Inflammatory bowel disease does not necessarily reduce your chances of making a baby, but there are some men and women who have Crohn's disease, and some men taking certain drugs for colitis, who may find they are less fertile. In very many of these cases something can be done to help.

It is important to remember, however, that a great many couples without ibd have problems with fertility. One in seven of all couples trying to have a child cannot conceive without help. So, if you wish to have a child but there is a problem, you should not necessarily assume - even if a doctor does - that your ibd is the cause. It is human nature to want a reason and, to a doctor who is well-meaning but not an ibd specialist, your Crohn's or colitis may seem as good a reason to offer you as any.

Problems with fertility in men
Men with Crohn's disease may produce fewer sperm when the disease is very severe, and the sperm they do produce may be damaged or may function less well than normal. This may also happen if you are very underweight and undernourished. These problems are thought to be temporary and treatment to improve the Crohn's should also restore your fertility to its natural level.

The same effects on sperm may be caused by the drug sulphasalazine (Salazopyrin), which is commonly used to treat mild inflammation or to prevent relapses in ulcerative colitis or in Crohn's disease of the colon. For the great majority of men, these effects, if they do occur, are temporary and fertility returns to its natural level two to three months after stopping medication.

Stopping immediately may not be practical, however, because the drug is prescribed to reduce the frequency of relapses and may need to be taken for months or years. Men on sulphasalazine who want to avoid the possibility that the drug may reduce their fertility, or who are comfortable on sulphasalazine but whose partners fail to conceive within six months of trying, should see their doctor to discuss changing to one of the alternative drugs. There are newer sulphasalazine-like drugs (mesalazine or olsalazine) which have the same action on the colon, but do not affect fertility.

Very rarely, men with ibd who have had their colon, including the rectum, removed may be unable to have an erection. This is usually temporary and, with more sophisticated surgical techniques that are less likely to damage nerves, this is much less likely to occur now.

Problems with fertility in women
Women who have ibd which is not active or is well controlled by drugs, should have no more difficulty in becoming pregnant than they would normally. However, women with active Crohn's disease may have problems if they are underweight and eating poorly, as this can affect fertility. Also if there is severe inflammation in the small intestine, the normal functioning of the ovaries can be affected. Unpleasant and painful occasional complications such as abscesses and fistulae in the vaginal area are likely to put a halt temporarily to having sex.

It is best not to try to get pregnant when ibd is very active as the symptoms can then be more problematic throughout the pregnancy. The likelihood of miscarriage is also higher. However, numerous women have had uneventful and successful pregnancies even when they have conceived during active phases of ibd. NACC publishes a useful booklet called Pregnancy in Inflammatory Bowel Disease, which is available from the address given below.

Self help tips for improving fertility
As fertility may be lowered by reasons other than ibd - or in addition to it - there are various suggestions for steps you can take to give yourselves the best chance of conception. Women should try to eat a very healthy balanced diet or, if this is difficult, you could discuss with your doctor taking some supplements to ensure you get all the nutrients needed. (Zinc and vitamin B6 are particularly important for fertility.) If you use the contraceptive pill, it might be worth talking with your partner about changing to a different method of contraception for a few months before starting to try for a baby.

Men can increase their likelihood of producing plenty of healthy sperm by not smoking, drinking only moderately, not exercising obsessively, getting sufficient relaxation, avoiding stress where possible and by eating a balanced healthy diet - zinc and B6 are important for male fertility too. The testicles need to be cooler than the rest of the body, to let sperm develop properly. So help yourself by wearing boxer shorts and looser trousers rather than tight underpants and trousers, which keep the genitals warm. Ensure too that you do not spend all day sitting down. If you sit on your way to work and all day during your work, try to find time when you can walk (perhaps for part of your journey), stand or take some exercise or sport.

Sex
When nothing is actually wrong with your fertility, one of the biggest preventers of pregnancy may be the feeling of pressure to have sex at the 'right' times every month. It is difficult to be sure exactly when the right time of the month is, despite all modern aids, and the stress of feeling you have to make love even if you actually don't feel like it - whether because you are not in the mood or your ibd is playing up - takes a very definite toll on both partners' ability to make a baby.

It is probably best, if you can, to try to stay relaxed and keep sex as a pleasure you share when you both want to, rather than testing and temperature-taking daily to work out when ovulation should occur and feeling obliged to leap into action accordingly.

Investigations
It may be that there are other physical causes for the fertility difficulties, in which case self-help measures will not be sufficient. If you have been trying to have a baby without success for some time, you can ask to be referred to a fertility clinic. Occasionally, women with Crohn's may find it harder to be accepted for fertility investigations and treatment and it may be helpful if your gastroenterologist can liaise with the gynaecologist about the likely effects of Crohn's on your fertility.

