Recent Articles - Fertility

Tim Brunt had a few questions when he and his wife Colleen started planning their family, which now includes four-year-old Josh and three-year-old Meagan. Tim – CCFC’s first Gutsiest Canadian contest winner and a veteran of 12 separate surgical procedures for Crohn’s disease – was being treated with biologics and immunosuppressants at the time they were trying to get pregnant. Tim began a vigorous research undertaking to ensure no treatments he was taking would impair his fertility.

The Brunt Family

FERTILITY FOR MEN
Dr. Hillary Steinhart, a gastroenterologist at Mount Sinai Hospital in Toronto and Chair of CCFC’s Scientific and Medical Advisory Council, echoes that thought when advising his male patients.

“When you’re not feeling well, you’re going to be less interested in sex so my advice is to ensure your disease activity is well controlled,” says Dr. Steinhart.

That’s not the complete picture for men with IBD to contemplate when planning a family, of course. While information on the long-term effects of IBD medications for both genders is limited, Dr. Steinhart can share the following useful information about male fertility and IBD:

• The disease itself is not known to affect sperm count or sperm motility. There is not a lot known about the effect of IBD medications on fertility other than that sulfasalazines can lower sperm count.
• Biologics and immunosuppressants are not known to affect sperm count or male fertility.
• Nerve damage caused by proctectomy (as part of a surgical ileal pouch procedure) can affect potency – more in older patients than younger.

GETTING PREGNANT

When Heather Fegan was diagnosed with Crohn’s-colitis at the age of 14, the idea of having a family was hardly top of mind. She was just a very young person trying to handle a flare-up so severe it required tube-feeding to give her bowel a rest.

Even when she got severely ill again in her first year of university, she wasn’t thinking about what treatment would give her the best chances of having a family later on – she chose surgery over biologic therapy because that treatment was still being tested and she didn’t feel comfortable with it.

Today, Heather has five cm of large bowel remaining and receives infusions of biologics every four weeks for a recurrence of Crohn’s disease. She’s also 28 years old, married, and starting to wonder how she’s going to manage her disease and start a family.

“My sister has Crohn’s and has three children and I have friends who have Crohn’s and have had kids, so I know it’s possible. But I’m concerned about how the frequency of my treatment can affect a fetus,” says Heather, who is also a long-time CCFC volunteer from Halifax.

“I’m nervous about what can happen to my body, too – will I flare really badly during a pregnancy?”

More is known about pregnancy and IBD, but Dr. Steinhart still advises his female patients to get their disease activity under control – and ideally be in remission – before becoming pregnant.

Unfortunately, for some women, waiting for remission won’t be an option. Some of the factors that can affect a woman’s ability to get pregnant during a flare are:

• Sex can be uncomfortable due to perianal complications such as fissures, fistulas or surgery; and
• Some women experience hormonal changes during a severe flare that may make menstrual cycles irregular or prevent an egg from being produced.
• Women who have had surgery known as an ileal pouch with anal anastomosis may also have lower fertility rates due to potential internal scarring around the fallopian tubes.

TREATMENT DURING PREGNANCY
There are more considerations once a woman does become pregnant, says Dr. Steinhart, which fall into what gastroenterologists call the rule of thirds: one-third of women will have no change to their IBD when pregnant, one-third will improve, and one-third will get worse.

If a woman is either not in remission and pregnant, or goes into a flare during pregnancy, there are risks to the pregnancy. Dr. Steinhart says a flare during pregnancy can affect the growth of the baby and contribute to low birth weight. There is a small risk of miscarriage early in the pregnancy, which can be caused either by nutritional deficiencies, hormonal issues or a direct effect of inflammation.

If medication is needed to get the disease under control during pregnancy, only one drug is known to definitely have harmful effects to the fetus and that’s methotrexate. This immunomodulator can induce miscarriage in the first trimester of pregnancy, and cause fetal malformation later in the pregnancy. Other than this drug, Dr. Steinhart says there is no known risk of malformations, either from having a flare during pregnancy or from medications.

Back to Heather’s original question, what’s known at this point about biologics and pregnancy is that while these drugs do enter the baby’s blood stream if taken during the third trimester, no harmful effects have been observed in babies up to six months after birth. But Dr. Steinhart cautions that there is not a lot of information available about the long-term effects of exposure to biologics in-utero, given that this therapy is relatively recent.

“In the past, many women were counseled not to get pregnant if they had IBD,” says Dr. Steinhart. “Now, our main advice is to get pregnant when you’re in remission.”

BEING PREGNANT

That’s the advice CCFC spokesperson Amanda Holmes received from her gastroenterologist when she and her husband Adam were ready to start a family. Amanda wasn’t in remission at the time, so she worked with her medical team to determine the best treatment to get her there. She chose immunosuppressant therapy even though she didn’t have a lot of information – just recommendations from friends who had been through the experience and the advice from her GI that the risk of a flare was greater to the baby than the treatment would be.

Amanda Holmes with son Wyatt and husband Adam