Prof Nahla Azzam — IBD, fertility and pregnancy: disease control before, during, and after — and which medications to continue
A focused clinical primer for the IBD patient planning pregnancy: how disease activity affects fertility and pregnancy outcomes, why pre-conception remission matters more than any single drug, and which IBD medications are safe to continue across pregnancy and lactation.
Topics covered
"Disease activity — not the medications — is the dominant driver of adverse pregnancy outcomes in IBD. A flare is riskier than the immunosuppression needed to prevent it."
Show notes
Prof Azzam opens with fertility. Women with quiescent IBD have fertility rates close to the general population — but active disease, ileo-anal pouch surgery, and certain medications (notably sulfasalazine, which reversibly affects sperm in men) lower fertility. The take-home: getting the disease into deep remission before trying to conceive is the single highest-yield intervention a woman with IBD can make for her pregnancy outcome.
The middle segment is on pregnancy itself. Active IBD at conception triples the rate of relapse during pregnancy, raises the risk of preterm birth, low birth weight, and small-for-gestational-age babies, and increases caesarean section rates. Disease activity, not the medications, is the dominant driver of adverse outcomes. The clinical priority through all three trimesters is to keep the patient in remission — flares are riskier than the immunosuppression needed to prevent them.
Prof Azzam closes on medications. The safe-to-continue list includes mesalazines, thiopurines (azathioprine, 6-MP — established safety with monitoring), and the anti-TNF biologics (infliximab, adalimumab — newer evidence supports continuation through pregnancy; some clinicians time the last infusion to minimise transplacental passage in the third trimester). Vedolizumab and ustekinumab data are reassuring. Methotrexate is absolutely contraindicated and must be stopped at least three months pre-conception. Breastfeeding is compatible with most IBD therapies including the anti-TNFs. The decision framework is shared, individualised, and reviewed at every visit.