When you make the exciting decision to embark on the journey of having a baby, you don’t always expect that things won’t go to plan. Inflammatory bowel disease (IBD), which includes conditions like Crohn’s disease and ulcerative colitis, can potentially affect fertility in both men and women. However, the impact varies depending on various factors such as disease severity, location, and treatment. IBD is often diagnosed in adolescents (12 – 18 years), and those between 20 and 35. This age for many, is when they will decide to start a family.
Bit of a recap first though – what is IBD?
IBD is a relatively vague umbrella term for ongoing inflammation of all or part of the digestive tract. There are two main types of IBD, ulcerative colitis and Crohn’s disease. Common symptoms of IBD include abdominal pain, persistent diarrhoea (sometimes with blood), unintended weight loss, fatigue, nutrient malabsorption, and reduced appetite.
Read more about Irritable Bowel Syndrome vs Inflammatory Bowel Disease here
So how might IBD increase risk of infertility?
Rates of pregnancy are not necessarily lower in those with IBD but unmanaged IBD can lead to a lack of nutrient absorption, increased rates of surgery, medications and inflammation in the abdominal region.
Surgery
As IBD (Crohn’s in particular) can involve surgery to manage structural changes, and disease development, this can put fertility at risk.
Larger surgeries around the pelvis, such as creation of an ileostomy or colostomy (a surgery where parts of the bowel are removed, and the remaining bowel is brought to an opening on the outside of the tummy, and waste goes into a bag) or removal of parts of the bowel can decrease fertility in both males and females. In women this can cause scarring to the fallopian tubes, abdominal wall, ovaries and outside the uterus. This can impact ovulation, transit of the sperm, and creation of an embryo.
In males, these types of surgeries can reduce a males ability to reach successful erection, or ejaculation. Newer surgical techniques such as laparoscopic surgery (keyhole) have been shown to improve these outcomes and fertility rates.
Inflammation
This is more of a concern in female fertility. Active inflammation in the reproductive organs, hormonal imbalances, and nutritional deficiencies can contribute to reduced fertility.
Inflammation in the pelvic region, can damage surrounding organs. In women, this might be the ovaries, fallopian tubes, and uterus. Inflammation can make it more difficult for an embryo to successfully implant in the uterus. This can also lead to an increased ovarian reserve (egg quantity) as surgery and inflammation can damage the eggs. The one positive thing here is that nutrition and lifestyle can play a significant role in improving egg quality. This has been shown in research in women with active Crohn’s disease. However they measured AMH levels which are not necessarily a direct reflection of ovarian reserve. The same results have not been seen in ulcerative colitis.
Medication
Many of the medications that are used in IBD are immunosuppressants. Some of these, such as methotrexate, thalidomide, azathioprine/6-MP and mycophenolate mofetil can significantly increase the risk of miscarriage or birth defects in pregnancy. Some medications can also interfere with sperm quality, and regular ovulation. They can also interfere with absorption of key nutrients such as folate or folic acid.
The main “take home message” from this, is to always involve your healthcare team when planning for a pregnancy, or if you do become pregnant with IBD.
Nutrient absorption
IBD can affect nutrient absorption, and it’s important to maintain adequate nutrition during pregnancy and in the preconception period. One of the main areas that dietitians will work to improve fertility in those without IBD is through ensuring peak nutrient absorption and intake.
IBD can significantly affect normal digestion and absorption, leading to a wide variety of potential nutritional consequences, including:
- Increased nutrient requirements
- Inadequate oral intake
- Inadequate energy intake
- Inadequate vitamin/mineral intake
- Impaired nutrient utilisation
- Altered biochemistry
- Food-medication interactions
The key nutrients that are often at risk of not being absorbed are iron, vitamin B12, folate, and vitamin D. This is especially imperative in patients who have small bowel disease that impacts more than 30cm of the intestines. For this reason, these patients should have annual bloods done, particularly in vitamin B12, vitamin D, iron and folate.
The absorption of dietary iron and folate happens in the duodenum (first part of the small intestine) and jejunum (middle of the small intestines). Vitamin D is absorbed in the jejunum and ileum (last part of the small intestine) and vitamin B12 is absorbed primarily in the ileum. Whilst these are all big anatomy words, what is important to understand is that absorption occurs mostly in the small intestine. The small intestine can be impacted in those with Crohn’s disease, which is why absorption is an issue.
Read more about the importance of nutrition in pregnancy here
In male fertility, active disease that impacts nutrient absorption can decrease sperm count. This can be improved with adequate medical management of IBD and correction of nutrient deficiency.
Women with active IBD may experience irregular menstrual cycles or even amenorrhea (absence of menstruation) due to malabsorption of nutrients, and malnutrition (a common risk in Crohn’s disease).
It is imperative that males and females are going into pregnancy with well-managed IBD and restored nutrient levels to ensure the health of themselves and the health of their future offspring. A dietitian or nutritionist with expertise in IBD can help develop an appropriate diet plan to meet your nutritional needs.
How about the risk factors in pregnancy?
Just as medications, and nutrient absorption issues impact fertility, these can extend to an impact in pregnancy. Pregnant women have an increased risk of pregnancy complications. Pregnant women with IBD may have a higher risk of certain complications such as preterm birth, low birth weight, lower rates of vaginal deliveries and increased risk of unplanned caesarean section.
The bottom line – if you have IBD that is well managed, you shouldn’t experience reduced fertility as a result of IBD. Having a great medical team behind you (including a dietitian) can reduce the risk of fertility issues, and complications through pregnancy.
