For patients with IBD – please check out our https://pregnancy.ibdclinic.ca/ website for more information including educational resources, and research opportunities.
Fertility
General Information
In a recent study conducted by The University of Alberta IBD clinic, women with IBD were surveyed on what they understood about IBD and pregnancy, and what their concerns were. More than 50% of the surveyed women had a lack of knowledge about IBD and pregnancy1. More than 50% of surveyed women were childless, and more than 10% said they chose not to become pregnant (“voluntary childlessness”)1. Our survey study and previous studies showed that the concerns patients with IBD have are often based on a lack of knowledge and/or incorrect information1,2.
Yes, it is possible to become pregnant with IBD.
Those with inactive IBD have similar fertility rates as the general population, which varies from 1 in 10 couples to 1 in 6 couples3.
However, if you have active IBD or have a history of pouch surgery, you may find it harder to become pregnant
Active IBD is associated with decreased fertility3,4 so it is important that people who are trying to become pregnant speak to their physician to ensure their IBD is controlled and inactive.
Patients who have had the ileal pouch-anal anastomosis (IPAA) surgery can also have decreased fertility5,6 – for more on this see the Surgery and Fertility section below.
There are also factors other than IBD that can affect fertility
Fertility decreases with age. . .
Women’s fertility peaks in their late teens and early 20s7. After the age of 35 years, fertility declines sharply and by 45 years, pregnancy is uncommon7,8. Older women also have increased odds of abnormal embryos7.
Male fertility significantly decreases after the age of 35 years8. The viability of sperm in the female reproductive tract decreases with age.
Preconception health can affect fertility . . .
Body weight: Extremes of body weight can decrease fertility. Obesity has been associated with an increased risk of infertility because of decreased sperm concentration and higher incidences of miscarriages9-11.
Nutritional Status: It is essential that people who are trying to conceive are getting enough vitamins and nutrients9-11. This is especially true for IBD patients as their diets may be limited. The Health Canada Food Guide suggests that patients attempting to become pregnant take daily multivitamins with iron and folic acid10.
Habits (smoking, drinking): Smoking and alcohol consumption should be stopped prior to attempting to become pregnant as they can affect the eggs and sperm, and decrease fertility11.
Family and personal history before pregnancy can affect fertility . . .
Family history of fertility issues: A family history of fertility issues may suggest a genetic disorder12,13.
Personal history of fertility issues and other medical conditions: An individual’s medical history can suggest reasons for decreased fertility. For example, polycystic ovarian syndrome14 and uncontrolled diabetes9 are associated with infertility.
References
Huang V et al. Does the level of reproductive knowledge specific to inflammatory bowel disease predict childlessness among women with inflammatory bowel disease. Can J Gastroenterol Hepatol 2015;29(2):95-103.
Selinger CP et al. IBD and pregnancy: Lack of knowledge is associated with negative views. JCC. 2012 Sep;7:206-213.
Habal F M & Huang V W. Review Article: a decision-making algorithm for the management of pregnancy in the inflammatory bowel disease patient. Aliment Pharmacol Ther. 2012 January;35:501-515.
Ng S W & Mahadevan U. My Treatment Approach to Management of the Pregnant Patient With Inflammatory Bowel Disease. Mayo Clin Proc. 2014 March;89(3):355-360.
Walijess A et al. Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in Ulcerative Colitis. Gut. 2006;55(11):1575-1580.
Tulchinsky A et al. Restorative proctocolectomy impairs fertility and pregnancy outcomes in women with Ulcerative Colitis. Colorectal Dis. 2013;15:842-847.
Craig B M et al. A Generation of Childless Women: Lessons from the United States. Women Health Iss. 2014;24-1:e21-e27.
Dunson D B, Colombo B, & Baird D D. Changes with age in the level and duration of fertility in the menstrual cycle. Human Reproduction. 2002;17(5):1399- 1403
Farhari N & Zolotor A. Recommendations for preconception counseling and care. Am Fam Physician. 2013. Oct 15; 88(8): 499-506
Sharma R et al. Lifestyle factors and reproductive health: taking control of your fertility. Reprod Biol Endocrin. 2013;11:66.
Shah K et al. The genetic basis of infertility. Reproduction. 2003;126:13-25.
Shapira S K & Dolan S. Genetic Risks to the Mother and the Infant: Assessment, Counseling, and Management. Matern Child Health J. 2006;10:S143–S146.
