Marla Dubinsky, MD, on Contraception and Preconception Counseling in IBD

Women with inflammatory bowel disease (IBD) often express significant fears about how their disease, or its treatment, may affect their reproductive lives, Marla Dubinsky, MD, said in her presentation at the American College of Gastroenterology (ACG) Postgraduate Course on October 23.

“They have fears about infertility, about harm to the baby from their therapy, about passing on IBD to their children, and not being physically able to care for a baby due to their IBD. But the true risk is of uncontrolled disease,” she said.

Dr Dubinsky is codirector of the Susan and Leonard B. Feinstein IBD Center, chief of Pediatric Gastroenterology and Hepatology, a professor of pediatrics at the Icahn School of Medicine at Mount Sinai in New York City.

“With. counseling and demystifying these issues—just by imparting knowledge—you can help debunk many of these fears,” she explained.

Contraception is among the subjects that should be discussed with women with IBD, Dr Dubinsky said. “This is one of the most underdiscussed subjects with our 17-year-old patients heading to college.”

Patients with IBD are at an increased risk of venous thromboembolic events (VTE), she said. “Are you increasing the risk with estrogen-based birth control?” She noted that a study showed that women with IBD and even more than 1 risk factor for VTE have been prescribed hormonal birth control.

A better choice for these patients would be long-acting reversible contraception. Studies of progesterone-only contraceptives and of intrauterine devices do not show an increased risk of VTE, although, she said, “This is a topic that we don’t have a lot of knowledge on.”

When patients are ready to consider parenthood, they often express concern about infertility. Dr Dubinsky said, “The only risk associated with infertility among women with IBD is for those who have had ileal pouch anal anastomosis, which can cause adhesions and scar tissue; that’s more of a plumbing issue.” It’s Important to focus on the right information about IBD and fertility, she said, including evidence that disease activity has a significant impact on fertility.

Still, almost 14% of patients with IBD have been told to avoid pregnancy, she said. However, she says of most of her female patients, “There should be no reason you cannot get pregnant.” The number 1 factor in infertility is age, and some women may put off pregnancy as they wait for their disease to improve.

There are no good studies on the risk of genetic inheritance of IBD, she noted. “We know that if both parents have IBD, risk is almost 40% that the child will develop IBD; that’s the highest risk factor.” When only one parent has IBD, the prevalence may be 4 to 8 times higher than in the general population, “which is still quite low.”

The biggest consequence to uncontrolled disease among pregnant patients with IBD is a 4-fold higher rate of miscarriage. “A maternal-fetal specialist needs to be our partner” in caring for patients while pregnant. Dr Dubinsky stressed that stopping medications during pregnancy risks not only spontaneous abortion, but also compromised and preterm labor.

But the biggest worry among pregnant women who want to become pregnant is whether their medications will harm their developing fetus. Dr Dubinsky explained that anti-tumor necrosis factor (TNF) agents do not cross the placenta during the first trimester, when organogenesis is occurring. “This is when it’s actually most important to keep the mom healthy, and there is no risk of harm to the baby.”

Disease control is paramount, Dr Dubinsky stressed. “The most important thing is to get your disease under control,” she tells her patients.

And she cautioned her colleagues, when advising patients about fertility and pregnancy, “What comes out of our mouths can shape that woman’s entire experience.”

--Rebecca Mashaw

Dubinsky, M. Contraceptive and Preconception Counseling for Women With IBD by the Gastroenterologist. Presented at the American College of Gastroenterology 2021 Postgraduate Course. Las Vegas, Nevada. October 23, 2021.