Starting a Family
You or your loved one has Inflammatory Bowel Disease (IBD) and you want to start a family. There may be many considerations associated with this decision, such as If you are a woman, you may wonder if you can get pregnant; if you are a man, you may wonder if you can father a child. What are the health consequences of starting a family? Should you take your meds if you are pregnant? Will your children have IBD?
These questions and many others may arise as you sort out the life and health issues related to fertility, pregnancy, and IBD. Your health does not follow a cookie-cutter approach and the factors you and your partner need to consider when having a family will be specific to your situation.
Can You Get Pregnant?
You may have heard that it is more difficult to conceive if you have IBD. Is this true?
Yes and no. Studies show that if your disease is not active (in remission) and you are healthy and well-nourished, you are just as likely to get pregnant as anyone else! If you are in the midst of an acute episode of your IBD, you might have more trouble conceiving during that period of time. Also, women with an IPAA (Ileal Pouch with Anal Anastomosis) tend to have reduced fertility rates, possibly due to internal scarring around the fallopian tubes (please see our booklet “The Cutting Edge: Surgery and IBD” for more details on the procedure).
If you have had surgery to remove part of your colon, studies also tell us that there is NO detrimental effect on fertility rates. However women who have an ileostomy as a result of a bowel resection could have a slightly decreased fertility rate.
Should You Get Pregnant?
In spite of the good news about fertility rates amongst women with IBD, current studies show that the actual rate of conception is lower than the general population. This indicates that women with IBD are physically able to get pregnant, but some are choosing not to. Why? Surveys suggest two possibilities: that some women with IBD are concerned about the adverse health consequences to themselves during and after pregnancy; and some are concerned for their children as a result of their disease, and are therefore choosing not to have children.
Are these concerns grounded in fact? Let’s start off by stating that the best time for you to get pregnant is when your IBD is in remission. If your disease is active at the time you conceive, there is a good chance that it will remain active throughout your pregnancy. In this case, there is an increased risk of having a miscarriage, delivering your baby prematurely, having a still birth or giving birth to a new born with low birth weight (LBW).
However, if you conceive when your disease is in remission, most studies show that you are as likely to have a normal pregnancy as a woman who does not have IBD. The important fact to remember is that you should plan your pregnancy at a time when your body is healthy and your IBD is under control. This makes a huge difference to you and your baby.
What about Fathering a Child?
Males who are experiencing an acute episode of their IBD tend to have decreased sperm counts during this time. However, once their symptoms have gone into remission, their sperm counts become normal- provided they are well nourished. When family planning begins, men should stop taking sulfasalazine and consider switching to an alternative medication such as 5-ASA at least three months before trying to father a child because this drug is known to decrease sperm counts.
Will Your Children Develop IBD?
At this time, the links between genetics, the environment, microbes and IBD are still being explored. Current studies do show a slightly increased risk for children to develop Crohn’s disease or Ulcerative Colitis if one or both parents have IBD. However, there is a greater possibility that children will not develop IBD than there is a chance that they will.
What about My IBD Medication?
The following list reflects current research on medications and pregnancy. We want to again emphasize that all drugs have some side effects, but these must be weighed against their benefits.
Current research shows that your medications do NOT affect fertility in either men or women, with the exception of sulfasalazine and methotrexate. As we noted earlier, sperm counts are reduced while men are taking this sulfasalazine, but will resume normal levels approximately three months after you stop taking the drug. Taking methotrexate is definitely not recommended when trying to start a family, as it not only reduces sperm counts in men as well as has been known to cause miscarriages and fetal deformities.
2. During Pregnancy
We want to emphasize that good control of your IBD is essential to a healthy pregnancy and a healthy baby; your IBD medication contributes to that healthy state. If you decide to stop taking you medication because you are pregnant and your disease subsequently flares up, the risks to your baby can be much greater than those associated with the drugs. Malabsorption, malnutrition, inflammation, diarrhea, and dehydration can all play havoc on the developing fetus. Please see our booklet, “Prescription for Health: Medication and IBD” for more information on side effects.
There are very small risks associated with aminosalicylates. In fact, these risks pose less of a hazard to your baby than not taking the medication if you need it. In fact, doctors can and will prescribe these drugs after your baby is born, even if you want to breastfeed.
Current opinion seems to vary as to whether or not antibiotics are safe during pregnancy. You should not take metronidazole when you are pregnant; in fact some physicians will recommend a therapeutic abortion if you were taking the drug at the time you conceived.
As for other antibiotics such as ciprofloxin and tetracycline, there are mixed findings on their effects on the fetus. Some studies indicate concern over possible fetal deformities while others simply recommend that antibiotics be avoided during pregnancy. Once again, the clinical necessity of taking an antibiotic must be weighed off against the potential for fetal consequences.