Setji T L & Brown A J. Polycystic ovary syndrome: update on diagnosis and treatment. AMJ 2014.
Surgery and Fertility
Patients with IBD may require surgery for various reasons: bowel narrowing (stricture) causing obstruction, connections between bowel and other organs (fistula), ongoing active disease despite treatment, and non IBD related reasons. Some types of IBD surgeries may affect fertility, pregnancy, and delivery method.
Having colitis and going through the ileal pouch-anal anastomosis (IPAA) surgery can have decreased fertility1,2. The second stage of the surgery is the creation of the pouch – this stage occurs deep in the pelvis and is associated with risk of damage and scarring of the fallopian tubes (the tubes that connect the ovaries to the uterus allowing the eggs to reach the uterus to be fertilized).
Those who need to have this surgery and who plan to become pregnant afterwards should speak to their surgeon. It is often recommended to have a staged procedure where the surgeon will create a temporary ileostomy after removing the colon and create the pouch after the patient has completed their pregnancies.
Crohn’s Disease
Ileal resection and ileocolic resection
For patients with Crohn’s Disease, two common surgeries are the ileal (small bowel only) resection and the ileocolic (small bowel and part of large bowel) resection. During these surgeries the portion of the bowel that is strictured or diseased is removed and the healthy ends are attached. These surgeries usually do not interfere with the reproductive organs and are unlikely to affect fertility. However, adhesions (scar tissue) can form from any surgery, and adhesions that block the fallopian tubes can lead to infertility.
Perianal abscess and Fistula surgeries
Patients with Crohn’s Disease who have abscesses around the anus need to have them incised (cut open) and drained. Patients with fistulas (connections from the bowel to the skin) around the anus may need to have them cut open or a seton inserted to prevent formation of abscesses.
A seton is a rubber band that is passed through the fistula tract as well as the anus, creating a loop as the ends are tied together. This surgery is performed to keep the fistula open so it can heal. As these surgeries do not interfere with an individual’s reproductive organs, they do not affect fertility.
Patients who have active perianal disease or complications from prior perianal disease should discuss the mode of delivery with their gastroenterologist, surgeon, and obstetrician.
Ulcerative Colitis
Colectomy and Ileal pouch-anal anastaomosis (IPAA)
For patients with ulcerative colitis unresponsive to medical therapy, colectomy is often needed. The small intestine is brought up to an opening in the abdominal skin and formed into an ostomy. An ostomy bag sits outside to collect the waste. The ostomy can be a permanent end-ileostomy, or a temporary ostomy, depending on the situation.
In some cases, the ileum (small bowel) is brought down into the pelvis, shaped into a pouch, and connected to the anus – ileal pouch-anal anastomosis (IPAA, or J-pouch).
Since the surgery occurs deep in the pelvis, injury can occur to the fallopian tubes (a reproductive organ through which an egg travels from the ovary to the uterus); scarring and adhesions that form after the surgery can block the fallopian tubes. The IPAA surgery is associated with infertility rates as high as 63% compared to an infertility rate of 20% in patients who are pre-IPAA3. However, laparoscopic IPAA are associated with lower rates of infertility (approximately 27%) as laparoscopic procedures result in fewer adhesions4,5.
For patients who need a colectomy but also wish to have children, it is suggested that they have the colectomy with a temporary ileostomy until they have finished having children. Then they can undergo the IPAA procedure to create a J pouch.
Studies have not found a significant increase in the incidence of maternal or fetal complications in patients who have had an IPAA6. Pregnancy may result in transient and inconvenient changes in pouch function (such as soiling, urgency, and perianal irritation), however these changes typically resolve after delivery6. Patients may also be at a small increased risk of small bowel obstruction, pouchitis (inflammation of the pouch), and perianal abscesses (infected cavity near the anal canal, typically containing pus)6.
Vaginal delivery has been associated with pouch dysfunction and risk of anal sphincter damage leading to incontinence. However, caesarean section also comes with it’s own risks and benefits as it is a surgical procedure. Patients with a pouch should therefore discuss mode of delivery with their gastroenterologist, general surgeon, and obstetrician.
Ostomy and Fertility
If you have an ostomy, either ileostomy or colostomy, here are some tips on sex, intimacy, and fertility:
In summary, most surgical options for patients with IBD do not affect fertility, unless there are complications or adhesions that block the fallopian tubes. An ileal pouch-anal anastomosis is associated with an increased risk of infertility, which is decreased with a laparoscopic approach.
