Preconceptional counselling of women with inflammatory bowel disease

Preconceptional counselling for women of reproductive age with inflammatory bowel disease (IBD) includes education around the effects of IBD on fertility and pregnancy, the effect of pregnancy on the disease process of IBD, medication safety, and the potential ef­fects of IBD on the fetus.

The principles of IBD management in pregnancy begin with opti­mization of therapy in preconception in order to achieve remission prior to conception. A recent study showed that women who conceive in remission have a decreased risk of having active disease during pregnancy (46). Optimization of preconceptional management in­cludes achieving monotherapy with oral aminosalicylate (5-ASA), thiopurines (azathioprine and mercaptopurine), or anti-tumour necrosis factor (anti-TNF), as these have been shown to be safe for use in pregnancy (47-50). If monotherapy is going to be considered, there is more evidence to suggest de-escalation to monotherapy with anti-TNF results in sustained remission (51). However discon­tinuation from combination anti-TNF and thiopurines to achieve monotherapy should be done 3-6 months preconceptionally, and only be considered in a select group of low-risk patients, including those in sustained remission for 12 months preconceptionally, with no history of anti-TNF medication failure, prior surgeries, or hospi­talizations in the past 3 years (52). Despite the improved outcomes from quiescent disease in preconception, unfortunately approxi­mately one-third of women still relapse in pregnancy, with most re­lapses occurring in the first trimester.

Optimization of therapy preconceptionally is also important to preserve fertility. Although there is no intrinsic infertility in the dis­ease process of IBD, active disease can affect fertility from inflam­mation of the fallopian tubes and most commonly previous surgical intervention (53-56). An important, but often forgotten, discussion includes the effects of IBD on male fertility (57). This effect is re­lated to both medication use as well as surgical intervention, and is a potentially reversible cause of infertility that should be addressed with couples in the preconception period (58, 59). The medication safety profile of pharmacological therapies for IBD should include discussion of both the female and male partner, as both fertility as well as teratogenic effects have been reported with specific medica­tions, including infertility with male partners taking sulfasalazine and potent abortifacient effect and congenital malformations with methotrexate (59, 60).

The preconceptional counselling of women with IBD should in­clude discussion around planning the mode of delivery. There are specific aspects of the IBD disease process that can affect vaginal de­livery, in which case elective caesarean section should be planned. In women who have active perianal disease, or those who have under­gone ileal pouch-anal anastomosis surgical procedure, an elective caesarean section is recommended (52). Although evidence is con­troversial, there is more evidence to show that the diagnosis of IBD alone is not sufficient to recommend delivery by caesarean section, with no difference in outcome for mother in exacerbations or neo­natal outcomes when there is no active perianal disease (61-63).