If you feel worried that the two specialist departments are not fully aware of each other's views, then probably the best thing to do is to decide which of your doctors you find most approachable and arrange an appointment to discuss your concerns.

Pregnancy

May drugs be taken whilst breast feeding?
There is no evidence that taking sulphasalazine (Salazopyrin ) while breast feeding is harmful to a healthy infant. if the mother is on large doses of costeroids she may not feel well enough to breast feed or the doctor may advise her not to do so.

What diet should be taken during pregnancy?
A normal and nutritious diet. Your doctor will advise you if any special restrictions, alterations or additions to your diet are necessary.

Can the disease start during or shortly after pregnancy?
Yes, but with modern medical treatment the disease is readily brought under control in the vast majority of patients.

X-rays during pregnancy?
During pregnancy the doctor will wish to avoid x-ray tests whenever possible.

Should a patient with an ileostomy become pregnant?
By all means. There may be minor episodes of pregnancy, but these nearly always settle quickly with medical treatment. On rare occasions swelling of the ileostomy occurs, but again without the need for surgery.

What is the likely course of the pregnancy?
The overall outcome is usually as good as for pregnant women in the generalpopulation. This is particularly true if the colitis is inactive at the start of pregnancy. Normal vaginal delivery is just as common as women with out colitis.

Is there an increased risk that the baby will be born abnormal?
No. There is no evidence that the risk of an abnormal baby is greater than in the general population.

May an abortion be required?
No. Even if the disease flares up during pregnancy there are few, if any, medical reasons for abortion in colitis today.

Contraception?
There is no evidence to suggest that the contraceptive pill is less effective then usual in women with diarrhoea or with an ileostomy. IBD is slightly more common among women who take the contraceptive pill than among those who do not, but the increased risk appears very small. Doctors sometimes advise patients to stop the pill for a trial period. Other methods of contraception, such as the ‘coil’, are not affected by IBD.

Sexual function in men with IBD
If a man with IBD is on Sulphasalazine ( Salazopyrin) and his wife fails to conceive, his sperm count should be checked. It may be necessary for him to come off the drug or change to mesalazine or similar drug for the chances of conception to be increased. Fertility returns when the drug is stopped, and there does not appear to be any increased risk of an abnormal child being born.The sexual function of men with severe IBD who are treated by surgical removal or the rectum is occasionally impaired as a consequence of the operation, though the possibility of this complication is greatly reduced by modern techniques. For this reason, surgery may sometimes be deferred if a couple wish to start or complete their family. A balance obviously has to be struck for each individual patient between the risk of postponing an operation and of proceeding with it. Your Doctor can advise you on this point.

Is drug treatment Important?
Avoid conception while taking the following drugs Azathioprine ( Imuran ). Sulphasalazine ( Salazopyrin ) can reduce fertility in men. Sulphasalazine and corticosteroids can be taken by women during pregnancy without danger to mother or baby.

May I breast-feed my child?
Yes. Sulphasalazine can be taken while breast feeding, as can low doses of prednisolone.

Crohn’s Disease
The answers to most questions are the same as for women with colitis, but the following paragraphs deal with questions where the answers are a little different.

Can patients with Crohn’s conceive?
The answer to this question is ‘Yes’ in the majority of cases. However, overall fertility may be somewhat impaired compared with that of women in the general population, Active Crohn’s may itself reduce fertility, sometimes by causing inflammation and blockage of the tubes leading to the ovaries to the womb. Also Crohn’s sometimes makes intercourse painful, thus less frequent, thereby reducing the chance of conception.When fertility is affected simply be general ill-health, improvement of health by medical treatment may allow conception to occur. If medical therapy alone is not successful, surgical removal of diseased bowel can sometimes improve a woman’s chance of becoming pregnant.

When should patients conceive?
It is unlikely that conception will occur while a patient with Crohn’s is having severe symptoms due to bowel inflammation. In any event, it is probably wise to wait until the disease settles down before embarking on a planned pregnancy.

Can the disease start during or shortly after pregnancy?
Yes, but if it starts during or just after pregnancy it will probably respond to medical treatment. Rarely an operation may be required.

Will pregnancy affect the disease?Overall the disease is more likely to improve than to deteriorate during pregnancy. If it does get worse, it nearly always responds to medical treatment ( rest, diet and drugs ).

Should a patient with an ilestomy become pregnant?
Yes, if she wants to. There are occasional problems with the ileostomy as in colitis, in addition, disease affecting the small bowel may flare up but such attacks usually Settle with simple medical treatment. Vaginal delivery is possible in the majority or patients, but may not be advisable because of scarring from previous surgery. For this reason, there is slightly increased chance that the infant will need to be delivered by Caesarean section.

