Patient Selection and Safety With TNF Inhibitors - Episode 9
Marla Dubinsky, MD: One of the most important things to note is that IBD [inflammatory bowel disease] happens or is more commonly diagnosed at the peak of childbearing potential. So when I am managing a patient who wants to get pregnant…or is pregnant, I explain the role of inflammation and their underlying immune disease, which are paramount to understanding what to do and how to manage them.
I’m going to start with the preconception counseling aspect, which is for a woman who has an underlying immune disease. Then I’ll speak more about IBD, because that’s the area I counsel women on regularly. They ask, “Can I get pregnant?” So let’s start with that question, because a lot of patients come to me sort of tearful that they read that they can’t get pregnant. I’m not sure where that information is located, but I obviously relieve that anxiety and concern immediately. I say, “You absolutely can get pregnant, but we need to control your inflammation.” So I think the disconnect is really in trying to understand, across these immune diseases, that inflammation control is paramount to all aspects of pregnancy.
The idea is that inflammation probably affects ovarian reserve. There have been a couple of studies that have suggested that there may be an impact on fertility in someone who has chronic inflammation. For the impact of inflammation on ovarian reserve, we can measure anti-Müllerian hormone. Obviously, the biggest impact of fertility is age. I should state that up front. Unfortunately, after age 35, if you look at IBD versus non-IBD patients, no matter what, the fertility risk drops. So age is paramount, but that’s across everything.
Let’s speak particularly about inflammatory diseases in which inflammation could affect your ability to get pregnant: Being in remission, regardless of what immune disease state you have and not having inflammatory mediators such as TNF [tumor necrosis factor], a very important inflammatory cytokine. And so, control of inflammation by way of controlling anything that has a downstream effect on TNF or other inflammatory mediators is paramount. So how do we explain that to one of our female patients? We say, “Our priority is for you to not have inflammation. In order for you to have a successful 10 months of gestation, we need to get it right at the beginning.” So the key is explaining that inflammation control is key and to get that sorted out. That’s how inflammation may affect getting pregnant.
Other than age and inflammation, I think 1 subgroup that we really need to pay attention to are women who have actually had what we call a J-pouch, or an ileal pouch-anal anastomosis. These are colitis patients who have undergone pelvic bisection surgery, in which they actually remove the rectum, connect the small bowel to the anal canal, and create a J-pouch, or ileal pouch anastomosis.
Women who’ve undergone pelvic surgery or pelvic dissection are at risk for developing scar issue. Adhesions could actually form around the fallopian tubes or the ovarian area. Therefore, it’s more of a plumbing issue, meaning fertilization of the egg would not happen naturally because of the scar tissue. So in women who’ve undergone this kind of surgery, we pay extra attention to their fertility. We also counsel women on the fact that this is a risk factor. However, we’re not doing surgery in women who need it because these colectomies are lifesaving in a lot of women. And so, what I will say to you is: The rate of infertility is based on very old retrospective data that is about 3 times higher. So there could be close to a 50% risk of infertility.
This doesn’t mean that they can’t have a child. It means that we may need to use some assisted reproductive technology, or IVF [in vitro fertilization]. We get our infertility physicians involved quite quickly. We don’t wait too long because we know that this is a risk factor. The good news is that data on assisted reproductive technology in patients with IBD who have undergone a J-pouch are the same as we see in women who have not undergone a J-pouch. So there’s a lot of good news, but there is a lot of information out there that makes it seem as if they can’t have a baby. This saddens me, but at the same time, when I’m able to tell them that news, it’s an amazing experience to be able to let them know that information.