Multiple Sclerosis (MS) and fertility

30th of May is designated as World Multiple Sclerosis Day. It was established in 2009 by the International Sclerosis Federation and is a day where we raise awareness about this chronic disease, and its effects on the daily life of the patients, as well as their families. In this article, we will take a better look at what is multiple sclerosis and if and how it affects fertility levels and possible pregnancies.

MS is one of the most common causes of disability in younger adults. It is a condition that can affect the brain and spinal cord, causing a wide range of potential symptoms, including problems with vision, arm or leg movement, sensation or balance. In many cases, symptoms can be treated, while, though, average life expectancy is slightly reduced for people with MS. It’s most commonly diagnosed in people in their 20s, 30s and 40s although it can develop at any age, while it’s about 2 to 3 times more common in women than men. The average life expectancy for people with MS is around 5 to 10 years lower, and this gap appears to be getting smaller all the time. 

Main symptoms are: fatigue, difficulty in breathing, vision problems, muscle stiffness and spasms, problems with balance and coordination, and problems controlling the bladder. 

MS is an autoimmune condition. This is when something goes wrong with the immune system and it mistakenly attacks a healthy part of the body – in this case, the brain or spinal cord of the nervous system. Exactly what causes the immune system to act in this way is unclear, but most experts think a combination of genetic and environmental factors is involved.

There is currently no cure for MS, but there are several treatments that can help control the condition and ease the symptoms. Those treatments can include treating relapses with short courses of steroid medicine to speed up recovery, specific treatments for individual MS symptoms and treatment to reduce the number of relapses using medicines called disease-modifying therapies (DMT). 

MS and fertility.

A big percentage of people having MS are young women of childbearing age, for whom pregnancy is often a major concern – particularly now that immunomodulatory treatment is successful and women with MS wish to lead fulfilling and healthy lives. There was a common disbelief that women having MS should not conceive because they couldn’t take care of their children as they should due to their fatigue or disability or because the children would inherit the condition. There is no clear evidence that women pass the condition to their offspring but there is data that indicate decreases in ovarian reserve, which is an infertility factor. For every 1,000 people who have a parent with MS, about 15 will get MS, and the condition is not passed on through breastfeeding, a common fear of women.

General infertility rates revolve around 10-20% in couples from western countries, with infertility in women with MS potentially accounting as a co-occurrence. A significantly greater proportion of women with MS have been handed a diagnosis of infertility when compared to women without MS. When stratified by age, a greater proportion of women with MS aged 18 to 34 and aged 42 years and older have been diagnosed with infertility compared to women without MS. The few studies on the subject present conflicting evidence about whether fertility in women with MS might be reduced and whether the use of infertility treatment affects the course of MS. Assisted reproductive technology has been reported to increase risk, although not enough studies support such a statement.

Impact of pregnancy on MS:

In one retrospective cohort study of 123 pregnancies in 123 women of reproductive potential, there was a marked increase in postpartum inflammatory activity on MRI that correlated with relapses; however, previous research has shown no effect of postpartum relapses on long-term disability. An investigation of 188 pregnancies ending with early termination (spontaneous and elective) found an increased rate of relapses and inflammatory lesions on MRI, with the effects being more pronounced in those with more active disease and more inflammatory lesions prior to conception. 

Impact of MS on pregnancy:

In general, MS does not impact miscarriage rates, congenital malformations or stillbirths. Several studies have found children born to women with MS have lower birth weights while others found infant birth weight to be the same as the general population.

Can DMTs harm the fetus?

Some of them may, so if you are planning to stay pregnant or already are, you should consult your neurologist in order to discuss your next steps. With beta interferons and natalizumab (Tysabri), you might agree to keep taking it for some months into the pregnancy, or to come off it before you get pregnant. One DMT, glatiramer acetate (Copaxone), is licensed for use while you’re pregnant. But some DMTs are not considered safe during pregnancy. For example, if you take fingolimod (Gilenya) or teriflunomide (Aubagio) you should speak to your neurologist about stopping before trying for a baby. If you stop a DMT because you plan to get pregnant, you’ll usually need to do this a few months in advance. That’s so the medication in your body drops to a safe level. Depending on the drug, that could take between 1 and 12 months.

DMTs while breastfeeding:

Some of them are allowed, but others should be avoided because they get into the milk and can harm the baby. For example, with beta interferons and glatiramer acetate, the Association of British Neurologists (ABN) advises that the benefits for the baby from breastfeeding are greater than any risks. But some other drugs, including fingolimod (Gilenya) and cladribine (Mavenclad) shouldn’t be used when breastfeeding. 

Vitamin D and pregnancy with MS:

In general, guidelines suggest a minimum of 10 micrograms/400 IU per day for everyone, women or not. If you are a pregnant woman with MS, consult your neurologist because there might be a suggestion of a higher dose. 

MS and infertility treatments:

Studies have reported increases in symptoms in women undergoing unsuccessful ART but treatments enrolled few patients and did not allow for significant data analysis. ART was associated with a 7-fold increase in the risk of MS exacerbation and with a 9-fold increase in the risk of enhanced disease activity as seen in MRI scans of lesions in patients prescribed the pituitary block protocol with a GnRH analog, and not when the block was performed with antagonists. There were no differences regarding injectable gonadotropins used to induce ovulation. Significant increases in relapsing disease were associated with the use of GnRH agonists and IVF failure. The proposed mechanisms included: cessation of DMT, stressful events associated with infertility, and immunological changes induced by GnRH, as well as augmented immune cell migration across the blood-brain barrier.

There was no difference between levels of FSH, LH, inhibits, estrogen, progesterone, free testosterone, AMH, or ovarian reserve in women with controlled MS or without the disease. However, patients with uncontrolled disease and subjects with active MS had smaller ovaries with fewer follicles and decreased AMH levels. No relationship was observed between MS and the production of anti-ovarian antibodies. Despite the small sample size and the limited number of studies examining the subject, the data suggested that the use of ART is not contraindicated in patients with MS; instead, it is recommended that ART be performed during a stable period of the disease and that treatment be maintained until pregnancy has been confirmed.

The most important thing you should remember after reading this article is that there is no clear evidence of a direct correlation between MS and infertility issues. Most of the time, women have successful pregnancies and healthy offspring. It will be more difficult to deal with motherhood due to the fatigue or disabilities but there are treatments that can help ease the symptoms. A fertility specialist and a neurologist are essential in order to guide you correctly through your fertility journey.

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Multiple Sclerosis (MS) and fertility