References
Walijess A et al. Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in Ulcerative Colitis. Gut. 2006;55(11):1575-1580.
Tulchinsky A et al. Restorative proctocolectomy impairs fertility and pregnancy outcomes in women with Ulcerative Colitis. Colorectal Dis. 2013;15:842-847.
Rajaratnam S G et al. Impact of ileal pouch-anal anastomosis on female fertility: meta-analysis and systematic review. Int J Colorectal Dis. 2011;26:1365-1374.
Beyer-Berjot L et al. A Total Laparoscopic Approach Reduces the Infertility Rate After Ileal Pouch-Anal Anastomosis: A 2 Center Study. Annals of Surgery. 2013 August; 258(2):275-282.
Bartels S A L et al. Significantly Increased Pregnancy Rates After Laparoscopic Restorative Proctocolectomy: A Cross-Sectional Study. Annals of Surgery. 2012 December; 256(6):1045-1048.
Seligman N S, Wingkan S,&Berghella V. Pouch function and gastrointestinal complications during pregnancy after ileal pouch-anal anastomosis. J Mat Fet Neo Med. 2011;24(3):525-530.
Pregnancy
IBD onset typically occurs during the reproductive years. Therefore, patients and their families often have concerns regarding how IBD and IBD medications affect their pregnancy and offspring. Many patients with IBD who wish to have children are often on medications that may need to be adjusted. Zelinkova (2010) conducted a study on IBD patients with active plans for conception and found that a large proportion of patients are taking IBD medications, especially immunosuppressants1.
How does IBD affect pregnancy?
IBD is associated with a slight increased risk of preterm delivery, small for gestational age infants, and miscarriages or spontaneous abortions compared to the general population2,3. These risks are increased even more in patients who have active IBD.
Active IBD increases risk of adverse outcomes
Patients with IBD should aim to be in remission before attempting to become pregnant. Patients who had active IBD within 3 months of conception are at risk of having active disease during pregnancy4. On the other hand, those patients who were in remission at time of conception will be more likely to stay in remission during pregnancy. They should continue the IBD medications that they need to stay in remission (the exception being methotrexate, which should be stopped 6 months prior to conception).
Medical Management During Pregnancy
Which IBD medications can be continued before and during pregnancy?
Most IBD medications are safe for use while trying to conceive and to continue during pregnancy but certain medications may need to be adjusted.
Aminosalicylates: Most formulations of 5-ASA are considered safe to continue into pregnancy5,6. Studies have found no significant association between 5-ASA drugs and poor pregnancy outcomes7. The coating of one 5-ASA medication (Asacol®) contains dibutyl phthalate (DBP) which has been associated with abnormal development in animal models. However, there has been no significant findings among humans5,8,9.
Sulfasalazine (Salazopyrin®) is considered safe to use before and during pregnancy6,8. However, since sulfasalazine inhibits folate synthesis, before and during pregnancy patients taking this medication should also be taking folic acid supplements5,7. Men taking sulfasalazine should be switched to another oral mesalamine because sulfasalazine has been associated with oligospermia (low sperm concentration)10.
Thiopurines: Azathioprine (Imuran®) and 6-mercaptopurine (6-MP) (Purinethol®) can be continued during preconception and during pregnancy if needed for maintenance therapy. Although studies have reported abnormalities in animal models, and older studies reported some risk of adverse outcomes among pregnant women taking these medications, recent larger studies on women with IBD taking thiopurines suggest no significant adverse outcomes6,11-14.
Corticosteroids: Steroids, such as budesonide (Entocort®) and prednisone (Deltasone®) can be used to treat active IBD before and during pregnancy15. However, there is a small risk of cleft palate in neonates exposed to corticosteroids in the first trimester and other adverse outcomes16-18.
Biologics (anti-TNF): Adalimumab (Humira® or biosimilars Amgevita®, Idacio®, Hadlima®, Hyrimoz®, and Hulio®), infliximab (Remicade® or biosimilars Avsola®, Inflectra®, Renflexi®, Remsima®), and golimumab (Simponi®) are considered safe to continue into pregnancy. However, studies have shown that these proteins cross the placenta to the neonate after 22 weeks of gestation. Therefore, physicians used to administer the last dose of biologics before the third trimester, to minimize fetal exposure to the medication. However, as more safety data becomes available, it is recommended that patients with IBD who require biologic anti-TNF therapy during pregnancy continue the medications as the risks of having uncontrolled IBD outweigh the risks of fetal exposure5,6,8,12-14,19,22,23.
