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 information^1,2.

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 fertility^3,4 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 fertility^5,6 – 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 uncommon^7,8. 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 miscarriages^9-11.
  • Nutritional Status: It is essential that people who are trying to conceive are getting enough vitamins and nutrients^9-11. 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 disorder^12,13.
  • 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.

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 fertility^1,2.  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 adhesions^4,5.

• 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:

Sex and parenthood for people with an ostomy (Hollister)

Intimacy with an ostomy (Convatec)

Sex with an ostomy (VeganOstomy)

Summary

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.

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 population^2,3. 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 pregnancy^5,6. 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 humans^5,8,9.
• Sulfasalazine (Salazopyrin®) is considered safe to use before and during pregnancy^6,8. However, since sulfasalazine inhibits folate synthesis, before and during pregnancy patients taking this medication should also be taking folic acid supplements^5,7.  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 outcomes^6,11-14.
• 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 outcomes^16-18.
• 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 exposure^{5,6,8,12-14,19,22,23}.
• 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 market^{14,20,24,25,26}. 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 experience^14,21,25-28. 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 pregnancy^5,8.  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 conceive^6,17.
• 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

For additional information on planning a pregnancy with IBD, please visit the American Gastroenterological Society IBD Parenthood Project website.

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 provider^1,2. The decision should be based on obstetrical reasons, while also considering the patient’s IBD condition^1,2. 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 function^2,3,5.
  • 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 incontinence^2,3,5.

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 life^8,9.

BREASTFEEDING: most IBD medications can be continued.

Class of medication	Examples	Notes for breastfeeding
Mesalamine (5-aminosalicylates)	Asacol®, Pentasa®, Salofalk®, Mesavant®, Sulfasalazine (Salazopyrin®)	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.
Immunosuppressant	Azathioprine (Imuran®), 6-mercaptopurine (6-MP, Purinethol®)	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.
Biologics	Infliximab, Adalimumab, Vedolizumab, Ustekinumab, Risankizumab, Mirikizumab	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.

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 countries^2,3. 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 colitis^2,3.  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 IBD^2,3.
  • 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 bacteria^2,3
    • 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.

For more information on baby vaccinations, please see Health Canada Parent’s Guide to Vaccinations.