Multiple sclerosis (MS) diagnoses often occur at pivotal points in young peoples’ lives. Too often, disease course and severity can interfere with future plans and potentially leave patients with the decision of prioritising treatment over family planning, or vice versa.
Around 3/4 of patients with MS are women of childbearing age, at least 1/5 of these patients will have children after disease onset.
The importance of multidisciplinary knowledge, education and pre-pregnancy counselling at regular intervals may help inform your patients to help achieve their family planning goals safely.
Patients may have a variety of concerns prior to family planning about the effect of MS on pregnancy and fertility. While the relationship between infertility and MS is a debated topic, emerging patterns in female patients show that controlling MS early could help prevent lower fertility, thus encouraging patients not to defer disease-modifying treatment may be beneficial for their future plans.
Fertility issues seem to arise in cases with aggressive and progressive disease, a review by Lamaita et al. (2021). found that the use of assisted reproductive technology was five times greater in patients with advanced MS.
Furthermore, women who failed to conceive via in-vitro fertilisation (IVF) may be in a higher risk for clinical or magnetic resonance imaging (MRI) disease activity for 3 months post IVF which is associated with the use of gonadotropin-releasing hormone (GnRH).
Additionally, a patient’s overall sexual function may be affected by disease course, quality of life or medication thus affecting fertility. Physical symptoms such as loss of sensitivity in the genital region, or emotional symptoms such as depression could contribute to issues in conception. A meta-analysis study by Kim et al. (2018). showed 62% of men and 63% of women with MS (n=14,538) reported sexual intercourse problems due to MS.
Confavreaux et al. (1998). showed with the “PRegnancy In Multiple Sclerosis” (PRIMS) study that generally, the rate of relapses decreases during pregnancy, especially during the third trimester.
Conversely, some patients will experience severe relapses while pregnant, which may require monitoring with MRI depending on frequency of relapses. Pregnant patients should also be aware that relapse rate increases 3-months postpartum and then returns to pre-pregnancy rates. Pharmacological treatments for MS vary and many are not approved for use during pregnancy and require careful consideration, therefore a treatment switch or discontinuation may be required.
Breastfeeding after delivery may be protective against relapses for up to 6 months postpartum, though this is not certain. A 1-year follow-up study by Hellwig et al. (2015) found that 38% non-breastfeeding and 24% exclusively breastfeeding mothers experienced a relapse within 6 months after delivery. This protective effect is thought to be limited to exclusive breastfeeding which could mean encouraging patients to store breastmilk in case of relapse or restarting treatment incompatible with breastfeeding.
There is an increased risk of postpartum depression in parents with MS, calling for awareness among both healthcare staff and the patient to prepare for the appropriate support to be in place if need be. The factors that influence the treatment of MS evolve over time alongside the personal circumstances of each patient. Remaining vigilant and maintaining a dialogue with your patients could improve treatment adherence while allowing your patients to obtain their family planning goals.
CI = confidence interval; HR = hazard ratio; MRI= magnetic resonance imaging; MS=multiple sclerosis.