Biologics (anti-α4β7 integrin): Vedolizumab (Entyvio®) is considered safe to continue into pregnancy, although has the least data in use in pregnancy as it is the first IBD gut specific drug on the market14,20,24,25,26. To minimize exposure to the fetus, timing of the dosing is approached in similar fashion as the anti-TNF agents6.
Biologics (anti-IL12/23 p40): Ustekinumab (Stelara®) is considered safe to continue into pregnancy, based on the limited available information from clinical trials observations, and clinical experience14,21,25-28. There are longer term safety data from the psoriasis PSOLAR registry. To minimize exposure to the fetus, timing of the dosing is approached in similar fashion as the anti-TNF agents6.
Biologics (anti-IL-23): Risankizumab (Skyrizi®) and Mirikizumab (Omvoh®) are the newest biologics for IBD, but are viewed to likely be similar safety as the previous biologics given they are IgG molecules.
Methotrexate (Rheumatrex®) is contraindicated to use in patients who are trying to become and during pregnancy5,8.Methotrexate can cause malformation of an embryo) and can cause fetal death.16 Furthermore, because it can remain in the body for an extended time period, physicians recommend that anyone with IBD who are on Methotrexate discontinue use for 3 to 6 months prior to trying to conceive6,17.
Small Molecule(JAK inhibitor): Tofactinib (Xeljanz®) and Upadacitinib (Rinvoq®) are contraindicated for use preconception and in pregnancy due to tetratogenic effects noted in animal pre-clinical studies, and limited evidence of safety in use in humans6.
Small Molecule (S1P modulator): Ozanimod (Zeposia®) is contraindicated for use contraindicated for use preconception and in pregnancy due to tetratogenic effects noted in animal pre-clinical studies, and limited evidence of safety in use in humans
Zelinkova Z et al. Reproductive wish represents an important factor influencing therapeutic strategy in inflammatory bowel diseases. Scand J Gastro. 2010; 45:46–50.
Getahund D et al. Association between maternal inflammatory bowel disease and adverse perinatal outcomes. J Perinatol. 2014 June; 34(6):435-440. doi: 10.1038/jp.2014.41.
Huang V W & Habal F M. From conception to delivery: Managing the pregnant inflammatory bowel disease patient. World J Gastroenterol. 2014;20(13).
Oron G et al. Inflammatory bowel disease: risk factors for adverse pregnancy outcomes and the impact of maternal weight gain. J Matern Fetal Neonatal Med. 2012;25:2256-2260.
Biedermann L et al. Pregnancy and Breastfeeding in Inflammatory Bowel Disease. Digestion. 2012;86:45-54.
Mahadevan U, Robinson C, Bernasko N, et al. . Inflammatory bowel disease in pregnancy clinical care pathway: a report from the American Gastroenterological Association IBD Parenthood Project Working Group. Gastroenterology. 2019;156:1508–1524.
Rahimi R et al. Pregnancy outcomes in women with inflammatory bowel disease following exposure to 5-aminosalicylic acid drugs: A meta-analysis. Reproductive Toxicology. 2008;25:271-275.
Ng S W &Mahadevan U. Management of inflammatory bowel disease in pregnancy. Expert Rev ClinImmunol. 2013;9(2):161-174.
Asacol (mesalamine), package insert. Warner Chilcott Pharmaceuticals Inc. OH, USA (2010).
Riley S A et al. Sulphasalazine induced seminal abnormalities in ulcerative colitis: results of mesalazine substitution. Gut. 1987 Aug;28(8):1008-12
Shim L et al. The effects of azathioprine on birth outcomes in women with inflammatory bowel disease (IBD). J Crohns Colitis. 2011;5:234-238.
Saha S & Wald A. Safety and efficacy of immunomodulators and biologics during pregnancy and lactation for the treatment of inflammatory bowel disease. Expert Opin. Drug Saf. 2012;11(6):947-957.
Casanova M J et al. Safety of thiopurines and anti-TNFα drugs during pregnancy in patients with inflammatory bowel disease. Am J Gastroenterol. 2013;108:433-440.
Mahadevan U, Long MD, Kane SV, et al. Pregnancy and neonatal outcomes after fetal exposure to biologics and thiopurines among women with inflammatory bowel disease. Gastroenterology 2021;160:1131–9.
