeding, with every effort being made to switch to other types of medication and minimise or eliminate use of corticosteroid once the disease is under control. Infants who are being breastfed while the mother is taking moderate or high doses of corticosteroids should be monitored by a paediatrician.

Antibiotics

Metronidazole and ciprofloxacin are the most common antibiotics used in the treatment of Crohn’s disease. Both medications are generally considered safe for use during pregnancy and breastfeeding, but are not recommended if other options are available.

Immunomodulators

Long and extensive experience with the use of azathioprine, 6-mercaptopurine and cyclosporin among pregnant women has not shown any increase in congenital abnormalities or adverse outcomes. The opinion is that these medications are safe and well-tolerated during pregnancy and breastfeeding and should be continued as required to control the disease.

Methotrexate, on the other hand, is known to cause congenital abnormalities and has been associated with an increase in spontaneous abortions. Methotrexate should never be used during pregnancy and should be discontinued at least three months prior to conception.

Biologicals

Those with IBD severe enough to require biological therapy tend to relapse when treatment is discontinued. At the same time, active disease poses a greater risk to successful pregnancy than use of a biological agent. There are now several thousands of reports of successful pregnancy outcomes with use of infliximab and adalimumab without harm to baby and infants followed out to 12 months and beyond. Note though that babies exposed to these drugs in utero must not receive any live vaccines until 12 months of age. As always, a balance must be struck between the risk of active disease and the risk of treatment. Women taking biological treatment who wish to conceive should discuss their situation with their clinical team.

Thalidomide

Thalidomide is occasionally used to treat refractory Crohn’s disease but should never be used if pregnancy is being considered.

Anti-diarrhoeal agents

Anti-diarrhoeal agents should always be used with caution. While occasional or low-dose use might be necessary from time to time, it is important that anti-diarrhoeal medications are avoided just before and during labour.

Enemas, foams, suppositories

Although there is some absorption into the bloodstream of the active ingredients of rectal formulations of IBD medications, the amount absorbed is rarely enough to cause any problems and need not be an issue, given that oral preparations of aminosalicylates and corticosteroids are considered safe to use during pregnancy.

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Is it safe to have diagnostic procedures during pregnancy?

In general, investigations involving x-rays and radiation, including CAT scans, should be avoided by pregnant women, especially during the first trimester (first three months). They should be done however when the need to investigate the mother’s health outweighs the risk to the foetus, as when there is a disease flare-up that is not responding as expected to treatment. In this instance, MRI might be performed instead of CT, or low-dose radiation techniques can be discussed with the specialist radiologist. Regardless of the method of diagnostic procedure, supreme care must be taken to shield the developing foetus from any radiation.

If diagnostic procedures are required during pregnancy to manage disease or plan a change in treatment, the following procedures are considered safe to perform:

  • abdominal ultrasound
  • sigmoidoscopy
  • rectal biopsy
  • gastroscopy
  • limited colonoscopy (a full colonoscopy is technically more demanding in the later stages of pregnancy and could present a greater risk)
  • MRI scans.

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Is it safe to have surgery during pregnancy?

If needed, yes it is, but routine surgery which could have been performed beforehand should not be done. This is one of the reasons one should be proactive when planning pregnancy and to aim to spend as much time in IBD remission as possible.

Any type of surgery during pregnancy raises concerns about the wellbeing of the mother and the foetus and, wherever possible, should be postponed until after delivery. Fortunately, there is rarely a need for IBD-related surgery during pregnancy.

In some cases, though, putting surgery off until after delivery might present a significant risk to the mother. And although any type of abdominal surgery presents risks to the developing foetus, there are also cases where the risk to the foetus would be greater if surgery was put off. As always, the risks involved with surgery need to be weighed against the danger of ongoing disease activity and the lack of response to medical treatment.

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Will previous surgery affect pregnancy?

Women who have had colectomy and ileostomy tend to experience relatively few surgically-related problems during pregnancy. A normal vaginal delivery can be expected without any additional complications caused by the surgery. It is possible, however, that the position, contour, and size of the ileostomy can change during pregnancy because of abdominal swelling. A stomal therapist can advice on the use of appliances during the course of pregnancy. Sometimes it might be advisable to postpone pregnancy for one year after construction of an ileostomy to allow the body time to adapt.

Women with active perianal disease and pouches will need to consider elective caesarians. This should be discussed between patient, obstetrician, IBD specialist, and surgeon.

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Will previous surgery affect delivery?

The majority of women with IBD can and do have a normal vaginal delivery. This method is preferred unless there are obstetric reasons to perform a caesarean section.

Women with Crohn’s disease complicated by perianal fistulae and abscesses involving the anal and genital areas are generally advised not to have an episiotomy (an incision to widen the birth canal) because of possible difficulties with the healing process. In these cases, caesarean delivery would be recommended.

Caesarean delivery will also be recommended for women who have had ileal pouch anal anastomosis surgery (IPAA) for ulcerative colitis, in order to preserve the function of the pouch and reduce the risk of pouch damage, although vaginal delivery is often possible in these cases.

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Will pregnancy make my IBD worse?

No, there is no evidence of this.

