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Fertility, Pregnancy, and Breastfeeding with Inflammatory Bowel Disease (IBD)

Uma Mahadevan, MD

Introduction

If you have inflammatory bowel disease (IBD) and are thinking about starting a family, you may wonder how your chronic illness and the medication you take can affect fertility, pregnancy, childbirth, and breastfeeding. The good news is that most people with IBD have normal fertility, and most women with IBD can expect a normal pregnancy and delivery, as well as a healthy baby. This newsletter will answer some of the more common questions you may have.

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Will IBD affect my fertility?

In general, neither men nor women with IBD have decreased fertility when compared to the general population, however there are several exceptions.

If you are a woman . . .

• Pelvic surgery to manage your IBD can result in scar tissue, making it difficult for you to conceive.
• IBD can increase your risk of precancerous cervical cells (especially if you are taking immunosuppressants or biologics), which can decrease your fertility.
• You may have irregular periods during flares, which can make it difficult to conceive.

If you are a man . . .

• Taking sulfasalazine can affect sperm count and quality, so be sure to talk to your physician about switching to a different medication several months prior to trying to conceive.

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Can I have a healthy pregnancy, even though I have IBD?

If your IBD is in remission, you are likely to have a healthy pregnancy, although your chance of complications – for example, miscarriage, premature delivery, or a low birth weight baby – is somewhat increased. Therefore, it is important that your obstetrician follows you as a high-risk patient.

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What steps can I take before conceiving to promote a healthy pregnancy?

The sooner any woman sets the stage for a healthy pregnancy, the better the odds. For example, all women considering pregnancy should eat a healthy diet and not smoke or drink alcohol. If you have IBD, it is also important to be in remission when you conceive and to ensure that your gastroenterologist and obstetrician work together as a team. You should have a plan in place prior to conception regarding the medications you can take during pregnancy and breastfeeding. Also confirm that you are up to date for all immunizations, a pap smear, and surveillance colonoscopy. If you are between the ages of 9 and 26, you may want to consider the human papillomavirus (HPV) vaccine, which protects against the infection that can lead to cervical cancer, especially if you have taken immunosuppressants or biologic therapy. Finally, be sure to have your B12, folate, and vitamin D levels checked, and take supplements if you need them.

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Are there specific foods I should eat for a healthy pregnancy?

When it comes to nutrition, the ideal goal for a healthy pregnancy is a balanced diet that includes fortified breads and cereals, vegetables, fruits, low-fat dairy products, and lean meat, chicken, fish and shellfish (be sure to choose types that are low in mercury, like shrimp, canned light tuna, salmon, pollock, and catfish).

The USDA’s “Daily Food Plan for Moms” can help you determine what and how much you need to eat, based on your age, weight, trimester, and other factors. Keep in mind that some foods may cause morning sickness or trigger your symptoms, so you might need to adjust your diet accordingly.

Finally, be sure to drink enough fluids. Pregnancy can increase the diarrhea that typically accompanies IBD, making adequate hydration even more important than usual.

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Does IBD make it more likely that I will have a flare during pregnancy?

Pregnancy has no impact on the likelihood of flares. In fact, some women with IBD report that their disease is less active during pregnancy.

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Is it true that IBD can increase my risk of hemorrhoids during pregnancy?

Diarrhea or constipation, which are common IBD symptoms, can increase the likelihood that you will have hemorrhoids during your pregnancy. To ease hemorrhoid discomfort, try soaking in warm water several times each day or applying ice packs or cold compresses to ease swelling. It also helps to avoid sitting for prolonged periods and to keep the anal area clean.

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Can I have a vaginal delivery, even though I have IBD?

Most women with IBD can have a normal, vaginal delivery. You might have heard about an increased rate of cesarean sections in women with IBD, but this is most likely due to patient or physician preference, and is not related to medical need.

You may need a cesarean section if you have active perianal disease, which can be aggravated by a vaginal delivery, or if you have an ileoanal pouch, since a vaginal delivery can damage the anal sphincter. Scarring in the perineum or rectum may also result in the need for a cesarean section, because it can impede the stretching required to accommodate your baby’s head during delivery.

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What if I need gastrointestinal surgery while I’m pregnant?

If you have IBD-related complications during your pregnancy, always consider non-surgical treatment first. If non-surgical treatment is not an option or is unsuccessful, surgery is typically well-tolerated, especially during the second trimester.

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What if I need a gastrointestinal diagnostic procedure while I’m pregnant?

There is no need for routine diagnostic procedures during pregnancy, however most procedures, including colonoscopy, sigmoidoscopy, upper endoscopy, and MRI , can be safely performed, if necessary. Exceptions include CT scans and standard X-rays, which should be ordered only in a medical emergency.

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Can I continue taking my IBD medication while I’m pregnant or breastfeeding?

You should always consult with your healthcare professional before starting medications during pregnancy or while breastfeeding. Many IBD medications are considered to be low-risk during pregnancy and compatible for use during breastfeeding. In fact, the risks related to a disease flare during pregnancy (miscarriage, low birth weight, and pre-term birth) are much greater than the risks related to most IBD medications. Therefore, stopping your medications, particularly without the knowledge and consent of your gastroenterologist, may be the biggest risk to your pregnancy. The following table lists common medications and recommendations for pregnancy and breastfeeding.

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Conclusion

Years ago, women with IBD were counseled against pregnancy, but that is no longer the case. Thanks to a better understanding of the disease and improved medication to treat it, most women can expect to have normal fertility, a successful pregnancy and delivery, and a healthy baby. If you have IBD and are planning to get pregnant, remember that each person’s disease is different. Be sure to involve your gastroenterologist and obstetrician in any decisions you make, so that you get the best possible support for you and your baby. Remember to tell your pediatrician what medications you took during pregnancy, as this may impact the vaccines given to your baby.

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