Ulcerative ColitisWhen should patients conceive?
If possible, women with colitis who wish to have children should plan to conceive when they do not have any diarrhoea or bleeding from the bowel. There are several reasons for this recommendation. And some of these are given in more detail below. However, even if conception occurs when symptoms from the colitis are present, pregnancy is usually successful.

Will pregnancy affect the disease?
If the disease is inactive at the time of conception, the chances are that it will remain so throughout pregnancy. Any flare-ups tend to occur in the first three months or pregnancy, but are usually mild and respond rapidly to medical treatment. If the disease is active at the time of conception, symptoms are likely to continue during pregnancy but are nearly always controllable by medical means. Operations to remove a severely inflamed bowel can occasionally be necessary during pregnancy, as in patients who re not pregnant, but pregnancy does not seem to make the need for operation more likely.In general, therefore, women who are having no trouble from colitis, when they conceive they do better, as far as the course of their colitis is concerned, than women who have symptoms at the start of their pregnancy.Symptoms of colitis may reappear or become worse shortly after childbirth. Some doctors try to prevent such set-backs by prescribing treatment, such as steroids, from the time of delivery. Other doctors prefer to start medical treatment only if it proves necessary.

May drugs be taken for colitis during pregnancy?There is nothing to suggest that taking corticosteroid tablets or enemas or Sulphasalazine ( Salazopyrin ) or mesalazine  ( Asacol ) will have a harmful effect on the unborn child. Most doctors advise patients to avoid pregnancy if they are taking Azathioprine ( Imuran ), a drug used more commonly in Crohn’s, but in fact no harm has come to mother or child in the small number of cases when pregnancy has occurred while the mother was taking this drug.

May other drugs be taken during pregnancy?
Iron and vitamins may need to be taken to an even greater extent than by a non-colitic pregnant woman. Your doctor will advise you on this.

Inheritance. Is it likely that any of my children will develop IBD?
IBD is more common in some families than in others. However, there is no clear pattern of inheritance and the actual risk that one of your children will develop IBD is small. It seems that it is not the disease itself which is passed from one generation to the next. But rather a greater tendency for the disease to develop when the individual is subjected to a factor or factors as yet unknown. There is general agreement that though the possibility of one of your children developing IBD is a little greater than in other families, the risk is not great enough to discourage you from starting a family, or having another baby, if you want to do so

The Menstrual Cycle, IBD, and IBS Research  
We often hear from women with IBD who ask if it's possible that their menstrual cycle affects their Crohn's disease or ulcerative colitis. Research at the University of Chicago and Rush-Presbyterian-St. Luke's Medical Center in Chicago noted similar comments among their patients, and performed a study. Dr. Sunanda V. Kane and colleagues report their findings in the October 1998 issue of the American Journal of Gastroenterology.

The group conducted phone interviews with 49 women with ulcerative colitis, 49 women with Crohn's disease, 49 women with irritable bowel syndrome (IBS), and 90 healthy women. Patients were asked about their premenstrual and menstrual symptoms, as well as changes in bowel habits and disease activity related to the menstrual cycle.

Ninety-three percent of all women reported premenstrual symptoms, but these symptoms were reported most often by women with Crohn's disease. Women with IBS and IBD were more likely than healthy women to experience premenstrual and menstrual bowel habit changes, and their disease activity worsened during these times. Again, women with Crohn's disease were most likely to report increased gastrointestinal symptoms during menstruation, most often diarrhea.

All women with IBD and IBS had more of a cyclical pattern to their bowel habits than did healthy women. This pattern of symptoms included diarrhea, abdominal pain, and constipation.

The authors comment that the increase in diarrhea might be due to increases in the substance prostaglandin production during menstruation, which might affect muscle contraction in the colon. Or, diarrhea may result from changing levels of the hormone progesterone during menstruation. These are topics for further study.

Dr. Kane and her team caution that the results may be subject to some bias. In any study in which patients are interviewed retrospectively, as opposed to during examination, they may over-report symptoms. Also, women may be using nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen during menstruation: NSAIDs can cause gastrointestinal inflammation.

Despite these caveats, however, the authors conclude that these patterns of menstruation and bowel disease are significant. "We believe that the physiological and clinical effects of the menstrual cycle are important considerations when evaluating bowel symptoms in menstruating women," they write.

Before considering major changes in treatment for patients with IBD or IBS, the authors suggest that physicians take a careful menstrual history with attention to any cyclical changes in bowel function. "Establishing a clinical pattern may better aid a physician in managing female patients," they note.

The Information Contained in this FAQ were Supplied by Di Cole, Barbara Skoglund (I)