The physical and emotional stresses of pregnancy or the postpartum period might cause the symptoms of IBD to worsen, or at any rate the new mother might feel worse, just as might happen at other times of stress during the course of the disease. But this in no way implies that stress causes IBD or that being pregnant worsens IBD.

Doctors advise patients to take good care of themselves throughout their pregnancy, and especially during the post-partum period which can be a particularly challenging time for new parents. It is best to rest as much as possible and to arrange for home help if necessary. If your IBD does flare up during pregnancy or the post-partum period, you should contact your clinical team to ensure that the inflammation is brought under control as quickly as possible.

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If I had problems during one pregnancy, can I expect the same for future pregnancies?

The short answer is no. There is no way to predict whether problems experienced in one pregnancy, such as disease flare-ups or development of complications, will occur in any subsequent pregnancies.

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Do I need to follow a special diet while I’m pregnant?

No. Pregnant women with IBD should follow the same well-balanced diet that is recommended for all pregnant women, which includes items from all major food groups. Most pregnant women are advised to take a folic acid supplement and some might also require additional iron. Supplemental folic acid is especially important to women with Crohn’s disease of the ileum (last segment of the small intestine) and/or those taking sulfasalazine, as the absorption of folic acid might be reduced. Prior to conception, women with IBD should be tested for iron deficiency which is quite common in IBD but often go unrecognised unless specifically investigated.

Depending on your individual circumstances, your clinical team might also recommend other vitamin and mineral supplements, or the addition of specific foods to your diet to ensure that you’re getting essential nutrients. If your disease is active, it might be necessary to eliminate specific foods from your diet that are causing you discomfort. Your dietitian will be able to provide you with further information about healthy and well-balanced diets during pregnancy and breastfeeding.

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Will I pass IBD on to my children?

In general, no. Generally speaking, your children are more likely to not have IBD than to have it. Unlike, for example, height or hair and eye colour, which are inherited directly from one or the other parent, IBD is not strictly a hereditary condition, although it does display a definite genetic predisposition.

What does this mean? It means that it is not the disease itself that is passed on from one generation to the next, but rather a tendency for the disease to develop in an individual. It is only when someone with a genetic predisposition to IBD encounters one or more still-unknown factors that the condition will ultimately develop.

It is estimated that the lifetime risk of a child developing IBD is about 9% if one parent has the condition, and about 36% if both parents have the condition. This means that a child has a 91% chance of not having IBD if one parent has it, and a 64% chance of not having it, even if both parents are affected. The risk is not considered large enough to discourage anyone with IBD from starting or adding to a family.

 

The ability to become pregnant when desired and to raise healthy and happy children are issues many of us face when deciding to have a family. Having IBD most certainly adds to the many challenges. But, it can be done and it can be done well. Just keep a positive attitude!

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The latest news and Research

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10 tips to feel better during flare-Ups

Posted: November 4 2018

You’ve had weeks on end symptom free, but you know it can’t stay this way forever. As people living with Crohn’s disease, we are often waiting for the other shoe to drop. When will Crohn’s rear its ugly head once again? Flares are a frustrating, unfortunate reality with Crohn’s. To help you the next time […]

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Crohn’s disease can’t stop Shane

Posted: October 22 2018

A Bunbury father is shaking off any ignominy around a disease many are reluctant to speak out about with an ultimate goal of finding a cure. Shane Maher was diagnosed with Crohn’s disease at the age of 26. “My life is different, I have to be mindful at all times of my condition,” the now […]

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Nobel Prize in Chemistry awarded for using evolution to develop adalimumab (Humira)

Posted: October 8 2018

Scientists Frances Arnold, George Smith and Sir Gregory Winter have won the 2018 Nobel Prize in Chemistry for research using directed evolution to produce enzymes for new chemicals and pharmaceuticals, the award-giving body says. “This year’s Nobel Laureates in chemistry have been inspired by the power of evolution and used the same principles — genetic […]

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Breastfeeding can limit Crohn’s progression in children

Posted: October 8 2018

Children with Crohn’s disease who are breastfed are less likely to experience progression to stricturing or penetrating disease, while other environmental factors, like smoking, are linked to adverse events among this population, according to research published in The American Journal of Gastroenterology. Ashwin N. Ananthakrishnan, MD, MPH, of the division of gastroenterology at Massachusetts General Hospital, and colleagues examined […]

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Family history tied to nearly eightfold increased CRC risk for IBD patients

Patients with IBD who have a first-degree relative with a history of colorectal cancer have a higher risk for also being diagnosed with that cancer.

Patients with inflammatory bowel disease who have a first-degree relative with a history of colorectal cancer have a higher risk for also being diagnosed with that cancer, according to research published in Clinical Gastroenterology and Hepatology. N. Jewel Samadder, MD, MSc, of the division of Gastroenterology and Hepatology at the Mayo Clinic in Phoenix, Arizona, and colleagues wrote that although […]

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Colonoscopies: Why are they performed and when should you have them?

Posted: September 7 2018

A recent study found up to 20 per cent of all procedures performed in a New South Wales hospital were either unhelpful or harmful. Some of these, which included performing a colonoscopy for constipation, were becoming more prevalent. A colonoscopy is a test where a small, flexible tube is inserted into the bowel to check for abnormalities […]

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