Huang V W & Habal F M. From conception to delivery: Managing the pregnant inflammatory bowel disease patient. World J Gastroenterol. 2014;20(13).
Neilsen O H, Maxwell C, & Hendel J. IBD medications during pregnancy and lactation. Nat Rev Gastroenterol Hepatol. 2014;11:116-127.
Van der Woude C J et al. European evidence-based consensus on reproduction in inflammatory bowel disease. J Crohns Colitis. 2010;4:493-510.
Odufalu F, Long MD, Lin K, et al. Exposure to coricosteroids in pregnancy is assocaited with adverse perinatal outcomes among infants of mothers with inflammatory bowel disease: results from the PIANO registry. In: Digestive Disease Week 2021; 2021; USA.
Huang V W & Habal F M. From conception to delivery: Managing the pregnant inflammatory bowel disease patient. World J Gastroenterol. 2014;20(13).
Mahadevan U, Vermeire S, Lasch K, et al. Vedolizumab exposure in pregnancy: outcomes from clinical studies in inflammatory bowel disease. Aliment Pharmacol Ther 2017;45:941-950.
Scherl E, Jacobstein D, Murphy C, et al. A109: Pregnancy Outcomes in Women Exposed to Ustekinumab in the Crohn’s Disease Clinical Development Program. JCAG 2018;1(2): 166.
Nielsen OH GJ, Juhl CB, Streett SE, Maxwell C. Biologics for Inflammatory Bowel Disease and their Safety in Pregnancy: A Systematic Review and Meta-analysis. Clin Gastroenterology Hepatol 2020.
Gubatan, J, Nielsen, OH, Levitte, S, et al. Biologics during pregnancy in women with inflammatory bowel disease and risk of infantile infections: a systematic review and meta-analysis. Am J Gastroenterol 2021; 116: 243–253.
Moens A, van der Woude CJ, Julsgaard M, et al. Pregnancy outcomes in inflammatory bowel disease patients treated with vedolizumab, anti-TNF or conventional therapy: results of the European CONCEIVE study. Aliment Pharmacol Ther 2020; 51:129–138.
Wils P, Seksik P, Stefanescu C, et al. Safety of ustekinumab or vedolizumab in pregnant inflammatory bowel disease patients: a multicentre cohort study. Aliment Pharmacol Ther. 2021 Feb; 53 (4): 460-70.
Chugh R, Long M, Jiang Y, et al. Maternal and Neonatal Outcomes in Vedolizumab and Ustekinumab Exposed Pregnancies: Results from the PIANO registry. Am J Gastroenterol 2023 Oct 5.
Avni-Biron I, Mishael T, Zittan E, et al. Ustekinumab during pregnancy in patients with inflammatory bowel disease: a prospective multicentre cohort study. Aliment Pharmacol Ther. 2022;56(9):1361-1369.
Mahadevan U, Naureckas S, Tikhonov I et al. Pregnancy outcomes following periconceptional or gestational exposure to ustekinumab: Review of cases reported to the manufacturer’s global safety database. Aliment Pharmacol Ther 2022;56(3):477-490.
Delivery and Postpartum
In general, having IBD does not affect delivery method. The decision about delivery method for an IBD patient should be made on an individual basis by the patient and their obstetric provider1,2. The decision should be based on obstetrical reasons, while also considering the patient’s IBD condition1,2. While some studies report higher rates of caesarean section among patients with IBD compared to healthy patients3, other studies report no significant difference in the rate of c-section4.
There are 2 IBD-related indications for recommending c-section over vaginal delivery:
Active perianal disease (disease located around the anus) in Crohn’s patients3.
it is recommended to avoid vaginal delivery because of concerns of worsening perianal disease activity due to poor wound healing2.
women who have significant scarring from prior perianal disease may also wish to discuss delivery method with their obstetrician.
Ileal pouch-anal anastomosis (IPAA, or “j pouch”) surgery
although vaginal delivery may be safe for patients with a pouch, a c-section may be recommended to prevent potential disruption of pouch function2,3,5.
there is concern that vaginal delivery could disrupt the function of the anal sphincter (a ring of muscle that controls the anus opening) and lead to an increased risk of incontinence2,3,5.