Loperamide and diphenoxylates are two anti-spasmodic drugs used to relieve diarrhea. Unfortunately there is not much information available on their effects on fetuses, nor is there information about their effects if the mother is breastfeeding her baby. It would be best to discuss these drugs with your doctor or pharmacist if you require an anti-spasmodic when pregnant (or afterwards, if you intend to breastfeed).
Biologics such as infliximab and adalimumab appear to be safe both during pregnancy as well as breastfeeding. There have been no significant increases in fetal malformations, miscarriages or other problems found with taking this class of drugs while carrying a baby. However, there has been less experience with these drugs in pregnant women with IBD compared to some of the other drugs used to treat IBD.
Taking corticosteroids has been shown to be quite safe for the fetus, except in the early stages of pregnancy when it would be preferable (if possible) to not take the drug. There is a very small risk of fetal deformity (cleft palate), premature delivery or LBW, but these are deemed acceptable against the need for a woman to take the lowest possible does of the medication to control her IBD. Babies of breastfeeding moms who are taking a corticosteroid should be monitored by a pediatrician.
At one time, physicians did not recommend that women take immunosuppressants while pregnant. However, current research has shown that there are better outcomes for babies whose mothers stay on their immunosuppressants, than for babies whose mothers went off the medication and subsequently suffered a relapse of their IBD. Data shows that there is either no increase in abnormalities for babies or a very small but insignificant increase when mothers continued with their immunosuppressants.
Congratulations- You’re Pregnant!
Many women with IBD have a normal pregnancy and delivery. Occasionally there are chances of premature delivery or LBW, particularly if the mother experiences a relapse of her IBD during pregnancy. However, there are far more women who have a wonderful, full-term pregnancy than those who have trouble.
Here are a few more thoughts we want to share, to help you maximize the health of your growing child as well as your own.
Make sure you eat well during this time. Your baby is depending on you for nutrition, so be sure you are eating properly. Also, you should talk with your doctor about taking folic acid supplements, as women with IBD are often deficient in this nutrient and it is important for proper neural development in the fetus. Please see our booklet “Food for Thought: Diet and IBD” for more information on your diet, nutrition and vitamin supplements.
IBD Symptoms and the Fetus
The symptoms associated with IBD that you might experience during pregnancy, such as nausea, diarrhea, gas and cramps, do not adversely affect the fetus. Your IBD is not directly harming the fetus unless these symptoms are interfering with your ability to eat a proper diet and absorb the necessary nutrients.
Regardless of whether or not you have IBD, smoking before, during or after you are pregnant is a bad idea. Smoking has been associated with LBW and possibly the development or worsening of Crohn’s disease.
Most diagnostic procedures are perfectly safe when you are pregnant. That includes endoscopic procedures for your bowel, biopsies, ultrasounds and MRI’s. However you should NOT have a CT scan or X-ray while you are pregnant, unless there is a medical emergency that necessitates them; this is true for all women, regardless of whether they have IBD or not.
The moment has arrived and your baby is on the way! Let’s talk briefly about options in the delivery process.
Vaginal Deliveries, Episiotomies, and Caesarean Sections
Women with IBD have the same rates of vaginal deliveries as women without IBD. Your obstetrician may decide to do an episiotomy at the time of delivery to avoid an uncontrolled tear in your perineum. This is particularly important for women with IBD, as the presence of active inflammation in the area can inhibit post-partum healing of an uncontrolled tear around the anal sphincter or rectum. A caesarean section may be recommended if you have a lot of perennial inflammation or fistulas to avoid the possibility of further trauma to your perineum.
Some Additional Post-partum Thoughts
Doctors recommend that women breastfeed their babies whenever possible because it is healthier for both mom and baby. However, if your IBD is active, you might not be able to produce enough breast milk. If you do decide to breastfeed, let your doctor know because there are some medicines (steroids, immunosuppressants, anti-diarrheals, sulfasalazine and 5-ASAs) that may pass into your breast milk. However, don’t let this alarm you. The risks to your baby vary according to the drug and dosage, so they should be discussed with your doctor.
What happens during one pregnancy is not an indicator of what you will experience in another. If you have a rough ride with IBD during your first pregnancy, it is by no means an indicator that a subsequent pregnancy will be the same. Make decisions about additional children based on other life and health issues, not based on the relapse or remission of your symptoms during your last pregnancy.
Women with IBD can use any form of contraception their doctor recommends. There is research suggesting that some types of birth control pills aggravate symptoms of IBD, while other studies reject this idea. There appears to be some question about the absorption and effectiveness of birth control pills for women who have had an ostomy. If you have suffered a relapse of your IBD symptoms, your gastroenterologist may test the effects of your contraceptive medicine by temporarily taking you off the pill and seeing if it makes any difference.