Overview of family planning with MS
For most women, the disease course itself will not be affected by pregnancy or breastfeeding. MS is highly individualized, and your disease characteristics and treatment plan are significant considerations in your family planning.
Fertility and conception with MS
There is no evidence that MS impairs fertility. Studies have shown that some types of fertility treatment may increase the risk of relapses in women with MS, with relapse rates increasing in the three months after in vitro fertilization. However, a more recent study did not find an increase in relapses with the use of fertility treatment (Bove et al, 2019). This is an area of ongoing research and more concrete recommendations will hopefully follow.
If you are on a disease modifying therapy (DMT) and you are of childbearing age, you are likely using some form of contraception (birth control). The decision of when to stop contraception and attempt pregnancy is different depending on which DMT you take.
None of the DMTs are approved by the US Food and Drug Administration (FDA) for use during pregnancy. It is generally recommended that all DMTs be stopped prior to conception. Some studies have demonstrated that interferon-beta and glatiramer acetate are safe to be taken up until conception and during pregnancy (Vukusic and Marignier, 2015). For women taking fingolimod or natalizumab, there may be a risk of “rebound’ disease activity after stopping the medication for pregnancy (Langer-Gould, 2019).
Family planning for someone with MS involves many unique considerations. Be sure to share your plans with your MS healthcare provider, including the use of fertility treatment and the timing of stopping contraception and DMTs.
Pregnancy and delivery with MS
There is no evidence that MS leads to an increased number of spontaneous abortions (miscarriage), stillbirths or congenital malformations. Several studies of large numbers of women have repeatedly demonstrated that pregnancy, labor, delivery and the incidence of fetal complications are no different in women who have MS than in women who do not have MS.
There are fewer MS relapses during pregnancy, especially in the second and third trimesters. Changes that take place in a woman’s body during pregnancy are believed to contribute to less inflammation, less MS activity and fewer relapses.
If you experience a relapse during pregnancy, treatment with corticosteroids (for example, methylprednisolone or prednisone) may be considered. Corticosteroids are believed to be safe in the second and third trimester but are not considered safe during the first trimester.
Some of your MS symptoms may feel worse during pregnancy, like fatigue or bladder symptoms. If you have balance or mobility problems, they might feel worse toward the end of your pregnancy with the additional weight of the baby.
Most medications that are used to treat MS symptoms are not safe to use during pregnancy. Work with your MS healthcare provider to determine if, when and how you should stop any medications you are taking.
Women with MS usually need no special gynecologic care during pregnancy. Labor and delivery are usually the same as in other women and no special management is needed. All forms of anesthesia are considered safe and well tolerated for women during labor and delivery.
Depending on your specific symptoms, there are modifications, like specific positions or the use of medications, that can make your birthing experience more comfortable. Discuss your MS symptoms and birth plan with both your MS healthcare provider and maternity care provider.
Post-partum and breastfeeding with MS
Your risk of a relapse is increased in the first three months postpartum and a recent review of studies suggests that breastfeeding reduces this risk (Krysko et.al, 2019). While this does not prove that breastfeeding will completely prevent post-partum relapses, we do know that breastfeeding is safe for people with MS and their babies and could be beneficial.
Post-partum relapses have not been shown to increase long-term disability. In the studies with long-term follow-up of women with MS who had children, no increased disability as a result of pregnancy was found. Some clinicians feel that with the evolving landscape of DMTs available, women are entering pregnancy in a well-controlled disease state, possibly decreasing their risk of a post-partum relapse.
Treatment with corticosteroids for an MS relapse is also safe post-partum but they will pass into breastmilk. The DMTs and some symptom management medications are not recommended during breastfeeding because it is not known if they pass into breastmilk. Work with your MS healthcare provider and maternity care provider to determine which medications are safe for you and your baby.
Depression is a common symptom of MS and some studies suggest that post-partum depression is more common in parents with MS. Talk to your MS healthcare provider or your maternity provider if you notice changes in your mood during pregnancy or after delivery.