May 19th is World Inflammatory Bowel Disease (IBD) Awareness Day. Five million people worldwide are affected by Crohn’s disease and ulcerative colitis. Pregnancy and fertility are often a concern within this population.
Because our office is located above a busy gastrointestinal clinic, many women and men with IBD come upon our office serendipitously. Of course when we have our consultation with these couples, we approach their infertility the standard way we do most infertile couples.
The most important diagnostic testing in IBD couples are the hysterosalpingogram (HSG) and the semen analysis. An HSG is an X-Ray for the woman to determine whether fallopian tubes are open. This brief test can be performed in the office of Carolina Conceptions. A semen analysis is the first test necessary in evaluating the man with IBD. This test can also be completed at Carolina Conceptions. Collection can be done at home if the couple lives within 30 minutes from the office.
Men with IBD may also have a higher incidence of infertility, but it is likely due to voluntary infertility, i.e. the husband not wanting to have children in the setting of chronic illness, or he is sexually inactive due to the presence of active disease. Additionally men may be concerned about their children inheriting IBD.
Fertility rates in women with IBD are no different in general from the normal population with about 5 to 14% of couples unable to conceive after one year of trying. Unfortunately there are factors that may increase the risk of infertility in women with IBD. For example the risk of infertility due to tubal abnormalities and pelvic adhesions increases markedly in women with IBD who have undergone colon surgery, especially ileal pouch anal anastomosis (IPAA). This is usually the result of pelvic adhesions that are a frequent consequence of the operative procedure, or adhesions that form from a subclinical unrecognized pelvic infection with resultant peritonitis from bowel anastomotic leaks etc. Infertility rates are two to three times higher after the IPAA procedure. It is not known whether laparoscopic IPAA is associated with a lower risk of infertility than open IPAA.
Is there a high recurrence rate of IBD in women once they conceive? Studies show that women with IBD are as likely to flare during pregnancy as when they are not pregnant, approximately one third flare during pregnancy. Women with IBD are more likely to experience preterm birth, low birth weight, and a baby that is smaller than the average baby (small for gestational age). C-sections occur more frequently in women with IBD. In general the decision to have a C section is based purely on obstetrical grounds. However there are two exceptions. C-section should be done in women who have undergone an ileoanal pull through operation so as not to injure the external anal sphincter, and a C-section should be done in women with active perineal disease, such as fissures or fistulas.
There is no difference in the incidence of congenital abnormalities in offspring born from mothers and dads with IBD according to a large Hungarian Case Control Surveillance study from 1980 to 1996.
What are the effect of IBD meds on fertility and pregnancy? Methotrexate and thalidomide are inadvisable in men and women trying to conceive. Sulfasalazine clearly causes sperm abnormalities and should not be taken by men with IBD trying to conceive. Switching to Asacol is better.
Most medications prescribed for IBD are safe during pregnancy. Be sure to discuss your medications and supplements with your doctor(s) to ensure the best health for mom and baby.
After diagnostic testing is complete, the IBD infertile couple is approached in the same manner as the infertile couple without inflammatory bowel disease. The only exceptions are that surgery is less frequently attempted, and in vitro fertilization is more quickly turned to in the woman with IBD who has undergone colon surgery.