Some patients can flare postpartum even if they have been well during pregnancy. It is important for patients to monitor their IBD during and after pregnancy, as physicians are currently unable to definitively predict which patients will flare postpartum. It has been reported that ulcerative colitis patients may be at increased risk for postpartum flares6. In general, the risk for postpartum flare depends on disease control during pregnancy, and on other factors that affect disease activity (eg. smoking in Crohn’s disease).
Breastfeeding
Patients with IBD can breastfeed. Breastfeeding is beneficial to the newborn as breast milk contains nutrients, immune proteins, and other beneficial factors. Some studies suggest that breastfeeding may have a protective effect against developing IBD7. It is thought that breastfeeding may help the newborn develop a healthy gut microbiome and immune system by helping newborns develop tolerance to certain bacteria, and thus prevent exaggerated immune responses to bacteria encountered later in life8,9.
BREASTFEEDING: most IBD medications can be continued.
Medications are excreted into the breast milk in very small amounts. Risk of toxicity to the child is very small2,10,13.
Corticosteroids
Prednisone (Deltasone®), Budesonide (Entocort®)
Steroids transfer into the breast milk in small amounts, with highest levels in the first 4 hours after taking the medication13. Recommended to pump and dump the first 4 hours of breast milk after taking the medication2,11.
These can be continued while breastfeeding13. To minimize the drug levels in the breast milk, pump and dump the first 4 hours of breast milk after taking the medication2,12.
Immunosuppressant
Methotrexate (Rheumatrex®)
MTX has teratogentic effects, and because it crosses into the breast milk, MTX is contraindicated while breast-feeding2,12,13.
These can be continued while breastfeeding. Although they cross into the breast milk, the levels are nil to minimal2,12-14. For Risankizumab and Mirikizumab, which are newer biologics, although there is no data on these in breastfeeding, they are likely to have similar safety as the older biologics.
References
Huang V W & Habal F M. From conception to delivery: Managing the pregnant inflammatory bowel disease patient. World J Gastroenterol. 2014;20(13).
Ng S W & Mahadevan U. My Treatment Approach to Management of the Pregnant Patient With Inflammatory Bowel Disease. Mayo Clin Proc. 2014 Mar;89(3):355-360.
Cornish J et al. A meta-analysis on the influence of inflammatory bowel disease on pregnancy. Gut. 2007;56:830-837.
Bortoli A et al. Pregnancy outcomes in inflammatory bowel disease: prospective European case-control ECCO-EpiCom study, 2003-2006. Aliment Pharmacol Ther. 2011;34:724-734.
Tulchinsky H et al. Restorative protocolectomy impairs fertility and pregnancy outcomes in women with ulcerative colitis. Colorectal Dis. 2013 July; 15(7):842-7.
Pedersen N et al. The course of inflammatory bowel disease during pregnancy and post-partum: a prospective European ECCO-EpiCom Study of 209 pregnant women. Aliment Pharmacol Ther. 2013;38:501-512.
Kane S & Lemieux N. The Role of Breastfeeding in Postpartum Disease Activity in Women with Inflammatory Bowel Disease. Am J Gastroenterol. 2005;100:102-105.
Frolkis A et al. Environment and the Inflammatory Bowel Disease. CJG. 2013 Mar; 3:e18-e24.
Belderbos M E et al. Breastfeeding modulates neonatal innate immune responses: a prospective birth cohort study. Pediatr Allergy Immunol. 2012 Feb;23(1):65-74.
Silverman D A et al. Is mesalazine really safe for use in breastfeeding mothers? Gut. 2005;54:170-171
Ost L et al. Prednisolone excretion in human milk. J Pediatr. 1985;26:45-51
Saha S & Arnold W. Safety and efficacy of immunomodulators and biologics during pregnancy and lactation for the treatment of inflammatory bowel disease. Expert Opin. Drug Saf. 2012;11(6):947-957.
Mahadevan U, Robinson C, Bernasko N, et al. . Inflammatory bowel disease in pregnancy clinical care pathway: a report from the American Gastroenterological Association IBD Parenthood Project Working Group. Gastroenterology. 2019;156:1508–1524.
Matro R, Martin CF, Wolf D, Shah SA, Mahadevan U. Exposure Concentrations of Infants Breastfed by Women Receiving Biologic Therapies for Inflammatory Bowel Diseases and Effects of Breastfeeding on Infections and Development. Gastroenterology [Internet]. 2018;155(3):696–704.
Infant Health
Will your child develop IBD?
Having a family history of IBD and having certain genes can predispose a person to developing IBD. The risk is less than 10% if one parent has IBD, and about 20-30% if both parents have IBD1.
There are factors other than genetics that can affect the risk of developing IBD
The environment is important . . .
The environment can provide triggers that lead to the development of IBD. There is a relatively high prevalence of IBD in Western and developed countries2,3. However, the incidence of IBD is rising in developing countries. Children who immigrate take on the risk associated with the country to which they are moving4. Living in an urban setting is associated with an increased risk of developing IBD – this association appears to be stronger for developing Crohn’s disease than ulcerative colitis4.
Smoking may play a role . . .
Smoking has been reported to be a risk factor for developing and worsening of Crohn’s disease, but a protective factor for developing and for decreasing disease activity in ulcerative colitis2,3. However, it is not recommended to smoke to decrease the risk of developing ulcerative colitis because of the risks associated with smoking (such as lung cancer, cardiovascular disease, and other health problems).
Diet may be important . . .
Although studies vary, diets rich in dietary fiber (fruits and vegetables) are thought to be protective against IBD3. Consuming excessive meat, fish, and fats may increase the risk of developing IBD2,3.
Vitamin D has been found to be low in IBD patients and Vitamin D deficiency may lead to immune deregulation and increase the risk of developing IBD5.
The intestinal microbiome is important . . .
The intestinal microbiome is made of all the bacteria in an individual’s gastrointestinal tract. It is established in infancy and childhood.
The microbiome helps to maintain a healthy immune system by
opposing certain inflammatory cytokines
regulating the development of immune cells that recognize foreign- and self-compounds
activating T regulatory cells, which can promote tolerance to microorganisms6
The intestinal microbiome needs to be balanced for each individual to have a healthy immune system.
Many things affect the intestinal microbiome . . .
The intestinal microbiome can be affected by a person’s genes, their environment (including diet), overall health, infections, and medications (such as antibiotics).
An unbalanced intestinal microbiome can lead to a dysregulated immune response . . .
Multiple factors interact and can lead to a change in the intestinal microbiome. An unbalanced intestinal microbiome can lead to a dysregulated immune response resulting in inflammation characteristic of inflammatory bowel disease.
the “hygiene hypothesis” proposes that
clean environments limit microbial exposure, leading to an altered immune system that is unable to differentiate between beneficial from harmful bacteria2,3
the altered immune system can predispose one to exaggerated immune responses, resulting in the chronic inflammation seen in IBD
Can your baby be vaccinated?
Live vaccinations – recommend to AVOID
Similar to how how you cannot have any live vaccinations while on a biologic, your baby should NOT have any live vaccinations until at least 6 months of age, ideally not until 12 months of age. This is because some studies have detected biologic drug in the baby’s blood until even 9 months of age, and in one case 12 months of age.
This should not be a major issue as most live vaccines are given at 12 months of age. The only one to pay attention to is Rotavirus (an oral live attenuated vaccine that is meant to protect against the Rotavirus gastroenteritis). This only is given between 2 to 4 months of age, and thus if your baby skips the vaccination, they would NOT receive it (it is unsafe to give the vaccination after 6 months of age).
Inactivated vaccinations – recommend to GIVE
Inactivated vaccinations, such as HiB, tetatanus, hepatitis B, can be given. In fact, studies show that the baby’s response to these vaccinations are similar to baby’s who were not exposed to biologics.
Habal F M & Huang V W. Review Article: a decision-making algorithm for the management of pregnancy in the inflammatory bowel disease patient. Aliment Pharmacol Ther. 2012 January; 35:501-515.
Aujnarian A, Mack D R, & Benchimol E I. The role on the Environment in the Development of Pediatric Inflammatory Bowel Disease. Curr Gastroenerol Rep. 2013 May;15(326).
Frolkis A et al. Environment and the Inflammatory Bowel Disease. CJG. 2013 Mar; 3:e18-e24.
Ng S C et al. Geographic variability and environmental risk factors in Inflammatory Bowel Disease. Gut. 2013;62:630–649.
Reich K M et al. Vitamin D improves Inflammatory Bowel Disease outcomes: Basic science and clinical review. World J Gastroenterol. 2014 May;20(17):4934-4947.
Petersen C & Round J L. Defining dybiosis and its influence on host immunity and disease. Cell Microbiol. 2014 May. Doi: 1111/cmi.12308